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Kubek LA, Angenendt N, Hasan C, Zernikow B, Wager J. Relevance of Potential Contributing Factors for the Development and Maintenance of Irritability of Unknown Origin in Pediatric Palliative Care. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1726. [PMID: 38002817 PMCID: PMC10670487 DOI: 10.3390/children10111726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023]
Abstract
Potential contributing factors (PCFs) for irritability of an unknown origin (IUO) in children with neurological conditions are identifiable through structured diagnostics. Uncertainty exists regarding the actual relevance of identified PCFs to IUO. Assessments from parents as well as nursing, psycho-social, and medical professionals were used to determine the contribution of different PCFs in the development and maintenance of IUO. For this, individual PCFs of N = 22 inpatient children with IUO were presented to four raters. Descriptive statistics, Kruskal-Wallis tests, and Krippendorff's alpha were used to determine which PCFs were most relevant to explain IUO and rater agreement. Psycho-social aspects (44.7%), hyperarousal (47.2%), pain (24.6%), and dystonia (18.1%) were identified as the most relevant PCFs for IUO. Descriptively, physicians' relevance rating regarding psycho-social aspects, hyperarousal, and dystonia deviated the most from the overall group rating. All professional raters considered psycho-social aspects to be more relevant than did parents. Parents rated pain as more relevant than the other raters. Kruskal-Wallis tests showed no significant differences between relevance ratings (H = 7.42, p = 0.059) or the four parties' deviations (H = 3.32, p = 0.344). A direct comparison of the six two-party constellations showed that across all factors, agreement was weak to moderate. The highest agreement was between physicians and nurses (α = 0.70), and the lowest was between nurses and psycho-social experts (α = 0.61). Understanding which psycho-social and various biological PCFs are significant for IUO can facilitate more targeted and individualized pediatric palliative care for affected patients.
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Affiliation(s)
- Larissa Alice Kubek
- PedScience Research Institute, 45711 Datteln, Germany; (B.Z.); (J.W.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany; (N.A.); (C.H.)
| | - Nina Angenendt
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany; (N.A.); (C.H.)
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
| | - Carola Hasan
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany; (N.A.); (C.H.)
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
| | - Boris Zernikow
- PedScience Research Institute, 45711 Datteln, Germany; (B.Z.); (J.W.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany; (N.A.); (C.H.)
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
| | - Julia Wager
- PedScience Research Institute, 45711 Datteln, Germany; (B.Z.); (J.W.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany; (N.A.); (C.H.)
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany
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2
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Goodall M, Irving K, Nevin M. The recognition, assessment and perceptions of total pain in people with profound intellectual disabilities: A mixed methods systematic review. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2023; 36:940-950. [PMID: 37365750 DOI: 10.1111/jar.13132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 05/23/2023] [Accepted: 06/03/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND People with profound intellectual disabilities are a population with complex comorbidities. Total pain recognises the interconnectedness of aspects of pain; social, psychological, physical, emotional, spiritual. Pain is under-recognised due to communication challenges and carers perceptions. This review's purpose is to synthesise current literature and provide guidance for future research and care. METHODS Five databases were searched in this mixed methods systematic review (Cinahl, Medline, Psycinfo, Web of Science, Scopus). Articles retrieved were reported via a PRISMA flow diagram. Quality appraisal utilised the mixed methods appraisal tool (MMAT). A convergent qualitative design was the method of data synthesis. RESULTS Data from 16 included articles generated four themes; Absent voices, reductionist assessment, pain intensity, valuing expertise. Data included physical pain only. CONCLUSION Multifaceted pain needs inclusion in research. Assessment must consider the unique expressions of pain by individuals with profound intellectual disabilities. A sharing of expertise may improve pain care.
