Toddlers: Pain and Autism

What is autism

a mental condition, present from early childhood, characterized by difficulty in communicating and forming relationships with other people and in using language and abstract concepts.

DSM-V Autism diagnosed

1) Persistent deficits in social communications and social interaction

2) Restricted, repetitive patterns of behaviour, interests, or activities

3) Symptoms must be present in the early developmental period and are not better explained by other intellectual or neurological disabilities, i.e., social communication disorder

When do we most commonly see signs of autism

Symptoms or these deficits we typically see around 18-24 months, but may not manifest until there is an increase in social demands

May even regress at this age and go backwards on their milestones

What are 3 things that occur due to persistent deficits in social communication and social interaction with autism

1) Social-emotional reciprocity

2) Nonverbal communicative behaviours

3) Social relationships

How are childrens social emotional reciprocity affected by autism

1) Abnormal back-and-forth conversations

2) Reduced emotions or affect

3) Inability to initiate/respond to social interactions

How are children's nonverbal communicative behaviours affected by autism

1) Poor eye contact

2) Inability to understand/convey nonverbal gestures

3) Difficulty adjusting behaviour to social context

How are children's social relationships affected by autism?

1) Inability to develop or maintain relationships

2) Lack of interest in peers or collaborative play

What are 4 things that occur due Restrictie, repetitive patterns of behaviour, interests, or activities with autism

1) Sterotyped or repetitive motor movements with objects or speech

2) Insistence on sameness

3)Highly restricted in interests that are abnormal in intensity and focus

4) Hyper- or hypo-reactive to sensory input or environmental change

Examples of stereotypes or repetitive motor movements with objects or speech with autism

1) Obsessive behaviours: lining tos, echolalia, idiosyncratic phrases

2) Motor stereotypes: Stimming behaviours

Examples of instances of sameness with autism

Inflexible adherence to routine & ritualized patterns: distress with small/ sudden changes or transitions

Examples of autistic children and their highly restricted interests that are abnormal in intensity and focus

strong attachment to objects

Examples of autistic children and hyper- or hypo-reactivity to sensory input or environmental change

1) Excessive smelling or touching of objects; may be oblivious to pain or temperature

2) Perturbed or fascinated by specific sounds, lights, textures

With children with autism, how might their behaviour change from example, routine, environment, constipation, fever etc. (PHYSICAL)

Biting

hitting

spitting

pulling hair

With children with autism, how might their behaviour change from example, routine, environment, constipation, fever etc. (EMOTIONAL)

Shouting or using derogatory language

With children with autism, how might their behaviour change from example, routine, environment, constipation, fever etc. (SELF INJURY)

head banging

With children with autism, how might their behaviour change from example, routine, environment, constipation, fever etc. (PICA)

eating things other than food

With children with autism, how might their behaviour change from example, routine, environment, constipation, fever etc. (SMEARING)

smears their feces on walls and objects

M-CHAT

Modified Checklist for Autism in Toddlers parent-completed questionnaire

can be used on kids 16-30 months of age

What is the space acronym for autism support

Sensory

Predictability

Acceptance

Communication

Empathy

example of sensory

Minimizing fluorescent lighting, reducing noise, offering noise-cancelling headphones, avoid unnessary procedures (e.g., blood pressure if not essential)

Example of predicatability

Provide advance notice of procedures, use visual schedules, maintain consistent routines, and offer social stories before visits. Space that is quiet and familiar can act like a reset

Example of acceptance

Respect stimming behaviours, avoid forcing eye contact, allow comfort objects, permit flexibility (e.g., not changing into hospital gowns)

Example of communication

Use clear, literal language; allow processing time; offer written/visual instructions; utilize augmentative communication devices

Examples of empathy

Recognize that behaviours that challenge may indicate distress; involve the patient in care planning, support autonomy

Risperidone

Antipsychotics for reducing irritability, hyperreactivity and stereotypes.

Side effects: Weight gain, metabolic disease

Methylphenidate

gold standard for comorbid ADHD

What pain scale do we use for individuals 0-4 years

FLACC Score

What pain scale do we use for individuals 4-7 years

Wong bakers face scale

What pain scale do we use for individual >7years of age

Likert Pain Scale (0-10)

What is the most common cause of pain in toddlers

Msk accounts for 40% of pain in toddlers. think of all there falls, etc.

Why might toddlers' pain be undertreated

a) lack of understanding of what causes pain versus distress (fear)

b) Toddlers cannot describe the intensity or type of pain

c) Cognitive, toddlers only understand "no woie" vs "little owie" vs "more owie."

The purpose of vibration in pain management

inhibits pain signal transmission from smaller A and C fibres

colds purpose in pain management

Decrease in nerve conduction velocity

topical anesthetics

should be used for all skin-breaking procedures. Topical anesthetics control pain but have little effect on distress.

2ml sucrose 24%

Are vital signs a good indicator of pain in children

HR, resp rate, etc does not give a good indicator for differentiating between anxiety and physical pain

pain management for MSK (pharmacological)

NSAIDS, as they are the first-line pharmacotherapy for acute pain in toddlers, are particularly effective for MSK injury

*Treatment for mild to moderate pain, Tylenol and NSAIDS*

Should codeine and tramadol be used in a pediatric population for pain management

No, they have unpredictable metabolism and have a risk of respiratory depression

Entonox

is a fast-acting pain relief gas made of 50% nitrous oxide and 50% oxygen, commonly used for short procedures (

When should Entonox not be used

When there is potential accumulation of gas within body spaces, pneumothorax, otitis media, OR severe renal, cardiac, pulmonary dx

what procedures might Entonoc be used for

Peripheral IV

Urinary Catheter

suture/ staple removal

Drain removal

What Ramsey Sedation Score is IDEAL for Entonox

3-4 ideally

peripheral IV Infiltration & Extravasation Chapion Program

It is a hospital-based initiative designed to improve early recognition, prevention, and management of IV complications in patients.

-PIV are truly necessary

-Fewest number of attempts possible

- Early identification for supports for difficult PIV insertion

what procedures might Entonoc be used for