Report of the Subcommittee on Assessment and Methodologic Issues in the Management of Pain in Childhood Cancer P. J. McGrath, J. Beyer, C.

Cleeland, J. Eland, P. A. McGrath and R. Portenoy Pediatrics 1990;86;814

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1990 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Report of the Subcommittee on Assessment and Methodologic Issues in the Management Pain in Childhood Cancer
P. J. McGrath P. A. McGrath, (co-ordinator), J. Beyer, and R. Portenoy C. Cleeland, J. Eland,

of

Pain is a complex, multidimensional experience that has at least two major components. The first, nociception, is a sensory component directly related to activity in neural pathways responsive to tissue damage. The second is the complex psychologic, physiologic, emotional, and behavioral response to
the nociception. This response is determined by

in children

aged

3 years

and

older

are

both

readily

available and validated. Several important features of pain are noteworthy.

1. The childs report of

of the
pain,

measurement
and

if available

many
children

intrinsic
will have

and
less

extrinsic
pain

factors.
when the

In

general,

solicited indicator the child

2.

in an appropriate manner, is the best of pain. If a child says he or she is in pain, should be believed.
becomes greater than that which is

exacerbating

If pain

factors, which are outlined in Table 1, are minimized. Because pain is experienced individually and subjectively, assessment of pain in each individual is
essential. Assumptions regarding an individuals

pain should not and cannot be inferred from the amount of tissue damage he or she has experienced. Therefore, regarding assessment of pain in children with cancer, the following principles were agreed upon.
1. Systematic assessment of pain should be con-

expected from known causes, undetected factors which may be affecting its intensity should be suspected. 3. If a child denies pain when there is obvious evidence of tissue damage or if altered behavior indicates pain (see Table 2), the reasons for the
inconsistency between physical infants feel findings, pain, and behavior,

and

self-report
4. Neonates

should
and

be investigated

thoroughly.
neonates

sidered a necessary part of the management of cancer. Most children with cancer will be at risk for significant pain at some time during the course of their illness. Such pain can be caused by the
disease itself, by invasive diagnostic and monitoring

procedures, and by treatment. Therefore, adequate care must include a plan for comprehensive assessment and management of all forms of pain in addition to the disease-management protocol. 2. Assessment of pain must be ongoing throughout the course of the illness. Sources of nociception and modifying factors will change through time and must be evaluated continuously.

are not less sensitive to noxious stimulation than older children and adults4 Therefore, assessment of pain, although more complex than in older children, should be considered essential to the care of neonates and infants. In infants, reliance on facial expression, cry, posture, and physiologic variables such as heart rate, respiratory rate, blood pressure, and palmar sweating are important as potential indicators of pain. 5. Questions such as How are you feeling? or How is your pain? should be considered social gambits and not measures of pain. 6. Developmental considerations play a major role in the selection of measures of pain (see Table 3). Before 2#{189} years of age, no quantifiable selfreport is usually available, and assessment of pain
is inferred When from behavioral language first and begins, physiologic only yes reor no sponses.

MEASUREMENT

OF PAIN

Although comprehensive assessment of pain must include more than measurement of intensity or severity, this aspect of pain is important and has been studied the most widely. Simple, clinically useful measures for evaluating the intensity of pain

determinations are possible. However, by 3 years of age, indications of greater or lesser are usually possible by use of terms from their own experience such as big hurt or little hurt. Thus by 3 years of age, most children without

814

PEDIATRICS

Vol. 86 No.5

November

1990

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TABLE

1.

Factors

Exacerbating

Childrens

Pain

suspicion tions even

and

should absence

prompt

additional report

investigaof pain.

