Event 1: Meet Nestor

Nestor’s Past Medical History

Born at Full Term
Severe perinatal asphyxia (APGARS scores: 0, 0, and 3)
Tonic-clonic seizure disorder
- Well controlled for 5 years, but over the past year, he has had one generalized seizure monthly
- Recent increase in levetiracetam
Aspiration Pneumonia x 3 (most recently, 2 years ago)
Mild Scoliosis
Cortical blindness
Severe developmental delay: requires total care for all activities of daily living

Nestor’s Past Surgical History

G-tube
Tracheostomy

Nestor’s Current Medications

Levetiracetam 500 mg via GT BID (40 mg/kg/day) – Seizures
Omeprazole 20 mg via GT – GERD
Miralax 17 grams via GT daily – Constipation

Nestor’s Allergies

NKDA

Dr. Korones Meets With Nestor's Mother

Dr. Korones makes a home visit to meet with Nestor's mother to go over the pain Nestor currently faces.

Summary of Findings From the History of Present Illness

Pain with movement and at rest
Grimacing
Heart and respiratory rate changes
Crying
Stiffness

Establishing a Baseline

Dr. Korones needs to establish what the patient is like at baseline, without apparent pain. This will provide useful information in determining the success of treatment.

Test Your Knowledge

How would you evaluate this child for pain?

Incorrect

Correct. The FLACC-revised scale is used in non-verbal children (children less than 3 years old and older children with developmental delay).

Incorrect

Learn More

Faces Pain Scale - revised

Neonatal Infant Pain Scale

Numeric Scale

FLACC - revised

Pieces of Hurt (formerly Hester Poker Chip Scale)

Assessment of Pain in a Child Using the FLACC Pain Scale

Dr. Korones explains to Nestor's mother that the examination may cause Nestor unintended discomfort.

Dr. Korones explains the FLACC Pain Scale to Nestor's mother.

Dr. Korones performs the FLACC Pain Scale assessment on Nestor.

Dr. Korones explains his findings of Nestor's assessment using the FLACC Pain Scale.

Test Your Knowledge

Question 1

Based on the history and physical exam, select the likely causes of these episodes.

Correct. Determining the etiology of pain in the non-verbal child with severe developmental delay is a challenge. All of these choices are frequent and possible causes. Because these children are not mobile, they spend a lot of time in fixed positions (e.g., in a stroller or wheelchair), and develop gradual dislocation of the hips and experience pain, particularly with movement at the hips.

Correct. Determining the etiology of pain in the non-verbal child with severe developmental delay is a challenge. All of these choices are frequent and possible causes. The combination of growth, inability to sit or stand, and increased or decreased tone result in scoliosis, pain, and respiratory compromise.

Correct. Determining the etiology of pain in the non-verbal child with severe developmental delay is a challenge. All of these are frequent and possible causes. Formula intolerance, GI dysmotility and constipation are a common cause of pain.

Correct. Determining the etiology of pain in the non-verbal child with severe developmental delay is a challenge. All of these are frequent and possible causes. “Neuro-irritability” is a sustained activated state associated with crying, inconsolability. It is thought to be related to autonomic dysregulation and can mimic pain or be considered a cause of pain.

Correct. Determining the etiology of pain in the non-verbal child with severe developmental delay is a challenge. All of these are frequent and possible causes. Seizures are common and can mimic pain.

Question 2

Based on the differential diagnosis, what imaging studies (if any) would you order?

Incorrect. A head MRI is unlikely to reveal any abnormality that might be the cause of Nestor’s pain. In addition it is an expensive test for which anaesthesia would be required.

Correct. Plain films of the spine would be indicated to assess for scoliosis. Nestor could be experiencing scoliosis, a common finding in developmentally disabled children who are unable to sit or stand on their own. However, the presence of scoliosis is not always associated with pain (often it is not). Plain films of the hips could be helpful in diagnosing dislocation of the hip, a relatively common finding in developmentally disabled children who are not mobile.

