5/30/15 Presentation download of all 3 presentations: Pain, Delirium or Neuroirritability? Child Neurology and Integrative Pediatric Pain and Palliative Care http://NoNeedlessPain.org Episodes of Inconsolability in Children with Developmental Delay- Definitions, Evaluation and Treatment With Drs Julie Hauer and Stefan Friedrichsdorf Audrey Foster-Barber, MD, PhD May 2015 2 A Case Neuroirritability • An 8 year old boy is admitted with 3 hours of screaming • Define irritability • Diagnosis of adrenoleukodystrophy, failed bone marrow transplant • What is the pathophysiology? • Model of neuroirritability- infantile colic • No vision, no language, spastic quadriparesis, g tube fed • Who is at highest risk? • Parents feel he is in pain • Distinguish from delirium • He has been doing this long crying jag each evening for a few weeks, but this is longer than most • Clinical evaluation- Dr. Hauer • Treatment- Dr. Friedrichsdorf • No fever, elevated HR, elevated BP • Is this pain? What is the source? Is this delirium? • Is this Neuroirritability? 3 4 What is Neuroirritability? Crying is Communication • Google and Pubmed search, poll of Child Neurologists • Crying as part of a communication loop • Nonverbal expression of need – Neuro-irritability – Neuro-cry • Caregiver physiologic response- increased heart rate, endocrine changes – Pathologic cry – Screaming of unknown origin • Caregiver tries to interpret and to meet the child’s need – Central Irritability • Successful interaction encourages communication, provides feedback to caregiver- solidifies bond – Pain-like behavior – Pain or Irritability of Unknown Origin, PIOU – Irritabile insomnia – Light-Switch mental status change – Paroxysmal fussiness 5 6 1 5/30/15 Crying differs in neurologic impairment Crying is not the only sign of distress • f0- frequency of cry- speed of opening and closing of the vocal cords • Facial features- grimace • Change in sleep pattern- increase or decrease • Typical f0 is 350-700 Hz, abnormal is 1000-2000 • Increase in abnormal movements- more spasticity, dystonia, stereotypy • higher f0 cries in prematurity, brain injury, chromosome abnormality • Decrease in movements- freezing • Autism spectrum often have few facial expression changes and cry modulation seen as atypical • Autonomic changes- HR, sweating, flushing • Self harm- biting, scratching, head banging • Higher f0 cry, atypical cry pattern is perceived as more aversive, distressing • Atypical or idiosyncratic reactions- laughing • Inability to soothe leads to risk of caregiver distress 7 8 Pathophysiology of Neuroirritability Pathophysiology of Neuroirritability • Abnormal cognitive, communication and motor systems • Abnormal cognitive, communication and motor systems • Is it pain? • Is it emotional? – This population at high risk for pain (musculoskeletal, skin, gi, dental, headache, csf shunt) – Overstimulation by the environment – Oversensitized to pain- from prior painful stimuli (gut dysmotility, GERD and constipation, hydrocephalus, surgeries) – More Rapidly cycling irritability- seen in patients with developmental delay and family history of bipolar disorder – Autistic patients- specific anxiety treatment often effective – Excessive response to mild discomfort- hyperalgesia – Caregiver distress- sometimes neuroirritable behavior varies with provider; cause or effect? – Pain response to typically nonpainful stimuli- allodynia 9 Pain Systems • Nociceptive – Normal response to tissue damage 10 Infantile Colic- Normal Neuroirritability? • Neuropathic • Paroxysmal fussiness in infancy • Irritable, cry, arch back, twist trunk, extend legs – Pain due to lesion or disease of the Peripheral or Central Nervous system • Typically starts after 2 weeks of age, decreases by 3-4 months • > than 3 hrs of crying, >3 days per week, for > 3 weeks in an infant – Genetic or acquired – Abnormal pain signals without ongoing injury • Inconsolable • Higher risk of poor bonding, of caregiver frustration, of abuse – Hyperalgesia, allodynia 11 12 2 5/30/15 Colic- Infant Migraine or Marker of Genetic Risk • Immature nervous system?- processing the sensory input of the day • Mothers with migraine 2x more likely to have infant with colic • Higher association with anxious parents- direction of causality? • Is it an infant migraine? Or sign of an abnormal nociceptive system? • Hyper-reactive or hyper-sensitive child • Infantile colic raises likelihood of migraine, OR 5.6 • Query gut pain? Though typical GI treatments (reflux, gas) not shown to impact this behavior • Predictor of Pediatric Migraine 13 14 Pediatric Migraine- Neuropathic pain? An oversensitive brain? • Pediatric Migraine triad • Colic as a model of developmentally typical Neuroirritability – tendency to motion sickness – Immature brain, based on a genetic tendency, associated with neuropathic pain syndrome – tendency to ice-cream headaches – suffer from growing pains • Neuroirritability in Severe Neurologic impairment • Overzealous pain reaction to simple stimuli – A normal or excessive response to nociceptive pain? – dehydration and/or – skipped meals – Pathological response to other non-pain stimuli? – poor sleep – hormonal changes – environmental changes- loud sounds bright light 15 16 Who is at risk of Neuroirritability • Any child with severe neurologic impairment- cognitive, communication, motor impairments • Degenerative neurologic disease- adrenoleukodystrophy, mucopolysaccharoidosis, Krabbe • Especially those with dynamic CNS changesneurodegeneration, inflammation, intractable seizures • Inflammatory brain disease- NMDA-R encephalitis, opsoclonusmyoclonus-ataxia, infectious encephalitis • Acute brain injury- hypoxic ischemic injury, trauma, kernicterus • More severe at higher risk • Metabolic disease- mitochondrial disease, amino acidopathies • May depend also on underlying genetic tendency to neuropathic pain • Chromosomal abnormalities- cri du chat (5p-), other • Severe impairment, subset of these patients- epileptic encephalopathy, quadriplegic cerebral palsy, autism with intellectual disability • May depend also on mood and environmental issues 17 18 3 5/30/15 Neuroirritability or Delirium? • Delirium • Any seriously ill patient is at risk of delirium • Patients with severe neurologic impairment at high risk, difficult to assess – Acute onset change in mental status – Fluctuations • May depend on context- is the patient ill? have there been acute neurologic changes? – Inattention or confusion – May have other symptoms- hallucinations, change in sleep wake cycle, autonomic instability • Neuroirritability often more prolonged, more chronic • Caused by acute disruption of brain centers controlling attention, arousal, memory – Seizure, infection, new focal injury, metabolic derangement 19 20 Medical Evaluation in Neuroirritability Treatment of Neuroirritability • Clinical diagnosis, not a diagnosis of exhaustive exclusion • Siden et al- PUP, Pathways for Unknown Pain – Standard analgesics • Take into context- parental report, relationship to feeding, evacuation, moving, environmental changes, medications – Gabapentin, other antiepileptics – Antispasmodics • Good examination- teeth, ears, skin, diaper area, belly, bones – Antiadrenergics, Benzodiazepines – Opioids • Neurologic status- worsened movement disorder, seizure • Nonpharmacologic interventions • Lab workup- infectious, inflammatory – Diaper change, vent g tube, change position • Imaging- brain, belly, bones – Decrease environmental stimulation – Music, massage, other sensory treatments 21 • • • • • • • • • • • • • • 22 Breau LM, Burkitt C. 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