Childpainmgmt PDF

PAIN MANAGEMENT IN
CHILDREN WITH CANCER

This Booklet was published by the
Texas Cancer Council
Copyright 1999
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AUTHORS:
Marilyn Hockenberry-Eaton, PhD, RN-CS, PNP, CPON, FAAN

Associate Professor of Pediatrics, Baylor College of Medicine
Director of Pediatric Nurse Practitioners,
Texas Children’s Cancer Center
Texas Children’s Hospital, Houston, Texas
Patrick Barrera, BS
Project Coordinator
Melody Brown, MS, RN, CPON
Coordinator, Children’s Hospice Services
The Hospice at the Texas Medical Center, Houston, Texas
Sarah J. Bottomley, MN, RN, CPNP, CPON
Pediatric Nurse Practitioner
Jill Brace O’Neill, MS, RN-CS, PNP, CPON
Texas Children’s Hospital Baylor College of Medicine

REVIEWERS:
Donna Wong, PhD, RN, PNP, CPN, FAAN

Nurse Consultant,
The Children’s Hospital at Saint Francis, Tulsa Oklahoma;
Nurse Consultant, The Hospital for Sick Children, Washington;
Adjunct Associate Professor, Department of Pediatrics,
University of Oklahoma College of Medicine-Tulsa;
Clinical Associate Professor, University of Oklahoma College of Nursing;
Adjunct Associate Professor and Consultant, Oral Roberts University,
Anna Vaughn School of Nursing, Tulsa, Oklahoma
C. Philip Steuber, MD
Professor of Pediatrics,
Baylor College of Medicine, Houston, Texas
Director, Leukemia Service,
Texas Children’s Cancer Center,
Douglas Strother, MD
Assistant Professor of Pediatrics,
Baylor College of Medicine, Houston, Texas
Texas Children’s Cancer Center,
Edith M. Eby, PharmD

Clinical Pharmacy Specialist,
Hematology/Oncology
Nancy E. Kline, PhD, RN, CPNP

Assistant Professor of Pediatrics,
Baylor College of Medicine
Pediatric Oncology Nurse Practitioner
ADVISORY COMMITTEE MEMBERS:
Carol Benefield Mary Choroszy, MSN, RN, CPNP

Parent Consultant Pediatric Nurse Practitioner
Candlelighters Childhood Pediatric Blood & Marrow Transplantation
Cancer Foundation U.T.M.D. Anderson Cancer Center
Alvin, Texas Houston, Texas
Dana Bond, MN, RN, CPNP John Foster, President

Advanced Nurse Practitioner Texas Non-Profit
Center for Cancer and Blood Disorders Hospice Alliance
Children’s Medical Center of Dallas Bryan, Texas
Dallas, Texas
Lanae Juno, RN, OCN
Marge Brown, RN Pediatric and Adolescent Oncology
Driscoll Children’s Hospital, Nurse Coordinator
Children’s Medical Center of South TX. Methodist Children’s Hospital
Corpus Christi, Texas Lubbock, Texas
Melody Brown, MS, RN, CPON Janine Primomo, MSN, RN

Coordinator, Children’s Department Head
Hospice Services Pediatric Hematology Oncology
The Hospice at the Santa Rosa Children’s Hospital
Texas Medical Center San Antonio, Texas
Houston, Texas
Kathleen M. White, MSN, RN, CPNP
Margaret Caddy, RN Cook Children’s Medical Center
Executive Director, Fort Worth, Texas
Houston Hospice;
President, Texas/New Mexico
Hospice Association
Houston, Texas
APON Clinical Practice Committee Reviewers:
Kathy Forte MS, RN, CPNP

Clinical Nurse Specialist, AFLAC Cancer Center
Egleston Children’s Hospital, Atlanta GA
Pat Brophy MSN, RN, CRNP

Children’s Hospital of Philadelphia, PA
Casey Hooke MSN, RN, CPON

Clinical Nurse Specialist, Pediatric Hematology/Oncology
Children’s Hospitals and Clinics, Minneapolis, MN
Susan Lively RN, CPON

Oncology Resource nurse
Backus Children’s Hospital, Savannah GA
Sal Leahy RN
Clinical Educator AFLAC Cancer Center
Egleston Children’s Hospital, Atlanta GA
Gina Mink MS, RN

Staff nurse
Children’s Hospital, Omaha, NE
Pain Management In Children With Cancer:
Content Outline
Introduction pp 8
I. Physiology of Pain pp 9-10
II. Etiology of Cancer Pain pp 11-13
III. Barriers to Effective Pain Management pp 14-16
IV. Pain Assessment pp 17-23
V. Pharmacologic Pain Management pp 24-44
VI. Procedure Related Pain pp 45-49
VII. Nonpharmacologic Pain Management pp 50-54
VIII. Special Considerations For The Dying Child pp 55-56
IX. Appendices
X. References
Note: As new scientific information becomes available through basic and clinical research, recommended
treatments and drug therapies undergo changes. The authors and reviewers have made every effort to make
the information presented in this booklet up-to-date and accurate in accordance with current standards and
research materials available. The authors and reviewers are not responsible for errors or omissions or for any
consequences that may result in the application of any of the information presented. Only trained health care
providers in accordance with approved professional standards should apply any practice described within this
publication. Health care providers are advised to always check product information, before administering
any drug, for changes and updates of information regarding dosing and contraindications.
Introduction
Pain in children with cancer is now recognized as a significant debilitating symptom that
affects quality of life. Although advances in pain management have been made, there is still a need
for improvement. Lack of knowledge on state of the art pharmacological and nonpharmacological
practices as well as common myths and misconceptions surrounding opioid use are the most
common barriers to effective pain management. Pain is a significant acute and chronic symptom
during or after treatment and is often undertreated.
This booklet, made possible by the Texas Cancer Council, is written to provide professionals
caring for children with cancer with a resource to improve pain management practices. Better
understanding of the nature of pain, as well as development of new interventions, agents, and
methods of pain medication delivery, are essential to improve care for children. This booklet
provides a broad overview of pain management for children with cancer, with a focus on care for
the terminally ill child.
Many health care professionals caring for children who are terminally ill may be experts in
the care of adults with limited experience in the care of children. Information in this booklet is
presented to allow the clinician access to important information related to the physiology of pain,
etiology of cancer pain in children, assessment of pain, appropriate strategies for pain
management, and effective drugs and dosages for use with children. The ability to reference
information quickly makes this booklet a useful tool in the clinical setting. Management of pain
caused by medical procedures is included, because so many children must undergo procedures
during the course of the illness. Nonpharmacologic pain strategies have been found to be highly
effective in decreasing pain in children and also provide opportunities for family members to
become involved in the care of their child. The final section provides specific information related to
the care of the dying child.

I. Physiology of Pain
Nociceptive Pain:
The sensation of nociceptive pain occurs when the nerve endings in the periphery are
activated by a noxious stimuli. Nociceptive pain generally results as a response to direct tissue
damage. The initial trauma causes the release of several chemicals including bradykinin, serotonin,
substance P, histamine, and prostaglandin. These chemicals facilitate the transmission of the pain
impulse to the spinal cord from the periphery. Small C fibers and large A delta fibers pick up the
messages at the site of injury and transmit the signals to the dorsal horn of the spinal cord.
Neurotransmitters that include glutamate, substance P and adenosine triphosphate allow the pain
message to ascend to the brainstem by the spinothalamic tract and enter the higher centers of the
brain. The cerebrum and thalamus are known as the control centers that process and register the
experience of pain. Once the impulse enters the higher centers of the brain, information about the
pain such as location and intensity is processed as well as other factors that include fear of the
situation, past and present experiences and the child’s current emotional status. All these factors are
considered before a response occurs in an attempt to stop the pain. The brain may respond by
blocking further pain impulses from reaching the higher centers or by producing endogenous
opioids (i.e., endorphins), which saturate pain receptor sites along the spinal cord and in the brain,
providing an analgesic effect.
Neuropathic Pain:
Neuropathic pain is caused by altered excitability of the peripheral or central nervous
system, usually caused by dysfunction or injury. Neuropathic pain is distinguished from
nociceptive pain by its persistence over a longer period of time. Neuropathic pain is frequently
described as a burning, stabbing, or shooting sensation. A complete neurologic exam is essential to
evaluate sensory, motor, cranial nerve, reflex, cerebellar, cognitive and emotional function (Olsson
and Berde, 1993). Sensory evaluation may elicit the presence of hyperalgesia (an increased
sensitivity to pain), or allodynia (pain caused by benign stimuli such as touch). These findings are
significant symptoms associated with neuropathic pain, especially when no apparent skin pathology
is present (Olsson and Berde, 1993). Table 1 describes in more detail the two types of pain found in
children with cancer.
Table 1. Neuropathic versus Nociceptive Pain
Two Major Types of Pain:
I. Nociceptive Pain II. Neuropathic Pain
A. Somatic Pain B. Visceral Pain C. Centrally Generated D. Peripherally Generated

Pain Pain
I. Nociceptive Pain: Normal process of II. Neuropathic Pain: Abnormal processing of sensory input
stimuli that damages normal tissues or has by the peripheral or central nervous system; treatment
the potential to do so if prolonged; usually usually includes adjuvant analgesics.
responsive to nonopioids and/or opioids.
A. Centrally Generated Pain
A. Somatic Pain: Arises from bone,
1. Deafferentation pain: Injury to either the
joint, muscle, skin, or connective
peripheral or central nervous system. Examples:
tissue. It is usually aching or
Phantom pain may reflect injury to the peripheral
throbbing in quality and is well
nervous system; burning pain below the level of a
localized.
spinal cord lesion reflects injury to the central
B. Visceral Pain: Arises from visceral nervous system.
organs, such as the GI tract and
2. Sympathetically maintained pain: Associated
pancreas. This may be subdivided:
with dysregulation of the autonomic nervous
1. Tumor involvement of the organ system. Examples: May include some of the pain
capsule that causes aching and associated with reflect sympathetic
fairly well-localized pain. dystrophy/causalgia (complex regional pain
syndrome, type I, type II).
2. Obstruction of hollow viscus,
which causes intermittent B. Peripherally Generated Pain
cramping and poorly localized
1. Painful polyneuropathies: Pain is felt along the
pain.
distribution of many peripheral nerves. Examples:
diabetic neuropathy, alcohol-nutritional
neuropathy, and those associated with Guillain-
Barré syndrome.
2. Painful mononeuropathies: Usually associated
with a known peripheral nerve injury, and pain is
felt at least partly along the distribution of the
damaged nerve. Examples: nerve root
compression, nerve entrapment, trigeminal
neuralgia.
A method of classifying pain is inferred pathophysiology: (1) nociceptive pain (stimuli from somatic and visceral
structures); (2) neuropathic pain (stimuli abnormally processed by the nervous system).
From Pain: Clinical manual, (p. 19), by M McCaffery and C Pasero, 1999. St. Louis: Mosby. Copyright 1999,
Mosby. Reprinted with permission.
II. Etiology of Cancer Pain
Pain in children with cancer can be caused by a number of factors (Table 2). The cancer
mass itself can produce pain by tissue distention or infiltration. Inflammation due to infection,
necrosis, or obstruction can also cause pain. Bone pain in children with cancer is caused by
infiltration of the periosteum, pathologic fractures, tumor growth of surrounding tissues, or
stimulation of the nerve endings in the endosteum by chemical agents released from the diseased
bone. These chemical agents include prostaglandin, bradykinin, substance P and histamine. Bone
marrow infiltration with malignant cells causes pain described as dull, aching, or penetrating, and
can be generalized to one or more areas, or localized. Tissue distention, infiltration or inflammation
may cause a generalized dull, throbbing pain. Visceral organ pain may be poorly localized because
the nociceptors that transmit pain messages back to the brain are not well established. Obstruction
of major organs can cause the onset of acute, severe pain. For example, tumors found in the
retroperitoneum may result in obstruction of a ureter, causing acute onset of sharp, localized pain
that is similar to pain caused by appendicitis. Children with nerve invasion often experience
weakness, numbness, or parasthesias. A child with a spinal cord tumor may complain of muscle
spasms, back pain and heaviness in the lower extremities. These children may also develop urinary
retention or incontinence.
Cancer treatment related pain in children occurs from the three commonly used treatment
modalities: surgery, chemotherapy, and radiation therapy. Children undergoing surgery for excision
of a primary tumor experience postoperative pain and are at risk for secondary infection that may
lead to additional pain. Chemotherapeutic agents can also be a cause of pain during treatment.
Vincristine, a plant alkaloid, is most commonly associated with peripheral neuropathies,
characterized by dysesthetic pain that presents as a burning sensation, causing pain upon light
contact with the skin. Mucositis is a common side effect of chemotherapy, often seen in children
receiving anthracyclines (i.e., daunorubicin), alkylating agents (i.e., cyclophosphamide),

antimetabolites (i.e., methotrexate), and epipodophyllotoxins (i.e., VP-16), and after receiving
preparative regimens for bone marrow transplantation. Radiation therapy to the head and neck area
is associated with severe mucositis in children. Post radiation pain may occur in certain body
regions, caused by fibrosis or scarring of connective tissues and secondary injury to nerve
structures. Other treatment-related side effects that cause pain include: skin reactions from
radiation therapy; abdominal pain from vomiting, diarrhea, or constipation; and infections such as
typhlitis, cellulitis, or sinusitis.