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Affiliation(s)
- Maeve Goodall
- School of Nursing, Psychotherapy & Community Health, Dublin City University, Dublin, Ireland
| | - Kate Irving
- School of Nursing, Psychotherapy & Community Health, Dublin City University, Dublin, Ireland
| | - Mary Nevin
- School of Nursing, Psychotherapy & Community Health, Dublin City University, Dublin, Ireland
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3
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Fishman I, Siden H, Vadeboncoeur C. Evaluation of children with severe neurological impairment admitted to hospital with pain and irritability. BMC Pediatr 2022; 22:571. [PMID: 36195849 PMCID: PMC9531516 DOI: 10.1186/s12887-022-03632-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is the most common symptom reported by caregivers of children with severe neurological impairment (SNI), a descriptive term for children with disorders affecting the neurological system across multiple domains. In SNI, cognition, communication, and motor skills are impaired and other organ systems are impacted. Pain is difficult to identify and treat in children with SNI because of communication impairment. When a clear cause of pain is not determined, the term "Pain and Irritability of Unknown Origin (PIUO)" is used to describe pain-like behaviours. This study explores the clinical care received by children with SNI admitted to hospital after presenting to the emergency department of a tertiary pediatric hospital with pain or irritability. Findings are compared to the approach suggested in the PIUO pathway, an integrated clinical pathway for identifying and treating underlying causes of pain and irritability in children with complex conditions and limited communication. METHODS Retrospective chart review of children (age 0 to 18 years inclusive) with diagnoses compatible with SNI presenting with pain, irritability, and/or unexplained crying that required hospitalization between January 1st, 2019 and December 31st, 2019. Descriptive statistics were used to analyze the clinical care received by children in whom a source of pain was identified or not. In children for whom no cause of pain was identified, investigations completed were compared to the PIUO pathway. RESULTS Eight hospital admissions of six unique children were included for data analysis. A cause for pain and irritability was identified and resolved in three patients. In children with PIUO, there were gaps in history taking, physical examination, and investigations that might have allowed a cause of pain and irritability to be found. Pain was assessed using the r-FLACC pain scale and varying medications for pain/irritability were given during each hospital admission. CONCLUSION Children with SNI admitted to a tertiary pediatric hospital did not undergo a standardized approach to identifying a cause of pain and irritability. Future efforts should explore the effectiveness of the PIUO pathway, a standardized approach to reducing and resolving pain in children with SNI.
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Affiliation(s)
- Isobel Fishman
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Harold Siden
- British Columbia Children's Hospital Research Institute, Vancouver, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, Canada.,Canuck Place Children's Hospice, Vancouver, Canada
| | - Christina Vadeboncoeur
- Faculty of Medicine, University of Ottawa, Ottawa, Canada. .,Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario, K1H 8L1, Canada. .,Roger Neilson House, Ottawa, Canada.
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4
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Dreier LA, Angenendt N, Hasan C, Zernikow B, Wager J. Potential Contributing Factors for Irritability of Unknown Origin in Pediatric Palliative Care. J Pain Symptom Manage 2022; 64:156-167. [PMID: 35430284 DOI: 10.1016/j.jpainsymman.2022.04.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/11/2022] [Accepted: 04/04/2022] [Indexed: 11/29/2022]
Abstract
CONTEXT In pediatric palliative care, irritability of unknown origin (IUO) in children with severe neurological impairment is a peculiarly complex and challenging symptom, yet its etiology remains poorly understood. OBJECTIVES Presenting a structured IUO diagnostic and therapeutic approach developed in a specialized inpatient pediatric palliative care facility for identifying IUO's potential contributing factors (PCFs). METHODS Prospective observational study with N = 22 children showing IUO at admission to the inpatient pediatric palliative care facility. Analysis of patient records and participation in ward routine to identify and treat PCFs. Treatment outcome was assessed using a standardized protocol for tracking IUO at 24-hour intervals. RESULTS Altogether, 136 PCFs were identified (average 6.18 per child) with pain and psycho-social problems being the most common. Two hundred and twenty-two diagnostic measures were initiated of which 159 (71.6%) helped identify a PCF. The majority of PCFs were identified by basic diagnostics (93.7%). Inpatient length of stay and duration of IUO phases correlated significantly. Between baseline (days 3-5; timing at which inpatients experientially show regular behavior) and discharge, patients showed a significant reduction in average 24-hours IUO duration by 1 hour and 26 minutes (Wilcoxon test: Z = -3.29, P < 0.01). CONCLUSION Results lead to a more thorough understanding of PCFs to IUO. Following a systematic approach such as the one presented, PCFs can be detected even by simple diagnostics. In addition to biological aspects, diagnostics and therapy should address psycho-social aspects of IUO.
