PAIN IN PEDIATRIC CANCER

Anky Tri Rini Kusumaning Edhy

Hematology – Oncology Working Group
 OBJECTIVES

 Definition of Pain
 Classification of Pain
 Pathophysiology of Pain
 Assessment of Pain
 Management of Pain
Can you imagine how painful it is?
 A, Girl, 13 yo
 Osteosarcoma stage IV
 DEFINITION

 An unpleasant sensory and emotional experience

associated with actual or potential tissue damage,
described in trems of such damage.

(International Association for the Study of Pain)

 In cancer,

 Related to the diseases

 Related to the procedures
 Related to the medications
 Related to care*
Palliative
Palliative care without Morphine is not Palliative care
CLASSIFICATION
 PATHOFISIOLOGY
1. Transduction:
Conversion of noxious thermal, mechanical, chemical
2. Transmission :
conduction of nerve impulse 
Spinal cord & Brain
3. Perception :
appreciation of signal pain,
assignment of meaning, behavioral response
4. Modulation :
inhibitory & facilitatory input
PAIN PATHWAYS
 MANAGEMENT
1. Pharmacological methods
 By the mouth
 By the clock
 By the child
 By the WHO pain ladder

2. Non Pharmacological methods

 Counter – irritation
 Psychological methods
Remember this…?
 But, now for children…*

Pain management
WHO Analgesic Ladder (modified for Pediatric, 2012)

Step 2
Strong Opioid + Non Opioid + Adjuvant
Step 1
Non Opioid + Adjuvant

www.icpcn.org.uk
Why?
 In children…

* = Lack of CYP2D6 gene in the body of a child

But look, she’s smiling…
How we
do it in
children?
 Distribution of Childhood Cancer
in “Dharmais” Cancer Hospital
According to Late Stage 2006-2013

Source: Childhood Cancer Registry, Dept. of Child Health, DCH

 Breaking news…

1. Heart Rate
2. Respiration Rate
3. Body Temperature
4. Blood Pressure

5. Pain
Do you feel any pain today?
 What happened if…

 Vital Signs:
1. Heart Rate : Fluid Resuscitation
2. Respiration Rate : Oxygen Therapy
3. Body Temperature : Antipyretic
4. Blood Pressure : Antihypertensive

5. Pain : Get rid of it A.S.A.P

Faces Scale

WONG-BAKER FACES PAIN RATING SCALE

 Numerical Pain Scale

Modified Pain Assessment

FLACC SCALE
VISUAL ANALOGUE SCALE
 Strong Opioid

Morphine:

 Morphine sulfate
 Preparation : (5/5ml, 10/5ml, 20/5ml, 100/5ml)
 Dose :
 1-12 months : orally 0,1 mg/Kg BW / 4 hours
 >12 months : orally 0,2- 0,4 mg/Kg BW / 4 hours
 Side Effects : constipation, difficulty breathing,
sedation, hypotension
 Morphine Sustained / MST
(Slow Release Morphine)

 Dose : 0,9 mg/Kg BW, orally, every 12 hours

(long acting)

 Side effects: constipation, headache, dry mouth

 Dose according to the needs / 24 hours

 Always start with oral immediate…
and don’t forget Laxatives
06.00 10.00 14.00 18.00 22.00 02.00

10 mg 10 mg 10 mg 10 mg 10 mg 10 mg

6 x 10 mg = 60 mg / day
 is there any breakthrough pain?

06.00 10.00 14.00 18.00 22.00 02.00

10 mg 10 mg 10 mg

10 mg 10 mg 10 mg 10 mg 10 mg 10 mg

6 x 10 mg = 60 mg / day
 is there any breakthrough pain?

06.00 10.00 14.00 18.00 22.00 02.00

10 mg 10 mg 10 mg

10 mg 10 mg 10 mg 10 mg 10 mg 10 mg

6 x 10 mg = 60 mg / day
3 x 10 mg = 30 mg / day
 90 mg / day : 6 = 15 mg / day
 So, the next day…

06.00 10.00 14.00 18.00 22.00 02.00

15 mg 15 mg 15 mg 15 mg 15 mg 15 mg

6 x 15 mg = 90 mg / day
 Is there still any breakthrough pain?

06.00 10.00 14.00 18.00 22.00 02.00

15 mg 15 mg 15 mg 15 mg 15 mg 15 mg

6 x 15 mg = 90 mg / day
 You got your fixed dose?
 Under treatment: possible to lowered the dose
after five days
 Under palliative care treatment: sometimes
impossible to lowered the dose
 Can change to oral intermediate morphine, IV, or
using the patch.
 Example:
From 6 x 15 mg / day immediate, we can change
to 2 x 45 mg /day intermediate
 FENTANYL

 Preparation : 25, 50, 75, 100 µ / hour

(transdermal patch).
 Dose : 2-4 mg/Kg BW/ hour
 Side effects : dry mouth, constipation,
sleepy, confusion, muscle rigidity, nausea,
vomiting, anorexia, profuse sweating.
 How to use :
 Before fentanyl applied  make sure that
the patient has got the analgesic drug
 Effect 12 hours after using
 Duration :72 hours (3 days)
 Location : applied to a flat, non irritated area on
the upper torso, clean skin and comfortable.
How to decrease the opioid dose

 After 5 days  dose to be decreased  1/3

dose / 3 days.
 Pain negative  change with MST / 12 hours.
How to calculate : Total dose in 24 hours 
divided by 2 .
 Breakthrough pain positive  give morphine
sulfate again.
 Morphine Immediate

Morphine Intermediate

Morphine Long Acting

Conversion dose?
Conversion Dose?
 Actually, still a lot to talk about
morphine…
 Dose conversion
 How to start giving the morphine
 How to stop the morphine
 Side effect of morphine
 The “myth”: Is it true?
 Adjuvant drugs
 Morphine for other use in palliative care setting
 etc…
Stop using Codein and other pain killer
for children
Go jump to Morphine
But I think its time for me to…