Pain in the Pediatric
Oncology Patient
Katherine L. Patterson, RN, MN Pediatric oncology nurses face many challenges in treating the pain associated with childhood cancer. The type and severity of pain children with cancer experience varies from acute, short-term, procedure-related pain to the progressive chronic pain associated with terminal illness. In addition, the unfounded fears of using strong narcotic analgesics and the underutilization of psychological techniques to treat pain in children limit the effectiveness of pain management. Armed with objective data, pediatric oncology nurses can work with other members of the cancer treatment team to provide relief from the pain associated with the diagnosis and treatment of childhood cancer. © 1992
by Association of Pediatric Oncology Nurses.
REA TMENT of pain in children with cancer is a complex process, and pediatric oncology nurses face many challenges in providing optimal pain relief for their patients. These challenges include barriers in assessment, unfounded fears of opioid analgesics held by physicians and nurses, and lack of empirical data to support various treatment methods used to control pain.
T
Increasingly, pediatric care providers are recognizing the pain control needs of their patients. Larger numbers of studies and clinical reviews of childhood pain control practices have appeared in the literature in the past 5 to 10 years. In addition, three books devoted to childhood pain have been published since 1987,1’3 and two international conferences on childhood pain have been held (Seattle, WA, 1988 and Montreal, Quebec, Canada, 1991). The most recent information regarding she assessment of pain in children, procedure-related pain control practices, and disease-related pain control practices that can be applied to the specific pain control needs of the child with cancer will be reviewed in this article.
From Pediatric Hematology-Oncology, Division of Patient Services, University of Missouri Hospital and Clinics,
Columbia, MO. Address reprint requests to Katherine L Patterson, RN, MN, Pediatric Hematology-Oncology, Division of Patient Services, University of Missouri Hospital and Clinics, One Hospital Dr, Columbia, MO 65212. © 1992 by Association of Pediatric Oncology Nurses. 1043-4542/92/0903-0003$03.00/0
Epidemiology of Childhood
Cancer Pain
Patients with cancer frequently experience pain as a result of the disease or the treatment of the disease 4 Bonica5 estimates that 50% of all adult cancer patients report having pain at some stage of their disease. Seventy percent of these patients report pain with advanced disease. An application of these data to United States cancer statistics would show in 1 year that an estimated 297,000 patients who died of cancer and 1,027,000 patients who survived cancer suffered pain during their disease. Until recently, data did not exist to document the prevalence of pain in children with cancer. Two studies have described the experience of pain in children with cancer. 6.7 Both document that the majority of these children will experience pain at some point during their therapy. Interestingly, the prevalence and the type of pain children experience differ from those of adults with cancer. Adults with cancer experience pain directly related to the tumor in 60% to 70% of painful episodes. 4 -5 In a study by Miser et all treatment-related pain predominated in children. Only one third of the inpatient population and one fifth of the outpatient population experienced tumor-related pain. The etiologies of pediatric cancer pain as described by Miser et ah are listed in Table 1.
Assessment of Pain in Children The assessment of pain in children is a multifaceted process. Children respond to pain both 119
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120
Behavioral Measures
TABLE 1.
Types of Pain in Childhood Cancer
Behaviors commonly associated with pain include facial expression, posture, and vocalization or verbalization. In children these behavioral indicators of pain are often the most important means of communicating pain, especially in those less than 4 years of age. Several scales have been developed to measure the behaviors of pain or distress in children 9-’2 (Table 2). These scales are commonly used in research of procedure-related pain and distress in the pediatric oncology patient Independent raters record children’s distress behaviors from videotapes of painful events or observations in the procedure room. Frequency and duration of these behaviors are scored on these scales to give a numerical value to measure the child’s overall distress. The scales measure an integration of pain, anxiety, fear, and distress
Adapted and reprinted with permission. 3r,
behaviorally and physiologically. In addition, the changing developmental levels of children complicate the assessment process. Pediatric care providers must use their knowledge of a child’s cognitive abilities, developmental level, and the nature of childhood pain to accurately assess an individual child’s pain. A comprehensive assessment of childhood pain should include: (1) nature of noxious stimuli; (2) physiological, behavioral, and emotional responses; (3) the patient’s self-report; (4) environmental and situational factors; (5) parental opinions of the child’s current status; and (6) the child’s reactions to previous painful stimuli.8 A number of instruments have been developed to measure the various aspects of a child’s pain experience. These include physiological, behavioral, and self-report measures. A brief review of each is necessary. -
Physiological Measures Physiological manifestations of acute pain are regulated by the autonomic nervous system. Increases in heart rate, respiratory rate, and blood pressure may occur. Pupillary dilation and/or diaphoresis may become evident It is important to note that adaptation occurs with any prolonged pain, and these physiological responses return to normal. Physiological measures are most useful in measuring pain responses to short-term medical procedures. .
during the painful
event.
Two of these observational scales have been
developed for rating procedure-related distress in pediatric oncology patients.10-11 Another new scale attempts to integrate elements of depression into the overall observations of childhood pain behaviors.9 The CHEOPS scale was de-
signed to
assess
postsurgical pain.’z ’
Self Report Measures Pain is a subjective experience; therefore,
as-
sessment must include the individual child’s de-
scription of the experience. Until recently, it was assumed that young children could not adequately describe an abstract concept such as pain. However, researchers have proven that if asked in a developmentally appropriate way, children as young as 3 years can identify the varying intensities of their pain experiences.’3 Visual analog scales 14 and the McGill Pain Questionnaire 15 are the mainstays for the assessment -of pain in adults. Tools developed for children use measurement concepts from these tools and adapt them for the varying cognitive and developmental levels of childhood. Currently available tools for the self-report of pain by children are given in Table 3.