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Affiliation(s)
- Larissa Alice Dreier
- PedScience Research Institute (L.A.D., B.Z., J.W.), Datteln, North Rhine-Westphalia, Germany; Department of Children's Pain Therapy and Paediatric Palliative Care (L.A.D., N.A., C.H., B.Z., J.W.), Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, North Rhine-Westphalia, Germany.
| | - Nina Angenendt
- Department of Children's Pain Therapy and Paediatric Palliative Care (L.A.D., N.A., C.H., B.Z., J.W.), Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, North Rhine-Westphalia, Germany; Paediatric Palliative Care Centre (N.A., C.H., B.Z., J.W.), Children's and Adolescents' Hospital, Datteln, North Rhine-Westphalia, Germany
| | - Carola Hasan
- Department of Children's Pain Therapy and Paediatric Palliative Care (L.A.D., N.A., C.H., B.Z., J.W.), Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, North Rhine-Westphalia, Germany; Paediatric Palliative Care Centre (N.A., C.H., B.Z., J.W.), Children's and Adolescents' Hospital, Datteln, North Rhine-Westphalia, Germany
| | - Boris Zernikow
- PedScience Research Institute (L.A.D., B.Z., J.W.), Datteln, North Rhine-Westphalia, Germany; Department of Children's Pain Therapy and Paediatric Palliative Care (L.A.D., N.A., C.H., B.Z., J.W.), Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, North Rhine-Westphalia, Germany; Paediatric Palliative Care Centre (N.A., C.H., B.Z., J.W.), Children's and Adolescents' Hospital, Datteln, North Rhine-Westphalia, Germany
| | - Julia Wager
- PedScience Research Institute (L.A.D., B.Z., J.W.), Datteln, North Rhine-Westphalia, Germany; Department of Children's Pain Therapy and Paediatric Palliative Care (L.A.D., N.A., C.H., B.Z., J.W.), Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, North Rhine-Westphalia, Germany; Paediatric Palliative Care Centre (N.A., C.H., B.Z., J.W.), Children's and Adolescents' Hospital, Datteln, North Rhine-Westphalia, Germany
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5
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Alghamdi K, Lysecki D. Role of gabapentin in reducing the need for high-risk medications in patients with stable severe neurological impairment. J Taibah Univ Med Sci 2022; 18:170-174. [DOI: 10.1016/j.jtumed.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/13/2022] [Accepted: 07/20/2022] [Indexed: 10/15/2022] Open
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6
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Burkitt CC, Genik LM. Special issue on pain and intellectual and developmental disabilities. PAEDIATRIC AND NEONATAL PAIN 2022; 4:1-2. [PMID: 35546917 PMCID: PMC8975184 DOI: 10.1002/pne2.12077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/24/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Chantel C. Burkitt
- Gillette Children's Specialty HealthcareSaint PaulMinnesotaUSA
- Department of Educational PsychologyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Lara M. Genik
- University of GuelphGuelphOntarioCanada
- Vanier Children's Mental WellnessLondonOntarioCanada
- Archways Centre for CBTLondonOntarioCanada
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7
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Rizakos S, Parmar A, Siden HH, Orkin J. The Parental Experience of Caring for a Child With Pain and Irritability of Unknown Origin. J Pain Symptom Manage 2022; 63:330-340. [PMID: 34343622 DOI: 10.1016/j.jpainsymman.2021.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/30/2021] [Accepted: 07/26/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Approximately 73% of children with severe neurological impairment (SNI) can experience episodes of pain and irritability often of unknown origin (PIUO). Limited research exists on how these experiences of PIUO may affect parental caregivers and families. The primary objective of this study was to understand the parental caregiver experience of caring for a child with SNI who experiences persistent PIUO. METHODS We conducted a qualitative study using semi-structured interviews to explore the experience of parental caregivers of children with SNI. Interview guide questions focused on exploring pain behaviours, the diagnostic process, pharmacological and non-pharmacological management, healthcare-team support, discussion surrounding irritability, and family impact. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed by 2 independent reviewers using thematic analysis. RESULTS 15 parental caregivers were interviewed, with 93% being mothers and 33% being a visible minority. Interviews revealed 3 major themes: 1) Variations in Clinical Care for PIUO; 2) The Experience and Challenges of Living with PIUO); 3) Managing the Impact of PIUO on Parental Well Being. Interviews demonstrated that parent and child can be viewed as a dyad, in which the child's experience is inherently linked to the parental experience. CONCLUSION Parental caregivers described caring for a child with persistent PIUO as physically and emotionally exhausting, and negatively impacting family quality of life. Interviews highlighted avenues of future exploration for clinical care, including both enhanced management pathways for children and supportive resources for education and coping for parents.