Intrinsic factors Childs anxiety, depression, and fear Previous experience with inadequately managed Childs lack of control Experience of other aversive symptoms (nausea, tigue, dyspnea) Childs negative interpretation of situation Extrinsic factors Anxiety and fears of parents and siblings Poor prognosis Invasiveness of treatment regimen Parental reinforcement of extreme under-reaction (stoicism) or over-reaction to pain Inadequate pain management practices of health staff Boring or age-inappropriate environment

in the clues report for

of a verbal

The
pain faconsidered

behaviors

outlined
to pain. In

in
the

Table
context

2 should
of known

be

pain-producing
the verbal justification is forthcoming.

stimuli,
and,

they
in

support
some cases, even

and
give

augment
ample

analgesic therapy, There are individual

if no report differences in

pain behaviors sultation with

most care familiar

that may the childs

with their

be assessed best in conparents, who are usually

childs behavior and its

implications. Behavioral responses to the acute pain of invasive procedures, such as bone marrow aspiration, are usually more pronounced than responses to chronic pain such as that caused by the

cancer. Like adults, children adapt to pain, and both behavioral and physiologic cancer
tensity

prolonged responses
such as

can

provide

reports of pain

of varying
setting, an the

levels
estimate

of inof own

may

not

be

evident.

More

subtle

changes,

of pain.

In a clinical interviewing

relative
through

intensity
careful

can

often

be

obtained

using

childs

language and his pain. More precise

older than mentally have been 3 years appropriate validated.57

or her previous measurement

is also possible specialized In these

experience with ofpain in children

using developmeasures that instruments, chil-

dren are presented with cartoon faces of children

comfort, mirrors and the they degree are

a series of photographs or in various phases of disto select they are the face accept find which these them experiencing.

a childs reduction in play, may be helpful in this context. Heretofore there has been a tendency to assume that the degree of childrens distress relates to factors other than pain, eg, separation from parents or anxiety. This attitude can compromise the medical staffs response to the childs pain. As in adults, the context of the pain should be used to clarify the behavior. In the presence of tissue damage, distress behaviors can be assumed to be caused by pain
unless there is evidence to the contrary.

asked of pain

Most children from 3 to 6 years of age measures easily. Medical staff generally extremely is strongly Simple, helpful, and encouraged. self-report their measures 6 years measuring scales use

in clinical are

practice

There are currently no physiologic measures that reliably indicate pain. Treatment of pain should never be withheld based on the lack of physiologic perturbations alone.
THE PAIN PROBLEM LIST

recommended

for children older than most useful scales for are (a) visual analogue

of age. Among the intensity of pain (either vertical or

horizontal) (see Fig. 1) and (b) simple numerical scales such as: If 0 means no hurt or pain and 10 means the biggest hurt or pain you could ever have, tell me how much hurt or pain you have now.

The committee proposes that clinicians develop and use a Pain Problem List for every child with cancer. The Pain Problem List is the outcome of an assessment process that begins with the pain
history. The history is used to characterize the pain

according visceral),
TABLE

to its mechanism the related 2.

Behavioral

(neuropathic, somatic, syndrome (spinal cord

of Pain Present 0 0 0 0 0 0 0 0 0 0

In contrast of adjectival moderate, recommended

to measurement of adult pain, the use categorical scales such as mild, severe, and excruciating are not for children younger than 13 years
should not behavioral be used in observa-

In dicators

Behavior Crying Fussing, irritability Withdrawal from social interaction Sleep disturbance Facial grimacing Guarding Not easily consoled Reduction in eating Reduction in play Reduction in attention span

Not Present 0 0 0 0 0 0 0 0 0 0

of age. Behavioral observations lieu of self-report. However, tions (Table situations. for example or in children

2) are invaluable (a) When self-report in children younger without verbal

in several important is not available, than 2 years of age due to disability

ability

or disease,
pain

behavior behavioral

assessment.

stimuli,

provides the primary means of (b) In the presence of noxious pain indicators should arouse

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SUPPLEMENT

815

TABLE

3. Age

Age and

Measures Self-report

of Pain Measures

Intensity*
Behavior Measures Physiologic Measures

Birth
3 y to

to 3 y
6 y

Not available Specialized,

mentally

Of primary developappropri-

importance

Of secondary
importance Of secondary importance

Primary

if self-report not available

>6

y
of pain McGrath,7

ate scales available Of primary importance

in children and Ross and have been

Of secondary tance
reviewed

imporand Wells,5 McGrath and

Measures

by Beyer

Unruh,6

Ross.8 3. Anxiety

related eating
and

to related

pain

and to mouth

concern pain
related

about

NO PAIN

PAIN
SEVERE POSSIBLE Fig 1. Visual analogue scale.