Treatment of Childhood Cancer Pain Pain is
a multidimensional experience comprised of two primary components. Nociception
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121
TABLE 2. Pain Behavior Scales for Children
Data from Gauvain-Picard et
al 9 Jay et al,’°
Katz et
al,&dquo;
and McGrath et al.12
is the sensory component directly related to activity in neural pathways responding to tissue damage. The second component is the combination of psychological, physiological, emotional, and behavioral responses to nociception. The degree of pain is not necessarily directly related to the amount of tissue damage but rather is due to complex interaction of the actual nociception and the modifying factors that may enhance or diminish the perception of pain. One must understand the subjective nature of TABLE 3. Pain and Assessment and Procedures: Child
pain to adequately treat it. Health care providers can not quantify the patient’s subjective experience of pain; only the patient can do this. Unfortunately, physicians and nurses often have a predetermined idea of how much pain each specific procedure or surgery will create for any patient. We often hear, &dquo;He shouldn’t be hurting this much so long after surgery.&dquo; lf physicians and nurses would dispense of their preconceived notions about pain in patients, they would make great strides in alleviating pain for all patients.
Self-Report
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’
122
Pain control in children is complicated by the varying abilities of children to understand and communicate their pain. Appropriate assessment measures must be combined with aggressive analgesic administration if health care providers are to adequately control the pain of childhood cancer. Often it is the pediatric nurse caring for the child 8 to 12 hours a day who must advocate for adequate pain relief for the child. In a recent article, Schechterz4 examined the scope of undertreatment of pain in children. This author built on the previous classic work by Eland and Anderson25 to analyze the reasons pediatric health care professionals have allowed the undertreatment of pain in children to continue. The undertreatment of pain in children was attributed to five erroneous assumptions: (1) there is a correct amount of pain for a given injury, (2) children’s nervous systems are too immature to experience pain, (3) children metabolize opioids differently, (4) children have no memory of pain, and (5) children become easily addicted to narcotics. These myths continue to interfere in the health care professional’s ability to properly manage a patient’s pain. 13 In the ensuing discussion, the current recommendatioris for pain control in childhood cancer will be explored. Recommendations have been based on currently available research of pain in children, information from the treatment of adult pain adapted for the child, and a recent position paper from the Academy of Pediatrics regarding the management of pain in childhood cancer.2s
Procedure-Related Pain The recent consensus conference on the treatment of pain in childhood cancer made very specific recommendations for the treatment of proZeltzer et al stated that: cedure-related
pain?6
Procedures for the management of pain and anxiety in children with cancer should be considered an integral part of the diagnostic and treatment protocol, beginning with the process of diagnosis. Evaluation and planning for pain management should be part of ’frontline’ treatment. The diagnostic process should not be so aversive that the child becomes fearful of treatment. For this reason, we recommend adequate preparation of the child and parents for all diagnostic evaluation and maximal, intense pharmacologic sedation and analgesic management of the initial bone marrow aspiration and lumbar puncture.2-7
These recommendations have set the standard of care for pediatric oncology practice. Pain control measures for medical procedures are
comprised of two distinct, different practices: pharmacological sedation and analgesia during the procedure and psychological preparation of the child and parent for the procedure. The goals of pain management during medical procedures are to minimize the suffering of the child and to allow for a successful procedure. Two recent comprehensive reviews of the management of procedure-related pain describe the various components of the pain management strategies used in procedure-related pain 28~29 Pharmacological sedation and analgesia should be used with the initial diagnostic procedures. Often the child is too sick and anxious to allow for adequate psychological preparation for these procedures. Unfortunately, there is a dearth of information regarding the best agents to use. A recent survey by Bernstein et al-3) documents the varied practices employed in this country for sedating children for painful medical procedures. The agents used for pharmacological management should be easy to administer, have a rapid and predictable onset of action, produce the desired sedation and analgesia, decrease vital signs and ventilation minimally, and have a short duration of action, minimal cost, and a low adverse or idiosyncratic reaction rate. 29 Unfortunately, no agents currently available are able to meet all these recommendations. The most commonly used agents for the pharmacological management of procedurerelated pain are shown in Table 4. The combination of a sedative agent and analgesic appears to be the most rational recommendation for the
pharmacological management
of
procedure-
related pain and distress.
Psychological preparation interventions for the child and parent(s) are aimed at decreasing anxiety and distress and enhancing the child’s ability to cope with these procedures. Often these interventions alone are adequate in the treatment of the pain associated with the repeated procedures, such as intravenous (IV) or intramuscular (IM) sticks, necessary during maintenance treatments for childhood cancer patients. Depending on the child, these interventions occasionally may be adequate for more invasive procedures such as bone marrow aspi-
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123
TABLE 4.
Pharmacological Management of Procedure-Related Pain
CiOTE The American
Academy
of Pediatrics has set
specific recommendations for
the
monitoring of patients during
conscious sedation: during conscious
oxygen, suction, ambubag, naloxone, and crashcart must be immediately available. Pulse oximetry may be useful for monitoring sedation. A staff member must be assigned to monitor for patient safety?6 Abbreviations: IV, intravenous; CT, computed tomography; MRI, magnetic resonance imaging; max, maximum; PO, orally. Data from Schechter, Altman, and Weisman~6 Zeltzer et al?7 Henry, Burwinide, and Klutman,31-and Juhlen and Evers.32
ration
or
lumbar puncture. However, ongoing
assessment of the child must be made to ensure
that
adequate interventions are being provided. Many techniques have been developed to assist children in coping with medical procedures. Psychological preparation techniques are categorized by the specific strategies employed. Current strategies used to reduce the child’s distress
and enhance
coping during medical procedures summarized in Tables 5 and 6. Often a combination of strategies is necessary. Several factors must be considered when
are
and psychological interventions for’ children with cancer. Prevention is the key: interventions used for the initial procedures should produce a maximal effect so
choosing pharmacological
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124
TABLE 5.
