Pediatrics Flashcards
1
Q
Children’s concepts of death table
A
-
Infancy 0-2 years
- sensory information
- estsablishing attachment
- aware of tension, unfamiliar, separation
- distressed by disruptions in routine
- comforted by sensory input (rocking, sucking, transitional object) and routines
-
Early childhood (2-6 years)
- death is reversible, not personalized, magical thinking, associative logic
- may not believe death can happen to them, believe can cause death by wishing someone would go away
- provide concrete info about being dead
- address guilt and feeling repsonsible because of thoughts
-
Middle childhood (6-12 years)
- mastering skills, fairness, cause and effect
- aware death is final, personalized
- understanding causality by external and internal causes
- aware that death can be caused by accident, illness
- may have difficulty with spiritual/abstract
- Child may request graphic details about death and illness
-
Adolescence (> 12 years)
- working on separation, individuation, identity formation
- universality of death, but distanced from it
- risky behaviour (everyone dies anyways, it can’t happen to me)
- access to supportive peers
- may need to talk about plans that will not be realized (school, marriage, kids, career, etc)
2
Q
List elements of sharing information about serious illness and death with children
A
- Explore how family communicates
- Find out HOW the family wishes information would be shared
- Do not talk to the children for the family. Assist.
- Use honest, gentle, simple language
- Let the child guide you
- Explore beliefs of child and family
- Be aware of your own beliefs (and differences)
- Reflect on emotions of child
- Work to support child and family in what is important to them
- Clarify child’s understanding in a non-testing way
3
Q
How can a family member speak to a child without crying?
A
- expression of emotion and grief normalizes feelings
- should not be so intense that child needs to comfort adult
- provide developmentally appropriate toys and play activities
- talk about favourite toys, shows, etc as introduction
- children may draw picture or used stuffed toys to express emotions
4
Q
Supportive measures for helping child through serious illness/ death
A
- Help families find language to use, developmentally appropriate concepts
- Misinformation leads to confusion and fear. Be honest
- Use videos, books, websites
- Support children in their play as it is often combined with grief.
- Share information paced according to needs
- Arrange environment to be welcoming and accessible to child
- support person for child
- Allow child to ask for what they need, listen to them and follow their lead
5
Q
Language tips for talking with children about death
A
- “He may look like he is sleeping, but being dead is very different than sleeping”
- “Dead means that a person’s heart isnt beating any more, they don’t need to eat anymore, they aren’t hungry or thirsty anymore, they don’t breathe anymore…”
- Use the words dead and death (unless sig cultural exceptions)
- Why? “Your sister died because she was born with something very wrong with her lungs that could not be fixed”
6
Q
Involving children at the time of death
A
- Children do better if involved in care of dying family member
- Support person (child life, volunteer. etc)
- Prepare them for what room and person will look like
- Let them know they can talk to their family member
- Ideas for ways child can say I love you.
7
Q
Children’s guilt
A
- Be aware of magical thinking
- Children can think they are responsible for death of family member because they wished they would go away
- Particular problem if child was bone marrow or organ donor
8
Q
Should children attend a funeral?
A
- do better if included in family rituals
- sadness is permissable, alright to cry, feel safe with own feelings
- Prepare child
- Give them details
- explain whether there will be a coffin
- simple language
- answer questions
- ask someone child trusts to accompany them
- allow child to choose whether to attend funeral or not
9
Q
Pain and Symptom Assessment in Children : principles similar to adults and unique to children
A
- 0-10 scale understood by 7-8year olds
- Faces Pain Scale - revised
- Behavioral observations of child by parents, health professionals
Principles similar to adults
- anticipate and prevent pain
- provide ATC meds
- oral route first
- IR for breakthrough
- titrate to pain relief
- anticipate and prevent adverse effects
- use adjuvants
- never limit opioids out of fear of constipation
Principles different to adults
- do not ignore or under treat pain in children
- non specific symptoms for pain (irritable, withdrawn etc)
- use pain scales for patient’s developmental stage
- Medical condition may affect pain assessment (cerebral palsy and facial grimacing)
- less likely to express specifics about pain
- IV > sc route as many kids already have access
- child may lack understanding of cause-effect relationship
- opioid rotations more common (instead of adding meds to manage Se of opioid)
10
Q
Pharmacokinetics and pharmacodynamics:
differences in children
A
- mg/kg
- non ventilated infants, dose is 1/3 usual dose and titrated.
