Cancer Pain in Children

Pediatric Nursing Department

Pain in Children (Myths)
Young infants do not feel pain
Children easily become addicted to narcotics
Children tolerate pain better than adults
Children are unable to tell you where they hurt
Children become accustomed to pain or painful
procedures
Children will tell you when they are experiencing pain
Children's behavior reflects their pain intensity
Children with pain
Children with pain
Pain Assessment
Quest Principles of Pain Assessment
(Baker and Wong, 1987)
Question the child.
Use pain rating scales.
Evaluate behavior and physiologic changes.
Secure parents' involvement.
Take cause of pain into account.
Take action and evaluate results.
Pain Scale
Introduction
Pain is one of the most common symptoms in children
with cancer.
Cancer pain should be approached with an understanding
of the individual child and family and with an open mind
about interpatient variability in analgesic response.
Multidisiplinary management may be needed, with a team
including social workers, physiotherapists, play therapists,
and music therapists.
Epidemiology
Pediatric cancer-related pain is usually secondary to
treatment (e.g. procedure-related, mucositis, or infection).
Tumor-related pain predominates at diagnosis, particularly
when diagnosis has been delayed, in early treatment, and
with advanced disease.
Intractable cancer pain is rare, but in the setting of
terminal disease it may be seen in children with solid
tumors metastatic to the central or peripheral nervous
system.
Chronic pain conditions secondary to cancer treatment
are rare in long-term survivors.
Nonpharmacological Pain Management
Modalities
Nonpharmacological strategies may be beneficial in
isolation or in tandem with phamacological agents.
They include:
Physical techniques (e.g. massage, acupuncture, or
transcutaneus electrical nerve stimulation)
Behavioral techniques (e.g. relaxation or music therapy)
Cognitive techniques (e.g. imagery, hypnosis, or music therapy)
Pharmacological Pain Management
Modalities
Prescription of analgesics should follow the WHOs
analgesic ladder: recommends non-opioids for mild pain
and opioids for moderate to severe pain.
Analgesia should be given to children by the simplest,
most effective, and least painful route.
Intravenous (i.v.) administration has its advantages (e.g.
rapid onset, easier titration), particularly in padiatric
patients who have long-term i.v. access.
Intramuscular analgesia is painful, and rectal
administration is discouraged due to infection risk in
cancer patients.
Pharmacological Pain Management
By the ladder
By the clock
PRN (pro re nata or as needed) has been found to be ineffective as
the only method of pain management, but can be appropriate when
used to provide extra doses of a regularly scheduled analgesia to
treat breakthrough pain (severe pain)
By the mouth
The least invasive route should be used to administer analgesic
medications.
By the child
The needs of the individual child must be taken into account when
determining dosages of pain medications. The goal is to provide each
child with the dose of analgesic medication that prevents recurrence
of pain prior to the next dose, keeping the child pain-free (McGrath,
1996)
Pharmacologic pain management (By the
Ladder)
Pharmacological Pain Management
Modalities
Non-opioid Analgesics
Acetaminophen (paracetamol) is the most commonly used
non-opioid analgesic, and i.v. Administration (where available) is
effective in similar doses, when oral administration is not
possible.
Nonsteroidal anti-inflammatory drugs impair platelet function
and are often contraindicated in pediatric oncology patients
who are at risk of thrombocytopenia and bleeding.
Opioid analgesics
Morphine is one of the commonly used opioids for moderate
to severe pediatric cancer pain and is generally the first-line
opioid agent.
Pharmacological Pain Management
Modalities
All opioids can potentially cause the same range of side
effects, which must specifically be asked about and
managed.
Although tolerance develops to most side effects, e.g.
Sedation, nausea, and pruritis, as with adults, children do
not develop tolerance to constipation, so regular laxatives
should be given.
Though a common parental concern, iatrogenic opioid
addiction is exceedingly rare in pediatric patients.
To prevent withdrawal symptoms following prolonged
opioid use, opioids should be slowly weaned.
Pharmacological Pain Management
Modalities
Adjuvant agents
Adjuvant analgesics may be added to improve analgesia or
allow dose reduction of opioids to minimize side effects.
Classess of adjuvant drugs include antidepressants,
anticonvulsants, local anesthetics and corticosteroids.
Anesthetic approaches to cancer pain, e.g. nerve blocks, are
usually confined to children with regional pain unresponsive to
other analgesics.
Challenge
Pain assessment is essential for good pain management.
Once pain assessment is a routine part of health care, pain
management will improve.
Understanding the unique needs of each child is essential to
provide appropriate pain interventions.
Nurses must use both pharmacologic and nonpharmacologic
interventions to provide relief from side effects.
Careful consideration of the childs situation provides
individualized nursing care that will promote quality of life.
References
Collins, J.J. Management of symptoms associated with
cancer: pain management. In: Carroll, W.L., Finlay, J.L.,
editors. Cancer in children and adolescents. Sudbury, MA:
Jones and Bartlett; 2009.
World Health Organization. Cancer pain relief and
palliative care in children. Geneva: World Health
Organization; 1998.
Thank you