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Gleason E, Malik K, Sannar E, Kamara D, Serrano V, Augustyn M. Challenging Case: A Multidisciplinary Approach to Demystifying Chronic Sleep Impairment in an Infant with a Complex Medical and Behavioral Profile. J Dev Behav Pediatr 2024; 45:e176-e179. [PMID: 38290114 DOI: 10.1097/dbp.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
CASE X is a 22-month-old White male infant with a complex medical history, including diagnoses of FBXO11 mutation, hypotonia, restrictive lung disease and mild intermittent asthma, laryngotracheomalacia, obstructive sleep apnea (OSA), feeding difficulties with a history of aspiration, gastroesophageal reflux disease (GERD), and developmental delays. X's medical presentation has resulted in multiple prior medical admissions for respiratory failure due to acute illnesses, procedures and treatments including gastrojejunostomy (GJ) tube dependence, supraglottoplasty to reshape tissues of the upper larynx, and the use of biphasic positive airway pressure (BiPAP) at night and room air during the day when he is at baseline. In addition, he has nocturnal events characterized by significant agitation, screaming, crying, body stiffening and limb movements with pauses in breathing, mouth breathing, restless sleep, and difficulty waking in the morning with concomitant daytime fatigue despite above treatments for OSA. There is no history of congenital heart disease or sudden unexplained death. Family history is noncontributory because parents are negative for the FBXO11 variant.X's sleep disruption has led to significant sleep deficits for both X and his caregivers, who spend much of the night strategizing on how to console him. X has undergone several sleep studies, starting when X was aged 4 months, at several children's hospitals across the nation to determine the cause of his chronic sleep disturbance, which yielded limited information and treatment success. As an infant, X received a medical workup and was subsequently treated with a proton pump inhibitor (PPI) for reflux. At 12 months, he was diagnosed with disordered sleep with myoclonic jerks and started on melatonin and gabapentin for involuntary movements. At 13 months, gabapentin was weaned back because of intolerance, and at 15 months, nortriptyline and clonidine were started because of worsening symptoms to target potential neuropathic pain. While most of his symptoms were at night, he had occasional daytime screaming episodes, particularly when experiencing illness. Gabapentin and clonidine were stopped because nortriptyline seemed most effective.At 17 months, the results from a sleep study led to a diagnosis of night terrors, and several clinicians agreed that X's sleep disruption was behavioral in nature. At this time, an infant mental health consultant met with a sleep psychologist on the family's behalf to support family in considering systematic desensitization therapy to increase tolerance to wearing his BiPAP mask, as well as other behavioral and sleep hygiene strategies, which were tried on several occasions and again, resulted in limited improvement in functioning.At 19 months, X's multidisciplinary team reconsidered a night terror diagnosis after a failed trial of clonazepam and pursued a differential diagnosis of periodic limb movement disorder (PLMD). X trialed gabapentin again, but this time only a nighttime dose, per sleep medicine and psychiatry recommendation. While this brought some temporary relief from nighttime distress, despite increasing to the highest dose for age and weight (15 mg/kg/dose), this became less effective, and he was weaned off at 22 months. He had been on iron supplementation since age 6 months and received an iron infusion at 22 months because of persistently low ferritin levels and PLMD in sleep.At 24 months, X was briefly trialed on levetiracetam. While no evidence for seizures on EEG was present, this medication was chosen for involuntary movements and genetic risk for seizures. However, this medication was not useful. At 25 months, an evaluation with a movement disorder physiatrist resulted in a diagnosis of nocturnal paroxysmal dystonia, and he was started on baclofen, which has provided some, but not complete relief to nighttime symptoms. Parents are reporting he has more "good nights" than "bad nights," but "bad nights" come in stretches of a few days in length with no known trigger or relief.Most recently, X was evaluated by general genetics. Whole exome sequencing (WES) was pursued which revealed a pathogenic de novo variant in FBXO11 and provides a likely cause for his neurodevelopmental phenotype. However, he has some features not explained by FBX011; thus, reanalysis of his WES was performed and revealed a de novo variant of uncertain significance in RAF1. Because pathogenic variants in RAF1 have been associated with dilated cardiomyopathy and Noonan spectrum disorder, it was recommended that X be followed periodically in a cardiac genetics clinic. Family is well connected into the FBXO11 community, including supportive Facebook groups. Parents have shared that they do not feel X's breathing issues and pain fit with the phenotype of other children with FBXO11 mutations.X is also enrolled in a medical child care program to facilitate development and social-emotional functioning and receives learning, speech, occupational, physical, and feeding therapy while in attendance. Despite periods of absence due to contracting numerous viral illnesses over the past several months, X continues to make progress across developmental therapies and happily engages when at the program.What additional diagnostic tests and treatment should be considered to better understand X's medical and behavioral presentation? What are the implications of chronic sleep deprivation and stress on the behavior and development of infant with X's profile? What are important psychosocial considerations because it relates to children with medical complexity (CMC), particularly for X and his family to support caregiver, family, and X's quality of life and overall well-being?