- infants higher risk of opioid toxicity because of higher surface area, incr fat-muscle ratio, decreased glycoproteins, decreased renal and hepatic clearance
- many medications not studied in children
11
Q
Fears and facts about pain medications in children
A
- address msiconceptions and fears with caregivers
- medications won’t impair ability to interact and play
- uncontrolled pain will impair ability to interact and play
- children not at increased risk of adverse effects
- not at increased risk for addiction
12
Q
What is the most common cause of pain in children with cancer, compared to adults
A
- procedures and treatment related interventions
- vs adults : disease related pain
13
Q
Checklist for analgesic therapy in children
A
- pain relief at lowest effective dose
- anticipate, prevent and treat side effects
- use ATC dosing
- Dosing:
- oral preferred or use port
- equianalgesic dose (oral: iv)
- ensure preparation is suitable to child (taste, frequency, etc)
- avoid IM, rectal
- no transdermal fentanyl if opioid naive
- no demerol, no mixed agonist-antagonists meds
- no codeine (metabolism)
- use topical anesthetics before needles
- Use analgesic to match pain
- acetaminophen mild
- Codeine - controversial for mild-moderate
- hydromorphone, morphine. diamorphone for moderate-severe pain
- Review pharmacokinetics
- < 50kg - mg/kg
- > 50 kg - usual adult dose
- non ventilated infants < 6 months, use 1/3 - 1/4 usual starting dose
- Start with IR dose
- Change to SR formulation once requirements are known
- Breakthrough analgesia q1h (10% MEDD). If> 4 BTD used in 24 h, increase ATC dose
- Bowel routine
- Adjuvant analgesics (gabapentin, steroids, TCA, ketamine)
- Use non pharm things (massage, tens, distraction, hynotherapy)
- Reassure family more options available
- Proactively address misperceptions, concerns
- Child is reliant on another for analgesia
14
Q
Pediatric Opioid dosing
A
- Morphine ORAL (3:1)
- < 50 kg : 0.15-0.3 mg/kg q4h
- > 50 kg : 5-10 mg q4h
- Morphine IV/SC
- < 50 kg : 0.05-0.1 mg/kg q4h
- > 50 kg 2.5-5 mg q4h
- Hydromorphone ORAL (1:3- 1:5)
- < 50 kg 0.06 mg/kg q4h
- > 50kg 1-2mg po q4h
- Hydromorphone IV/SC
- < 50 kg 0.015 mg/kg q4h
- > 50 kg 1 mg q4h
- Codeine ORAL (1:1.5)
- < 50 kg 0.5-1mg/kg
- > 50 kg 30-60 mg q4h
- Codeine IV/SC
- < 50 kg: 0.5 mg / kg q4h
- > 50 kg: 15-60 mg q4h
- Oxycodone ORAL
- < 50 kg : 0.2 mg/kg q4h
- > 50 kg : 5-10 mg q4h
15
Q
Dyspnea in pediatrics
A
- cancer
- cystic fibrosis
- muscular dystrophy
- spinal muscular atrophy
- cerebral palsy with infections
- congenital heart disease
- metabolic storage disease
- neurodegenerative disease
16
Q
Measurement / Assessment of dyspnea
A
- Are you a little or a lot breathless?
- Can you show my how breathless you feel? (VAS)
- What can you do / not do because your breathlessness is bothering you?
- Dalhousie Dyspnea Scale (effort, constriction, throat tightness) > 8 years
17
Q
Non Pharmcological Treatment of Dyspnea
A
- cold facecloth
- fan
- scent
- positioning
- child may not be able to position themselves (infant, CP, SMA)
- bad side down for effusion
18
Q
Pharmacological treatment of dyspnea
A
- Opioids
- Benzodiazepine
- sedation
- advise family that medications won’t change appearance or pattern of breathing
- secretions treat for family
19
Q
How are children different than adults wrt palliative care?
A
-
Different disease type and longer trajectory (60% non malignant)
- congenital, genetic, neuromuscular, respiratory, cancer, GI
- high prev cognitive impairment
- HIV AIDS
-
Communciation
- verbal, non verbal and cognitive impairment
-
Complexity of ethical dilemmas
- cannot consent, but can assent
-
Drug dosing
- not tested or approved for kids
- mg/kg dosing
- drug clearance
- surface area of child
- delivery mode
-
Children depend on proxy for medications and assessment
- situational, cultural and family role impact this.
