Neuropathic Pain as Potential Source of Feed-induced Dystonia in Children With Severe Central Nervous System Disorders

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To the Editor:
I wish to highlight further considerations to the important case series of 12 children with enteral feed–induced dystonias by Mordekar et al (1). In a study of 22 children with severe impairment of the central nervous system and persistent pain, recurrent muscle spasms and changes in body position were noted in 86% (19/22), although all were already on 1 or more medications for spasticity and dystonia (2). In addition, gastrointestinal symptoms were noted in 14 (64%), with all receiving treatment for gastroesophageal reflux disease. In this series, gabapentin resulted in improvement, including a decrease in pain and vomiting, improved feeding tolerance, weight gain, and change from jejunostomy to gastrostomy tube feedings (2). Theoretical reasons for benefit with gabapentin include treatment of central neuropathic pain, a source that can include pain triggered by visceral distention.
Guidelines for identifying and treating pain in children with severe impairment of the central nervous system are provided in a recent clinical report from the American Academy of Pediatrics (3). Features that indicate pain in such children include intermittent changes in muscle tone, posture, and movement. Medications directed at sources such as central neuropathic pain can then decrease the features associated with spasticity and dystonia. Medication trials include gabapentinoids and tricyclic antidepressants, including evidence of added benefit when used in combination. Awareness of this information can expand treatment options before invasive interventions such as parental nutrition or intrathecal baclofen pump.

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