What oral baclofen dosing and titration schedule should be used for a child with cerebral palsy, including starting dose, increment schedule, maximum total daily dose, and weight‑based limits?

Oral Baclofen Dosing for Children with Cerebral Palsy

Start oral baclofen at 5 mg three times daily in children with cerebral palsy, increase by 5 mg per dose every 3 days as tolerated, with a maximum total daily dose of 30-40 mg/day in most pediatric patients, though some sources cite up to 60 mg/day in divided doses. 1

Starting Dose and Initial Titration

• Begin with 5 mg orally three times daily regardless of weight, as this minimizes the risk of sedation and other central nervous system adverse effects 1
• The low starting dose is critical because older persons (and by extension, children with neurological conditions) rarely tolerate doses greater than 30-40 mg per day 1
• Monitor closely for muscle weakness, urinary dysfunction, cognitive effects, and sedation during the initial titration period 1

Titration Schedule

• Increase the dose by 5 mg per dose (15 mg total daily) every 3 days as tolerated 1
• This gradual titration approach reduces the risk of dose-limiting adverse effects including excessive weakness, confusion, and sedation 1
• Assessment should occur within 24 hours of any dose change to evaluate both therapeutic response and adverse effects 2

Maximum Dosing

• The practical maximum for most children is 30-40 mg per day in divided doses (e.g., 10-15 mg three times daily) 1
• Some children may tolerate higher doses, but this requires careful monitoring and is associated with increased risk of adverse effects 1
• Doses above this range are rarely tolerated and should only be attempted under close supervision 1

Critical Safety Considerations

• Never discontinue baclofen abruptly due to risk of central nervous system irritability, withdrawal symptoms, and potential seizures 1
• Baclofen may potentiate seizures in children with epilepsy, even at therapeutic doses—monitor for increased seizure activity or EEG changes 3
• Clinical adverse effects include confusion, agitation, insomnia, diffuse hypotonia, and hyporeflexia, which can occur even within therapeutic dosing ranges 3
• Oral baclofen has limited efficacy for cerebral spasticity due to poor lipid solubility and limited CNS penetration—only mild improvement should be expected 4

When Oral Therapy Fails

• Approximately 25-30% of patients fail to respond adequately to oral baclofen, and 4-27% discontinue due to intolerable adverse effects 5
• Consider intrathecal baclofen therapy for children with inadequate response to oral therapy or intolerable side effects, as intrathecal doses achieve far higher CSF concentrations (1/100th the oral dose) with fewer systemic side effects 4, 6
• Intrathecal baclofen is particularly effective for severe spasticity affecting both upper and lower extremities and may improve upper extremity function and activities of daily living 4, 6

Common Pitfalls to Avoid

• Do not escalate doses too rapidly—this is the most common cause of intolerable adverse effects 1
• Do not use baclofen as monotherapy expecting dramatic improvement in cerebral palsy spasticity—oral baclofen provides only mild benefit 4
• Do not overlook the need for concurrent physical therapy and rehabilitation, as medication alone is insufficient 5
• Be aware that baclofen has no effect on athetosis or other movement disorders at doses used to treat spasticity 4