Table 2. Cancer Pain in Children
Type Clinical Presentation Causes
Bone -Aching to sharp, severe pain generally more -Infiltration of bone

-Skull pronounced with movement. Point tenderness -Skeletal metastases - irritation and
-Vertebrae common stretching of pain receptors in the
-Pelvis/femur -skull – headaches, blurred vision periosteum and endosteum.
-spine – tenderness over spinous process -Prostaglandins released from bone
-arms/extremities – pain associated with destruction.
movement or lifting
-pelvis/femur – associated with movement;
pain with weight bearing and walking
Neuropathic -Complaints of pain without any detectable -Nerve injury caused by tumor
-Peripheral tissue damage infiltration; can also be caused by
-Plexus -Abnormal or unpleasant sensations, generally injury from treatment (i.e.,
-Epidural described as tingling, burning, or stabbing vincristine toxicity).
-Cord compression -Often a delay in onset -Infiltration or compression of
-Brief, shooting pain peripheral nerves
-Increased intensity of pain with receptive -Surgical interruption of nerves
stimuli (phantom pain post amputation).
Visceral -Poorly localized -Obstruction – bowel, urinary tract,

-Soft tissue -Varies in intensity biliary tract
-Tumors of the -Pressure, deep or aching -Mucosal ulceration
bowel -Metabolic alteration
-Retroperitoneum -Nociceptor activation, generally
from distention or inflammation of
visceral organs
Treatment Related
-Mucositis -Difficulty swallowing, pain from lesions in
the oropharynx. May extend throughout the
entire GI tract.
-Infection -Infection may be localized pain from a Direct side-effects of

focused infection or generalized (i.e., tissue treatment for cancer
infection versus septicemia) -Chemotherapy
-Radiation
-Post-LP headaches -Severe headache following lumbar puncture -Surgery
-Radiation -Skin inflammation causing redness and

dermatitis breakdown
-Post-surgical -Pain related to tissue trauma secondary to

surgery
III. Barriers To Effective Pain Management
Pain in children is often under treated. The reasons for the lack of adequate pain control
may include: myths about pain and pain management, fears held by parents and health
professionals, and the lack of appropriate pain assessment tools or knowledge of pain assessment.
Myths surrounding pain management may prevent the timely and appropriate treatment of children.
1) Myth: Young infants do not feel pain. Children’s nervous systems are immature and are
unable to perceive and experience pain the way adults do. In the past, procedures such as
circumcision, suturing, or other minor operations on infants have been performed without
the benefit of anesthetic or pain medication. Fact: The central nervous system of a 26-week-
old fetus possesses the anatomical and neurochemical capabilities of experiencing
nociception (Anand, 1998).
2) Myth: Children easily become addicted to narcotics. Fact: Less than 1% of children treated
with opioids develop addiction. Opioids are no more dangerous for children than they are
for adults when appropriately administered (Foley, 1996).
There is confusion regarding three terms associated with drug use; narcotic addiction,
drug tolerance and physical dependency. The following are definitions for these
terms.
• Narcotic addiction - A voluntary psychological behavioral pattern characterized

by drug-seeking behavior and an intense craving for a drug’s mind-altering
properties rather then use for intended medical purposes. Addiction is not a
pharmacological side effect.
• Drug tolerance - An involuntary physiologic adaptation to a drug exhibited by a
need for larger doses of an opioid to maintain the desired analgesic effect.
• Physical dependence - An involuntary physiologic effect of withdrawal
symptoms noted when following abrupt discontinuation of opioids, or
administration of a narcotic antagonist (e.g., naloxone).
3) Myth: Children tolerate pain better than adults. Fact: Younger children experience higher
levels of pain during procedures then older children. Children’s tolerance for pain
increases with age (Broome, Rehwalt and Fogg, 1998; Broome and others 1990).
4) Myth: Children are unable to tell you where they hurt. Fact: Children may not be able to
express their pain in the same manner as adults. However with proper use of pain
assessment scales, children are able to express and identify pain. Studies have shown that
children as young as 3 years of age can use pain scales, such as the faces pain scale,
accurately (Wong and Baker, 1988). Children are able to point to the body area where they
are experiencing pain or draw a picture illustrating their perception of pain.
5) Myth: Children become accustomed to pain or painful procedures. Fact: Children exposed
to repeated painful procedures often experience increasing anxiety and perception of pain
with repeated procedures (Zeltzer, 1990).
6) Myth: Children will tell you when they are experiencing pain. Fact: Children may not
report pain due to fear of administration of a painful analgesic (injection) or fear of
returning to the hospital. Children who have experienced chronic pain may not be aware
that they are experiencing pain. Young children may not have adequate communication
skills or others may not think it is necessary to tell health professionals about the pain
(Favaloro and Touzel, 1990).
7) Myth: Children’s behavior reflects their pain intensity. Fact: Children are unique in their
ways of coping. Children’s behavior is not a specific indication of their pain level (Beyer,
McGrath and Berde, 1990). A child who is experiencing pain may be active and playing
“normally”. For example, a school age child may spend hours with a puzzle rather then
lying in bed as a way to distract attention from pain and attempt to enjoy a favorite activity.
Fears
1) Fear of respiratory depression. Respiratory depression is a serious and well-known side effect
of opioids; however, it rarely occurs in children. Several studies have documented the safe and
effective use of opioids in children without increased risk of respiratory depression (Kart,
Christrup and Rasmussen, 1997; Sabatino and others, 1997; Hertzka and others, 1989). As
children develop a tolerance to the analgesic effect of opioids they often develop a tolerance to
the respiratory depressant effect as well. For this reason, as pain increases, a child should be
able to receive an increased dose of opioids. The most common opioid side effect is
constipation, not respiratory depression. It is important to note that pain acts as a natural
antagonist to the analgesic and the opioid side effects of respiratory depression.
2) Fear of addiction (see myths). The patient or the family may have misconception/fear of
addiction which may lead to reluctance to report pain or take prescribed medications.
3) Fear that pain is a sign that the disease is worsening.
4) Fear that the use of morphine means the child is close to death. In an attempt to avoid facing
that reality, they may not acknowledge pain.
Other Barriers To Adequate Pain Control (Martin, 1998)
1) With a shift towards managed care in an attempt to contain costs, illness/treatment related pain
relief may not be viewed as a cost effective treatment modality.
2) There is often a lack of a comprehensive approach to pain assessment.
3) Healthcare providers may underestimate the intensity of the child’s pain.
4) An inadequate dose may be prescribed, or the use of inappropriate medication for symptoms
may occur. This may be due to the misunderstanding of the pharmacokinetics of agents and
appropriate IV to PO conversions.
5) Health care providers frequently have limited knowledge regarding state of the art pain
management.
6) There is often reluctance by nurses or family members to administer medications due to fear
of addiction, over medication, and/or side effects.
IV. Pain Assessment
Pain is both a sensory and emotional experience. For this reason several different
assessment strategies are needed to provide qualitative and quantitative information about pain.
Qualitative assessment is a description of the location, duration and characteristics of the pain, as
well as factors affecting the pain. Quantitative assessment evaluates the intensity of the pain using
a pain scale. In the clinical assessment of pain it is essential to ask the patient about his/her pain on
a regular basis and to assess pain systematically. The clinician should believe the patient and/or the
family reports of pain and what treatments they feel are most effective. Empower patients and their
families by involving them in the decision making for pain control. This involvement will ensure
that the pain control option chosen is the most appropriate for the patient, family and setting. It is
important that pain control interventions are delivered in a timely, logical and coordinated fashion
(Jacox and others, 1994). The QUEST approach to pain assessment is comprehensive and promotes
the use of multiple sources to evaluate pain in a child. The following methods are used to assess the
child’s pain.
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.
Figure 1. Key Factors In The Assessment of A Child In Pain
Pain Assessment
Self Report Physical Behavioral Physiologic Measures

Examination Observation & Diagnostic Results
1. Self Report
Self report is the most critical component of pain assessment. Children should be
encouraged to describe their pain since their statements reflect the most reliable indicators of pain.
In obtaining the patient's pain history, involve the parents, since they know their child (Table 3).
Know what word the child uses for pain (e.g., hurt, “owie” or “boo-boo”). Specific words used for
“pain” in different languages are found in Appendix A.
Assessment involves both the clinician and the patient and should describe the pain:
• Location (does the pain radiate, is there referred pain)
• Intensity/severity
• Aggravating and relieving factors
• Goals for pain control [document the patient’s preferred assessment tool and goals for pain
control (scores)]
• Description of the pain (i.e., sharp, pulsing, dull)
• Duration
• Determine associated symptoms and/or side effects the patient may be experiencing in addition
to the pain or discomfort (e.g. nausea, vomiting, constipation, sedation, fatigue).
• Choose an instrument to measure pain, giving consideration to the patient's developmental level;
introduce the instrument prior to painful procedures when possible; use the same instrument
consistently to assess level of pain; know the validity and reliability of pain rating scale chosen
(Figure 1 and Table 4). A self report tool is appropriate for children greater than 3 years of age
and provides the most accurate measure of pain.
• Children experiencing chronic pain need to be assessed for pain at regular intervals to define a
baseline rating for pain.
• Several scales have been developed to aid in measuring pain in nonverbal children (Appendix B
contains references for additional pain assessment scales).

Table 3. Pain Experience History
Child Form Parent Form

Tell me what pain is. What word(s) does your child use in regard to pain?
Tell me about the hurt you have had before. Describe the pain experiences your child has had before.
Do you tell others when you hurt? If yes, who? Does your child tell you or others when he/she is hurting?
What do you do for yourself when you are hurting? How do you know when your child is in pain?
What do you want others to do for you when you hurt? How does your child usually react to pain?
What don’t you want others to do for you when you hurt? What do you do for your child when he/she is hurting?
What does your child do for him/herself when he/she is
What helps the most to take your hurt away?
hurting?
Is there anything special that you want me to know about you
What works best to decrease or take away your child’s pain?
when you hurt? (If yes, have child describe.)
Is there anything special that you would like me to know about
your child and pain? (If yes, describe.)
From Reliability and validity of preverbal pain assessment tools, by BA Joyce, JG Schade, JF Keck, J Gerkensmeyer, T Raftery,
S Moser and G Hunter, 1994, Issues Comp Pediatr Nurs 17(3), p 121–135. Copyright 1994 Hemisphere Pub. Corp.
Adapted with permission.
Table 4. Pain Rating Scales for Children
Pain Scale Description Recommended Age
FACES Pain Rating Scale Consists of six cartoon faces ranging from a Children as young as 3 years
( Whaley and Wong, 1987 with smiling face for “no pain” to tearful face for
permission; Appendix C, Spanish “worst pain” (numbers for coding may vary).
version of the scale).
0 1 2 3 4 5
No Hurt Hurts Hurts Hurts Hurts Hurts
Little Bit Little More Even More Whole Lot Worst
Numeric Scale Children as young as 5 years,

Uses straight line with end points identified as
as long as they can count and
“no pain” and “worst pain”; divisions along
have some concept of
line are marked in units from 0 to 5 (high
numbers and their values in
number may vary)
relation to other numbers.
Scale may be used horizon-
tally or vertically.
0 1 2 3 4 5
No Pain Worst Pain
FACES Scale From Nursing Care of Infants and Children, 3rd ed., (p 1070), by LF Whaley and DL Wong, 1987. St. Louis: Mosby. Copyright 1987,
2. Physical Examination
Performing a complete physical examination is vital to a thorough assessment of a patient’s
pain. The physical examination should attempt to establish the relationship of the pain complaint to
the disease. Special attention should be given to the abdomen and gastrointestinal system prior to
initiation of narcotic therapy due to the potential side effect of constipation. Key components to the
complete physical examination include:
General Inspection
Head (Eyes, Ears, Nose & Throat) and Neck
Chest/Lungs
Heart
Abdomen
Urinary
Genitalia & Rectum
Musculoskeletal
Neurologic
Skin
3. Behavioral Observation
Behavioral observation can be used with pre-verbal or nonverbal patients, in addition to self-
report in all other cases. Observations include: vocalizations, verbalizations, facial expressions,
motor responses, body posture, activity and/or appearance (Table 5). Remember pain will be
expressed differently depending on the age and developmental level of the patient (Table 6).
Interpret behaviors cautiously. Behaviors such as watching television, playing or sleeping can
be distraction strategies used for coping with pain.
Cultural background may also play a role in children's reports and responses to pain. It is
accepted that culture is important to consider when assessing a child’s pain; however, little
empirical data exists that compares differences in pain experience and response patterns among
children of various cultures. Clinicians should become familiar with the beliefs and practices
common to the cultural groups they serve, be willing to elicit information about these matters in a
nonjudgmental manner, and accommodate cultural practices in keeping with acceptable medical
practice.
Table 5. Behavioral Pain Assessment Scales For Young Children