Strategies for Reducing Children’s Pain and Distress During Medical Procedures
search by Johnson and Baldwin 34 documented the effect of parental anxiety on their child’s response to medical events. Parents should be included in the overall assessment of a child’s response to medical procedures. Often parents will have a preference as to how their child is
managed during painful procedures. The available supportive care staff at individual centers may include nurses, psychologists, child life workers,
or social workers who have in special expertise the psychological preparation of children for medical procedures. These professionals may be helpful in the overall management of the child undergoing painful medical procedures. Practicality and cost issues must also be considered. A three-phase approach may be helpful in meeting the needs of these children: (1) medical protocols for the manage-
TABLE 6. Methods Used to Introduce Psychological Preparation Strategies to Children
Adapted and reprinted with permíssion?8
does not develop. The and cognitive level will dictate which practices are used. Individual coping styles and previous experiences with painful procedures should be considered. Coping styles of children have been labeled as repressors versus sensitizers or avoiders versus information seekers. 33 Repressors may benefit from primarily pharmacological measures. Information seekers ’mary prefer psychological interventions. Parental preference should be considered as well. Early re-
that
anticipatory anxiety
child’s.age
Adapted and reprinted with permission.2&dquo;
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125
ment of initial procedures are set; (2) assessment of the child and family is undertaken to
psychological interventions and (3) appropriate staff members are identified to provide the interventions to the child and family. determine the best
to be
used;
Disease-Related Pain Disease-related pain in children with cancer be divided into two categories: acute and chronic. Acute pain is the pain that may occur can
during the initial diagnosis, postoperative pain, and painful procedures. Chronic pain is usually the progressive pain that occurs during the terminal phase of illness. Occasionally, other forms of chronic pain may be the result of cancer treatment such as phantom limb pain or chronic neural pain from vinca alkaloids. The treatment of these chronic pain syndromes is beyond the scope of this article. The reader is referred to the excellent review texts for further reading.’ -3 Approaches to each type of pain have the same underlying goal: adequate analgesics given in an appropriate dosage and schedule to prevent the occurrence of pain. The World Health Organization (WHO) has developed a ladder approach to the analgesic treatment of cancer pain (Fig 1).35 This ladder approach can be used as a model when assessing and treating the child in acute or chronic pain. The specific analgesic agents used to treat pain have been divided into three major classes:
nonopioid peripherally acting agents, opioid agents, and adjuvant agents. The nonopioid peripherally acting agents include drugs such as acetaminophen, aspirin,
salicylates such as choline magnetrisalicylate (Trilisate; Purdue Frederick, Norwalk, CT) and the nonsteroidal antiinflammatory drugs (NSAIDs). Some authors classify all nonopioid peripherally acting agents and other sium
as
NSAIDS. These agents
are
believed
to block
peripheral generation of afferent nerve impulses in sensory neurons related to tissue injury or inflammation. In contrast to opioid agents, these drugs have a ceiling effect, ie, doubling the the
dose does not double the
analgesia.. Acetaminophen is the most commonly prescribed drug for pain control in children. Unfortunately, acetaminophen may be contraindicated in pediatric cancer patients due to its
FIGURE 1. WHO ladder approach to the analgesic treatment of cancer pain. (Adapted and reprinted with permis-
sion 35) antipyretic effects, which may mask an imporsign of infection. Salicylates are very useful to treat pain from inflammation or bone or joint pain. Unfortunately, side effects such as gastritis and platelet dysfunction, in addition to the concerns of aspirin’s association with Reyes syndrome, limit their use in pediatric cancer patients. The use of choline magnesium trisalicylate may be promising for children. This drug does not cause excess gastritis or bleeding problems in therapeu-
tant
tic doses. However, little data are available regarding its use in young children. Anecdotal reports suggest good results with few problems in older children and adolescents. NSAI©s produce analgesia peripherally by inhibiting the release of prostaglandin synthetase. These drugs are especially useful in the treatment of bone.pain; however, the potential for bleeding problems limits their use in pediatric ’
patients. Opioid analgesics
cancer
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are
the
mainstay
of treat-
126
ment for moderate to severe
pain. These drugs less effective in pain of neuropathic origin. If a child does not seem to respond to increasing doses of opioids, pain of neuropathic origin must be considered.36.37 are
Opioids produce analgesia by binding to opioid receptors in the brain, brain stem, and spinal cord. These drugs exert effects centrally by decreasing the distress (suffering) component of
pain. Opioid analgesics can be given by a variety of routes. The oral route is preferred due to its
simplicity. The oral and IV routes are most commonly used in children with cancer. Side effects of opioids include sedation, respiratory depression, nausea, pruritus, slowed gastrointestinal motility, urinary retention, biliary spasm, cough suppression, and vasodilation. The unfounded fears of the side effects of opioid analgesics have historically prevented the effective
use
of these agents. Often the side effects of
opioids can be used for effective symptom management in children with a combination of problems, ie, patients with severe mucositis and diarrhea after total body irradiation or sedation before painful procedures. Illicit drug use has become so destructive in our society that the use of the term narcotic or narcotic analgesics should be avoided. Opioid analgesic is the preferred term. In addition, intensive patient and parent education regarding opioid analgesia often is necessary to explain its usefulness in the treatment of cancer pain. Paras well as many health care need to understand the differprofessionals, ences between the concepts of addiction, dependence, and tolerance. Tolerance and dependence are physiological properties of opioid analgesics. Addiction is a psychological condition. The definitions of these concepts are de-
ents and
-
fined
as
children,
folloWS.315,37
Dependence Physiological dependence may occur following regular administration of opioids for as little as 2 weeks. Dependence is characterized by the onset of withdrawal syndrome (dysphoria, agitation, nasal congestion, lacrimation, tremors, anorexia, piloerection (&dquo;goose flesh&dquo;), tachypnea, tdchycardia, sweating, or diarrhea) when opioids are discontinued abruptly. Withdrawal syndrome may be avoided by slowing tapering doses over 5 to 7 days. Addiction
Psychological dependence is characterized by an overwhelming obsession with obtaining and using the drug for effects independent of pain relief. This condition rarely, if ever, occurs with the use of opioids in the treatment of childhood cancer pain. Commonly used nonopioid and opioid analgesics used to treat cancer pain in children are craving for the drug and
shown in Tables 7 and 8.