-
Role of family in peds is different
- long term nature of illness, heavy burden
- ++ support needed for families
20
Q
List factors that impact pain in peds
A
-
Cognitive:
- understanding
- control
- expectations
-
Behavioural
- overt actions
- parent/staff response
- physical restraint
- physical activities
- social activities
-
Emotional
- anxiety
- fear
- frustration
- anger
- depression
All influenced by :
- age
- developmental level
- previous pain experience
- culture
- family learning
- gender
21
Q
Myths in pain in children :
Newborns do not experience pain, do not have mature nervous system
A
- 26 weeks in utero fetus can feel pain
- newborn is highly sensitive to pain
22
Q
Myths in pain in children:
Children do not feel as much pain as adults
A
- as much or more than adults
23
Q
Myths in pain in children: Children will get used to pain. They will have no memory of it, or lasting effect
A
- Continuing pain has long lasting effects on CNS
- permanent reorganization of neural pathways
- negative impact on future pain experiences
24
Q
Myths in pain in children: Children cannot explain pain reliably
A
- 20 months can say where it hurts, how much, and what makes it better
- Pain intensity at 3 years
- 4 years can indicate on body chart
25
Q
Myths in pain : If a child is distracted, they are not in pain
A
- Distraction and play is a coping mechanism for pain
26
Q
Myths in pain : If a child says he is in pain, but does not appear in pain, they do not need medications
A
- The child is the authority on whether they are in pain
- adults under-rate pain
- adults often have concerns that children exaggerate pain
- Adults diminish importance of pain in kids
27
Q
Myths in pain : A sleeping child is a comfortable child
A
- Sleep may be from exhaustion from pain
28
Q
Myths in pain : Opioids are dangerous for children and may result in addiction
A
- Invaluable for pain relief in kids
- children no more at risk for addiction than adults
- addictions not experienced in patients with true pai on therapeutic doses
29
Q
Impact of child’s pain on parents
A
- parents are experts in their children
- parents who encourage kids to engage in normal activities have better pain control
- losing normal environment, isolation –> more pain
- parental education of pain and management important
- parents who respond to pain with calm approach usually have kids with better controlled pain
30
Q
Pain assessment : infants 0-2 years
A
- totally dependent
- facial expression
- pitch of cry
- deviation from normal behaviours
- older babies anticipate painful situation and cry
31
Q
Pain assessment : toddlers (1-2 years)
A
- pain language 12-24 months
- can describe pain and body part
- fear of pain ful situations
- anger, sadness, upset if painful situation
*
32
Q
Pain assessment : Preschool (2-5 years)
A
- think in concrete terms
- cause and consequence of pain
- magical thinking : may believe pain is punishment for unrelated behaviour or event
- may be withdrawn if chronic pain
- express themselves adn describe pain
33
Q
Pain assessment : School Aged children (6-12 years)
A
- 7-10 years can explain why it hurts
- cause and effect
- can learn details about their pain
- explanation of facts helpful
- can have misperceptions that are allayed with knowledge
34
Q
Pain assessment : Adolescents > 12 years
A
- can think in abstract way about pain
- understand physical and psychological elements
- Have insight
- pain can be an injsutice and aggressor
- receptive to coping strategies
- Response to pain based on understanding of disease, emotional and cognitive factors
- Worry is common
35
Q
Pain severity measures
A
- Self report
- FACES-R (FAces Pain Scale revised)
- Visual analogueu scale
- Observational / behavioural
- < 3 years and those with cog impairment
- Physiological
- heart rate, BP, RR etc. Poor correlation and not specific
36
Q
Behavioural / Observational responses to acute and chronic pain
A
- ACUTE PAIN BEHAVIOURS
- facial expression
- positioning /body movement
- Inability to be consoled
- Crying
- Moaning
- CHRONIC PAIN BEHAVIOURS
- abnormal posture
- fear of being moved
- lack of facial expression
- lack of interest
- withdrawn / quiet
- irritable
- low mood
- poor sleep
- anger
- poor appetite
- poor school performance
37
Q
2012 WHO Approach to Pain Management in Children with Medical Illness
A
- Detailed assessment
- By the clock
- Breakthrough analgesic
- By the most appropriate route (oral)
- By the child (tailor/titrate to child)
38
Q
WHO 2 step approach:
- Mild Pain
A
- Acetaminophen (paracetamol)
- safe under 3 months
- syrup, tablets, cheweable, rectal, IV
- 15mg/kg
- hepatoxicity rare : malnutrition, interactions with carbamazepine, rifampicin, phenobarbitone
- Ibuprofen
- 10 mg/kg
- care with dehydration
- Cancer: risk of platelet dysfunction, bleeding
39
Q
WHO Step 2 : moderate to severe pain
A
- Morphine first line
- Half life of opioids is reduce in children
- q4h IR formulation
- q8h for CR formulation in some kids
*
40
Q
Differences in opioids in children vs adults
A
- dosage interval may need ot be shorter; half life is reduced in children > 12 months for morphine
- q8h CR dosing
- NEONATES / INFANTS < 12 months:
- half life if INCREASED
- reduced renal clearance
- increased surface area
- fat to muscle ratio
- decreased glycoproteins
- lower starting dose at q6-8h
- 1/3 normal mg/kg dose if non ventilated
- Oral route preferred
- palatability important
- open capsules, crush tablets, dissolve into solution and mix with food/drink
41
Q
Parenteral route if:
A
- poor absorption
- disordered Gi motility
- inability to comply
- unconscious
- nausea
- risk of aspiration
- medication refusal
- pain crisis needing rapid titration
42
Q
Other routes of medication adminstration
A
- sc, IV, transdermal
- No IM - painful
- PICC or central line (port) used frequently
- PCAs can be used by children > 7-8 years
- Rectal route for infants/young children (opioids, anticonvulsants)
- Transmucosal route
- avoid first pass metabolism of GI tract, rapidly absorbed.