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Affiliation(s)
- Sara Rizakos
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Arpita Parmar
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada; Schulich School of Medicine and Dentistry, Western University, London ON, Canada
| | - Harold Hal Siden
- Department of Pediatrics, University of British Columbia, BC, Canada; Child and Family Research Institute, BC Children's Hospital, Vancouver, BC, Canada; Canuck Place Children's Hospice, Vancouver, BC, Canada
| | - Julia Orkin
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada; Division of Pediatric Medicine, Complex Care Program, The Hospital for Sick Children, Toronto, Canada.
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8
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Orlova N, Riga O, Ishchenko T, Onikiienko О, Omelchenko O, Urivaeva M, Alenina I. CHRONIC PAIN AND PHYSICAL THERAPY IN CHILDREN WITH PARALYTIC SYNDROMES: ARE THERE ANY CHANGES DURING LOCKDOWN? WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:2262-2269. [PMID: 36378706 DOI: 10.36740/wlek202209215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The aim: To evaluate an influence of physical therapy on chronic pain in children with paralytic's syndrome and to maternal emotional status on lockdown time during the COVID-19 pandemic. PATIENTS AND METHODS Materials and methods: Data from 96 children and their mothers (96 persons) were included in the study. On-site services of physical therapists before the pandemic (2018- 2019) were received by 64 children and by 32 children during quarantine measures due to COVID-19 pandemic (2020). The age of the children ranged from 1 to 6 years, the median age was 3 years and 3 months. RESULTS Results: We note that there were more boys with paralytic syndromes. Among the leading paralytic syndromes, the most common was spastic tetraparesis. The frequency of children with level III-V motor disorders prevailed. CONCLUSION Conclusions: The authors consider that physical rehabilitation in children with paralytic syndromes reduces the incidence of moderate chronic pain and improves the emotional state of parents. But, these changes do not occur during the pandemic.
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Affiliation(s)
| | - Olena Riga
- KHARKIV NATIONAL MEDICAL UNIVERSITY, KHARKIV, UKRAINE
| | | | | | | | | | - Inna Alenina
- KHARKIV NATIONAL MEDICAL UNIVERSITY, KHARKIV, UKRAINE
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9
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Barney CC, Andersen RD, Defrin R, Genik LM, McGuire BE, Symons FJ. [Challenges in pain assessment and management among individuals with intellectual and developmental disabilities : German version]. Schmerz 2021; 36:49-58. [PMID: 34515871 DOI: 10.1007/s00482-021-00589-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Intellectual and developmental disabilities (IDD) include conditions associated with physical, learning, language, behavioural, and/or intellectual impairment. Pain is a common and debilitating secondary condition compromising functional abilities and quality of life. OBJECTIVES This article addresses scientific and clinical challenges in pain assessment and management in individuals with severe IDD. METHODS This Clinical Update aligns with the 2019 IASP Global Year Against Pain in the Vulnerable and selectively reviews recurring issues as well as the best available evidence and practice. RESULTS The past decade of pain research has involved the development of standardized assessment tools appropriate for individuals with severe IDD; however, there is little empirical evidence that pain is being better assessed or managed clinically. There is limited evidence available to inform effective pain management practices; therefore, treatment approaches are largely empiric and highly variable. This is problematic because individuals with IDD are at risk of developing drug-related side effects, and treatment approaches effective for other populations may exacerbate pain in IDD populations. Scientifically, we are especially challenged by biases in self-reported and proxy-reported pain scores, identifying valid outcome measures for treatment trials, being able to adequately power studies due to small sample sizes, and our inability to easily explore the underlying pain mechanisms due to compromised ability to self-report. CONCLUSION Despite the critical challenges, new developments in research and knowledge translation activities in pain and IDD continue to emerge, and there are ongoing international collaborations.
