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PAIN AND SYMPTOM MANAGEMENT IN CHILDREN
Pamela M. Sutton, M.D.
October 2012
OBJECTIVES
The listener will:
• Develop insight into pain and symptom challenges in children
• Review pain assessment
• Understand the role of NSAIDS in bone and joint pain
• Understand the relative strengths and appropriate use of opioids
• Learn the role of adjuvant analgesics
• Consider symptom management in various cases
PAIN AND SYMPTOM MANAGEMENT IN CHILDREN
Pamela M. Sutton, M.D.
October 2012
OUTLINE
I. GOALS OF CARE
II. PAIN ASSESSMENT
III. TREATMENT OF PHYSICAL PAIN
A. Analgesic Ladder
B. NSAIDS
C. Opioids
D. Adjuvants (Co-analgesics)
IV. NON-PAIN SYMPTOMS
V. CASES
PALLIATIVE CARE
TO CURE SOMETIMES
TO RELIEVE OFTEN
TO COMFORT ALWAYS
15th Century Folk Saying
IDEAL GOALS OF CARE
• CARE AND CURE
• CURATIVE ATTEMPTS MADE MORE
COMFORTABLE WITH ACTIVE
SYMPTOM MANAGEMENT AND
EMOTIONAL, SOCIAL, and
SPIRITUAL SUPPORT.
PAIN
CANCER PAIN IS
TOTAL PAIN
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“EVERYTHING HURTS”
PHYSICAL PAIN
FAMILY PAIN
EMOTIONAL PAIN
CAREGIVER PAIN
SOCIAL PAIN
DOCTOR/STAFF PAIN
SPIRITUAL PAIN
FINANCIAL PAIN
OBSTACLES TO PAIN RELIEF
• LACK OF EDUCATION ABOUT
TREATMENT
• LACK OF AVAILABILITY OF MEDICATION
DUE TO LAWS AND/OR EXPENSE
• WORRIES ABOUT SIDE EFFECTS
INCLUDING ADDICTION AND ABUSE
OBSTACLES TO PAIN
RELIEF
Inability of child to communicate due to
age, language, illness, anxiety, lack of
awareness.
A child may fear treatments and not ask
for help.
PAIN ASSESSMENT
• HISTORY FROM PATIENT(AND/OR
FAMILY IF PATIENT TOO YOUNG OR
UNABLE TO COMMUNICATE WELL)
• BELIEVE THE PATIENT!
• PAIN IS WHAT THE PATIENT SAYS
IT IS!
PAIN ASSESSMENT
YOUNG CHILD
• FLACC SCALE (INFANT OR
UNRESPONSIVE
PATIENT)
• FACES SCALE
PAIN ASSESSMENT
OLDER CHILD
• ASK SEVERITY OF PAIN ON A
SCALE OF ZERO TO TEN
PAIN ASSESSMENT
OLDER CHILD
• ASK:
• LOCATION
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QUALITY (ACHING, BURNING,
SHOOTING)
DURATION (INTERMITTENT OR
CONTINUOUS)
WHAT MAKES PAIN BETTER
WHAT MAKES IT WORSE
PAIN ASSESSMENT
• ASSESS EMOTIONAL STATE
Emotional pain may cause ongoing
suffering despite appropriate physical
measures
• PHYSICAL EXAM(There may not be
any objective physical finding.)
• Consider tests.
• REASSESS PAIN FREQUENTLY
PHYSICAL PAIN
NOCICEPTIVE PAIN
(tissue injury)
vs
NEUROPATHIC PAIN
(nerve injury)
TREATMENT OF PHYSICAL
PAIN
• PERSISTENT PAIN SHOULD BE
TREATED ON A REGULAR BASIS
(NOT PRN) TO PREVENT RETURN
OF PAIN AND TO HELP NORMALIZE
THE PATIENT’S LIFE.
TREATMENT OF PHYSICAL
PAIN
• PROPER USE OF MEDICATIONS
CAN SUCCESSFULLY TREAT PAIN
IN 90% OR MORE OF CANCER
PATIENTS
TREATMENT OF PHYSICAL
PAIN
• ORAL MEDICATION IS PREFERRED
BECAUSE OF EASE OF
ADMINISTRATION, STEADY BLOOD
LEVELS, SAFETY.