Adjuvant agents are used in symptom control for patients who must receive chronic opioid analgesics to treat their pain. In addition, some of these drugs have direct analgesic effects in certain pain syndromes. The tricyclic antidepressants and anticonvulsants are useful in the treatment of neuropathic pain in children with cancer, such as neuropathies associated with vinca alkaloids, postirradiation pain, pain from invasion of nerves, or phantom limb pain. In addition, these drugs can help to normalize sleep in patients with chronic pain. Amitriptyline in low doses (0.5 to 1.5 mg/ kg 1 to 2 hours before bedtime) may improve sleep and reduce pain in 3 to 5 days. Carbamazepine may be useful for sharp, stabbing
pain.36
Tolerance Tolerance is a state in which increasing doses of drug are needed to produce same analgesia. Tolerance of analgesic effect does not always predict tolerance of side effects of the opioids. For example, tolerance to sedation and respiratory depression tend to parallel tolerance to analgesia, but constipation may show less tolerance to increasing doses.
Psychostimulants can enhance analgesia and decrease sedation in patients taking opioid analgesics. Although little data are available to support their use in children, anecdotal reports indicate that stimulants given in the morning and at lunch may reverse severe sedation in children on
opioid analgesics.36,37
are useful in the treatment of headache due to increased intracranial pressure. These agents also have been reported to be useful in the treatment of pain associated
Corticosteroids
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127
TABLE 7.
Analgesics Commonly Used for Mild
to Moderate Pain
*
Equianalgesic doses are the equivalent doses across medications found to provide the same level of analgesia, ie, 30 mg 650 mg aspirin. t Upjohn, Kalamazoo, MI. t Syntex, Palo Alto, CA. § McNeil, Spring House, PA.
codeine po
=
with swelling and inflammation, such as in bony metastasis and prolonged post-lumbar puncture
headache. 36,37
Sedative and hypnotic drugs should not be used in place of opioid analgesics. Often these drugs will increase sedation without benefit of added analgesia. Diphenhydramine and hydroxyzine are useful in treating pruritus associated with opioid analgesics. In addition, some antiemetic effect may be
produced.
Alternative routes of administration should be
employed in the treatment of the child who can not tolerate the oral administration of opioid analgesics. Continuous infusions of opioid analgesics, primarily morphine, often are preferable to intermittent bolus injections because the analgesia is constant, and decreased nursing time is required to administer this type of therapy.36.39 A new route of analgesic administration is now available through fentanyl transdermal patches.4o Unfortunately, few data are available to document the effectiveness of this
agent in children. Patient-controlled analgesia, alone or in conjunction with continuous morphine infusion, has been reported to be effective in children as young as 3 years of age?6.41 lntrathecal and epidural opioid administration of morphine has
been used in adults with intractable
cancer
pain.
invasive approach of administration limits its use in young children. 36
Unfortunately, the
Recommendations for the Treatment of Disease-Related Pain in Children Two recent reviews provide more detailed information regarding the pharmacological treatment of pain in children 37 and in children with cancer.36 Several basic principles apply to the management of pain in children with cancer: 1. Careful initial and ongoing assessments are necessary to determine the potential etiology of the pain as well as whether pain control strategies are effective. Assessment of intensity, quality, and location of the pain can be accomplished in children as young as 3 years. The anticipated duration of pain will impact analgesic recommendations. In addition, the previous analgesic history will show previous toxicities, tolerance, effectiveness, and possible patient and family bias towards certain analgesics. 2. The use of oral medication is preferable to other routes. If the oral route is contraindicated, the N route is recommended. IM ad-
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128
TABLE 8.
Analgesics Commonly Used for Severe Pain
Abbreviations: cont, continuous; subq, subcutaneous; ICP, intracranial pressure; CNS, central nervous system. * Based on clinical experience. IM and N doses are considered equianalgesic. t Clinical experience and anecdotal reports suggest an N-to-oral ratio of 1:3 (not based on research). Data from McCaffrey and Beebe,19 Schechter, Attman, and Weisman~6 Miser and Miser,36 and Shannon and Berde.37
ministration of
analgesics
in children is
contraindicated because this route is unacceptable to children. Changing from one route to another should be based on equianalgesic dosing (Tables 7 and 8). 3. Use the WHO analgesic ladder (Fig 1) to administer drugs based on the type and severity of pain. 4. Analgesic medications should be given on an around-the-clock schedule, not as needed. Regular administration results in even pain relief and often results in lower overall analgesic requirements.
5.
Dosages of opioid analgesics should be tailored to patient response. Dosages in Tables 7 and 8 are starting doses only. 6. Ens6re adequate sleep at night. Often patients in pain will &dquo;cat nap&dquo; during the day and therefore disturb normal sleep cycles. This can be treated with either a mild hypnotic or increased opioid dosage at bedtime. 7. Side effects of opioid analgesics should be anticipated and prevented. Constipation will occur uniformly in children on opioid analgesics. A stool softener and/or laxative
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129
should be initiated at the beginning of the opioid administration. 8. Pain control of children with cancer is the responsibility of every health care practitioner involved with the care of these children. Pediatric oncology nurses are especially important in this treatment team. Nurses spend most of the time with hospitalized patients and, therefore, have primary responsibility for communication and advocating for pain control in children with cancer.
Complete pain relief can
be
accomplished
in
most cases if the above steps are taken and continued assessment and interventions employed. Patients and parents need to be told that
pain control plan may take some adjustment, but adequate analgesia can usually be achieved for each patient. The recent report of the Consensus Confer-
the
the Management of Pain in Childhood Cancer26 has set standards of care for the treatment of pain. Research priorities were defined by the individual subcommittees in the area of ence on
assessment and
methodology, disease-related and pain, procedure-related pain. 26 Pediatric onnurses have played, and will continue to cology a role in the continued development play, major of pain control practices for their patients through research, clinical practice, and education of their colleagues, both nursing and medical.