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Affiliation(s)
- Chantel C Barney
- Gillette Children's Specialty Healthcare, 200 University Ave E., 55101, Saint Paul, MN, USA. .,Department of Educational Psychology, University of Minnesota, Minneapolis, MN, USA.
| | - Randi D Andersen
- Department of Research, Telemark Hospital Trust, Skien, Norwegen
| | - Ruth Defrin
- Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine & Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
| | - Lara M Genik
- Department of Psychology, University of Guelph, Guelph, ON, Kanada
| | - Brian E McGuire
- School of Psychology and Centre for Pain Research, National University of Ireland, Galway, Irland
| | - Frank J Symons
- Department of Educational Psychology, University of Minnesota, Minneapolis, MN, USA
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10
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Alotaibi Q, Dighe M. Managing challenging pain and irritability in OSTM1 mutation-related infantile malignant osteopetrosis. BMJ Case Rep 2021; 14:14/5/e242498. [PMID: 34011644 DOI: 10.1136/bcr-2021-242498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Osteopetrosis describes a heterogeneous group of diseases characterised by increased bone density due to impaired osteoclast. The malignant infantile autosomal recessive (MIOP) form caused by mutations in OSTM1 is the most severe form of osteopetrosis. Children with this phenotype exhibit multisystemic complications, of which the neuropathic manifestations are the most severe. Infants with MIOP may present with pain and irritability that are likely to become continuous and debilitating as the disease progresses. There is limited understanding of the aetiology and management of pain in MIOP. Here, we describe a 2 month-old infant with OSTM1 mutation-related MIOP presenting with severe irritability and pain. This case provides the opportunity to discuss the cause and management of these distressing symptoms. We also review similar cases and the possible underlying mechanisms of pain and irritability to help provide a conceptual framework for the management of these symptoms in infants with OSTM1 MIOP.
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Affiliation(s)
| | - Manjiri Dighe
- Pediatrics, Al Adan Hospital, Al Ahmadi Health District, Kuwait
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11
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Zernikow B. [Rare is frequent! Pain and pain therapy in rare diseases]. Schmerz 2020; 34:373-375. [PMID: 32960379 DOI: 10.1007/s00482-020-00505-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- B Zernikow
- Deutsches Kinderschmerzzentrum und Kinderpalliativzentrum Datteln, Vestische Kinder- und Jugendklinik Datteln, Lehrstuhl für Kinderschmerztherapie und Pädiatrische Palliativmedizin, Universität Witten/Herdecke, Dr.-Friedrich-Steiner-Str. 5, 45711, Datteln, Deutschland.
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12
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Challenges in pain assessment and management among individuals with intellectual and developmental disabilities. Pain Rep 2020; 5:e821. [PMID: 32656458 PMCID: PMC7302581 DOI: 10.1097/pr9.0000000000000822] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 04/22/2020] [Indexed: 12/16/2022] Open
Abstract
Pain is common for individuals with intellectual and developmental disabilities, and we need to accelerate the use of evidence-based approaches to assess and manage pain. Introduction: Intellectual and developmental disabilities (IDD) include conditions associated with physical, learning, language, behavioural, and/or intellectual impairment. Pain is a common and debilitating secondary condition compromising functional abilities and quality of life. Objectives: This article addresses scientific and clinical challenges in pain assessment and management in individuals with severe IDD. Methods: This Clinical Update aligns with the 2019 IASP Global Year Against Pain in the Vulnerable and selectively reviews recurring issues as well as the best available evidence and practice. Results: The past decade of pain research has involved the development of standardized assessment tools appropriate for individuals with severe IDD; however, there is little empirical evidence that pain is being better assessed or managed clinically. There is limited evidence available to inform effective pain management practices; therefore, treatment approaches are largely empiric and highly variable. This is problematic because individuals with IDD are at risk of developing drug-related side effects, and treatment approaches effective for other populations may exacerbate pain in IDD populations. Scientifically, we are especially challenged by biases in self-reported and proxy-reported pain scores, identifying valid outcome measures for treatment trials, being able to adequately power studies due to small sample sizes, and our inability to easily explore the underlying pain mechanisms due to compromised ability to self-report. Conclusion: Despite the critical challenges, new developments in research and knowledge translation activities in pain and IDD continue to emerge, and there are ongoing international collaborations.