TREATMENT OF PHYSICAL
PAIN
• MEDICATION
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BY LADDER
BY CLOCK
BY APPROPRIATE ROUTE
BY THE CHILD
WORLD HEALTH ORGANIZATION 3 STEP METHOD
FOR CANCER PAIN RELIEF
(“Analgesic Ladder”)
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STEP 1. NON-OPIOID +/- ADJUVANT
If pain persists or worsens, go to:
STEP 2. MILD OPIOID + NON-OPIOID +/ADJUVANT
If pain persists or worsens, go to:
STEP 3. STRONG OPIOID +/- NON-OPIOID+/ADJUVANT
ANALGESIC LADDER
W.H.O. PREFERRED ORAL
MEDICATIONS(1986)
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STEP 1: ASPIRIN (ACETAMINOPHEN)
STEP 2:
CODEINE(DEXTROPROPOXYPHENE)
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STEP 3: MORPHINE (METHADONE)
PREFERRED ANALGESICS
STEP ONE: ASPIRIN
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Advantages: Widely available, cheap,
effective for pain of inflammation.
Disadvantages: Potential GI/renal toxicity.
Interferes with platelet function.
(increased bleeding)
Possible association with Reyes
Syndrome.
PREFERRED ANALGESICS
STEP ONE: ACETAMINOPHEN
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Advantages:
Widely available, cheap,
effective for mild pain.
Disadvantages: Potential liver toxicity.
Not an anti-inflammatory
medication. Not the best
choice for bone pain.
PREFERRED ANALGESICS
STEP ONE ALTERNATIVE(USA): NSAID’S (eg. Ibuprofen,
Naproxen)
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Advantages: Anti-inflammatory effects
especially helpful for bone pain.
Dosage may be less frequent
than aspirin or acetaminophen.
Disadvantages: Costly. Potential GI side effects
and/or possible interference with
platelet function.
PREFERRED ANALGESICS
POSSIBLE STEP TWO MEDICATIONS (USA)
a.Tylenol with Codeine (Tabs or Elixir)
codeine/acetaminophen
BUT: CODEINE must be converted to
morphine in body to give analgesia
and ineffective in many children.
b. Lortab (Tabs or Elixir)
hydrocodone/acetaminophen
PREFERRED ANALGESICS
STEP 3--IMMEDIATE-RELEASE ORAL
MORPHINE
Oral morphine is one third as potent as
parenteral morphine when given on a
regular basis. In other words, a patient
receiving 10 mg of morphine sulfate IV
every 4 hours who is switched to oral
dose would need 30 mg morphine sulfate
orally every 4 hours.
Titrate dose as needed to control pain.
The correct dose is that which relieves
pain!
PREFERRED ANALGESICS
• STEP THREE ALTERNATIVE: LONG-ACTING MORPHINE
PREPARATIONS
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Add up the dose of oral morphine in 24 hours
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and divide by 2. Example: If the patient is
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taking 10 mg of immediate-release morphine
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every 4 hours around the clock, the 24 hour total
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is 60 mg. This patient would take 30 mg of a
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long-acting preparation every 12 hours.
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ALTERNATIVE STEP THREE OPIOIDS
a. Oxycodone
Percocet-5
Percocet-10
Roxicet Oral Solution
Oxycodone Tablets 5 mg; 15 mg; 30 mg
Roxicodone Oral Solution.
Roxicodone Intensol.
Oxycontin Long acting tablets which usually last 12 hours.
b. Hydromorphone(Dilaudid)
Tablets
Oral Liquid
Suppositories
IV/Subcutaneously
c. Fentanyl (Should not be used if opioid naïve)
IV
Patches
BEWARE of buccal preparations. Potent and potentially dangerous.
d. Methadone
BEWARE titration difficulties. May accumulate.