References 1. McGrath PA: Pain in Children: Nature, Assessment and Treatment New York, NY, Guilford, 1990 2. McGrath PJ, Unruh AM: Pain in Children and Adolescents. Amsterdam, The Netherlands, Elsevier, 1987 3. Ross DM, Ross SA: Childhood Pain: Current Issues, Research and Management. Baltimore, MD, Urban & Schwarzenberg, 1988 4. Daut RL, Cleeland CS: The prevalence and severity of pain in cancer. Cancer 50:1913-1918, 1982 5. Bonica JJ: Treatment of cancer pain: Current status and future needs, in Fields HL, Dubner R, Cervero F (eds): Advances in Pain Research and Therapy, vol 9. Proceedings of the Fourth World Congress on Pain. New York, NY, Raven, 1985, pp 589-616 6. Cornaglia C, Massimo L, Haupt R, et al: Incidence of pain in children with neoplastic disease. Pain 2:S28, 1984 (Supplement to the 4th World Congress on Pain, Seattle, .
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Oncology Patient
Katherine L. Patterson, RN, MN Pediatric oncology nurses face many challenges in treating the pain associated with childhood cancer. The type and severity of pain children with cancer experience varies from acute, short-term, procedure-related pain to the progressive chronic pain associated with terminal illness. In addition, the unfounded fears of using strong narcotic analgesics and the underutilization of psychological techniques to treat pain in children limit the effectiveness of pain management. Armed with objective data, pediatric oncology nurses can work with other members of the cancer treatment team to provide relief from the pain associated with the diagnosis and treatment of childhood cancer. © 1992
by Association of Pediatric Oncology Nurses.
REA TMENT of pain in children with cancer is a complex process, and pediatric oncology nurses face many challenges in providing optimal pain relief for their patients. These challenges include barriers in assessment, unfounded fears of opioid analgesics held by physicians and nurses, and lack of empirical data to support various treatment methods used to control pain.
T
Increasingly, pediatric care providers are recognizing the pain control needs of their patients. Larger numbers of studies and clinical reviews of childhood pain control practices have appeared in the literature in the past 5 to 10 years. In addition, three books devoted to childhood pain have been published since 1987,1’3 and two international conferences on childhood pain have been held (Seattle, WA, 1988 and Montreal, Quebec, Canada, 1991). The most recent information regarding she assessment of pain in children, procedure-related pain control practices, and disease-related pain control practices that can be applied to the specific pain control needs of the child with cancer will be reviewed in this article.
From Pediatric Hematology-Oncology, Division of Patient Services, University of Missouri Hospital and Clinics,
Columbia, MO. Address reprint requests to Katherine L Patterson, RN, MN, Pediatric Hematology-Oncology, Division of Patient Services, University of Missouri Hospital and Clinics, One Hospital Dr, Columbia, MO 65212. © 1992 by Association of Pediatric Oncology Nurses. 1043-4542/92/0903-0003$03.00/0
Epidemiology of Childhood
Cancer Pain
Patients with cancer frequently experience pain as a result of the disease or the treatment of the disease 4 Bonica5 estimates that 50% of all adult cancer patients report having pain at some stage of their disease. Seventy percent of these patients report pain with advanced disease. An application of these data to United States cancer statistics would show in 1 year that an estimated 297,000 patients who died of cancer and 1,027,000 patients who survived cancer suffered pain during their disease. Until recently, data did not exist to document the prevalence of pain in children with cancer. Two studies have described the experience of pain in children with cancer. 6.7 Both document that the majority of these children will experience pain at some point during their therapy. Interestingly, the prevalence and the type of pain children experience differ from those of adults with cancer. Adults with cancer experience pain directly related to the tumor in 60% to 70% of painful episodes. 4 -5 In a study by Miser et all treatment-related pain predominated in children. Only one third of the inpatient population and one fifth of the outpatient population experienced tumor-related pain. The etiologies of pediatric cancer pain as described by Miser et ah are listed in Table 1.
Assessment of Pain in Children The assessment of pain in children is a multifaceted process. Children respond to pain both 119
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120
Behavioral Measures
TABLE 1.
Types of Pain in Childhood Cancer
Behaviors commonly associated with pain include facial expression, posture, and vocalization or verbalization. In children these behavioral indicators of pain are often the most important means of communicating pain, especially in those less than 4 years of age. Several scales have been developed to measure the behaviors of pain or distress in children 9-’2 (Table 2). These scales are commonly used in research of procedure-related pain and distress in the pediatric oncology patient Independent raters record children’s distress behaviors from videotapes of painful events or observations in the procedure room. Frequency and duration of these behaviors are scored on these scales to give a numerical value to measure the child’s overall distress. The scales measure an integration of pain, anxiety, fear, and distress
Adapted and reprinted with permission. 3r,
behaviorally and physiologically. In addition, the changing developmental levels of children complicate the assessment process. Pediatric care providers must use their knowledge of a child’s cognitive abilities, developmental level, and the nature of childhood pain to accurately assess an individual child’s pain. A comprehensive assessment of childhood pain should include: (1) nature of noxious stimuli; (2) physiological, behavioral, and emotional responses; (3) the patient’s self-report; (4) environmental and situational factors; (5) parental opinions of the child’s current status; and (6) the child’s reactions to previous painful stimuli.8 A number of instruments have been developed to measure the various aspects of a child’s pain experience. These include physiological, behavioral, and self-report measures. A brief review of each is necessary. -
Physiological Measures Physiological manifestations of acute pain are regulated by the autonomic nervous system. Increases in heart rate, respiratory rate, and blood pressure may occur. Pupillary dilation and/or diaphoresis may become evident It is important to note that adaptation occurs with any prolonged pain, and these physiological responses return to normal. Physiological measures are most useful in measuring pain responses to short-term medical procedures. .
during the painful
event.
Two of these observational scales have been
developed for rating procedure-related distress in pediatric oncology patients.10-11 Another new scale attempts to integrate elements of depression into the overall observations of childhood pain behaviors.9 The CHEOPS scale was de-
signed to
assess
postsurgical pain.’z ’
Self Report Measures Pain is a subjective experience; therefore,
as-
sessment must include the individual child’s de-
scription of the experience. Until recently, it was assumed that young children could not adequately describe an abstract concept such as pain. However, researchers have proven that if asked in a developmentally appropriate way, children as young as 3 years can identify the varying intensities of their pain experiences.’3 Visual analog scales 14 and the McGill Pain Questionnaire 15 are the mainstays for the assessment -of pain in adults. Tools developed for children use measurement concepts from these tools and adapt them for the varying cognitive and developmental levels of childhood. Currently available tools for the self-report of pain by children are given in Table 3.