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Affiliation(s)
- Erica Gleason
- Child & Adolescent Psychiatry, University of Colorado Medicine, Children's Hospital of Colorado, Aurora, CO
| | - Kristina Malik
- Department of Pulmonary and Sleep Medicine, KidStreet & Special Care Clinic, Children's Hospital of Colorado, Aurora, CO
| | - Elise Sannar
- Child & Adolescent Psychiatry, University of Colorado Medicine, Children's Hospital of Colorado, Aurora, CO
| | - Dana Kamara
- Department of Pediatrics, Pulmonary & Sleep Medicine, University of Colorado Medicine, Children's Hospital of Colorado, Aurora, CO
| | - Verenea Serrano
- Psychiatry, University of Colorado Medicine, Children's Hospital of Colorado, Aurora, CO
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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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Bullock JL, Gradick K, Proctor C, Rogers MA, Hobson WL. Interprofessional Collaboration Improves Quality of Life of a Young Adult With Rett Syndrome. Cureus 2023; 15:e36921. [PMID: 37128525 PMCID: PMC10148724 DOI: 10.7759/cureus.36921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Rett syndrome (RTT) is a genetic neurodevelopmental disease characterized by early normal development followed by regression in motor and language skills. Patients with RTT often exhibit seizure disorders, growth failure, heart and lung disorders, bruxism, and dental caries. We report on a female patient in her 20s with Rett syndrome who presented to her primary care clinic with increasing agitation and pain. This case reports describes a collaborative, interprofessional approach between medical and dental providers who work in an integrated outpatient setting. It demonstrates that interprofessional collaboration, goals of care discussions, and attention to social drivers of health can improve quality of life for a medically and socially complex patient.
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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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Jersak T, Noritz G. Evaluation of Pain in Adults With Childhood-Onset Disabilities and Communication Difficulties. Front Neurol 2021; 12:722971. [PMID: 34675866 PMCID: PMC8523837 DOI: 10.3389/fneur.2021.722971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/07/2021] [Indexed: 11/25/2022] Open
Abstract
Adults with childhood-onset disabilities, particularly those with central nervous system impairment, commonly experience pain. Because many such individuals have difficulties in communication, caregivers and medical professionals must identify and interpret non-verbal behaviors as indicators of pain. This process is challenging and can lead to poor outcomes through delayed or incorrect diagnosis and treatment. Most research in the evaluation of pain in individuals with neurologic impairment has focused on the pediatric population, and evidence-based guidelines do not exist for adults. The purpose of this paper is to review current recommendations for pain assessment in adults with communication impairment. This approach includes guidance for history-taking, pharmacologic review, physical examination, and the judicious use of laboratory and imaging tests. Finally, we discuss adult-specific diagnoses to consider when evaluating pain in adults with childhood-onset disabilities and communication difficulties.
