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Pain Management:
Pediatric Chronic Illness
Gregory Kirkpatrick, MD
Pediatric Hematology/Oncology
Childhood Chronic Pain
Position Statement from the American Pain Society
Significance of the problem:
Affects 15% to 20% of children (Goodman & McGrath, 1991).
Creates significant emotional and social consequences.
Financial costs, healthcare utilization and indirect costs are high
Impact child’s overall health and may predispose for adult
chronic pain (Campo et al., 1999; Walker, Garber, Van Slyke,
& Greene, 1995).
Defining Pain
Pain means an unpleasant sensory and
emotional experience associated with actual
or potential tissue damage or described in
terms of such damage.
Acute pain signals a specific nociceptive event and is
self-limited
Chronic pain has been defined as pain that lasts
longer than 3 (6) months and continues beyond the
normal time expected for resolution of the problem
or persists or recurs for other reasons.
Defining Pain
Acute Pain Classification
Somatic Pain: Result of activation of nociceptors (sensory
receptors) sensitive to noxious stimuli in cutaneous or deep
tissues. Experienced locally and described as constant,
aching and gnawing. The most common type in cancer
patients.
Visceral Pain: Mediated by nociceptors. Described as
deep, aching and colicky. Is poorly localized and often is
referred to cutaneous sites, which may be tender. In cancer
patients, results from stretching of viscera by tumor growth.
Defining Pain
Chronic Pain Classification
Nociceptive pain: Visceral or somatic.
stimulation of pain receptors by tissue inflammation, mechanical
deformation, ongoing tissue injury. Responds well to common
analgesic medications and nondrug strategies.
Neuropathic Pain:
Involves the peripheral or central nervous system. Does not
respond predictably to conventional analgesics. May respond to
adjuvant analgesic drugs.
Mixed or undetermined pathophysiology:
Treatment is unpredictable; requires various approaches.
Psychologically based pain syndromes:
Traditional analgesia is not indicated.
Assessing Pain
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Assessing Pain
Age variations in abilty to identify
Location
Quality
Time element
Source
Assessing Pain
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• Wong/Baker FACES Pain Rating Scale
• FLACC
• Pain Intensity Rating
Assessing Pain
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Assessing Pain
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Assessing Pain
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Assessing Pain
Managing Pain
General Treatment Principles:
Ask about pain regularly.
Believe the patient's and family's reports of
pain and what relieves it.
Choose appropriate pain control options.
Deliver interventions in a timely, logical, and
coordinated fashion.
Empower patients and their families.
Managing Pain
Opioid Medications
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Managing Pain
Opioid Medications
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Managing Pain
Opioid Medications
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Managing Pain
Opioid Medications
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Managing Pain
Non-steroidal Anti-inflammatory
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Managing Pain
Adjuvant Medication for Pain
Corticosteroids
Decadron
Prednisone
Most specific indication for brain metastasis and
spinal cord compression. May add benefit for pain
associated with inflammatory process.
Side effects common: hunger and weight gain,
stretch marks, muscle weakness
Managing Pain
Adjuvant Medication for Pain
Anticonvulsants
Carbamazepime
Gabapentin
Neuropathic pain:
May be helpful as antidepressant
Managing Pain
Adjuvant Medication for Pain
Antidepressants
Amytriptyline
Doxepin
Trazadone
Neuropathic pain of
peripheral nerve injury
Serotonin re-uptake inhibitors
May be helpful as antidepressant
Managing Pain
Adjuvant Medication for Pain
Diphenhydramine
Transdermal clonidine (0.1 to 0.2 mg/day)
Wisconsin Cancer Pain Initiative
Managing Pain
Managing Pain
Physical Pain Management
Exercise regimen
Cutaneous stimulation techniques:
superficial heat and cold, massage,
pressure or vibration
Physical therapy: active and passive
range-of-motion exercises to prevent
joint contracture, muscle atrophy,
cardiovascular deconditioning
Managing Pain
Rehabilitation Treatment Modalities
Physical Therapy
Occupational Therapy
Alternative Interventions: Acupuncture, reflexology,
aroma therapy, music therapy, dance therapy, yoga,
hypnosis, relaxation and imagery, distraction and
reframing, psychotherapy, peer support group,
spiritual, chiropractic, magnet therapy, bio-feedback,
meditation, relaxation techniques
Managing Pain
Nonpharmacologic Interventions: Invasive Procedures
With rare exception, noninvasive treatments
should precede invasive palliative approaches
Palliative radiation therapy: treatment of symptomatic metastasis
where tumor has caused pain, obstruction, or compression.
Radiation should be administered in the fewest fractions
possible to promote patient comfort during and after treatment.
Neurolytic blockade of peripheral nerves should be reserved
with rare exception for instances in which other therapies
(palliative radiation, TENS, pharmacotherapy) are ineffective,
poorly tolerated, or clinically inappropriate.
Intraspinal medication (Ommya resevoir)
Managing Pain
Psychological Intervention
Managing Pain
Painful Procedures
Perceived Pain
Specific Disease States
Sickle Cell Anemia
Bone Infarction
Pneumonia
Abdominal Crisis
Specific Disease States
Cancer Bone Pain
Primary Bone Tumors
Bone Metastasis
Bone Marrow Metastasis
Specific Disease States
Cancer Nerve Pain
Spinal Cord Compression
Increased Intracranial Pressure
Peripheral Nerve Compression/Injury
Specific Disease States