AS AS

prognosis 4. Reduced 5. Nightmares disturbed sleep to

compression, generalized bone pain), and other key features that may influence the decision to implement one therapy rather than another. Whenever possible, it is essential to identify the source of the tissue-damaging stimuli. In some cases, such as procedure-related pain, the source is obvious, and the clinician should proceed to assess the characteristics of this pain (intensity, location, temporal

bone marrow aspirations. This problem list then serves as the basis generating specific interventions to ameliorate pain. The Pain Problem List is a subsection of patients problem list and should be entered in appropriate section of the medical record.

for the the the

ASSESSING THE INTERVENTIONS

EFFECTS

OF

characteristics, pain quality, and provocative palliative factors) and the modifying factors
1). When the source of nociception is not

and (Table
obvious,

vigorous efforts should be made to elucidate it by means of the medical history, physical examination, and confirmatory imaging and other laboratory
tests. It is rare for pain to be present without an

underlying cause. Underlying causes may result from complex interactions between the disease and the treatment of the disease. The purpose of the Pain Problem List is to identify problems amenable to intervention and to assist in selecting the most appropriate treatments to

reduce pain in accord with the cause and contributing factors. The Pain Problem List can be particularly helpful because there are multiple sources and dimensions of pain; there are multiple treatments available, and several may be required simultaneously; pain occurs in the context of ongoing medical disease and other ongoing medical and psychosocial problems which will require continuing care; and optimal management may require a multidisciplinary approach, and the problem list will help organize the resources.
For example, the current Pain Problem List for

The goal of analgesia is to provide maximum pain relief with minimal side effects. In some cases, adequate analgesic management can produce complete elimination of pain without uncomfortable effects. In others, a trade-off will have to be made balancing pain against side effects. The wishes of the child and the childs family should be paramount in assessing this aspect of analgesic therapy. For example, some children tolerate some pain so that complete alertness can be retained, whereas others will accept drowsiness which may indeed become a welcome relief from the struggle against the disease. Children and adolescents have difficulty responding to scales that assess the degree of improvement. Therefore, it is usually unwise to ask, How much has your pain improved? Repeated measures of intensity should be used, and reductions in pain
intensity scores should be considered an indication

of improvement. Children can be reminded of their previous rating to help them assess changes as well. Children younger than 6 years of age are often unable to answer questions regarding the acceptability of the side effects of analgesics.

a 4 year old with acute leukemia chemotherapy might be:

1. Severe 2. Mild mouth bone pain pain related related to

and

mucositis

after

ASSURING
Every sponsible
agement

QUALITY
member for the
of pain.

CARE
team is reand manproblem that

to mucositis invasion of bone

of the childs health appropriate assessment

Pain is a complex

marrow

816

MANAGEMENT

OF

CANCER

PAIN

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frequently plines. The

requires primary

the care

input giver

of all (physician

health discior clinical

Recently, assurance

Mohide audit,

et al9 scoring

have developed guide, and

a quality instruction

nurse) should
ment of vital bedside sheets mended.

should compile the Pain Problem be entered in the medical chart.

of pain should be regularly in the such considered recorded medical charting the chart. and signs and and entered may facilitate

List which Measureequivalent

at the
Pain are

childs
flow recom-

Institutional

Quality

Assurance

Programs

should require the measurement

these measures of pain and

and should monitor treatment standards.

manual for adult cancer pain. Such an approach should be developed for pediatric cancer pain. Parents have a key role to play in the assessment and management of their childs pain. Parents are usually careful observers of their childs behavior and will notice subtle changes caused by pain. Parents should be encouraged to exercise their rights to be advocates for adequate pain control for their children.

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SUPPLEMENT

817

Report of the Subcommittee on Assessment and Methodologic Issues in the Management of Pain in Childhood Cancer P. J. McGrath, J. Beyer, C. Cleeland, J. Eland, P. A. McGrath and R. Portenoy Pediatrics 1990;86;814
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1990 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on November 18, 2012