FLACC Scale
Scoring
Categories 0 1 2
Face No particular expression or Occasional grimace or Frequent to constant quivering chin,
smile frown, withdrawn, clenched jaw
disinterested
Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up
Activity Lying quietly, normal Squirming, shifting back and Arched, rigid or jerking
position, moves easily forth, tense
Cry No cry (awake or asleep) Moans or whimpers; Crying steadily, screams or sobs,
occasional complaint frequent complaints
Consolability Content, relaxed Reassured by occasional Difficult to console or comfort
touching, hugging or being
talked to, distractible
Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, which results in a
total score between zero and ten.
From The FLACC: A behavioral scale for scoring postoperative pain in young children, by S Merkel and others, 1997,
Pediatr Nurse 23(3), p. 293-297. Copyright 1997 by Jannetti Co. University of Michigan Medical Center. Reprinted with
permission.
Behavior/ Riley Infant Pain Scale Assessment Tool

Category 0 1 2 3
Facial Neutral/smiling Frowning/grimacing Clenched teeth Full cry expression
Body Calm, relaxed Restless/fidgeting Moderate agitation Thrashing, flailing, incessant
Movement or moderate mobility agitation or strong voluntary
immobility
Sleep Sleeping quietly Restless while asleep Sleeps intermittently Sleeping for prolonged periods
with easy (sleep/awake) of time interrupted by jerky
respirations movements or unable to sleep
Verbal/vocal No cry Whimpering, Pain crying Screaming, high-pitched cry
complaining
Consolability Neutral Easy to console Not easy to console Inconsolable
Response to Moves easily Winces when Cries out when High-pitched cry or scream
movement/ touched/moved moved/touched when touched or moved
Touch
From Comparison of three preverbal scales for post operative pain assessment in a diverse pediatric sample, by JG Schade,
BA Joyce, J Gerkensmeyer, and JF Keck, 1996, J of Pain and Symptom Management 12(6) p. 348-359. Copyright
1996 Elsevier Science Inc. Reprinted with permission.
Table 6. Developmental Differences in Pain Expression
Developmental Group Expressions of Pain
Infants May:
l Exhibit body rigidity or thrashing, may include arching
l Exhibit facial expression of pain (brows lowered and drawn together, eyes
tightly closed, mouth open and squarish)
l Cry intensely/loudly
l Be inconsolable
l Draw knees to chest
l Exhibit hypersensitivity or irritability
l Have poor oral intake
l Be unable to sleep
Toddlers May:
l Be verbally aggressive, cry intensely
l Exhibit regressive behavior or withdraw
l Exhibit physical resistance by pushing painful stimulus away after it is applied
l Guard painful area of body
Preschoolers/Young May:
Children l Verbalize intensity of pain
l See pain as punishment
l Exhibit thrashing of arms and legs
l Attempt to push stimulus away before it is applied
l Be uncooperative
l Need physical restraint
l Cling to parent, nurse, or significant other
l Request emotional support (e.g. hugs, kisses)
l Understand that there can be secondary gains associated with pain
School-Age Children May:
l Verbalize pain
l Use an objective measurement of pain
l Be influenced by cultural beliefs
l Experience nightmares related to pain
l Exhibit stalling behaviors (e.g., “Wait a minute” or “I’m not ready”)
l Have muscular rigidity such as clenched fists, white knuckles, gritted teeth,
contracted limbs, body stiffness, closed eyes, or wrinkled forehead
l Include all behaviors of preschoolers/young children
Adolescents May:
l Localize and verbalize pain
l Deny pain in presence of peers
l Have changes in sleep patterns or appetite
l Be influenced by cultural beliefs
l Exhibit muscle tension and body control
l Display regressive behavior in presence of family
4. Physiologic Measures and Diagnostic Studies
Physiologic measures should only be used as adjuncts to self-report of pain and behavioral
observation. As with behavioral measures of pain, physiologic or biologic measures cannot
discriminate well between physical responses of pain and other forms of stress on the body.
Physiologic responses include: skin flushing; diaphoresis, elevated blood pressure, tachycardia,
tachypnea; decreased oxygen saturation; restlessness; and dilation of the pupils. There are marked
variations in the occurrence of these symptoms from patient to patient. A review of pertinent
diagnostic studies including imaging procedures and laboratory studies obtained to further evaluate
and determine the source of pain is critical to being able to effectively treat pain.
Key Points To Remember
Failure to assess pain is a critical factor leading to under treatment. Assessment should occur:
At regular intervals after initiation of treatment.
At each new report of pain.
After pharmacologic or nonpharmacologic intervention, at an appropriate interval (e.g., 15-30
minutes after parenteral therapy, 1 hour after oral administration); Follow-up assessment is
crucial.
It is essential to document the pain assessment on the patient’s medical record.
When there is uncertainty about the presence or amount of pain even after using assessment
strategies as with infants or young children, a diagnostic trial of analgesics is appropriate.

V. Pharmacologic Pain Management
The current standard for the management of cancer pain in children consists of four
concepts: “by the ladder”, “by the clock”, “by the mouth”, and “by the child”. This means that
pain management in children should follow the World Health Organization Analgesic Stepladder,
be administered on a scheduled basis, be given by the least invasive route, and be tailored to the
individual child’s circumstance and needs (McGrath, 1996).
By the Ladder:
The WHO Analgesic Stepladder is a multi-step approach to treating pain, and is a guide for
initiating analgesic drugs and dosages that correspond to the patient’s reported level of pain (Figure
2). The ladder starts with non-opioid oral drugs for mild pain and progresses to strong opioids,
adjuvants and invasive therapies for severe and/or intractable pain. It is important to keep in mind
Figure 2. Therapeutic Ladder for Pain Management.

that the potency of analgesia should be matched to the child’s reported level of pain. For example,
if children report severe pain, they should be started on a potent opioid such as morphine. It would
be inappropriate to start a child with severe pain on ibuprofen or a weak opioid and progress up the
ladder from that point.
Analgesic Drugs:
NSAIDs / Acetaminophen
Non-steroidal anti-inflammatory drugs (NSAIDs) have analgesic, anti-pyretic, and anti-
inflammatory activity. NSAIDs act peripherally to provide their analgesic effect by interfering
with the synthesis of prostaglandin, through the inhibition of cyclooxygenase (COX). There are
two isoenzymes of COX; COX-1 and COX-2. The COX-1 isoform is expressed primarily in the
kidney, gastrointestinal tract and on platelets. In contrast, the COX-2 isoform is found in low
levels in tissues, but is induced during inflammation. By selectively inhibiting the COX-2
isoform, prostaglandin pathways are influenced, decreasing pain and inflammation and avoiding
the toxicities of the inhibition of COX-1. Most NSAIDs are non selective inhibitors of COX.
There are now two selective COX-2 inhibitors available (Table 7). However, there is limited
pediatric data for dosing and side effects of these selective COX-2 inhibitors.
The side effects of nonselective NSAIDs include decreased platelet aggregation, gastric
irritation, and the potential for renal toxicity with long term use. Children with low platelet
counts or who are neutropenic should be monitored carefully when taking nonselective NSAIDs
for pain relief. The nonselective NSAID choline magnesium trisalicylate does not interfere with
platelet aggregation, but its use should be avoided in children with platelet counts less than
20,000 or with active bleeding (Collins and Berde, 1997). Acetaminophen has similar analgesic
and antipyretic effects to the NSAIDs, but does not provide an anti-inflammatory effect.
Acetaminophen does not affect platelet function or irritate the stomach, but hepatic toxicity can
occur with high doses of acetaminophen (i.e., >75 mg/kg/day or 4 g/day).
Acetaminophen preparations are available with the opioid drugs codeine, oxycodone and
hydrocodone (Table 8). These combination drugs are beneficial for mild to moderate pain that
does not respond to acetaminophen or NSAIDs alone. When using acetaminophen in
combination with codeine or hydrocodone, it is important not to exceed the maximum daily
dose of the acetaminophen component of the drug (Table 7). If pain increases or persists
beyond the maximum dosage of a combination preparation, switching to a stronger opioid agent
would be the next step in managing a child’s pain. NSAIDs are limited to a ceiling dose where
increasing the dose only produces toxicity and no pain relief.
Table 7. Nonsteroidal Anti-Inflammatory Drugs Used for Cancer Pain

Drug Type Typical Starting Dose
Acetaminophen 10 to 15 mg/kg/dose q 4 hr PO to a max of 650 mg/dose
Aspirin 10 to 15 mg/kg/dose q 6 to 8 hr PO to a max of 650
mg/dose
Ibuprofen 10 mg/kg/dose to a max single dose of 800 mg q 6 to 8 hr
PO
Choline magnesium trisalicylate 7.5 to 25 mg/kg/dose bid-tid; max single dose of 1500 mg
PO
Diclofenac sodium 1 to 1.5 mg/kg/dose to a max single dose of 75 mg q 8 to 12
hr PO
Naproxen 5 to 7.5 mg/kg/dose to a max of 500 mg/dose q 12 hr PO
Naproxen sodium Same as Naproxen
Ketorolac 0.5 to 1 mg/kg as single dose IM to a max of 60 mg,
followed by 0.5 mg/kg IV q 6 hr to a max single dose
of 30 mg. Max duration is 5 days (useful in short term
pain management). Limited data on use of oral
Ketorolac in children
Celecoxib (Cox-2 inhibitor) 100 mg to 200 mg PO q day for patients > 18 years. No
information in patients < 18 years
12.5 mg PO q day for patients > 18 years; max: of 25
Rofecoxib (Cox-2 inhibitor)
mg/day. No information for patients < 18 years
Opioids
Opioids bind with certain receptors (Mu, Kappa, Delta) in the CNS and peripheral
tissues to provide analgesic effects. Mu receptors are located in the CNS and provide central
analgesia, but also play a role in the development of respiratory depression, physical
dependence and withdrawal symptoms. Kappa receptors are located in greatest concentration in
the cerebral cortex and substantia gelatinosa of the dorsal horn. Kappa receptors are responsible
for analgesia at the level of the spinal cord and the brain, but have less of a role in physical
dependence and withdrawal. Delta receptors are concentrated in the substantia gelatinosa of the
dorsal horn and have a primary effect upon spinal and supraspinal analgesia.
Mu-agonist drugs are the most commonly used class of opioids, and include drugs such
as morphine, fentanyl, and codeine (Table 8). The analgesic effect of these drugs has no ceiling,
and dosing is limited only by the presence of unmanageable side effects (Leahy, Hockenberry-
Eaton, and Sigler-Price, 1994). Meperidine also falls into the class of Mu-agonists. However,
meperidine has fallen out of favor as an analgesic drug, due to its short duration of action and
the accumulation of a toxic metabolite normeperidine, which causes undesirable CNS side
effects, including seizures, at low doses of the drug. Meperidine should not be used for
chronic pain control in children. Depending on the opioid, they can be given orally, rectally,
as subcutaneous or intravenous infusions, intramuscularly, transdermally, and directly into the
CNS via epidural/caudal/intrathecal injection. The most common side effects of opioid
analgesia in children are constipation, sedation, pruritis, and nausea/vomiting. Respiratory
depression, although the most frequently cited concern of health care providers, is a relatively
rare occurrence. The risk of respiratory depression decreases significantly when children are on
opioid analgesics for prolonged periods of time. In the event mild respiratory suppression
occurs it is easily managed by awakening the child, giving oxygen, and decreasing further
opioid doses by 25%. In the event of severe respiratory depression, the American Pain Society
(1999) recommends using naloxone in small doses for children < 40 kg. They recommend a
dose of 0.5 mcg/kg IV every two minutes until respirations improve (Table 10). The important
issue to consider is the goal of a reversal agent is to improve respiratory status without
compromising pain management.
All opioids have the potential for tolerance, physical dependence, and addiction. The
phenomenon of drug tolerance must be separated from the fear of addiction in order to
appropriately use opioid therapy. Tolerance refers to the progressive decline in analgesic
potency and the need to increase doses of the opioid to achieve the same analgesic effect over
time. Tolerance also occurs to the side effects of opioids with long term administration,
particularly sedation and respiratory depression. Tolerance to these side effects is beneficial,
because doses can be increased to control pain without increased incidence of sedation or risk of
respiratory depression. Concerns about the development of tolerance should not lead the health
care provider to ‘save’ opioid drugs for later use. Tolerance is easily managed by increasing the
dose of the opioid, adding appropriate adjuvants, or switching to another opioid drug. Cross-
tolerance between opioids is incomplete; therefore, the dose for the new opioid should be
reduced up to 50% of the equianalgesic dose and re-titrated from there for adequate pain relief.
Table 8. Starting Doses and Conversion Factors for Commonly