Incorrect. This might be indicated if significant pathology was noted on the plain film of the spine, and an orthopedist felt that the additional information might help guide management.

Incorrect. An upper GI might be worth exploring if Nestor’s pain appeared to be abdominal in origin or was associated with feeding problems or vomiting.

Imaging Ordered

Dr. Korones elects to order hip films on Nestor.

Nestor's Hip Films

The plain film of the hip reveals a left hip dislocation. Note the erosion of the left femoral head and the lack of interface between the femoral head and the acetabulum (see arrow). Compare the left and right hips.

XRAY of Nestor's hips that shows a left hip dislocation. — Left hip dislocation

Test Your Knowledge

What recommendation(s) for pain management will you make at this time?

Incorrect. Ibuprofen around the clock is indicated, but one should anticipate that a referral to an orthopedist will likely be needed as well.

Incorrect. Acetaminophen is unlikely to help since it has not been helpful in the past.

Incorrect. Morphine may ultimately be required, given the severity of the pain, but it is reasonable to start with ibuprofen.

Incorrect. Referral to an orthopedist is indicated, but Nestor should also be started on some anti-pain medication since it takes time to arrange such referrals.

Correct. Ibuprofen is a safe and effective non-steroidal anti-inflammatory drug that is particularly effective in relieving bony pain. Since Nestor has pain with movement of his legs and you suspect a dislocated hip, his pain is likely to be bony in origin. Regularly scheduled ibuprofen therefore may help relieve his pain. However, given the nature of his problem, ibuprofen alone is unlikely to control the pain. He will likely require the input of a pediatric orthopedic surgeon (especially if there is a dislocation) to determine whether a surgical intervention or less invasive intervention (like a brace) is necessary.

Explanation of Treatment

Dr. Korones explains his choice of treatment to Nestor's mother.

Non-Opioid Medications Used In Pediatric Pain Management

The following table describes the major non-opioid medications used in pain management for the pediatric population. Note clinical considerations and contraindications for each agent.

Non-Opioid Pain Medications Used in Pediatric Pain Management
Drug	Properties	Usual Pediatric Dose	Clinical Comments
Acetaminophen	Inhibits central prostaglandin synthesis	PO: 10-15 mg/kg/dose every 4-6 hours; not to exceed 5 doses Rectal: 20 mg/kg/dose every 6 hours	Caution with prescription and non-prescription combination products containing acetaminophen Avoid use in patients with liver disease
Ibuprofen	Non-steroidal anti- inflammatory (NSAID)	PO: 10 mg/kg/dose every 6-8 hours	Caution in patients with renal insufficiency; increased risk of GI ulcers and bleeds Avoid in <6 months of age
Ketorolac	Non-steroidal anti- inflammatory (NSAID)	IV: 0.25 - 0.5 mg/kg/dose every 6-hours	Maximum duration of treatment is 5 days May have GI and hematological effects
Naproxen	Non-steroidal anti- inflammatory (NSAID)	PO: 5 – 6 mg/kg/dose every 8 - 12-hours	May have GI and hematological effects

References

Berde CB and Sethna NF. Analgesics for the treatment of pain in children. NEJM 2002; 347: 1094-1103. (Accessed August 26th, 2013)
FDA. Acetaminophen overdose and liver injury-background and options for reducing injury. May 2009. (Accessed August 26, 2013).

Factors Placing Pediatric Patients at Increased Risk of Adverse Reactions with Medications

Pharmacokinetic Differences
Calculation of Individualized Doses
- Age
- Weight (mg/kg)
- Body Surface Area
Lack of available dosage forms
Lack of published information or FDA approval
Lack of communication skills
Limited Internal reserve to buffer errors

Reference

Levine SR, Cohen MR, Blanchard NR et al. Guidelines for preventing medication errors in pediatrics. J Pediatr Pharmacol Ther 2001;6:427-443. (Accessed August 26, 2013)