Treatment of Childhood Cancer Pain Pain is
a multidimensional experience comprised of two primary components. Nociception
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121
TABLE 2. Pain Behavior Scales for Children
Data from Gauvain-Picard et
al 9 Jay et al,’°
Katz et
al,&dquo;
and McGrath et al.12
is the sensory component directly related to activity in neural pathways responding to tissue damage. The second component is the combination of psychological, physiological, emotional, and behavioral responses to nociception. The degree of pain is not necessarily directly related to the amount of tissue damage but rather is due to complex interaction of the actual nociception and the modifying factors that may enhance or diminish the perception of pain. One must understand the subjective nature of TABLE 3. Pain and Assessment and Procedures: Child
pain to adequately treat it. Health care providers can not quantify the patient’s subjective experience of pain; only the patient can do this. Unfortunately, physicians and nurses often have a predetermined idea of how much pain each specific procedure or surgery will create for any patient. We often hear, &dquo;He shouldn’t be hurting this much so long after surgery.&dquo; lf physicians and nurses would dispense of their preconceived notions about pain in patients, they would make great strides in alleviating pain for all patients.
Self-Report
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’
122
Pain control in children is complicated by the varying abilities of children to understand and communicate their pain. Appropriate assessment measures must be combined with aggressive analgesic administration if health care providers are to adequately control the pain of childhood cancer. Often it is the pediatric nurse caring for the child 8 to 12 hours a day who must advocate for adequate pain relief for the child. In a recent article, Schechterz4 examined the scope of undertreatment of pain in children. This author built on the previous classic work by Eland and Anderson25 to analyze the reasons pediatric health care professionals have allowed the undertreatment of pain in children to continue. The undertreatment of pain in children was attributed to five erroneous assumptions: (1) there is a correct amount of pain for a given injury, (2) children’s nervous systems are too immature to experience pain, (3) children metabolize opioids differently, (4) children have no memory of pain, and (5) children become easily addicted to narcotics. These myths continue to interfere in the health care professional’s ability to properly manage a patient’s pain. 13 In the ensuing discussion, the current recommendatioris for pain control in childhood cancer will be explored. Recommendations have been based on currently available research of pain in children, information from the treatment of adult pain adapted for the child, and a recent position paper from the Academy of Pediatrics regarding the management of pain in childhood cancer.2s
Procedure-Related Pain The recent consensus conference on the treatment of pain in childhood cancer made very specific recommendations for the treatment of proZeltzer et al stated that: cedure-related
pain?6
Procedures for the management of pain and anxiety in children with cancer should be considered an integral part of the diagnostic and treatment protocol, beginning with the process of diagnosis. Evaluation and planning for pain management should be part of ’frontline’ treatment. The diagnostic process should not be so aversive that the child becomes fearful of treatment. For this reason, we recommend adequate preparation of the child and parents for all diagnostic evaluation and maximal, intense pharmacologic sedation and analgesic management of the initial bone marrow aspiration and lumbar puncture.2-7
These recommendations have set the standard of care for pediatric oncology practice. Pain control measures for medical procedures are
comprised of two distinct, different practices: pharmacological sedation and analgesia during the procedure and psychological preparation of the child and parent for the procedure. The goals of pain management during medical procedures are to minimize the suffering of the child and to allow for a successful procedure. Two recent comprehensive reviews of the management of procedure-related pain describe the various components of the pain management strategies used in procedure-related pain 28~29 Pharmacological sedation and analgesia should be used with the initial diagnostic procedures. Often the child is too sick and anxious to allow for adequate psychological preparation for these procedures. Unfortunately, there is a dearth of information regarding the best agents to use. A recent survey by Bernstein et al-3) documents the varied practices employed in this country for sedating children for painful medical procedures. The agents used for pharmacological management should be easy to administer, have a rapid and predictable onset of action, produce the desired sedation and analgesia, decrease vital signs and ventilation minimally, and have a short duration of action, minimal cost, and a low adverse or idiosyncratic reaction rate. 29 Unfortunately, no agents currently available are able to meet all these recommendations. The most commonly used agents for the pharmacological management of procedurerelated pain are shown in Table 4. The combination of a sedative agent and analgesic appears to be the most rational recommendation for the
pharmacological management
of
procedure-
related pain and distress.
Psychological preparation interventions for the child and parent(s) are aimed at decreasing anxiety and distress and enhancing the child’s ability to cope with these procedures. Often these interventions alone are adequate in the treatment of the pain associated with the repeated procedures, such as intravenous (IV) or intramuscular (IM) sticks, necessary during maintenance treatments for childhood cancer patients. Depending on the child, these interventions occasionally may be adequate for more invasive procedures such as bone marrow aspi-
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123
TABLE 4.
Pharmacological Management of Procedure-Related Pain
CiOTE The American
Academy
of Pediatrics has set
specific recommendations for
the
monitoring of patients during
conscious sedation: during conscious
oxygen, suction, ambubag, naloxone, and crashcart must be immediately available. Pulse oximetry may be useful for monitoring sedation. A staff member must be assigned to monitor for patient safety?6 Abbreviations: IV, intravenous; CT, computed tomography; MRI, magnetic resonance imaging; max, maximum; PO, orally. Data from Schechter, Altman, and Weisman~6 Zeltzer et al?7 Henry, Burwinide, and Klutman,31-and Juhlen and Evers.32
ration
or
lumbar puncture. However, ongoing
assessment of the child must be made to ensure
that
adequate interventions are being provided. Many techniques have been developed to assist children in coping with medical procedures. Psychological preparation techniques are categorized by the specific strategies employed. Current strategies used to reduce the child’s distress
and enhance
coping during medical procedures summarized in Tables 5 and 6. Often a combination of strategies is necessary. Several factors must be considered when
are
and psychological interventions for’ children with cancer. Prevention is the key: interventions used for the initial procedures should produce a maximal effect so
choosing pharmacological
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124
TABLE 5.