Prescribed Opioids
Starting Doses IV to
Oral Starting Doses Dosage Forms
Drug IV PO
Codeine 0.5 to 1 mg/kg Tablet, as sulfate: 30 mg N/A N/A
q 4 to 6 hr; Liquid: 3 mg/mL
max: 60 mg/dose
Acetaminophen 0.5 to 1.0 mg/kg/dose of Elixir: acetaminophen 24 mg and N/A N/A
and Codeine codeine q 4 to 6 hr; codeine 2.4 mg/mL with alcohol
max: 2 tablets/dose; 15 7%
mL/dose Suspension: acetaminophen 24 mg
and codeine 2.4 mg/mL alcohol
free
Tablet: #3: acetaminophen 300 mg
and codeine 30 mg
Starting Doses IV to
Oral Starting Doses Dosage Forms
Drug IV PO
Hydrocodone 3 to 6 years: 5mL 3 to 4 Tablet: hydrocodone 5 mg and N/A N/A
and times/day acetaminophen 500 mg
Acetaminophen 7 to 12 years: 10 mL 3 to Oral solution at: 0.5 mg hydrocodone
4 times/day and 33.4 mg/mL acetaminophen
>12 years: 1 to 2 tablets q
4 to 6 hr; max: 8
tablets/day
Oxycodone Instant release: 0.05 to Instant release: 5 mg N/A N/A

0.15 mg/kg/dose up to 5
mg/dose q 4 to 6 hr
Sustained release: for Sustained release: 10 mg, 20 mg,
patient’s taking >20 40 mg, 80 mg
mg/day of oxycodone
can administer 10 mg q
12 hr
Morphine 0.3 to 0.6 mg/kg/dose Injection: 2 mg/mL, 5 mg/mL, 0.1 mg/kg/ dose 10 mg
every 12 hr for sustained 10 mg/mL, 15 mg/mL 0.1 to 0.2 IV =
release Injection, preservative free: 1 mg/mL mg/kg/dose q 2 30 to
Solution: 2 mg/mL to 4 hr; max: 15 60 mg
0.2 to 0.5 mg/kg/dose q 4 Tablet: 15 mg (instant release) mg/dose PO
to 6 hr prn for solution Tablet, controlled release: 15 mg,
of instant release tablets 30 mg, 60 mg, 100 mg, 200 mg
Fentanyl Lozenge: Lozenge: 100 mcg, 200 mcg, 1 to 2 N/A
< 15 kg: contraindicated 300 mcg, 400 mcg mcg/kg/dose;
> 2 years (15 kg to 40 kg): max: 50 mcg/
5 to 15 mcg/kg; max: dose
dose 400 mcg Continuous IV
> 40 kg: 5 mcg/kg; max: infusion: 1
dose of 400 mcg mcg/kg/hr
Transdermal: See Table Patch: 25 mcg/hr, 50 mcg/hr, 75

12 mcg/hr, 100mcg/hr
Injection: 50 mcg/mL
Hydromorphone 0.03 to 0.08 mg/kg/dose Injection: 1, 2, 3 and 4 mg/mL 15 mcg/kg IV q 1.5 mg

PO q 4 to 6 hr; max: 5 4 to 6 hr; max: 2 IV =
mg/dose Tablet: 2 mg, 4 mg mg/dose 7.5 mg
PO
Syrup: Hydromorphone 1mg and
guafenesin 100 mg/5 ml
Suppository: 3 mg
Methadone 0.1 to 0.2 mg/kg q 4 to 12 Tablet: 5 mg, 10 mg 0.1 mg/kg IV q 4 10 mg
hr; max: 10 mg/ dose Solution: 1 mg/mL to 12 hr; max: 10 IV =
Concentrate: 10 mg/ml mg 20 mg
Injection: 10 mg/mL PO
Adjuvants
Adjuvant drugs are used in combination with non-opioid and opioid drugs to enhance pain
management, and are used more frequently in complicated neuropathic pain syndromes.
Adjuvant drugs can by divided into two categories: co-analgesic drugs and drugs that treat side
effects. Co-analgesics include drugs from a variety of classes, including antidepressants,
anticonvulsants, corticosteroids and sedative/hypnotics (Table 9). Drugs used to treat side effects
include antihistamines, psychostimulants, laxatives, neuroleptics, and antiemetics (Table 10).
Table 9. Co-analgesic Adjuvant Drugs
Category/Drug Dosage Indication Comments

ANTIDEPRESSANTS
Amitriptyline 0.2 to 0.5 mg/kg PO hs Continuous Provides analgesia by blocking re-
Titrate upward by 0.25 mg/kg every 5 to 7 neuropathic pain uptake of serotonin and
days as needed with burning, norepinephrine possibly slowing
Available in 10 mg and 25 mg tablets aching, dysthesia transmission of pain signals
Usual starting dose is 10 to 25 mg with insomnia Helps with pain related to insomnia
and depression (use nortriptyline
if patient is over-sedated)
Analgesic effects seen earlier than
antidepressant effects
Side effects include dry mouth,
constipation, urinary retention
Nortriptyline 0.2 to 1.0 mg/kg PO a.m. or bid Neuropathic pain

Titrate up by 0.5 mg q 5 to 7 days as above without
Max: 25 mg/dose insomnia
ANTICONVULSANTS
Gabapentin 5 mg/kg PO at bedtime Neuropathic pain Mechanism of action unknown.
Increase to bid on day 2, tid on day 3 Side effects include sedation, ataxia,
Max: 300 mg/day nystagmus, dizziness
Carbamazepine <6 years Sharp, lancinating Similar analgesic effect as
2.5 to 5 mg/kg PO bid initially neuropathic amitriptyline
Increase 20 mg/kg/ 24 hr divide bid q pain Monitor blood levels for toxicity
week prn; max: 100 mg bid Peripheral only
6 to 12 years neuropathies Side effects include decreased blood
5 mg/kg PO bid initially Phantom limb counts, ataxia, and GI irritation
Increase 10 mg/kg/24 hr divide bid q week pain
prn to usual max: 100 mg/dose bid
>12 years
200 mg PO bid initially
Increase 200 mg/24 hr divide bid q week
prn to max: 1.6 to 2.4 gm/24 hr
ANXIOLYTICS
Lorazapam 0.03 to 0.1 mg/kg q 4 to 6 hr PO / IV; max:
2 mg/dose May increase sedation in
Muscle spasm combination with opioids
Anxiety Can cause depression with
prolonged use
Diazapam 0.1 to 0.3 mg/kg q 4 to 6 hr PO / IV; max:

10 mg/dose
CORTICOSTEROIDS
Dexamethasone Dose dependent on clinical situation; Pain from Side effects include edema,
higher bolus doses in cord compression, increased gastrointestinal irritation,
then lower daily dose. Try to wean to intercranial increased weight, acne
NSAIDs if pain allows pressure Use gastroprotectants such as H2
Cerebral edema: 1 to 2 mg/kg load then 1 Bony metastasis blockers (ranitidine) or proton
to 1.5 mg/kg/day divided every 6 hr; Spinal/nerve pump inhibitors such as
max: 4 mg/dose compression omeprazole for long-term
administration of steroids or
Anti-inflammatory: 0.08 to 0.3 mg/kg/day NSAIDs in end-stage cancer with
divided every 6 to 12 hr bony pain
OTHERS
Clonidine 2 to 4 mcg/kg PO q 4 to 6 hr Alpha 2 adenoreceptor agonist
May also use a 100 mcg transdermal patch modulates ascending pain
q 7 days for patients > 40 kg sensations
Routes of administration include
oral, transdermal, and spinal
Management of withdrawal
symptoms
Neuropathic Monitor for orthostatic
pain. hypertension, decreased HR
Lancinating,
Sedation common
sharp,
electrical,
shooting
pain.
Phantom limb
pain
Mexiletine 2 to 3 mg/kg/dose PO tid may titrate Similar to lidocaine, longer acting

0.5 mg/kg q 2 to 3 weeks as needed Stabilizes sodium conduction in
max: 300 mg/dose nerve cells, reduces neuronal
firing
Can enhance action of opioids,
antidepressants, anticonvulsants
Side effects include dizziness,
ataxia, nausea, vomiting
May measure blood levels for
toxicity
Side Effects
Opioids have side effects that can create discomfort for children. The most commonly
occurring side effects include constipation, sedation, pruritis, and nausea/vomiting.
Constipation can become a troublesome side effect of opioid analgesic use. Children on opioids
should be immediately started on a stool softener combined with a mild peristaltic stimulant in
an effort to prevent constipation. Constipation can be treated by recommending increased fiber
such as bran cereals and fluids such as prune juice, however this is often unpalatable in children.
Severe constipation, caused by inhibition of peristalsis from the opioids, may require the use of
a stimulating cathartic drug (Table 10). Enemas and suppositories, rarely used in children with
cancer, are administered when other measures have not relieved the problem. The following
guidelines can be used to prevent and manage constipation caused by opioid use.
• Routinely assess the patient's usual bowel habits, use of laxatives and date of last bowel
movement. Optimally, bowel movements should occur a minimum of every 2 days.
• Encourage fluids and fiber products (i.e., water, prune juice, fruits, bran products), but do not
force their use. They can worsen symptoms in the presence of an impaction.
• Begin stool softener or laxative at initiation of opioid use (i.e., Senokot-S®); use of a combined
laxative and stool softener (i.e., Peri-Colace®) should be started if bowel movements are less
frequent than every 2 days.
• Titrate the medications dependent upon the number of bowel movements. For children on long-
term and/or high doses of opioids, constipation can become a chronic problem. If a child has
not had a bowel movement in greater than 3 days despite oral laxatives and softeners, consider
the use of a suppository (i.e., glycerin or bisacodyl). If constipation persists, a strong cathartic
such as oral magnesium citrate or enema may be indicated.
Uncommon side effects of opioids include respiratory depression, seizures, dry mouth,
myoclonus and urinary retention. If a child is receiving a dosage of an opioid analgesic that
provides pain relief but is accompanied by an undesirable side effect, consider switching to
another opioid in equianalgesic dose or add a drug to treat the side effect.
Table 10. Management of Opioid Side-Effects

Nonpharmacologic
Side Effect Adjuvant Drugs
Techniques
Senna and docusate sodium:
Constipation Increase water intake
Tablet:
Prune juice, bran cereal,
2 to 6 years Start: ½ tablet once a day; max: 1
vegetables
tablet twice a day
6 to 12 years Start 1 tablet once a day; max: 2
tablets twice a day
> 12 years Start 2 tablets once a day; max: 4
tablets twice a day
Liquid:
1 month to 1 year: 1.25 to 5 mL q hs
1 to 5 years = 2.5 to 5 mL q hs
5 to 15 years = 5 to 10 mL q hs
> 15 years = 10 to 25 mL q hs
Casanthranol and docusate sodium