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Affiliation(s)
- Taylor Jersak
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Garey Noritz
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, United States
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Bogetz JF, Lemmon ME. Pediatric Palliative Care for Children With Severe Neurological Impairment and Their Families. J Pain Symptom Manage 2021; 62:662-667. [PMID: 33485937 PMCID: PMC8295396 DOI: 10.1016/j.jpainsymman.2021.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 01/11/2023]
Affiliation(s)
- Jori F Bogetz
- Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, WA, United States.
| | - Monica E Lemmon
- Division of Neurology, Department of Pediatrics and Population Health Sciences, Duke University School of Medicine, Duke University Medical Center 3936, Durham, NC, United States
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Zarean E, Azadeh A, Pirali H, Doroushi B, Edrisi A, Ahmadi A, Baharizadeh A, Torkian S. Association between depression, anxiety, and insomnia with musculoskeletal pain source: a multi-center study. MIDDLE EAST CURRENT PSYCHIATRY 2021. [DOI: 10.1186/s43045-021-00083-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Abstract
Background
Musculoskeletal pain syndrome (MPS) is one of the modern diseases. Musculoskeletal pain (MP) may develop at any age and impact physical and mental health. This study aimed to evaluate the association between anxiety, depression, and insomnia with musculoskeletal pain source. This cross-sectional study was conducted on 450 patients with musculoskeletal pain. Goldberg depression (GB), Beck Anxiety Inventory (BAI), and Morin Insomnia Severity Index (ISI) questionnaires were used to collect data. Participants have divided into two groups: individuals with unknown musculoskeletal pain sources and individuals with known musculoskeletal pain sources. Anxiety, depression, and insomnia scores were compared between the two groups. For statistical analysis of data mean (SD), frequency (%), Chi-square, Mann-Whitney test, and Logistic regression models were used. All analysis was performed using SPSS 26.
Results
In this study, 39.4% of the participants were in severe depression, 31.1% in severe anxiety, 34.7% in the no clinically significant, and 32.9% in the sub-threshold insomnia group. There was a significant difference between the severity of anxiety and insomnia in the two groups with the known and unknown pain sources (p < 0.05). However, the score of depression (OR = 1.00, 95% CI 0.99–1.01), anxiety (OR = 1.00, 95% CI 0.99–1.02), and insomnia (OR = 1.01, 95% CI 0.98–1.03) was not related to the pain source.
Conclusion
There was a statistically significant relationship between anxiety and insomnia severity with musculoskeletal pain source. According to the high prevalence of depression, anxiety, and depression in both groups with known and unknown musculoskeletal pain sources, the cooperation of orthopedists, rheumatologists, and physical therapists with psychiatrist can be useful in improving the condition of patients.
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Morse BL, Serna RW, LaLumiere M, Rogal M, Foley K, Lombardo M, Manganello C, Pugh V, Veloz A, Solodiuk JC, Mauskar S. Leveraging Parent Pain Perspectives to Improve Pain Practices for Children with Medical Complexity. Pain Manag Nurs 2020; 22:169-176. [PMID: 33384241 DOI: 10.1016/j.pmn.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/02/2020] [Accepted: 11/21/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Children with medical complexity (MC) must rely on others to notice and address pain. Parents are aware of child pain behaviors and can serve as reliable proxy reporters. Thus, there is a critical need to understand parent perspectives to improve pain practices. DESIGN Individual interviews were used as a data collection method in this qualitative study. METHODS Participants were recruited via mail and social media postings. Interviews were audio-recorded and transcribed verbatim. Transcribed documents were imported to NVIVO for qualitative analysis. Conventional and directed approaches to qualitative content analysis were used. RESULTS From the data analysis, major themes included: pain experiences, confidence in caregivers, parents are partners, proactive communication, and a spontaneous theme, "they can hear us." Emotional pain and challenges identifying the source pain were identified as sub-themes of pain experiences. CONCLUSIONS Parents in this study shared methods helpful to identifying pain in their children, as well as suggestions for discussing pain with caregivers. Priorities for future research include identifying methods for sharing pain information that are thorough, but do not burden parents or providers. Researchers should also determine how parents and caregivers can partner to identify and address pain in children with MC. Going forward, conversations about pain should be a key part of any admission assessment or first encounter. As pain episodes among children with MC can be complex and may not always be re-created in front of a provider, nurses may advise parents to take photos or videos to share with caregivers.
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Affiliation(s)
- Brenna L Morse
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts.
| | - Richard W Serna
- College of Fine Arts, Humanities and Social Sciences, University of Massachusetts Lowell, Lowell, Massachusetts
| | - McKenzie LaLumiere
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Micaela Rogal
- Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Kerri Foley
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Miranda Lombardo
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts
| | | | - Victoria Pugh
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Amy Veloz
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Jean C Solodiuk
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Sangeeta Mauskar
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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