Symptom control in serious paediatric illness

Your progress

Saved on this device.

Target exams

Red flags

• Treating a reversible cause as terminal distress — constipation, urinary retention, hypoglycaemia, hypoxia, sepsis, intracranial bleed and medication adverse effect can all masquerade as agitation or pain at the end of life and must be excluded before attributing the symptom to dying
• Escalating an opioid for agitation or delirium that is actually opioid-induced neurotoxicity — myoclonus, allodynia, confusion and twitching are a signal to rotate opioids or reduce the dose, not to push the same drug higher
• Prescribing codeine or tramadol in a child under 12 years, or in any child under 18 after adenotonsillectomy — CYP2D6 ultrarapid metabolism can produce lethal respiratory depression; use morphine
• Failing to prescribe anticipatory (just-in-case) medicines for a child expected to die at home, so that the first breathlessness, pain, seizure or agitation episode finds the family with no drug and no plan
• Using repeated blind suction for death rattle on an unconscious child — it distresses the child, rarely helps, and the family is usually the distressed party; use an anticholinergic and position
• Sedating a child because staff or the family are distressed rather than because the symptom is refractory — palliative sedation must be proportionate to a refractory symptom, not a response to the room's discomfort
• Rotating opioids at full equianalgesic dose — always reduce by 25 to 50 per cent for incomplete cross-tolerance, and seek specialist input for methadone whose ratio rises steeply at high doses

Life stages

Care settings

Clinical exam formats

Board mappings

• General Paediatrics — recognise and assess distressing symptoms in a seriously ill child
• Apply the WHO analgesic ladder with weight-based paediatric dosing
• Recognise the deteriorating or dying child and the need for palliative input
• Paediatric palliative care — lead multidisciplinary symptom control in life-limiting illness
• Perform a safe opioid rotation and titrate palliative sedation for refractory symptoms
• Coordinate home-based palliative symptom care with anticipatory prescribing
• Written Examination — pharmacology and ethics of symptom control in serious paediatric illness
• Clinical Applications — symptom assessment, opioid dosing, palliative sedation, end-of-life ethics
• Long case — the child with a life-limiting illness and escalating symptoms
• Communication station — goals-of-care and anticipatory prescribing conversation
• Short case — bedside assessment of pain, breathlessness and agitation
• Level 2 — manages common symptoms at the end of life in partnership with palliative care
• Patient safety — anticipatory prescribing and opioid safety in the dying child
• Safeguarding and communication — family-centred end-of-life care and honest conversations
• Applied Knowledge in Practice — palliative symptom pharmacology and the WHO ladder
• Foundations of Practice — ethics of palliative sedation and the doctrine of double effect
• Communication scenario — breaking bad news, goals of care and anticipatory prescribing
• History and management — the child with a life-limiting illness and distressing symptoms
• General Pediatrics Content Outline — palliative and end-of-life care
• General Pediatrics EPA — manage distressing symptoms in a seriously ill child
• Patient Care — provide palliative symptom management aligned with goals of care
• Systems-Based Practice — coordinate home and hospice palliative services
• Professionalism — honest, family-centred end-of-life communication
• Pediatrics — palliative care and symptom management in serious illness
• Medical Expert and Communicator — goals-of-care and anticipatory prescribing