Liquid: 5 to 15 ml q hs
Capsules: 1 cap PO q hs
Bisacodyl: PO or PR
3 to 12 years 5 mg/dose/day
> 12 years 10 to 15 mg/dose/day
Lactulose: 7.5 mL/day after breakfast
Adult: 15 to 30 mL PO q day
Mineral oil: 1 to 2 tsp PO/ day
Magnesium Citrate:
< 6 years = 2 to 4 mL/kg PO once
6 to 12 years = 100 to 150 mL PO once
> 12 years = 150 to 300 mL PO once
Milk of Magnesia (MOM)
< 2 years = 0.5 mL/kg/dose PO once
2 to 5 years = 5 to 15 mL PO q day
6 to 12 years = 15 to 30 mL PO once
> 12 years = 30 to 60 mL PO once
Sedation Caffeine: single dose of 1 to 1.5 mg PO Caffeinated drinks (i.e.,
Dextroamphetamine: 2.5 to 5 mg PO in a.m. and Mountain Dew, cola
early afternoon drinks)
Methylphenidate: 2.5 to 5 mg PO in a.m. and early
afternoon
Consider opioid switch if sedation is persistent
Nausea/Vomiting Promethazine: 0.5 mg/kg q 4 to 6 hr; max: 25 Imagery, relaxation
mg/dose Deep, slow breathing
Ondansetron: 0.1 to 0.15 mg/kg IV or PO q 4 hr;
max: 8 mg/dose
Granisetron: 10 to 40 mcg/kg q 2 to 4 hr; max: 1
mg/dose
Droperidol: 0.05 to 0.06 mg/kg IV q 4 to 6 hr; can
Nonpharmacologic
Side Effect Adjuvant Drugs
Techniques
be very sedating
Pruritus Diphenhydramine: 1 mg/kg IV / PO q 4 to 6 hr Oatmeal baths, good
prn; max: 25 mg/dose hygiene
Hydroxyzine: 0.6 mg/kg/dose PO q 6 hr; max: 50 Exclude other causes of
mg/dose itching
Naloxone: 0.5 mcg/kg/hr continuous infusion
Change opioids
(diluted in a solution of 0.1 mg of naloxone
per 10 ml of saline)
Butorphanol: 0.3 to 0.5 mg/kg IV (use cautiously
in opioid tolerant children, may cause
withdrawal symptoms); max: 2 mg/dose
because mixed agonist/antagonist
Respiratory depression: Hold dose of opioid Arouse gently, give O2,
Mild—moderate Reduce subsequent doses by 25% encourage to deep
breath
Respiratory depression: Naloxone: O2, bag and mask if
Severe During Disease Pain Management: indicated
0.5 mcg/kg in 2 minute increments until
breathing improves (APS, 1999; McCaffery
and Pasero, 1999)
Reduce opioid dose if possible
Consider opioid switch
During Sedation for Procedures:
5 to 10 mcg/kg until breathing improves
(Yaster, 1997, Taketomo, Hodding and Kraus,
1997-98)
Reduce opioid dose if possible
Consider opioid switch
Dysphoria/confusion Evaluate medications, eliminate adjuvant Rule out other physiologic
/hallucinations medications with CNS effects as symptoms causes
allow
Consider opioid switch if possible
Haloperidol (Haldol®): 0.05 to 0.15 mg/kg/day
divided in 2 to 3 doses; max: 2 to 4 mg/day
Urinary retention Evaluate medications, eliminate adjuvant Rule out other physiologic
medications with anticholinergic effects; i.e., causes
antihistamines, tricyclic antidepressants In/out or in-dwelling urinary
Occurs with spinal analgesia more frequently than catheter
with systemic opioid use
Oxybutynin: 1 year = 1 mg tid
1 to 2 years = 2 mg tid
> 5 years = 5 mg tid
By the Clock
One of the most common causes of under-medication of children with analgesic drugs is the
use of PRN (pro re nata or “as needed”) dosing schedules. The goal of pain management is to
optimize pain relief while minimizing undesirable side effects. When analgesics are administered
on a scheduled basis a steady therapeutic state is achieved, providing consistent pain relief, and
allowing for tolerance to side effects to develop. When a PRN schedule is used, analgesia is
frequently administered in a random pattern. This results in brief periods of pain relief followed by
potentially long periods of pain with increasing undesirable side effects. PRN dosing 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 (i.e., episode
of intense or severe pain).
By the mouth
The route used to administer medication to children must be carefully considered.
Generally, the least invasive route should be used to administer analgesic medications. Children
present a special challenge in administering medications depending on their age, level of
cooperation, and temperament. If taking medication becomes a struggle, children and parents will
often under report pain to avoid the trauma of taking or giving the medicine.
Routes of Administration
Oral/Sublingual
Children who are able to swallow tablets can achieve excellent pain control with oral
medications, and this route should be the first choice for administration of analgesic medication.
Oral sustained release preparations such as MS-Contin and Oxy-Contin are popular choices due to
the long lasting effects, approximately 8 to 12 hours (DO NOT CRUSH OR CHEW). Fentanyl a
drug used for procedural pain, is now commercially available in a transmucosal lozenge (lollipop)
preparation and has proved to be an effective way to administer medication to children.

Unfortunately, most liquid medication used to manage pain in young children can be unpalatable.
A compounding pharmacist can be very helpful in providing medications in a flavored suspension
or lozenge (troche) form that makes the medication more palatable to young children. In addition, a
compounding pharmacist can formulate medications to be administered by different routes. For
information about specially compounded medications ask your pharmacist or seek national
assistance from: Professional Compounding Centers of America (PCCA), [phone 800-331-2498;
www.thecompounders.com] and the International Academy of Compounding Pharmacists (IACP).
Oral opioids undergo a ‘first pass effect’ in the liver, which requires that oral doses be
higher than parenteral doses. Drugs that can be administered sublingually prevent the first pass
effect as the drug is absorbed directly into the bloodstream and provides a more rapid effect. When
changing from parenteral administration to oral administration of opioid analgesics, health care
providers must calculate the appropriate dosage adjustment to maintain equal analgesic strength to
the parenteral dose to assure adequate pain control (Table 12).
Rectal
Many drugs are available in rectal suppositories, however absorption of drugs by the rectal
route can be inconsistent. The rectal route is also contraindicated in children with neutropenia or
thrombocytopenia because of the risk of infection or bleeding. Generally, children find the
administration of suppositories uncomfortable and invasive. It is not a preferred route if there are
other less invasive routes available.
Transdermal/Topical
Fentanyl patches are the only commercially available opioid in a transdermal preparation.
Onset of action is slow, over 12-18 hours for the first dose, and each patch has a duration of 72
hours before the patch needs to be changed. This route is not useful for rapid dose titration for a
child who is experiencing escalating or severe pain, and is most appropriately used to switch a
patient from oral or parenteral routes who has achieved pain control on another opioid analgesic.
Oral doses of an immediate-release opioid should be continued on a PRN basis for breakthrough
pain.
Intramuscular
The intramuscular route should be avoided in administering analgesic medication to a child.
Children instinctively fear ‘shots’ and will not report pain if they believe they will be given an
injection as a result.
Subcutaneous
Most of the medications used for pain management are available in parenteral form and can
be given as a continuous subcutaneous (SC) infusion. For children who cannot take oral
medications and have no intravenous access, this route is an acceptable alternative and provides
excellent pain control. EMLA® (prilocaine/lidocaine) or other topical agents, such as vapocoolants
or Numby Stuff®, should be used to anesthetize the site prior to inserting the subcutaneous needle
or cannula, making the procedure virtually painless (preparation for invasive procedures p. 44).
Numby Stuff®, an iontophoretic drug delivery system, utilizes an electrical current to facilitate
local dermal anesthesia. Active drug ions are transported into the skin by an electrical current being
passed through dermal patches.
Intravenous
Oral analgesic medications should be given for as long as the child is able and willing to
take them, and as long as the pain can be adequately controlled. However, for children with
analgesic dose requirements that exceed reasonable oral dosing, or for whom oral medications are
not tolerated, the intravenous route is the most appropriate. Patient, parent, or nurse controlled
analgesia (PCA) pumps can be used both in the hospital setting and at home for subcutaneous and
intravenous administration of analgesic medications (Table 11). Many PCA pumps available for
use at home are small and allow the child to remain ambulatory.
Epidural/Caudal/Intrathecal
When high doses of systemic opioids are ineffective in relieving pain or are causing
intolerable side effects (severe constipation, myoclonus, excessive nausea/vomiting), administration
of analgesics via the epidural or intrathecal route will often relieve pain. Administration of analgesia
through an indwelling epidural/caudal/intrathecal catheter directly inhibits pain at very low doses,
thereby reducing undesirable side effects. Decisions regarding patient eligibility, level of catheter
placement, and appropriate drugs and doses should be made in consultation with an anesthesiologist
and according to institutional policies.
By the child
The needs of the individual child must be taken into account when determining dosages of
pain medications. There is not a standard dose that will work for all children. 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). Health care providers must be educated and
provide information to patients and families regarding the appropriate medical use of opioids as
analgesic agents.
Dosing
Selecting an initial dose of opioid analgesic depends on the child’s prior exposure to opioids,
the severity of the pain and route of administration. When initiating analgesic therapy in children
with no prior exposure to opioids, follow the recommended dosage range for the selected opioid
outlined in Table 8. For children with severe pain, it is necessary to titrate the opioid dose
frequently to achieve pain relief as quickly as possible. One method to accomplish this goal is to
start with a short acting opioid such as immediate-release oral morphine, and instruct the family to
give a dose every 2 hours as needed for the first 24 to 48 hours. The total daily dose the patient
required to achieve pain relief is then calculated, and converted to an equivalent dose of an extended
release drug such as MS Contin® or a fentanyl patch. It is important to continue to provide rescue
doses of medication in immediate release form whenever an extended relief form of opioid is used.
Patient controlled analgesia (PCA) offers a highly effective and efficient method for the
treatment of moderate to severe pain (Table 11). For children who are prescribed PCA pumps, a
similar method to titrate the dose as with that of oral morphine is used by the bolus function of the
PCA. A child should be started with a loading dose, if needed, of 0.05 to 1 mg/kg, followed by a
moderate basal rate, 0.01 to 0.2 mg/kg/hr of morphine, with boluses of 0.015 to 0.025 mg/kg
available every 10 to15 minutes. The PRN use should be evaluated on an hourly basis. If a child
experiences persistent or worsening pain on a current dose of opioid, increase the dose by 50% and
re-evaluate within an hour if the dose is given by mouth. When the opioid is given intravenously,
pain assessment should be within 15 minutes of administration. Continue to increase dose by 50%
to 100% q 1 to 2 hours, depending on severity of pain and re-evaluate until comfort is achieved.
Adjust the basal dose of opioids accordingly. After 24 hours the total dose is calculated and the
basal rate adjusted to meet the patient’s demands. It is important that the child and family
understand the use of PRN or bolus doses, and administer additional doses until the pain is under
control. The goal is to stay ahead of the pain, as opposed to ‘chasing’ the pain.
Table 11. Patient Controlled Analgesia– (Morphine)
PCA Programming Purpose Initial Dose Recommendations

Loading dose Obtain immediate pain control 0.05 to 0.1 mg/kg; max: 10 mg
Background infusion To maintain continuous pain relief 0.01 to 0.02 mg/kg/hr

(basal rate)
Interval dose A bolus interval dose will allow the 0.015 to 0.025 mg/kg
patient to titrate his/her own pain control
Lockout To prevent overdose in an opioid naïve 6 to 15 minutes
patients
Four-hour maximum To avoid overdose in an opioid naïve 0.25 to 0.35 mg/kg
patient. Assess q hr to determine
adequate pain management and adjust
dose as necessary (McCaffery, 1999)
Equianalgesic Conversions
The dose of one analgesic drug that is equivalent in pain relieving potential to another
analgesic drug is referred to as an equianalgesic dose. The standard equianalgesic conversion is
based on the pain relieving potential of 10 mg of parenteral morphine. To convert from the oral
route to another route, or from one opioid to another, find the equianalgesic dose of the present
opioid and the opioid you wish to convert in the equianalgesic table (Table 12). Multiply the 24
hour dose of the current drug by the dose of the new opioid from the equianalgesic table. Then
divide by the dose of the new opioid. This will give you the 24 hour dose of the current opioid.
The following example takes you through the conversion process from PO sustained release
morphine to IV hydromorphone.
Example: Johnny is taking sustained release morphine at a dose of 30 mg PO q 8 hr. He is having difficulty
swallowing and the plan is to change to IV hydromorphone as a continuous intravenous infusion.
Step 1: Begin by calculating the 24 hour oral morphine requirement

He has been receiving 30 mg every 8 hours or times a day:
30 mg x 3 times a day = 90 mg q 24 hr
Step 2: Next convert the 90 mg of oral morphine Johnny is taking each day to an equianalgesic dosage of
IV morphine
IV 10 mg IV = X mg IV morphine = 10 x 90 = 900
To PO 60 mg PO 90 mg PO morphine/24 hr 60 60
X = 15 mg IV morphine/24 hr
Step 3: Now convert the 24 hour IV morphine dose to the 24 hour hydromorphone dose
10 mg IV morphine = 15 mg IV morphine (1.5 x 15) = X

1.5 mg IV hydromorphone X mg IV hydromorphone 10
X = 2.25 mg IV hydromorphone (24 hr dose)

Step 4: Take the 24 hour calculated dose and divide by 24 to get the hourly dose
The new dose of IV hydromorphone = 2.25 mg/24 hr
2.25 = 0.1 mg/hr IV hydromorphone

24
Table 12. Equianalgesic Conversion Table
Drug Onset (min) Peak(h) 1 ½ (h) EquianalgesicDoses †
IV/IM Oral
(mg) (mg)
Codeine 10-30 0.5-1 3 120 200
Fentanyl 7-8 ND 1.5-6 0.1 NA
Hydrocodone ND ND 3.3-4.5 ND ND
Hydromorphone 15-30 0.5-1 2-3 1.5 7.5
Methadone 30-60 0.5-1 15-30 10 20
Morphine 15-60† 0.5-1 1.5-2 10 60
Oxycodone, P.O. 15-30 1 ND NA 30
Oxymorphone 5-10 0.5-1 ND 1 10#
From: Texas Children’s Hospital, Pharmacy Department: Drug information and formulary, ed 5, Hudson,
Ohio, 1999, Lexi-Comp. Adapted with permission.
ND = no data available; NA = not applicable

