Pain, feeding and respiratory care in severe neurodisability: SAQ

This child carries all three threats of severe neurodisability at once: a behavioural change that is pain or a treatable source until proven otherwise, an unsafe swallow with failure to thrive, and recurrent respiratory illness with probable sleep-disordered breathing. The marker principle is to assess each domain with the right tool and treat all three together, because the cycle of chest infection amplifying pain and feeding failure seeding the chest will otherwise accelerate. ^[1][10]

Question 1 (10 marks)

Outline your assessment and immediate management of the pain and feeding problems over the first 24 to 48 hours. ^[1]

The first principle is that a change from baseline in a non-verbal child is pain or a treatable medical cause until proven otherwise, so I would not attribute the arching and grimacing to his baseline dystonia. I would assess his pain with a validated observational tool, the revised FLACC or the Paediatric Pain Profile, and give prompt analgesia so the distress settles enough to allow a focused examination, rather than waiting for the full workup. ^[1][3]

I would then search systematically for a treatable source, working head to toe and by system. I would examine the hips 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, and I would request targeted tests: a hip X-ray, an abdominal X-ray, urinalysis, and dental review. I would treat the source once found, using stepwise analgesia with paracetamol, an anti-inflammatory, or an opioid as needed, and a gabapentinoid if the pattern suggests neuropathic or centrally mediated pain. ^[1]

For the feeding problem, I would arrange an instrumental swallow assessment, ideally a videofluoroscopic swallow study, to confirm aspiration, and a dietetic assessment of intake and energy needs, and I would track his growth on cerebral palsy-specific charts. With an unsafe swallow, failure to thrive, and prolonged distressing meals, I would plan gastrostomy feeding to secure his nutrition and reduce food aspiration, while assessing and treating coexisting reflux because a gastrostomy does not stop the aspiration of saliva and reflux. I would involve the speech and language therapist, dietitian, and the family in a shared decision about the gastrostomy. ^[8][9]