Cerebral palsy - pain and irritability

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  • See also       

    Cerebral palsy

    Cerebral palsy: increased seizures

    Cerebral palsy: chest infections

    Acute pain management

    Key Points

    1. A careful history and thorough ‘head to toe’ examination is required to assess for the wide range of causes
    2. Pay particular attention to the concerns of parents about behavioural change
    3. Unexpected changes to children’s physical, social and cognitive abilities can be due to untreated pain
    4. Provide analgesia while assessing the child but be cautious with opioid prescription
    5. Admission may be required for observation and/or further investigations


    Unexpected changes to children’s physical, social and cognitive abilities can be due to untreated chronic or recurrent pain which can have a significant impact on quality of life, sleep and mood

    A careful history and thorough ‘head to toe’ examination is required. There is a wide range of causes for pain or irritability in children with cerebral palsy


    • Upper or lower respiratory tract infection with increased secretions
    • Pharyngitis/tonsillitis with throat pain/reduced intake
    • Otitis media
    • Dental infection
    • UTI
    • Skin, bone, or joint infections
    • Meningitis/infected VP shunt


    • Accidental fractures
    • Consider non-accidental injury (under reported in this group)
    • Pathological fractures/osteoporosis
    • Hip dislocation or subluxation
    • Contractures
    • Spasticity (can cause pain or is often secondary to pain)
    • Back pain/scoliosis


    • Increased seizure activity
    • Dystonia
    • Headache
    • Increased intracranial pressure (consider in children with VP shunts - blocked shunt especially with vomiting or change in level of consciousness)
    • Neuropathic pain


    • Constipation
    • Gastro-oesophageal reflux
    • Gallstones
    • Pancreatitis
    • Gastro-intestinal motility disorders/dumping syndrome (look for post prandial hypoglycaemia, evaluate gastric emptying if PEG/PEJ in situ)
    • Issue with feeding tube (if NG/NJ or PEG/PEJ in situ)
    • Renal stones (increased risk if on topiramate)
    • Gynaecological eg dysmenorrhoea
    • Appendicitis
    • Ovarian or testicular torsion


    • Emotional and behavioural difficulties (consider changes in environment eg home, school or family)
    • Anxiety or depression
    • ASD or ADHD


    • Sleep deprivation (associated with pain and spasm)
    • Medications
    • Nutritional deficiencies (eg vitamin A deficiency can lead to eye pain)


    • Establish a timeline as to when change in behaviour, features of irritability or pain started
    • Full physical examination including dentition, ENT, abdomen, hips and limbs in particular and investigate as indicated
    • Check blood pressure
    • Assess VP shunt if present
    • Check urine for blood (stones) or white cells (infection)
    • Consider further imaging that might be useful eg hip X-ray, abdominal US, CT, bone scan, gastroscopy, CT brain
    • Consider dental review


    • Treat identifiable causes
    • Provide adequate analgesia
      • Caution with opioid use in children with cerebral palsy due to increased risk of respiratory depression. Seek specialist advice early
    • Under guidance of specialist, consider trial of medication if unable to identify cause eg
      • Empiric analgesia with paracetamol or NSAIDs
      • Antacid/PPI
      • Laxatives, see constipation
      • Bisphosphonates, if osteopenia suspected
      • Gabapentin, for neuropathic pain
      • Medications for sleep, eg melatonin
    • Consider physiotherapy and occupational therapy for positioning, seating, splinting etc
    • Consider dietetics for assessment of diet/feed type
    • Admission may be required for observation, further investigation and management

    Consider consultation with local paediatric team when

    • No identifiable cause has been found for pain/irritability and ongoing pain/irritability despite adequate simple analgesia
    • Escalating analgesic requirements beyond simple analgesia

    Consider transfer when

    The child requires care beyond the comfort level of the hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    Pain or irritability has been appropriately assessed and managed and follow up arranged

    Last updated July 2023

  • Reference List

    1. Benvenuto et al. A Pragmatic Approach to Assessment of Chronic and Recurrent Pain in Children with Severe Neurological Impairment. Children (Basel) 2022 Jan;9(1): 45. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8774866/ (viewed 07 Sept 2022).
    2. NICE guideline [NG62]. Cerebral Palsy in under 25s: assessment and management. Retrieved from https://www.nice.org.uk/guidance/ng62 (viewed 07 Sept 2022).