† Based on acute, short-term use. Chronic administration may alter pharmacokinetics and decrease the oral:parenteral
dose ratio. The morphine oral:parenteral ratio decreases to 1.5-2.5:1 upon chronic dosing.
# Rectal.
I.V. administration is most reliable and rapid; I.M. or S.C. use may cause delayed absorption and peak effect. especially
with impaired tissue perfusion. Many agents undergo a significant first-pass effect. All are metabolized by the liver
and excreted primarily in urine. Meperidine is metabolized to normeperidine, a metabolite with significant
pharmacologic activity. The half-life of normeperidine is 15-30 hours and accumulates with chronic dosing, especially
in patients with renal dysfunction. The accumulation of the metabolite may lead to CNS excitation (e.g., tremors,
twitches, seizures).
Table 13. Equianalgesic Doses for Converting
Morphine to Transdermal Fentanyl1
Oral 24-Hr IM 24-Hr Duragesic®
Morphine Morphine Dose
(mg/day) (mg/day) (µg/hr)
45-134 8-22 25
135-224 23-37 50
225-314 38-52 75
315-404 53-67 100
405-494 68-82 125
495-584 83-97 150
585-674 98-112 175
675-764 113-127 200
765-854 128-142 225
855-944 143-157 250
945-1034 158-172 275
1035-1124 173-187 300
1
The analgesic activity ratio of 10 mg IM morphine to 100 mcg IV
fentanyl was used to derive the equivalence of morphine to
Duragesic. A 10 mg IM or 60 mg oral dose of morphine every
4 hr for 24 hr (total of 60 mg/day IM or 360 mg/day oral) was
considered approximately equivalent to Duragesic 100 mcg/hr.
From Janssen Pharmaceutica, Inc., Fentanyl Duragesic®, product
insert, 1997. Adapted with permission.
Tapering Opioids
When a patient is ready to stop an opioid and has received the opioid for more than 3 weeks,
it is advisable to taper the medication. The opioid should be decreased by 20% every other day. If
the patient has signs and symptoms of withdrawal (flu-like symptoms, abdominal cramping,
diarrhea), the dose may need to be decreased in smaller amounts over a longer period of time.
Other opioids may need to be tapered even more slowly such as bezodiazapene which should be
decreased by 10% every 3 days (McCaffery, 1999).

Management of Complex Pain Problems
The majority of children with cancer pain can experience complete relief of pain using the
previous discussed agents. However a small number of children, particularly those with extensive
bony tumor metastasis and/or nerve involvement, may require more invasive pain management
techniques. Children with complex pain problems require thorough consideration of the
pathogenesis of the pain and consultation with a variety of specialty services who are experienced in
the management of pain in children. Clear communication with the child and family as to the goals
of any potential interventions is essential. When considering invasive therapies to control pain, the
risks and discomforts associated with the procedure must be weighed against the likelihood of pain
relief for the child.
Palliative Chemotherapy/Radiation Therapy
Intractable pain from increased tumor bulk, that is not responding to increasing doses of opioids,
may be responsive to palliative chemotherapy or radiation. The patient and family must understand
the goal of treatment with these modalities and consent to their use. Palliative chemotherapy can
be effective in reducing pain and symptoms if the tumor is still chemosensitive. The least toxic
drug and dose is used, and side effects are aggressively managed. Palliative radiation therapy can
be very effective in relieving localized pain from extensive bony metastasis, bone marrow disease,
and/or nerve compression.
Therapeutic nerve blocks
Tumors that are compressing nerves in a specific area can lead to intense focal pain. The use
of locally administered anesthetic nerve blocks can provide immediate relief from pain that is
otherwise not responsive to other less invasive techniques. Neuroablation with alcohol or phenol
can permanently destroy individual nerves. These interventions are used only in extreme cases of
nerve entrapment and excruciating pain when other interventions have failed. There is no assurance
that such blocks or ablative techniques will provide complete or permanent relief. When successful,
pain relief can be immediate. Gradual discontinuation of opioids and monitoring for respiratory
suppression and withdrawal symptoms should be the primary focus of care after such procedures.
Terminal Sedation
In very rare circumstances, children may experience such unrelenting pain or other
symptoms, that the need for sedation may be considered. Sedation is generally indicated when pain
and distress cannot be controlled by any other means either due to limited timeframe or risk of
excessive morbidity. The health care professional must determine what are truly uncontrollable
pain or symptoms versus under-treated pain and/or symptoms. It is important that prior to
considering sedation, all efforts have been made to achieve pain and symptom control.
Sedation must not be confused with euthanasia. Euthanasia refers to the active intent by
another person to end a terminally ill person’s life for the sake of compassion or mercy. The
ethical principle of double effect clarifies such issues. Double effect states that some interventions
have risks and benefits associated with them. If the intent is to provide benefits (pain relief), then
the risks (respiratory depression, death) are acceptable. The goal of sedation is to relieve obvious
pain and suffering of the child by adding drugs to induce sleep, but does not intend to hasten death.
Presenting the option of sedation to a child and family requires a caring, open relationship
between the treating health care professionals and the family. If the child and family are opposed to
sedation, they should be reassured that all efforts to gain control of pain and distress will continue.
If the child and family choose sedation, there are a number of pharmacological agents available to
produce the desired level of relief. It is important to recognize that sedation alone does not provide
analgesia, and a level of opioid analgesia that provides the most comfort possible should be
continued while the child is sedated. Consultation with a hospice physician would be appropriate to
determine the clinical appropriateness and best agents to use to achieve the desired comfort goals of
the child and family.

VI. Procedure-Related Pain Management
Invasive procedures are documented as the most painful and traumatic events experienced
by children. Although procedure-related pain represents an acute, short-lived experience, it is
accompanied by a great deal of fear and anxiety. For example, researchers have reported that bone
marrow aspirations/biopsies and lumbar punctures are perceived as extremely painful by children
with cancer (Broome, Rehwaldt and Fogg, 1998; Broome and others 1990). Previous studies have
shown that children do not adapt to the discomfort associated with intrusive procedures, but
experience greater levels of anxiety with repeated painful experiences (Zeltzer, 1990). Children
often experience symptoms such as depression, insomnia, and anorexia before the clinic or hospital
visit which will include a procedure. Consensus among professionals caring for children with
cancer supports a developmental approach to managing pain associated with procedures in children
with cancer. The goal is to provide comfort and support during all procedures experienced by the
child with cancer. The Consensus Conference on the Management of Pain in Childhood Cancer has
established the following principles that apply to all children undergoing painful interventions
(Table 14).
Table 14. Managing Childhood Procedure Related Pain
1. Prepare the child and parent(s) with specific interventions.
2. Provide maximum treatment of pain and anxiety for the initial procedure to reduce
the development of subsequent anticipatory anxiety symptoms.
3. Provide adequate knowledge of behavioral and pharmacologic treatment of acute

pain and anxiety by medical staff responsible for procedures.
4. Use appropriate monitoring and resuscitative equipment in the procedure room when
using sedation.
5. Assure adequate mechanical skill in individuals who plan to perform pediatric

procedures.
6. Provide ongoing evaluation of the child to assess efficacy of treatment for pain and
anxiety.
7. Create as pleasant an environment as possible in the treatment room.
From: Report of the Subcommittee on the Management of Pain Associated With Procedures in Children with Cancer, by LK Zelter,
and others, 1990. Pediatrics, 86(5), p 827. Copyright 1990 American Academy of Pediatrics. Adapted with permission
Goals of Procedural Pain Management (Schechter, Berde and Yaster, 1993)

There are three goals associated with successful procedural pain management. All require the early
determination of appropriate outcomes. These three goals include:
Minimize pain – coordinate painful procedures such as blood drawing and lumbar punctures; limit
the number of attempts for a procedure.
Maximize patient cooperation – early preparation of parent and child with information, role
playing, and audio visual aids can be of benefit.
Minimize risk to the patient – adequate monitoring and resuscitative equipment must be available
and operational; pulse oximetry is a necessity; psychologic intervention can help to reduce need for
pharmacologic agents.
Interventions
• During the course of treatment, children will frequently undergo invasive procedures which can
often be painful; for this reason, it is essential that the child be able to cope with this situation.
The first and most essential intervention is to prepare the child and family for the painful
procedure. The use of dolls to teach the younger child about what will occur during the
procedure can help to relieve some of the child’s anxiety and dispel misconceptions the child
may have. In addition, parents may benefit from written educational information, as well as a
review of the procedure and what to expect.
• The use of EMLA® cream (prilocaine/lidocaine) or anesthetic disc has proven successful in the
relief of procedure related pain. EMLA® cream or anesthetic disc is a topical anesthetic which
effectively penetrates intact skin and should be applied one to one and a half hours, but not
longer than four hours, before the procedure is to occur.
• For patients who receive a bone marrow aspirate or biopsy, buffered lidocaine may provide
subcutaneous analgesia that penetrates deeper than EMLA. The purpose of buffering lidocaine
is to alter the pH with an alkaline solution so that there is less burning with the injection. To
buffer the lidocaine, add 0.2 mL of sodium bicarbonate to 2 mL of lidocaine. Inject the buffered
lidocaine slowly into the subcutaneous tissue, using a 25 gauge needle. Wait two minutes, then
change the needle to a larger gauge and inject the lidocaine directly into the surface of the
periosteum. Wait an additional two to three minutes. This waiting time allows the lidocaine to
numb the area.
Pharmacologic management of procedural pain should provide both analgesia and sedation.
A pharmacologic approach known as conscious sedation is currently favored in many institutions.
The American Academy of Pediatrics defines conscious sedation as “a minimally depressed level of
consciousness that retains the patient’s ability to maintain a patent airway independently and
continuously, and respond appropriately to physical stimulation and/or verbal command” (AAP,
1992). Conscious sedation can be achieved with a variety of pharmacologic approaches (Table 15),
most of which combine an opioid analgesic with a benzodiazepine for anxiolysis and sedation. The
mixture DPT (Demerol, Phenergan, Thorazine) or Kiddie Cocktail administered
intramuscularly in many institutions for years as sedation is no longer recommended as the injection
is painful, and, most importantly, the drug combination is associated with a high incidence of side
effects. An opioid and/or benzodiazepine can be titrated to an individual patient’s response and
reversed with available agonists (naloxone: 5 to 10 mcg/kg/dose and flumazenil: 0.2 mg/dose). It is
critical for the practitioner sedating the child for a painful procedure to be familiar with the
pharmacokinetics and pharmacodynamics of the drugs selected in order to anticipate the onset and
duration of expected side effects.
Table 15. Examples of Sedation Medications
Drug Dosing Side-Effects Reversal Agents

CONSCIOUS SEDATION:
Midazolam:
A Benzodiazepine Oral: 0.2 to 1 mg/kg; 30 to 45 Respiratory distress, Flumazenil: 0.2
(short acting), CNS minutes before procedure; max: 20 depression, apnea, PVC's, mg/dose q 1 minute;
depressant mg amnesia, blurred vision, or max cumulative = 1
Onset: 1 to 5 minutes hyperexcitibility mg
Peak Effect: 3 to 5 IV: 0.05 mg/kg 3 minutes before
minutes (IV) procedure (may repeat dose X 2);
Half Life: 1.5 to 12 max: 2 mg/dose
hr
Fentanyl:
A Narcotic analgesic IV: 0.5 to 3 mcg/kg/dose; may Respiratory distress or Naloxone: 5 to 10
Onset: 1 to 5 repeat after 30 to 60 minutes; max: depression, apnea, seizures, mcg/kg/dose; Single
minutes 50 mcg/dose shock, chest wall rigidity dose should not
Peak Effect: (no data Use lower doses (0.5 to 1 (most likely to occur with exceed max
available) mcg/kg/dose) when used in rapid infusion or high doses) recommended adult
Half Life: 1.5 to 6 hr combination with other agents, such dose of 0.2 mg
as midazolam (Taketomo,
Hodding and Kraus,
1997-98)
Morphine:
A Narcotic Analgesic IV: 0.05 to 0.1 mg/kg Sedation, somnolence, Naloxone: 5 to 10
Onset: 15 to 60 5 minutes prior to procedure; max: respiratory distress or mcg/kg/dose; Single
minutes 15 mg/dose depression, pruritis dose should not
Peak Effect: 30 exceed max
minutes to 1 hr recommended adult
Half Life: 1.5 to 2 hr dose of 0.2 mg
(Taketomo,
Hodding and Kraus,
1997-98)
UNCONSCIOUS SEDATION:
Propofol:
A General anesthetic IV: 1 to 2 mg/kg followed by 75 to Pain on injection, None
Onset: within 30 100 mcg/kg/minute involuntary movements,
seconds (Only with qualified anesthesia hypotension, apnea
Drug Dosing Side-Effects Reversal Agents
Peak Effects: 3 to 10 personnel available)
minutes
Half Life:
3 compartment
model:
initial: 2 to 8
minutes
2nd Distribution: 40
minutes
terminal: 200
minutes
Ketamine:
A General anesthetic Oral: 6 to 10 mg/kg given 30 Laryngospasm, severe None
Onset: 30 seconds minutes prior to procedure hypo/hypertension,
with IV respiratory depression,
administration; PO IV: 0.25 to 0.75 mg/kg apnea, excessive salivation
20 to 45 minutes (Only: with qualified anesthesia
Peak Effects: 5 personnel available)
minutes
Half Life: unknown
• There is the potential for pediatric patients to develop a syndrome referred to as “late sedation”
with these conscious sedation medications. Late sedation can occur even when the child does
not seem to be sedated at the end of the procedure, and can be due to continued drug uptake,
delayed excretion, pharmacodynamics, or the lack of external stimulation. For this reason the
child should be observed in an appropriate recovery facility for at least one hour prior to
discharge.
• Specific agonists or reversal agents must be available whenever opioid analgesics or
benzodiazepines are administered prior to a procedure (Table 15). Before or concomitantly with
pharmacologic reversal, patients who become hypoxemic or apneic during the procedure
should: 1) be encouraged or stimulated to breathe deeply; 2) receive positive pressure
ventilation if spontaneous ventilation is inadequate; and 3) receive supplemental oxygen. After
reversal, patients should be observed long enough to ensure that cardiorespiratory depression
does not recur (American Society of Anesthesiologists, 1996).

