Meeting Reviews
SPA Session 4 - Holistic Care of Special Needs Children: It Takes a Village to Raise a Child
Reviewed by Franklin Chiao, MD
New York-Presbyterian Hospital/Weill Cornell Medicine
Distract, Drag, or Drug? A view from the opposite side of the bed
James E. Hunt, MD (Arkansas Children’s, Little Rock) gave a very interesting and personal lecture. Caring for patients with neurodevelopmental disorders/intellectual disability is challenging for multiple reasons. They have difficulty communicating their needs or being understood. Challenges include identity, behaviors, architecture and pain.
Every encounter has consequences because it influences the next encounter. Behavior is learned, and it is a language. There are many components of behavior that we need to be aware of including genetics, culture, language and past experiences. To understand how to better care for them, it is notable that these children can be sensitive to sensory environmental factors like light, noise and touch. They may communicate with signs or devices. Safety may be an issue with violence to self or others. Transitions are important with routines and triggers. It is important to limit foot traffic into their room. A mobile sensory cart can also help keep the patient calm.
There is a scoring system that can be used to determine what the child may need:
ASD/ID Screening
- Does your child have autism, or are you concerned your child may have autism?
2 Points (Autism) - Does your child have difficulty communicating their needs to others?
1 Point (Communication) - Do issues such as light, noise, or textures cause your child additional stress or anxiety?
1 Point (Environment) - Should we anticipate your child might become violent toward self or others, or attempt to leave their room?
1 Point (Safety) - Does your child have difficulty adjusting to changes in routine or environment?
1 Point (Transition)
Scores <2 may benefit from ipad and sensory items. Scores 2-3 benefit from addition of story books, environment controls. Scores >4 are more severe and social work and child life additions may help.
Children with Special Needs: Is their anesthetic experience different?
Jeffrey L. Koh, MD (Doernbecher Children’s Hospital, Portland OR) delivered a helpful lecture about children with special needs. The lecture focused on children with cerebral palsy, Down's Syndrome, and autism. In terms of an approach for anesthesia pre-operatively, one can see if they are combative or non-communicative. One determines the balance of parent needs and child needs, and the interaction of anesthesia with their home meds. In discussion with the family, he suggested asking about previous history in the medical setting, communication about pain, expectations, and thoughts about premedication. Elliot et al examined anxiety issues in this population. They found that these children do not self report anxiety most of the time. Parental report of their own and their child’s anxiety showed no difference between ASD and non-ASD patients. Induction compliance scores were higher in the ASD group. There are a variety of premedication options including ketamine.
In terms of cerebral palsy, one should inquire about contractures, baclofen pumps, preferred body position, reflux issues, seizures, vagal nerve stimulators, and home medications. Temperature control, and baclofen withdrawal are additional concerns intraoperatively. Down Syndrome patients have several challenges. These include atlantoaxial instability, congenital heart disease, obesity, and sleep apnea. Autism concerns are related to the variable behavioral spectrum, sensory processing issues, difficulty adjusting to new environments, ADHD, seizure disorders, home medications, and parental perceptions.
In terms of pain management for cognitively impaired children, there are several key elements. Dr. Voepel-Lewis evaluated the FLACC scale in 79 patients after orthopedic or dental procedures. FLACC scores compared well to parent scores and analgesic drug usage. She noted that the FLACC tool may be useful as a measure of postoperative pain in this population. Stallard et al analyzed six “core cues” as indicators of pain. This list of cues included:
- Crying with or without tears
- Screaming, yelling, groaning, moaning
- Screwed up or distressed face
- Body appears stiff or tense
- Difficult to comfort or console
- Flinches or moves away if touched
Everything except "Crying" was found to be a reliable marker of pain.
Koh's pain research looked at 138 children with cognitive impairment. Children with impairment were given somewhat less opioid in the operating room. Post-op pain scores and opioid amounts were similar between groups.
In terms of the post-anesthesia recovery unit (PACU), several additional findings have been described. Parental presence can be extremely helpful in the PACU. Experienced pediatric PACU nurses also have a big impact. Average PACU length of stay for autistic patients was the same. There were no differences in adverse events including behavior issues.
He recommended these papers:
- Autism Spectrum Disorder (ASD) and its perioperative management
Taghizadeh N. et al; Pediatric Anesthesia 2015 - Preoperative evaluation and comprehensive risk assessment for children with Down Syndrome
Lewanda AF, et al; Pediatric Anesthesia 2016 - Perioperative management of the paediatric patient with coexisting neuromuscular disease
Lerman J; British Journal of Anaesthesia 2011 - Anaesthesia and pain management in cerebral palsy
Nolan J et al; Anaesthesia 2000
