1133 - Approach to obtaining a swallow study in a 5 y.o. with a disability & significant procedural anxiety: a case report

Case Diagnosis: Procedural anxiety in a child with spastic quadriplegic cerebral palsy and communication delay undergoing dysphagia evaluation

Case Description: A 5-year-old male with spastic quadriplegic cerebral palsy and communication delay whose diet consisted of pureed solids and no liquids was evaluated in clinic for inability to obtain further dysphagia assessment due to significant procedural anxiety. Multiple prior attempts were aborted despite efforts to console the patient. It was deemed medically necessary to further attempt swallow evaluation to rule out aspiration due to developmentally delayed oral-motor skills. There was an extensive discussion with an interdisciplinary team and the family regarding options. Ultimately the comprehensive approach taken involved premedication with buspirone, desensitization, distraction, & positive reinforcement while also taking the patient’s specific needs into consideration. With this approach the fluoroscopic swallow study was successfully completed, and the patient’s diet was upgraded to include moderately thickened liquids.

Discussions: Management of procedural anxiety in special populations such as children with disabilities and those who cannot tolerate traditional sedatives is not well-researched. The lack of definitive recommendations regarding these issues increases the difficulty of managing these patients and can leave providers feeling unequipped. Our case highlights one successful approach to addressing these individual needs using techniques such as distraction, redirection, desensitization, and non-sedating anxiolytic medications, which are widely available. Additionally, this case reinforces the need to identify the underlying cause for procedural anxiety and involve an interdisciplinary team.

Conclusions: An attempt should be made to identify underlying factors driving procedural anxiety in the specific patient rather than generically treating anxiety. After discussing with the patient and/or family, relevant information should be relayed to staff with an open-ended invitation to propose ideas. While hospitals do not have equivalent resources, concerns related to unfamiliarity, underlying anxiety, and locus of control can be addressed with limited resource utilization, as demonstrated in this case.