It is always important to maximize the intervention for the first procedure so that anticipatory
anxiety does not develop. The use of deep sedation or general anesthesia for initial procedures is
one approach which can assure that a patient and family do not have an initial traumatic experience.
For some children pharmacologic treatment may diminish their sense of control and they may feel
helpless and ineffective. Treatment should be individualized to the needs of the patient. The goals
of procedure pain management are to make the procedure as nonthreatening and comfortable as
possible.
VII. Nonpharmacologic Pain Interventions
Nonpharmacologic interventions in the management of pain have been found to be highly
effective for some children and for some procedures. These techniques are easy to learn and should
be used when possible to give the child some control in the management of pain. The examples
given for distraction, muscle relaxation, and guided imagery are easy techniques to learn and can be
used with young children. Additional interventions requiring specialized training include
therapeutic touch and accupressure. However, nonpharmacologic interventions are an adjunct to,
not a substitute, for pharmacological interventions.
Distraction
Distraction is used to focus the child’s attention away from the pain. For children, simple
distraction techniques can be very effective in decreasing pain. Simple measures such as looking at
books, blowing bubbles, and counting are favorite distraction techniques for children. Touch can
be an important distraction technique by stroking, patting and rocking infants as well as children
who are in distress.
Deep breathing is the easiest technique to use with young children. The child is
instructed to take a deep breath through the nose and blow it out through the mouth. Making a
conscious effort to count the child’s respirations focuses attention on the breathing. For school age
children, asking them to hold their breath during a painful procedure transfers their focus to their
breathing and not on the procedure. Asking children to “blow away their pain” has also been
discussed as an effective distraction tool (French, Painter and Coury, 1994).
Parents should be taught distraction measures and encouraged to hold their children for
comfort as much as possible (Table 16). Parent coaching gives them a way to participate in
decreasing their child’s pain and also may provide some benefit in decreasing parent anxiety and
worry.
Table 16. Distraction Techniques in Children
Age Methods
0-2 years Touching, stroking, patting, rocking, playing music, using mobiles over the crib
2-4 years Puppet play, storytelling, reading books, breathing, blowing bubbles
4-6 years Breathing, storytelling, puppet play, talking about favorite places, TV shows, activities
6-11 years Music, breathing, counting, eye fixation, thumb squeezing, talking about favorite places, activities on
TV shows, humor
Muscle Relaxation
Muscle relaxation is used to decrease mental and physical tension. It is used most
effectively in older children and adolescents because it involves the relaxation of voluntary skeletal
muscles. Slowly each muscle is tensed and then relaxed in a systematic way. Attention is placed
on breathing which causes the individual to be aware of the feelings of tension and relaxation.
Once breathing is under control, attention is focused on the muscles to promote progressive
relaxation. This technique is useful prior to an anxiety producing procedure. Conscious awareness
of the tension creates a more relaxed state, enabling the procedure to be completed more easily.
The following exercise can be used with most children over 5 years of age.
Muscle Relaxation exercise:
Make yourself as comfortable as possible. Move around in your chair or bed until you feel good.
Close your eyes when you are ready. Take a deep breath through your nose and breathe it our
slowly. Breathe again in and out slowly. Now focus on your hand, make a tight fist and hold it, hold
it, now let it relax. Focus your attention on the muscles of your arm, push down your elbow against
the arm of the chair or onto the bed, hold it, hold it, now relax your arm. Let’s begin relaxing the
muscles of our head and neck. Lift your eyebrows up as high as possible, hold those muscles tight,
hold them, now relax and let them go. Squint your eyes and wrinkle your nose, hold those muscles
tight, hold them, now relax and let them go. Bite your teeth together and make a smile, hold those
muscles tight, hold them, now relax and let them go. Pull your chin down toward your chest, hold it
tight, hold it, now relax and let it go. Take a deep breath, hold it, hold it, pull your shoulders back,
now relax and let it go. Pull your stomach in and try to hold it, hold it tight, now relax those
muscles and let them go. Lift your leg and hold it out straight, hold it, hold it, now relax and let it
rest again on the floor or bed. Left the other leg and hold it out straight, hold it, now relax and let it
rest again on the floor or bed. Point your toes toward the ceiling, hold them tight, keep them
pointed, now relax them, let them go. Take another deep breath through your nose and let it our
slowly through you mouth, breathe in again slowly and let it our through your mouth. Notice how
relaxed your muscles feel.
Guided Imagery
Guided imagery engages the child by focusing on a pleasant activity, providing distraction
from the pain, or changing the perception of the painful experience. Imagery is used to give the
child the opportunity to imagine being in a more pleasant situation (Table 17). Effective use of
imagery involves all of the child’s senses. When imagining a favorite place the child is asked to
feel the warmth all around, see the colors, smell the odors, and hear the sounds. This helps the child
create a clear scene in their mind. It is important to stress that every child needs a favorite place to
go that is safe. This safe place provides a means of escape. Children often like to imagine they are
watching a favorite TV show or movie. The child can be involved in this type of imagery by asking
the child to discuss what is happening on the TV show like a cartoon. The child can sometimes
imagine being a particular character in the cartoon. The following is an exercise that can be used
with school age children and adolescents.
Guided Imagery Exercise:
Make yourself as comfortable as possible. Move around in your chair or bed. Take a deep breath
through your nose and breathe it out slowly. I am going to count and with each number you will
notice yourself becoming more comfortable. 12, breathing softly, 11-10-9-8, you can close your eyes
if you wish. You may want to imagine in your mind a place that is special to you. It may be at the
seashore, by a river, in the mountains. There may be other people there with you, or you might want
to be by yourself. 7-6-5-4, you can enjoy this special place and know that your mind will remember
it when you need to return. 3-2-1, your breathing is now slow and easy. The muscles of your face
are relaxed. Let yourself see, feel, and hear the surroundings of that special place. It is yours.
(Pause a few minutes and let them enjoy that special place). When you are ready to return from that
special place all your own, you will become more aware of my voice, aware of the light in the room.
You may want to stretch your muscles, take a deep breath. You can open your eyes when you are
ready.
Table 17. Favorite Imagery Scenes for Children
Visual Imagery
Favorite places
Animals
Flower gardens
TV or movies
Favorite room
Favorite sport
Auditory Imagery
Conversations with significant others
Favorite song
Playing a musical instrument
Listening to music
Environmental sounds (waves, etc.)
Movement Imagery
Flying
Swimming
Skating
Amusement rides
Any activity
Comfort Measures
Comfort measures can be a useful treatment option for reducing pain. Comfort measures
can be used as a distraction to help to relieve the anxieties and fears associated with painful
procedures. These measures generally allow the child to feel more relaxed and at ease. Various
comfort measures that can be useful to children with cancer are discussed in Table 18.
Table 18. Comfort Measures
Comfort Measure Description
Quiet presence Sitting quietly and displaying a sense of calmness.

Massage Includes stroking, rubbing or deep manipulation of muscles.
Music Can help to provide the child with a familiar environment;
children often come to the hospital or hospice with their own
music.
Heat Warm compress or use of a heating pad, to the painful site
(moist or dry heat).
Cold/Ice Cold compress or ice pack. Precaution: assure ice pack is
wrapped allowing comfortable sensation of cold without
damaging the skin by freezing tissue. Limit ice application to
10 minutes, then rotate site. If skin becomes blanched,
discontinue cold treatment.
Baths Warm soak; can include whirlpool/jacuzzi.
Vibration Over the counter massage devise. May be used to stimulate
skin and muscle tissue.
Menthol Product (e.g., Apply to skin, however caution must be used to avoid areas of
Ben-Gay) open wounds or irritated skin. Product selection is important
as some contain salicylates which may be contraindicated in
some patients.
VIII. Special Considerations for The Dying Child
When a child is diagnosed with cancer there is a strong possibility that cure can be achieved.
Options for cure and goals of treatment are outlined with the child and family, and the child is
placed on the most up-to-date treatment protocols available. The health care team monitors
treatment response frequently and assesses for side effects.
For the child and family who do not achieve cure, it is imperative that they receive the same
level of monitoring and assessment of pain and discomfort throughout the terminal phase of the
illness. When the goal of care shifts from a curative intent, to palliation of symptoms and support
through the dying process, health care professionals should inform parents of the options available
for managing pain and other symptoms. Families should be reassured that continued attentive care
and support will be provided. The goal of care becomes freedom from pain and discomfort and
enhancement of the quality of the time remaining to the child and family.
The majority of children with cancer who are terminally ill will require pain relief. Children
with solid tumors often experience metastasis throughout the body and may present with mixed
etiologies (e.g., bone, nerve, visceral) for their pain. These patients may require a combination of
opioids, adjuvants, and invasive therapies to provide adequate pain relief. Children with
hematologic malignancies often experience rapid onset of pain due to marrow infiltration; however,
they are usually managed very successfully on a combination of opioids and adjuvants. Pain in
terminally ill children not only varies with the degree and location of physical damage to tissues but
also by the psychological, social, and cultural factors unique to each child.
Goals of Pain Management in Terminally Ill Children
● The child can sleep undisturbed by pain.
● Side effects from pain medications will be prevented or minimized.
● The child is pain-free when at rest.

● The child can move about or be handled without discomfort.
● The family is educated regarding the pain treatment plan.
● The family is involved in choosing the most effective and appropriate pain management for the
child.
● The family is able to identify increasing pain and provide analgesics to relieve the pain.
Principles for managing pain in terminally ill children
● Consider the concept of complete pain control at all times and conduct a thorough but rapid
assessment of the pain.
● Titrate medications as needed.
● Avoid unnecessary delay in treating the pain, especially if it is severe.
● Follow the WHO analgesic stepladder and utilize pain management interventions appropriate to
the level of pain reported by the child.
● Consider adjuvant therapy at all stages. These drugs have little or no intrinsic analgesic activity
but produce useful pain relief either alone or as an adjuvant to standard analgesic drugs. These
include corticosteroids, antidepressants, anticonvulsants, muscle relaxants, and anxiolytics
(Table 9).
● Give drugs by the least traumatic route available. If a young child refuses oral medications and
administration is traumatic for the parent and child, consider alternative routes such as dermal,
subcutaneous or intravenous infusion to decrease the distress on the child and family.
● Use appropriate conversions when changing route.
● Use around the clock dosing to provide consistent pain relief. Provide extra doses for the
management of escalating or breakthrough pain. PRN doses are only useful for breakthrough
pain, not as the primary management.
● Frequently reassess the child’s pain, particularly after adjusting dosages or adding additional
drugs. If pain is severe, reassess every 30 minutes and continue to modify doses and drugs until
pain relief is achieved. Seek consultation with other pediatric specialties or hospice and
palliative care professionals in complex pain presentations.
● Anticipate side effects associated with analgesic therapy and treat them prophylactically when
possible. Manage any distressing symptoms aggressively as they occur.