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13
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Allen J, Molloy E, McDonald D. Severe neurological impairment: a review of the definition. Dev Med Child Neurol 2020; 62:277-282. [PMID: 31237356 DOI: 10.1111/dmcn.14294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2019] [Indexed: 12/30/2022]
Abstract
Severe neurological impairment (SNI) is a term commonly used in the medical literature, though there is no agreed definition. This limits opportunities for research into healthcare needs, treatment opportunities, resource planning, and outcome. We reviewed the literature to establish consistency of use of the term and to place it in the context of other commonly employed terms used to describe children with severe, complex medical needs. Forty-two articles were included for full-text analysis, with 23 including a definition of SNI. Motor impairment, intellectual disability, communication difficulties, and increased care needs were included in the definition in 80%, 70%, 30%, and 13% of papers respectively. Dependence on others for decision-making, chronicity, and distinction between disorders of the central nervous system and peripheral nervous system were less frequently included. There is wide variation in the use of the term SNI. A consensus-based definition of this term would be useful to facilitate future research. WHAT THIS PAPER ADDS: There is inconsistency in use of the term severe neurological impairment (SNI), limiting research efforts. In defining SNI, considerations are mobility, intellectual disability, communication difficulties, and increased care needs. Distinction between acute and chronic, central and peripheral nervous system disorders, and dependence on others for decision-making were less significant.
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Affiliation(s)
- John Allen
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Discipline of Paediatrics and Child Health, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College, University of Dublin, Dublin, Ireland
| | - Eleanor Molloy
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Discipline of Paediatrics and Child Health, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Translational Medicine Institute, St. James' Hospital, Dublin, Ireland.,Neonatology, Coombe Women and Infants' University Hospital, Dublin, Ireland.,Neonatology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Denise McDonald
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Discipline of Paediatrics and Child Health, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College, University of Dublin, Dublin, Ireland
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14
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Doody O, Bailey ME. Understanding pain physiology and its application to person with intellectual disability. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2019; 23:5-18. [PMID: 28502222 DOI: 10.1177/1744629517708680] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The issue of pain warrants attention as, by virtue of having an intellectual disability, a person may have associated medical or physical conditions and associated factors increasing their risk of pain disorders. People with intellectual disability experiencing pain need to be provided with the best possible care. The focus of this article is on the exploration of pain: physiology and types; manifestations and responses in the context of intellectual disability in order to promote effective, knowledgeable assessment and management of pain for this client group. Pain is a subjective, complex, physiological and psychological phenomenon that can be acute or chronic and may be classified according to its cause. Within the experience of pain, the concept of total pain describes the physical, psychological, social and spiritual factors that influence the experience of pain.
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Collins A, Mannion R, Broderick A, Hussey S, Devins M, Bourke B. Gabapentin for the treatment of pain manifestations in children with severe neurological impairment: a single-centre retrospective review. BMJ Paediatr Open 2019; 3:e000467. [PMID: 31414063 PMCID: PMC6668755 DOI: 10.1136/bmjpo-2019-000467] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/18/2019] [Indexed: 12/31/2022] Open
Abstract
Pain, irritability and feeding intolerance are common symptoms affecting quality of life in children with severe neurological impairment (SNI). We performed a retrospective study to explore the use of gabapentinoid medications for symptom control in children with SNI. Patients attending the palliative care or gastroenterology department being treated with gabapentin for irritability, vomiting or pain of unknown origin were included. Information was gathered retrospectively from medical documentation. Irritability was reduced in 30 of the 42 patients included. Gabapentin was discontinued in 15 children, 12 of whom then received pregabalin. Three children had a good response to pregabalin, six a minimal improvement and three no improvement. These results support the use of gabapentinoids in this patient cohort.
