Pain, feeding and respiratory care in severe neurodisability: Case

This is a classic severe neurodisability long case, and the candidate who frames it around the three intertwined threats of pain, feeding, and breathing, and who shows that the problems feed one another, will pass well. The arching and grimacing are pain or a treatable source until proven otherwise, the difficult meal with choking and falling weight is an unsafe swallow with failure to thrive, and the recurrent chest infections with snoring and daytime sleepiness are chronic aspiration and sleep-disordered breathing. The unifying message is that these three must be assessed with the right tool and treated together. ^[1][10]

The pain assessment and the search for a source

The candidate states the governing principle first: a change from baseline in a non-verbal child is pain or a treatable medical cause until proven otherwise, and the default of attributing it to his baseline dystonia is the most common and most harmful error. The assessment uses a validated observational tool, the revised FLACC or the Paediatric Pain Profile, because he cannot self-report, and prompt analgesia is given so the distress settles enough to examine. ^[1][3]

The search then runs head to toe and by system. The hips are examined for an adducted posture and painful limited rotation suggesting dislocation, the spine for scoliosis, the mouth for dental caries and abscess, the abdomen for constipation and impaction, and the skin for pressure injury, with targeted tests of a hip X-ray, an abdominal X-ray, urinalysis, and dental review. The likely finds in this boy include a dislocating hip from his non-ambulant posture, severe constipation, and dental disease, and each is treated. If the pattern suggests neuropathic or centrally mediated pain, a gabapentinoid such as gabapentin is first-line, started low and titrated, with retrospective evidence supporting its use for recurrent pain in this population. ^[1][6]