- midazolam / fentanyl
- Fentanyl 1-2 ug/kg intranasally
- Midazolam 0.3mg/kg intranasally
43
Q
By the Child
A
- Initiation :
- < 50kg per KG
- > 50 kg adult dosing
- Titration:
- by 50% previous opioid dose (if not opioid naive)
- lowest effective dose with fewest side effects
- Maintenance
- long acting if possible
- Long acting morphine granules
- Fentanyl patch 12 ug = MEDD 30-40 mg
44
Q
Opioid switching / rotation
A
- dose limiting side effects
- dose reduction 25-30% for incomplete cross tolerance
- used more liberally in children
45
Q
Opioid Side effects in children
A
- Sedation - subsides
- morphine 6 glucaronide
- Psychostimulants not good evidence
- Respiratory depression - rare with careful titration
- naloxone 1 ug/kg q 3 minutes
- Toxicity : same risk factors as adults
- renal failure
- removal of painful stimuli (intrathecal, radiation etc)
- accidentally ingestions
- rare paradoxical agitation
- nausea - rare in peds
- Constipation
- Pruritis : more common in peds
- Myoclonus
- Urinary retention : more frequent
46
Q
Adjuvants in peds
A
- Adjuvant = medication that has a primary indication for something other than pain, but has analgesic properties.
- Steroids : not commonly used
- Bisphosphonates : not commonly used, poor evidence
- TCA, SSRI, SNRI : no good evidence
- Ketamine
- benzos, baclofen no good evidence
- Many of these medications are trialled in palliative patients.
47
Q
Pain syndromes: Muscle Spasm
A
- neuromusclar syndromes
- Triggers: constipation, seizures, GERD, orthotic supports
- Dantrolene
- Baclfoen
- Opioids
- Botox
- Intratehcal
- Surgical interventions
48
Q
Peds Pain syndromes: Bone Pain
A
- neuromuscular conditions, cerebral palsy, cancer (ALL)
- inheited metabolic disorders, mucopolysaccarhidosis
- osteogenesis imperfecta
- HIV/AIDS: infection, osteopenia, cancer
- distortion of normal skeleton
- low bone density
- increased fracture risk
- Immobility, feeding difficulties, anticonvulsants, low Vit D
Treatment:
- ortho surgery
- 2 step WHO strategy
- Bisphosphonate for osteopenia
- radiation therapy
- chemotherapy
- radiopharmaceuticals
49
Q
Peds Pain syndromes: Neuropathic pain
A
- numbness, itching, tingling, burning
- shivering, tickling, fizzing, pricking
- peripheral neuropathy : HIV AIDS
50
Q
Peds Pain Syndromes: Cerebral irritability
A
- persistent unremitting agitation and distress
- high pitched scream and pain behaviours:
- spasticity, seizures, autonomic dysfunction, vx, sleep wake disturbance
- chronic pattern
- can be confused with agitated delirium at EOL
- non verbal child with severe neuro impairment
- infants with acute illness
- kids with neurodegnerative disorders
- EOL malignancy
- pathophysiology unknown : central neuropathic and visceral hypersensitivity
- abnormal brain and processing
- Difficult to know if pain : morally treat as pain
- Exclude other causes of pain
51
Q
Peds Pain Syndromes: Central Pain
A
- damage to central somatosensory system
- Neurodegenerative conditions, hypoxic or traumatic brain injury
- Persistent screaming and distress
52
Q
Peds Pain Syndromes: Visceral Hyperalgesia
A
- Altered response to visceral stimulation
- Usually GI, bowels/digestion sx
- Motor abnormality, high gut luminal pressures, high pain sensation
- Feeding intolerance
- ? result of painful repeated GI experiences in infancy
- TCAs, anticonvulsants, gabapentin, NMDA antagonists
- Benzos : midazolam or LA clonazepam up to 4 weeks
- Opioids not first line, but are often used.