Strategies for Reducing Children’s Pain and Distress During Medical Procedures
search by Johnson and Baldwin 34 documented the effect of parental anxiety on their child’s response to medical events. Parents should be included in the overall assessment of a child’s response to medical procedures. Often parents will have a preference as to how their child is
managed during painful procedures. The available supportive care staff at individual centers may include nurses, psychologists, child life workers,
or social workers who have in special expertise the psychological preparation of children for medical procedures. These professionals may be helpful in the overall management of the child undergoing painful medical procedures. Practicality and cost issues must also be considered. A three-phase approach may be helpful in meeting the needs of these children: (1) medical protocols for the manage-
TABLE 6. Methods Used to Introduce Psychological Preparation Strategies to Children
Adapted and reprinted with permíssion?8
does not develop. The and cognitive level will dictate which practices are used. Individual coping styles and previous experiences with painful procedures should be considered. Coping styles of children have been labeled as repressors versus sensitizers or avoiders versus information seekers. 33 Repressors may benefit from primarily pharmacological measures. Information seekers ’mary prefer psychological interventions. Parental preference should be considered as well. Early re-
that
anticipatory anxiety
child’s.age
Adapted and reprinted with permission.2&dquo;
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125
ment of initial procedures are set; (2) assessment of the child and family is undertaken to
psychological interventions and (3) appropriate staff members are identified to provide the interventions to the child and family. determine the best
to be
used;
Disease-Related Pain Disease-related pain in children with cancer be divided into two categories: acute and chronic. Acute pain is the pain that may occur can
during the initial diagnosis, postoperative pain, and painful procedures. Chronic pain is usually the progressive pain that occurs during the terminal phase of illness. Occasionally, other forms of chronic pain may be the result of cancer treatment such as phantom limb pain or chronic neural pain from vinca alkaloids. The treatment of these chronic pain syndromes is beyond the scope of this article. The reader is referred to the excellent review texts for further reading.’ -3 Approaches to each type of pain have the same underlying goal: adequate analgesics given in an appropriate dosage and schedule to prevent the occurrence of pain. The World Health Organization (WHO) has developed a ladder approach to the analgesic treatment of cancer pain (Fig 1).35 This ladder approach can be used as a model when assessing and treating the child in acute or chronic pain. The specific analgesic agents used to treat pain have been divided into three major classes:
nonopioid peripherally acting agents, opioid agents, and adjuvant agents. The nonopioid peripherally acting agents include drugs such as acetaminophen, aspirin,
salicylates such as choline magnetrisalicylate (Trilisate; Purdue Frederick, Norwalk, CT) and the nonsteroidal antiinflammatory drugs (NSAIDs). Some authors classify all nonopioid peripherally acting agents and other sium
as
NSAIDS. These agents
are
believed
to block
peripheral generation of afferent nerve impulses in sensory neurons related to tissue injury or inflammation. In contrast to opioid agents, these drugs have a ceiling effect, ie, doubling the the
dose does not double the
analgesia.. Acetaminophen is the most commonly prescribed drug for pain control in children. Unfortunately, acetaminophen may be contraindicated in pediatric cancer patients due to its
FIGURE 1. WHO ladder approach to the analgesic treatment of cancer pain. (Adapted and reprinted with permis-
sion 35) antipyretic effects, which may mask an imporsign of infection. Salicylates are very useful to treat pain from inflammation or bone or joint pain. Unfortunately, side effects such as gastritis and platelet dysfunction, in addition to the concerns of aspirin’s association with Reyes syndrome, limit their use in pediatric cancer patients. The use of choline magnesium trisalicylate may be promising for children. This drug does not cause excess gastritis or bleeding problems in therapeu-
tant
tic doses. However, little data are available regarding its use in young children. Anecdotal reports suggest good results with few problems in older children and adolescents. NSAI©s produce analgesia peripherally by inhibiting the release of prostaglandin synthetase. These drugs are especially useful in the treatment of bone.pain; however, the potential for bleeding problems limits their use in pediatric ’
patients. Opioid analgesics
cancer
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are
the
mainstay
of treat-
126
ment for moderate to severe
pain. These drugs less effective in pain of neuropathic origin. If a child does not seem to respond to increasing doses of opioids, pain of neuropathic origin must be considered.36.37 are
Opioids produce analgesia by binding to opioid receptors in the brain, brain stem, and spinal cord. These drugs exert effects centrally by decreasing the distress (suffering) component of
pain. Opioid analgesics can be given by a variety of routes. The oral route is preferred due to its
simplicity. The oral and IV routes are most commonly used in children with cancer. Side effects of opioids include sedation, respiratory depression, nausea, pruritus, slowed gastrointestinal motility, urinary retention, biliary spasm, cough suppression, and vasodilation. The unfounded fears of the side effects of opioid analgesics have historically prevented the effective
use
of these agents. Often the side effects of
opioids can be used for effective symptom management in children with a combination of problems, ie, patients with severe mucositis and diarrhea after total body irradiation or sedation before painful procedures. Illicit drug use has become so destructive in our society that the use of the term narcotic or narcotic analgesics should be avoided. Opioid analgesic is the preferred term. In addition, intensive patient and parent education regarding opioid analgesia often is necessary to explain its usefulness in the treatment of cancer pain. Paras well as many health care need to understand the differprofessionals, ences between the concepts of addiction, dependence, and tolerance. Tolerance and dependence are physiological properties of opioid analgesics. Addiction is a psychological condition. The definitions of these concepts are de-
ents and
-
fined
as
children,
folloWS.315,37
Dependence Physiological dependence may occur following regular administration of opioids for as little as 2 weeks. Dependence is characterized by the onset of withdrawal syndrome (dysphoria, agitation, nasal congestion, lacrimation, tremors, anorexia, piloerection (&dquo;goose flesh&dquo;), tachypnea, tdchycardia, sweating, or diarrhea) when opioids are discontinued abruptly. Withdrawal syndrome may be avoided by slowing tapering doses over 5 to 7 days. Addiction
Psychological dependence is characterized by an overwhelming obsession with obtaining and using the drug for effects independent of pain relief. This condition rarely, if ever, occurs with the use of opioids in the treatment of childhood cancer pain. Commonly used nonopioid and opioid analgesics used to treat cancer pain in children are craving for the drug and
shown in Tables 7 and 8.