IV/Subcutaneously but may cause nodules subq
Oral Liquid
Oral Intensol
Tablets
CONCERNS ABOUT OPIOIDS
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1. ADDICTION
Physical Dependence and Psychological Craving is
necessary for addiction.
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2. TOLERANCE
Rarely a practical problem. Dose can be increased if
tolerance occurs.
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3. RESPIRATORY DEPRESSION
Rarely a problem when appropriate dose of oral
narcotic is titrated to level of pain.
CONCERNS ABOUT OPIOIDS
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4. LETHARGY
Sleepiness may occur in first few hours/days but
usually improves. Dose may need to be adjusted.
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5. NAUSEA
Occurs in less than half of patients. May resolve,
but if not, patient can be given anti-emetic or an
alternative opioid.
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6. CONSTIPATION
Frequent problem--should be anticipated with stool
softener/laxative. Avoid bulk laxatives.
POSSIBLE ROUTES OF
ADMINISTRATION OF OPIOIDS
RECTAL
BUCCAL
SUBCUTANEOUS
INTRAMUSCULAR
INTRAVENOUS
TRANSDERMAL
EPIDURAL,INTRATHECAL
ADJUVANT ANALGESICS
a. ANTIDEPRESSANTS
b. ANTICONVULSANTS
C. ANESTHETIC AGENTS
D. CORTICOSTEROIDS
OTHER TREATMENTS OF
PAIN
• SUPPORTIVE-- FAMILY/FRIENDS/STAFF/PLAY
• BEHAVIORAL--DEEP
BREATHING/PROGRESSIVE RELAXATION
• PHYSICAL--TOUCH/HEAT,COLD/ETHYL
CHLORIDE/ EMLA / TENS
• COGNITIVE--DISTRACTION,IMAGERY
NON-PAIN SYMPTOMS
NAUSEA/VOMITING:
a. Phenothiazines--act on chemoreceptor
trigger zone
Chlorpromazine (sedating)
Prochlorperazine
b. Promethazine--phenothiazine with
antihistaminic effect.
Mildly sedating.
c. Haloperidol--acts on chemoreceptor
trigger zone
d. Ondansetron—serotonin antagonist
e. Scopolamine--anticholinergic
f. Antihistamines:
Hydroxizine
Diphenhydramine
g. Lorazepam
h. Corticosteroids
CONSTIPATION
Constipation likely if taking opioids.
Treat with fluids and combination of fecal softener
and large bowel stimulant if possible.
-Docusate, senna, bisacodyl, cascara sagrada.
-Milk of magnesia may be useful if other methods
unsuccessful.
-Glycerin or bisacodyl suppositories or small tap
water enema may be helpful.
PALLIATIVE CARE
PEDIATRIC CASES
TWO YEAR OLD WITH
NEUROBLASTOMA TRANSFERED
FROM SLOAN KETTERING TO
DIE AT HOME
LOGISTICAL PROBLEMS
SYMPTOM MANAGEMENT
EMOTIONAL SUPPORT
FIVE YEAR OLD BOY WITH
LEUKEMIA DYING AT HOME
FEAR OF INJECTIONS
BONE PAIN
HEADACHE
FAMILY DISTRESS AT TIME AND
AFTER DEATH
SEVEN YEAR OLD DYING WTH
END STAGE AIDS AT HOME
TWELVE YEAR OLD WITH HIV
ENCEPHALOPATHY IN HOSPITAL
35 year old survivor of Ewing’s
Sarcoma at age 7.
Chronic pain and treatment
challenges for life.
USEFUL REFERENCES
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CANCER PAIN RELIEF, WORLD HEALTH ORGANIZATION, GENEVA, 1986.
CANCER PAIN RELIEF AND PALLIATIVE CARE IN CHILDREN, WHO, 1998.
CARING FOR PEDIATRIC PATIENTS; UNIPAC EIGHT, AAHPM, 2012.
PEDIATRIC CANCER PAIN; NCCN CLINICAL PRACTICE GUIDELINES IN
ONCOLOGY; V.I.2007
PRIMER OF PALLIATIVE CARE, 5th Edition; AAHPM, 2010.