53
Q
Peds Pain Syndromes: Cancer Pain
A
- WHO strategy
- epidural/intrathecal blocks
- RT
- chemotherapy
- Polypharmacy should be avoided
- Similar strategy to adults
54
Q
Peds Pain Syndromes: Intractable Pain
A
- palliative sedation acceptable
- indications same as for adults
- typical use in end stage cancer pain or HIV/AIDS
- opioids, benzos, neuroleptics, anesthetic agents
55
Q
Team in peds palliative care:
A
- nurses
- mds
- social workers
- chaplain
- allied health
- therapists
56
Q
Role of nursing in peds palliative care
A
- generalist nursing : core set of knowledge and skills
- specialist palliative care nurse : support, consults
- specialist interventions outside of palliative care: wound care, etc
57
Q
Volunteers
A
- flexible
- cost efficient
- alleviates family distress
- fill support gap
- prevent family from feeling guilty or indebted to family/friends
58
Q
Symptom measurement tools in peds
A
- Memorial Symptom Assessment Scale (MSAS)
- ages 7-12
- agres 10-18 versions
59
Q
Palliative Emergencies: Seizure control in peds
A
- cerebral mets, metabolic derangement, infection, hypoxia
- treat cause
- Buccal midazolam 0.3 mg/kg, max 15 mg
- status epilepticus : barbituate, propofol
60
Q
Spinal Cord Compression
A
- unusual in children, late in cancer
- back pain presenting sign
- MRI, steroids, radiotherapy
61
Q
Emergencies: Bleeding in Peds
A
- uncommon massive hemorrhage
- use of blood products controversial if dependent on them
- fear of bleeding can impact care and location of care
62
Q
Emergencies : terminal dyspnea
A
- causes: pulm mets, intrinsice lung disease, infection, cardiac failure
- acidosis, muscle weakness
- NIV for neuromuscular disorders
- bronchospasm : bronchodilators
- 02, opioids, cbt, non pharm measures
- careful use of benzos if + anxiety
63
Q
Emergencies : secretions
A
- explanation to parents
- positioning
- gentle suctioning
- anticholingerics
64
Q
Emergencies: terminal delirium
A
- hypoxia, metabolic, CNS disease, infection, fever
- reverse simple causes depending on prognosis, goals
- haldol, benzo if terminal delirium
65
Q
Constipation in peds
A
- reduced activity, metabolic derangement, obstruction, poor diet, poor fluid intake
- opioids, meds
- r/o obstruction
- treatment:
- diet
- hydration
- mobility
- laxatives
- senna, lactulose, peg
- methylnaltrexone
66
Q
Fatigue in peds palliative
A
- etiology: anemia, nutrition, metabolic, meds, dypsnea, psychological factors
- stimulants limited data
- opioid rotation for somnolence
67
Q
Insomnia in peds palliative
A
- physical, mental, environmental factors
- depression
- lifestyle, behavioural changes, exercise
- Low dose amitryptiline
- melatonin
68
Q
Nausea and vomiting in peds palliative
A
- vomiting centre in brain activated by:
- cerebral cortex
- vestibular apparatus
- CRTZ
- vagus nerve
- direct action on vomiting centre
69
Q
Psychosocial issues in peds palliative
A
- death of a child challenges beliefs and assumptions about world
- parents will die before children
- parents can protect their children
- sense of confidence, safety and security as a parent
70
Q
QI Program in Peds Palliative
A
- Identify quality lead to create and implement plan
- Identify standards and measure clinical service against standards
- DEvelop measures of quality for palliative care
- Collate and evaluate data from QI programme, look for opportunities for improvement
- Implement quality review ongoing basis as part of clinical care.
71
Q
Visiting an ill or dying parent
A
- Explore and alleviate worries ahead of time
- Prepare children for what they will see:
- hospital, hospice
- medical equipment
- patients
- physical condition
- functional status of parent
- Bring extra supportive adult who can leave when child is ready
- Provide structure or activity for younger children
- avoid agitated or delirious patient
- Debrief after visit
- Provides alternatives for personal visit
- Many opportunities to say goodbye
72
Q
Codeine and children
A
- Codeine is pro-drug metabolized to morphine by CYP 2D6
- Polymorphic phenotypes
- normal metabolizers
- poor metabolizers
- ultrarapid metabolizers
- Unpredictable metabolism, can lead to rapid accumulation of morphine
- Respiratory depression
- Death
- Do NOT use kids