Adjuvant agents are used in symptom control for patients who must receive chronic opioid analgesics to treat their pain. In addition, some of these drugs have direct analgesic effects in certain pain syndromes. The tricyclic antidepressants and anticonvulsants are useful in the treatment of neuropathic pain in children with cancer, such as neuropathies associated with vinca alkaloids, postirradiation pain, pain from invasion of nerves, or phantom limb pain. In addition, these drugs can help to normalize sleep in patients with chronic pain. Amitriptyline in low doses (0.5 to 1.5 mg/ kg 1 to 2 hours before bedtime) may improve sleep and reduce pain in 3 to 5 days. Carbamazepine may be useful for sharp, stabbing
pain.36
Tolerance Tolerance is a state in which increasing doses of drug are needed to produce same analgesia. Tolerance of analgesic effect does not always predict tolerance of side effects of the opioids. For example, tolerance to sedation and respiratory depression tend to parallel tolerance to analgesia, but constipation may show less tolerance to increasing doses.
Psychostimulants can enhance analgesia and decrease sedation in patients taking opioid analgesics. Although little data are available to support their use in children, anecdotal reports indicate that stimulants given in the morning and at lunch may reverse severe sedation in children on
opioid analgesics.36,37
are useful in the treatment of headache due to increased intracranial pressure. These agents also have been reported to be useful in the treatment of pain associated
Corticosteroids
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127
TABLE 7.
Analgesics Commonly Used for Mild
to Moderate Pain
*
Equianalgesic doses are the equivalent doses across medications found to provide the same level of analgesia, ie, 30 mg 650 mg aspirin. t Upjohn, Kalamazoo, MI. t Syntex, Palo Alto, CA. § McNeil, Spring House, PA.
codeine po
=
with swelling and inflammation, such as in bony metastasis and prolonged post-lumbar puncture
headache. 36,37
Sedative and hypnotic drugs should not be used in place of opioid analgesics. Often these drugs will increase sedation without benefit of added analgesia. Diphenhydramine and hydroxyzine are useful in treating pruritus associated with opioid analgesics. In addition, some antiemetic effect may be
produced.
Alternative routes of administration should be
employed in the treatment of the child who can not tolerate the oral administration of opioid analgesics. Continuous infusions of opioid analgesics, primarily morphine, often are preferable to intermittent bolus injections because the analgesia is constant, and decreased nursing time is required to administer this type of therapy.36.39 A new route of analgesic administration is now available through fentanyl transdermal patches.4o Unfortunately, few data are available to document the effectiveness of this
agent in children. Patient-controlled analgesia, alone or in conjunction with continuous morphine infusion, has been reported to be effective in children as young as 3 years of age?6.41 lntrathecal and epidural opioid administration of morphine has
been used in adults with intractable
cancer
pain.
invasive approach of administration limits its use in young children. 36
Unfortunately, the
Recommendations for the Treatment of Disease-Related Pain in Children Two recent reviews provide more detailed information regarding the pharmacological treatment of pain in children 37 and in children with cancer.36 Several basic principles apply to the management of pain in children with cancer: 1. Careful initial and ongoing assessments are necessary to determine the potential etiology of the pain as well as whether pain control strategies are effective. Assessment of intensity, quality, and location of the pain can be accomplished in children as young as 3 years. The anticipated duration of pain will impact analgesic recommendations. In addition, the previous analgesic history will show previous toxicities, tolerance, effectiveness, and possible patient and family bias towards certain analgesics. 2. The use of oral medication is preferable to other routes. If the oral route is contraindicated, the N route is recommended. IM ad-
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128
TABLE 8.
Analgesics Commonly Used for Severe Pain
Abbreviations: cont, continuous; subq, subcutaneous; ICP, intracranial pressure; CNS, central nervous system. * Based on clinical experience. IM and N doses are considered equianalgesic. t Clinical experience and anecdotal reports suggest an N-to-oral ratio of 1:3 (not based on research). Data from McCaffrey and Beebe,19 Schechter, Attman, and Weisman~6 Miser and Miser,36 and Shannon and Berde.37
ministration of
analgesics
in children is
contraindicated because this route is unacceptable to children. Changing from one route to another should be based on equianalgesic dosing (Tables 7 and 8). 3. Use the WHO analgesic ladder (Fig 1) to administer drugs based on the type and severity of pain. 4. Analgesic medications should be given on an around-the-clock schedule, not as needed. Regular administration results in even pain relief and often results in lower overall analgesic requirements.
5.
Dosages of opioid analgesics should be tailored to patient response. Dosages in Tables 7 and 8 are starting doses only. 6. Ens6re adequate sleep at night. Often patients in pain will &dquo;cat nap&dquo; during the day and therefore disturb normal sleep cycles. This can be treated with either a mild hypnotic or increased opioid dosage at bedtime. 7. Side effects of opioid analgesics should be anticipated and prevented. Constipation will occur uniformly in children on opioid analgesics. A stool softener and/or laxative
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129
should be initiated at the beginning of the opioid administration. 8. Pain control of children with cancer is the responsibility of every health care practitioner involved with the care of these children. Pediatric oncology nurses are especially important in this treatment team. Nurses spend most of the time with hospitalized patients and, therefore, have primary responsibility for communication and advocating for pain control in children with cancer.
Complete pain relief can
be
accomplished
in
most cases if the above steps are taken and continued assessment and interventions employed. Patients and parents need to be told that
pain control plan may take some adjustment, but adequate analgesia can usually be achieved for each patient. The recent report of the Consensus Confer-
the
the Management of Pain in Childhood Cancer26 has set standards of care for the treatment of pain. Research priorities were defined by the individual subcommittees in the area of ence on
assessment and
methodology, disease-related and pain, procedure-related pain. 26 Pediatric onnurses have played, and will continue to cology a role in the continued development play, major of pain control practices for their patients through research, clinical practice, and education of their colleagues, both nursing and medical.
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