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Affiliation(s)
- Aedin Collins
- National Centre for Paediatric Gastroenterology, Hepatology and Nutrition, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Rory Mannion
- National Centre for Paediatric Gastroenterology, Hepatology and Nutrition, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Annemarie Broderick
- National Centre for Paediatric Gastroenterology, Hepatology and Nutrition, Children's Health Ireland at Crumlin, Dublin, Ireland.,National Children's Research Center and Department of Paediatrics, UCD School of Medicine and Medical Science, Dublin, Ireland
| | - Séamus Hussey
- National Centre for Paediatric Gastroenterology, Hepatology and Nutrition, Children's Health Ireland at Crumlin, Dublin, Ireland.,National Children's Research Center and Department of Paediatrics, UCD School of Medicine and Medical Science, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons, Ireland, Dublin, Ireland
| | - Mary Devins
- Department of Paediatric Palliative Care, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Billy Bourke
- National Centre for Paediatric Gastroenterology, Hepatology and Nutrition, Children's Health Ireland at Crumlin, Dublin, Ireland.,National Children's Research Center and Department of Paediatrics, UCD School of Medicine and Medical Science, Dublin, Ireland
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16
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Siden H. Pediatric Palliative Care for Children with Progressive Non-Malignant Diseases. CHILDREN-BASEL 2018; 5:children5020028. [PMID: 29461497 PMCID: PMC5835997 DOI: 10.3390/children5020028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/04/2018] [Accepted: 02/12/2018] [Indexed: 11/16/2022]
Abstract
A substantial number of children cared for by pediatric palliative care physicians have progressive non-malignant conditions. Some elements of their care overlap with care for children with cancer while other elements, especially prognosis and trajectory, have nuanced differences. This article reviews the population, physical-emotional and social concerns, and trajectory.
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Affiliation(s)
- Harold Siden
- Canuck Place Children's Hospice, BC Children's Hospital, University of British Columbia, Vancouver, BC V6H 3N1, Canada.
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17
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Avez-Couturier J, Joriot S, Peudenier S, Juzeau D. [Pain in children with neurological impairment: A review from the French Pediatric Neurology Society]. Arch Pediatr 2017; 25:55-62. [PMID: 29273448 DOI: 10.1016/j.arcped.2017.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 08/03/2017] [Accepted: 11/04/2017] [Indexed: 12/01/2022]
Abstract
Management of pain is one of the major expectations of children with neurological impairment and their families. The medical literature is poor on this topic accounting for approximately 0.15 % of the publications on pain in general. The objective of the French Pediatric Neurology Society was to review the current knowledge on this topic. Bibliographic research was conducted with PubMed and RefDoc for publications between 1994 and 2014 in French or English. A total of 925 articles were retrieved and 92 were selected for review. Pain is common in this population: a 2-week survey indicated that pain occurs in 50-75 % of children. Pain negatively impacts the quality of life of children and their parents. Children with neurological impairment express their pain with pain expression patterns and specific patterns common to children (change of tone, abnormal movements, spasticity, paradoxical reactions, such as laughter, self-injury or vasomotor dysfunction). Some children with neurological impairment are able to use self-report pain scales. If not, observational measures should be used. Behavioral rating scales specifically designed for this population are more sensitive than others. Scales must be selected according to children's communication skills, type of pain, and the context. Sometimes behavioral changes are the only expression of pain: any change in sleep, tone, feeding, or mood must suggest pain in this population. Management of pain remains difficult. There are no specific guidelines. Procedural pain management guidelines and the usual analgesic drugs can be used in children with neurological impairment with specific concerns regarding tolerance and side effects. These children are particularly at risk for neuropathic pain. A multidisciplinary approach is helpful, involving physicians, nurses, physiotherapists, psychologists and parents.