Appendix A: Translations for “pain”
Language Translation
Spanish Dolor
French Douleur
German Schmerz
Italian Dolore
Vietnamese Đau
Chinese Tong
Appendix B: Additional Behavioral Assessment Scales
Tools and Authors/

Ages of Use Reliability and Validity
Objective Pain Score (OPS) No testing in original publication
(Hannallah and others, 1987) Later tested by original authors
Ages of use: 4 months–18 years 1988–concurrent validity with Linear Analogue Pain Scale, Spearman’s r = 0.721
with scores ∞ 6 and 0.419 with scores < 6
1991–interrater agreement, coefficient alpha = 0.986 for one rater and 0.983 for
the other
1991–concurrent validity with CHEOPS, Pearson correlation coefficient = 0.88
and 0.94
Children’s Hospital of Eastern Interrater reliability = 90%–99.5%
Ontario Pain Scale (CHEOPS) Internal correlation = significant correlations between pairs of items
(McGrath and others, 1985) Concurrent validity between CHEOPS and VAS = 91; between individual and
Ages of use: 1–5 years total scores of CHEOPS and VAS = 0.50–0.86
Construct validity with preanalgesia and postanalgesia scores = 9.9 – 6.33
Nurses Assessment of Pain Inventory Not tested by original author. Later tested by Joyce and others (1994).
(NAPI) Interrater agreement: weighted kappa 0.37–0.80
(Stevens, 1990) Discriminant validity: statistically significant differences between preanalgesia
Ages of use: newborn–16 years and postanalgesia scores ( p < .0001)
Reliability: Cronbach’s alpha = 0.35–0.69
Behavioral Pain Score (BPS) Original article stated, “reliability of the BAS and BPS scores was tested by a k
(Robieux and others, 1991) test”; no further testing of reliability or validity was mentioned
Ages of use: 3–36 months
Modified Behavioral Pain Scale Concurrent validity between MBPS and VAS scores = correlation coefficient 0.68
(MBPS) (p < 0.001) and 0.74 (p < 0.001)
(Taddio and others, 1995) Construct validity using prevaccination and postvaccination scores with EMLA vs.
Ages of use: 4–6 months placebo: significantly lower scores with EMLA (p < 0.01)
Internal consistency of items = significant correlations between items
Interrater agreement: ICC = 0.95, p < 0.001
Test–retest reliability: r = 0.95, p < 0.001
Riley Infant Pain Scale (RIPS) Interrater agreement using Intraclass Correlation Coefficient = 0.53–0.83, p <
(Schade and others, 1996) 0.0001
Ages of use: <36 months and Discriminant validity using Mann–Whitney U test with preanalgesia and
children with cerebral palsy postanalgesia scores = statistically significant (p < 0.001)
Sensitivity = 0.31–0.23
Specificity = 0.86–0.90
FLACC Postoperative Pain Tool Interrater reliability using two–way cross tabulations and kappa statistics (r[87] =
(Merkel and others, 1997) 0.94; p < 0.001) and kappa values above 0.50 for each category
Ages of use: 2 months–7 years Validity using ANOVA for repeated measures to compare FLACC scores before
and after analgesia; preanalgesia FLACC scores were significantly higher
than postanalgesia scores at 10, 30, and 60 minutes (p < 0.001 for each time)
Correlation coefficients used to compare FLACC pain scores and OPS pain scores;
significant positive correlation between FLACC and OPS scores (r = 0.80; p
< 0.001); positive correlation also found between FLACC scores and nurses’
global ratings of pain (r[47] = 0.41; p < 0.005)
Appendix C: Spanish Translation for FACES Pain Rating Scales for
Children
FACES Pain Rating Scale
(Whaley and Wong, 1999,
with permission)
0 1 2 3 4 5
No Hurt Hurts Hurts Hurts Hurts Hurts
Little Bit Little More Even More Whole Lot Worst
FACES Scale From Nursing Care of Infants and Children, 6th ed., (p 2040), by DL Wong and others, 1999. St. Louis: Mosby. Copyright 1999,
Expliquele a la persona que cada cara representa una persona que se siente feliz perque no tiene
dolor o triste perque siente un poco o mucho dolo. Cara 0 se siente muy feliz perque notiene dolor.
Cara 1 tiene un poco de dolor. Cara 2 tiene un poquito más de dolor. Cara 3 tiene más dolor.
Cara 4tiene mucho dolor. Cara 5 tiene el dolor más fuerte que usted pueda imaginar, aunque usted
no tiene que estar llorando para sentirse asi de mal. Pidale a la persona que escoja la cara mejor
descibe su proprio dolor.
Esta escala se puede usar con personas de tres años de edad más.
References:
AAP – American Academy of Pediatrics, Committee on Drugs (1992). Guidelines for monitoring
and management of pediatric patients during and after sedation for diagnostic and
therapeutic procedures. Pediatrics, 89(6), 1110-1115.
APS – American Pain Society (1999). Principles of analgesic use in the treatment of acute pain
and cancer pain, (4th ed.). Glenview, IL: American Pain Society.
American Society of Anesthesiologists (1996). Practice Guidelines for Sedation and Analgesia by
Non-Anesthesiologists. A Report by the American Society of Anesthesiologists Task Force
on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology, 84, 459-471.
Anand KJ (1998). Clinical importance of pain and stress in preterm neonates. Biol Neonate, 73(1),
1-9.
Baker CM and Wong DL (1987). QUEST: a process of pain assessment in children. Orthop Nurs
6(1),11-21.
Beyer JE, McGrath PJ and Berde CB (1990). Discordance between self-report and behavioral pain
measures in children aged 3-7 years after surgery. J Pain Symptom Manage 5(6), 350-356.
Broome ME, Rehwaldt M and Fogg L (1998). Relationships between cognitive behavioral
techniques, temperament, observed distress, and pain reports in children and adolescents
during lumbar puncture. J Pediatr Nurs 13(1), 48-54.
Broome ME, Bates TA, Lillis PP and McGahee TW (1990). Children’s medical fears, coping
behaviors, and pain perceptions during a lumbar puncture. Onc Nurs Forum 17(3), 361-367.
Collins JJ and Berde CB (1997). Management of cancer pain in children. In PA Pizzo and DG
Poplack (Eds), Principles and Practice of Pediatric Oncology, 3rd ed, (pp. 1183-1199).
Philadelphia: Lippincott-Raven.
Favaloro R and Touzel B (1990). A comparison of adolescents’ and nurses’ postoperative pain
ratings and perceptions. Pediatr Nurs, 16(4), 414-424.

French GM, Painter EC, and Coury DL (1994). Blowing away shot pain: A technique for pain
management during immunization. Pediatrics, 93(3), 384-388.
Foley KM (1996). Controlling the pain of cancer. Sci Am 275(3),164-165.
Hertzka RE, Gauntlett IS, Fisher DM and Spellman MJ (1989). Fentanyl-induced ventilatory
depression: effects of age. Anesthesiology 70(2), 213-218.
Jacox A, Carr DB, Payne R and others (1994). Management of Cancer Pain: Adults Quick
Reference Guide, (No 9, AHCPR Publication No 94-0593). Rockville, MD: Agency for
Health Care Policy and Research, Public Health Service, US Department of Health and
Human Services.
Kart T, Christrup LL and Rasmussen M (1997). Recommended use of morphine in neonates,
infants and children based on a literature review: Part 2—Clinical use. Paediatr Anaesth
7(2), 93-101.
Leahy S, Hockenberry-Eaton M and Sigler-Price K (1994). Clinical management of pain in
children with cancer: selected approaches and innovative strategies. Cancer Practice 2(1),
37-45.
Martin G (1998). Experience talks: How we’ve managed pain and symptoms in our pediatric
hospice patients. Hospice, 9(1), 21-23.
McCaffery M and Pasero C (1999). Pain: A Clinical Manual, 2nd ed. St. Louis: Mosby.
McGrath PA (1996). Development of the World Health Organization guidelines on cancer pain
relief and palliative care in children, J Pain Symptom Manage 12(2), 87-92.
Micromedex® Healthcare Series: MICROMEDEX Inc, Englewood, Colorado, 1999.
Olson G and Berde C (1993). Neuropathic pain in children and adolescents. In NL Schechter, CB
Berde and M Yaster (Eds), Pain in Infants, Children, and Adolescents (pp 473-493).
Baltimore, MD: Williams & Wilkins.

Physicians’ Desk Reference, 53rd ed. (1999). Montvale, New Jersey: Medical Economics
Company.
Sabatino G Quartulli L, Faio S and Ramenghi, LA (1997). Hemodynamic effects of intravenous
morphine infusion in ventilated preterm babies. Early Hum Dev 47(3), 263-270.
Schecter NL, Berde CB and Yaster M, (Eds). (1993). Pain in Infants, Children, and Adolescents.
Baltimore, MD: Williams & Wilkins.
Taketomo CK, Hodding, JH and Kraus DM (1998). Pediatric dosage handbook, 4th ed, 1997-1998.
Hudson, Ohio: Lexi-Comp.
Tesler MD and others (1991). Children’s words for pain. In SG Funk and others, (Eds), Key
aspects of comfort: management of pain, fatigue, and nausea. New York: Springer.
Texas Children’s Hospital, Pharmacy Department (1999). Drug information and formulary, 5th ed.
Hudson, Ohio: Lexi-Comp.
Whaley L and Wong DL (1987). Nursing care of infants and children, 3rd ed. St Louis: CV
Mosby.
Wong DL and Baker C (1988). Pain in children: comparison of assessment scales. Pediatr Nurs
14(1), 9-17.
Yaster M and others (1997). Pediatric pain management and sedation handbook. St. Louis:
Mosby.
Zeltzer LK, Jay SM and Fisher DM (1989). The management of pain associated with pediatric
procedures. Pediatr Clin North Am 36(4), 941-964.

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PAIN MANAGEMENT IN

CHILDREN WITH CANCER

For further booklets or information, contact the Web site:

IN APPRECIATION TO THE FOLLOWING ORGANIZATIONS

Visit Our Pediatric Pain Management Web site at:

Marilyn Hockenberry-Eaton, PhD, RN-CS, PNP, CPON, FAAN

Texas Children’s Hospital Baylor College of Medicine

Donna Wong, PhD, RN, PNP, CPN, FAAN

Edith M. Eby, PharmD

Nancy E. Kline, PhD, RN, CPNP

Carol Benefield Mary Choroszy, MSN, RN, CPNP

Dana Bond, MN, RN, CPNP John Foster, President

Melody Brown, MS, RN, CPON Janine Primomo, MSN, RN

Kathy Forte MS, RN, CPNP

Pat Brophy MSN, RN, CRNP

Casey Hooke MSN, RN, CPON

Susan Lively RN, CPON

Gina Mink MS, RN

I. Physiology of Pain pp 9-10

II. Etiology of Cancer Pain pp 11-13

III. Barriers to Effective Pain Management pp 14-16

IV. Pain Assessment pp 17-23

V. Pharmacologic Pain Management pp 24-44

VI. Procedure Related Pain pp 45-49

VII. Nonpharmacologic Pain Management pp 50-54

VIII. Special Considerations For The Dying Child pp 55-56

during or after treatment and is often undertreated.

the terminally ill child.

the care of the dying child.

providing an analgesic effect.

Neuropathic pain is caused by altered excitability of the peripheral or central nervous

system, usually caused by dysfunction or injury. Neuropathic pain is distinguished from

described as a burning, stabbing, or shooting sensation. A complete neurologic exam is essential to

children with cancer.

Table 1. Neuropathic versus Nociceptive Pain

Two Major Types of Pain:

I. Nociceptive Pain II. Neuropathic Pain

A. Somatic Pain B. Visceral Pain C. Centrally Generated D. Peripherally Generated

infiltration of the periosteum, pathologic fractures, tumor growth of surrounding tissues, or

Vincristine, a plant alkaloid, is most commonly associated with peripheral neuropathies,

receiving anthracyclines (i.e., daunorubicin), alkylating agents (i.e., cyclophosphamide),

typhlitis, cellulitis, or sinusitis.

Bone -Aching to sharp, severe pain generally more -Infiltration of bone

Visceral -Poorly localized -Obstruction – bowel, urinary tract,

-Infection -Infection may be localized pain from a Direct side-effects of

-Radiation -Skin inflammation causing redness and

-Post-surgical -Pain related to tissue trauma secondary to

old fetus possesses the anatomical and neurochemical capabilities of experiencing

nociception (Anand, 1998).

for adults when appropriately administered (Foley, 1996).

• Narcotic addiction - A voluntary psychological behavioral pattern characterized

are experiencing pain or draw a picture illustrating their perception of pain.

with repeated procedures (Zeltzer, 1990).

report pain due to fear of administration of a painful analgesic (injection) or fear of

(Favaloro and Touzel, 1990).

3) Fear that pain is a sign that the disease is worsening.

that reality, they may not acknowledge pain.

Other Barriers To Adequate Pain Control (Martin, 1998)

2) There is often a lack of a comprehensive approach to pain assessment.

3) Healthcare providers may underestimate the intensity of the child’s pain.

QUEST PRINCIPLES OF PAIN ASSESSMENT (Baker and Wong, 1987)

Figure 1. Key Factors In The Assessment of A Child In Pain

Self Report Physical Behavioral Physiologic Measures