Symptom control in serious paediatric illness — formative SAQs

SAQ 1 — Breathlessness, secretions and palliative sedation in a dying child (10 marks, 15 minutes)

Stem: A 7-year-old with a progressive brainstem glioma is in the last days of life. He becomes increasingly breathless with audible gurgling secretions, and his parents are frightened. He is unconscious and on no regular opioid. Outline the assessment and the stepwise pharmacological and non-pharmacological management of his breathlessness and secretions, and explain when and how you would use palliative sedation. [9]

Model answer (structured as marked): [1]

Assessment and goals of care (2 marks)

• Confirm this is refractory end-of-life symptom distress: assess work of breathing, oxygenation, the work of the family, and review reversible causes (pleural effusion, pneumothorax, aspiration) against the burden of transfer.
• Anchor the plan in a goals-of-care conversation with the parents: the intent is comfort, the child is not distressed by the secretions himself, and the family's distress is a treatment target too. [1]

Breathlessness — non-drug and drug management (3 marks)

• Position upright and forward; airflow on the face (fan or open window); parent presence and calm.
• Give oxygen only if the child is hypoxaemic and finds it relieves the choking sensation — not simply for a "low number", and tubing may add to distress.
• Give a low-dose opioid: morphine 0.05 to 0.1 mg/kg subcutaneously or intravenously, repeated after 15 to 30 minutes, or a small regular dose. Explain to the parents that opioids relieve the sensation of breathlessness centrally and may not change the saturation — the number was never the target. [9]

Noisy respiratory secretions (death rattle) (2 marks)

• Reassure the parents that the child is unconscious and not distressed by the sound; reposition on the side; provide gentle mouth care; reduce non-essential hydration that worsens secretions.
• Give an anticholinergic: glycopyrronium 4 to 10 mcg/kg/24h subcutaneously (preferred, as it does not cross the blood-brain barrier and is less deliriogenic), or hyoscine hydrobromide 10 to 20 mcg/kg subcutaneously if sedation is wanted. Avoid repeated blind suctioning, which traumatises the child and rarely helps. [11]

Palliative sedation — when and how (3 marks)

• Indication: a refractory symptom (severe pain, breathlessness, agitation or convulsions) that has not responded to escalating specialist-guided treatment.
• Drug: subcutaneous midazolam infusion started at 0.05 to 0.1 mg/kg/hour (30 to 60 mcg/kg/h) and titrated upward to the minimum sedation that relieves the symptom; add levomepromazine if midazolam alone is insufficient.
• Consent and ethics: the goals conversation (ideally held earlier) documents the intent — relief of a refractory symptom, not the ending of life; proportionate sedation is justified by the doctrine of double effect and is ethically distinct from euthanasia. [5]

SAQ 2 — Pain ladder, breakthrough dosing, opioid rotation and anticipatory prescribing (10 marks, 15 minutes)

Stem: A 9-year-old with relapsed metastatic sarcoma is on a stable oral morphine regimen totalling 40 mg per 24 hours. He develops sudden breakthrough pain, and over the following week he develops myoclonus, twitching and a hyperactive delirium on a rising morphine dose. Outline the WHO two-step ladder, the breakthrough dose, the management of the neurotoxicity, and the anticipatory prescribing plan for home. [2]

Model answer (structured as marked): [1]

WHO two-step ladder (2 marks)

• Step 1: non-opioid analgesics — paracetamol 15 mg/kg every 4 to 6 hours and, where not contraindicated, ibuprofen 5 to 10 mg/kg every 6 to 8 hours.
• Step 2: a strong opioid (morphine) for moderate to severe pain, titrated to effect with no fixed ceiling. The old weak-opioid step (codeine) was dropped in 2012 because CYP2D6 variability causes fatal respiratory depression in ultrarapid metabolisers; codeine and tramadol are contraindicated in children under 12. [2]

Breakthrough morphine dose (2 marks)

• Breakthrough (rescue) dose is one-sixth to one-tenth of the total 24-hour opioid dose: for 40 mg/day that is roughly 4 to 7 mg.
• Give by a fast route (oral if building, subcutaneous/intravenous for immediate relief), reassess at 15 to 30 minutes parenteral or 45 to 60 minutes oral, and repeat if needed. Repeated breakthroughs mean the background regimen needs upward titration. [2]

Management of opioid-induced neurotoxicity (3 marks)

• Recognise the syndrome: myoclonus, twitching, allodynia, vivid dreams and a hyperactive delirium on a rising opioid dose, driven by excitatory morphine metabolites.
• Do NOT escalate the same opioid to "treat" the agitation — it worsens the neurotoxicity.
• Rotate to a structurally different opioid (for example oxycodone): calculate the equianalgesic dose (oral morphine 30 mg ≈ oral oxycodone 20 mg), REDUCE by 25 to 50 per cent for incomplete cross-tolerance, and re-titrate. Seek specialist input for methadone whose ratio is non-linear at high doses. [2]

Anticipatory (just-in-case) prescribing for home (3 marks)

• Prescribe a drug for each likely symptom BEFORE discharge: an opioid (morphine or oxycodone injection) for pain and breathlessness; midazolam for agitation and seizures; an antiemetic (often levomepromazine or haloperidol) for nausea; an anticholinergic (hyoscine or glycopyrronium) for secretions.
• Write each dose by weight with a labelled indication, and rehearse the response to a breathlessness or seizure episode with the family before it happens.
• Plan the subcutaneous route and syringe driver for the dying child who cannot swallow, supported by a community palliative nurse with a clear escalation pathway. [1]