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Affiliation(s)
- J Avez-Couturier
- Service de neuropédiatrie, CHU de Lille, rue du Pr-Émile-Laine, 59000 Lille, France; Consultation douleur enfant, CHU de Lille, rue du Pr-Émile Laine, 59000 Lille, France; CIC-IT 1403, Maison régionale de la recherche clinique, hôpital universitaire de Lille, CHU de Lille, 6, rue du Professeur-Laguesse, 59000 Lille, France.
| | - S Joriot
- Service de neuropédiatrie, CHU de Lille, rue du Pr-Émile-Laine, 59000 Lille, France
| | - S Peudenier
- Service de pédiatrie, hôpital Morvan, CHRU de Brest, 2, avenue Foch, 29609 Brest cedex, France
| | - D Juzeau
- Réseau neurodev, bâtiment Paul-Boulanger, 1, boulevard du Pr.-Jules-Leclercq, 59000 Lille, France
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18
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Hauer J, Houtrow AJ, Feudtner C, Klein S, Klick J, Linebarger J, Norwood KW, Adams RC, Brei TJ, Davidson LF, Davis BE, Friedman SL, Hyman SL, Kuo DZ, Noritz GH, Yin L, Murphy NA. Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System. Pediatrics 2017; 139:peds.2017-1002. [PMID: 28562301 DOI: 10.1542/peds.2017-1002] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children.
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Affiliation(s)
- Julie Hauer
- Complex Care Service, Division of General Pediatrics, Boston Children’s Hospital, Assistant Professor, Harvard Medical School, Boston Massachusetts
- Seven Hills Pediatric Center, Groton, Massachusetts; and
| | - Amy J. Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pediatric Rehabilitation Medicine, Rehabilitation Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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19
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Developing a Sense of Knowing and Acquiring the Skills to Manage Pain in Children with Profound Cognitive Impairments: Mothers' Perspectives. Pain Res Manag 2017; 2017:2514920. [PMID: 28458591 PMCID: PMC5385219 DOI: 10.1155/2017/2514920] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 02/11/2017] [Accepted: 03/09/2017] [Indexed: 11/18/2022]
Abstract
Children with profound cognitive impairment (PCI) are a heterogenous group who often experience frequent and persistent pain. Those people closest to the child are key to assessing their pain. This mixed method study aimed to explore how parents acquire knowledge and skills in assessing and managing their child's pain. Eight mothers completed a weekly pain diary and were interviewed at weeks 1 and 8. Qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics. Mothers talked of learning through a system of trial and error (“learning to get on with it”); this was accomplished through “learning to know without a rule book or guide”; “learning to be a convincing advocate”; and “learning to endure and to get things right.” Experiential and reflective learning was evident in the way the mothers developed a “sense of knowing” their child's pain. They drew on embodied knowledge of how their child usually expressed and responded to pain to help make pain-related decisions. Health professionals need to support mothers/parents to develop their knowledge and skills and to gain confidence in pain assessment and they should recognise and act on the mothers' concerns.
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Rasmussen LA, Grégoire MC. Challenging neurological symptoms in paediatric palliative care: An approach to symptom evaluation and management in children with neurological impairment. Paediatr Child Health 2015; 20:159-65. [PMID: 25914579 PMCID: PMC4403283 DOI: 10.1093/pch/20.3.159] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2014] [Indexed: 11/13/2022] Open
Abstract
Neurological symptoms are very common in children with life-limiting conditions and are challenging in terms of burden of illness. Moreover, neurological symptoms can significantly impact the child's quality of life and contribute to distress among parents, families, caregivers and health care providers. Knowing how to manage and alleviated these symptoms is essential for providing good palliative care. In the present article, the more common neurological symptoms of agitation/irritability, spasticity and dystonia will be reviewed. The aim of the present brief review is to provide a basic approach to both the identification and treatment of these neurological symptoms. A medication table is provided for quick reference. A brief commentary and guidance for the management of pain are also incorporated, with reference to further literature sources.
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Affiliation(s)
- Lisa Ann Rasmussen
- Department of Paediatrics, McGill University/Montreal Children's Hospital, Montreal, Quebec
| | - Marie-Claude Grégoire
- Department of Paediatrics, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia
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