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The first consensus guidelines on the management of pain in children with cancer
have been published by the World Health Organization in December 1998. Experts from
anesthesiology, neurology, nursing, oncology, pediatrics, pastoral care, palliative care
and psychology from around the world prepared the draft document on which the guidelines
are based.
This issue of Cancer Pain Release presents excerpts of the guidelines which have
been approved by the World Health Organization and the International Association for the
Study of Pain.
The guidelines can be ordered from the WHO Distribution and Sales Office, 1211 Geneva,
Switzerland. Telephone: 41-22-791-24-76. Telefax: 41-22-791-48-57. Email:
publications@who.ch. The book can also be ordered from WHO sales agents in most countries.
A list of sales agents is available on the internet at: www.who.dk/docpub/sales.htm. In the USA,
order from the WHO Publications Center, 49 Sheridan Ave, Albany, NY 12210. Telephone:
518-436-9686, ext. 118. Telefax: 518-436-7433. Email: QCORP@compuserve.com
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Types of cancer pain in children
"Children with cancer can experience pain from the disease,
from diagnostic procedures or from treatments. Non-cancer-related sources can also cause
pain (see Table 1).
Regardless of the source, children often do not receive adequate treatment for their pain.
[...] The most common childhood malignancies, such as leukemia, lymphoma, and
neuroblastoma, often produce diffuse bone and joint pain.
| Pain can have devastating effects, both
physically and psychologically for children with cancer and can interfere with their
therapy. By educating them, their parents and their physicians on effective methods
to lessen the pain associated with treatment, we can decrease the potential physical and
psychological effects and increase their chances for successful treatment. --WHO Expert Committee |
Therapeutic strategies
Figure 1 shows that
management begins with a thorough physical examination and assessment of the sensory
characteristics of the pain. [...] It is best to always evaluate every child with
cancer for potential pain, because children may experience pain, even though they may not
be able to express it.[...] Pain severity can be determined by teaching children to use
quantitative scales. All such scales are based on the concept of counting, which is
universal. Thus, it is possible to develop tools for pain assessment that are appropriate
for all cultures.
Both children and families need information to prepare them for what will happen during the course of the disease and its treatment. Telling a child what will happen and how it will feel can help. It is best to give the child choices about which techniques to use to control pain. [...] Psychosocial treatment is an integral part of cancer pain treatment. It should be used in all situations, often with analgesic drug therapy.
Figure 2
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Guidelines for analgesic drug therapy
The four key concepts underlying the use of analgesics are :
"by the ladder," "by the clock," "by the appropriate route,"
and "by the child."
The ladder approach is based on the premise that health care professionals should learn how to use a few drugs well. [...] Medication should be administered to children by the simplest, most effective and least painful route. To select the best route, one should consider the severity of the pain, the type of pain, the potency of the drug, and the required dosing interval.
The opioid dose that effectively relieves pain varies between children and in the same child at different times. [...] Non-opioid analgesics have a ceiling effect. Opioid drugs do not. The correct dose of opioid is the dose that provides adequate relief of pain with an acceptable degree of side effects.
The strong opioid of choice included in WHO's Model List of Essential Drugs is morphine. Alternatives are hydromorphone, methadone and fentanyl. Dosage guidelines are summarized in Table 2.
| Opioid | Equianalgesic doses (a) |
Usual IV or SC starting dose (b) Child <50kg |
P/O dose ratio |
Usual oral starting dose ratio (b) Child <50kg |
Biological |
|
Parenteral |
Oral |
|||||
| Short half-life opioids | ||||||
| Codeine | 130mg | 200mg | N/R | 1:1.5 | 0.5-1mg/kg every 3-4 hours |
2.5-3 |
| Oxycodone | N/A | 30mg | N/A | N/A | 0.2mg/kg every 3-4 hours |
2-3 |
| Pethidine N/R |
75mg N/R |
300mg N/R |
.75mg/kg every 2-4 hours N/R |
1:4 | 1-1.5mg/kg every 3-4 hours N/R |
3 |
| Morphine | 10mg | 30mg | Bolus dose: 0.05-0.1mg/kg IV or SC every 2-4 hours Continuous infusion: 0.03mg/kg/hour |
1:3 | 0.15-0.3mg/kg every 4 hours |
2.5-3 |
| Hydromorphone | 1.5mg | 7.5mg | 0.015mg/kg every 2-4 hours |
1:5 | 0.06mg/kg every 3-4 hours |
2-3 |
| Oxymorphone | 1mg | N/A | 0.02mg/kg every 2-4 hours |
N/A | N/A | 1.5 |
| Fentanyl | 100µg single dose | N/A | .5-2µg/kg/hour as continuous infusion |
N/A | N/A | 3 |
| Long half-life opioids | ||||||
| Controlled-release morphone | N/A | N/A | N/A | N/A | 0.6mg/kg every 8 hours or 0.9mg/kg every 12 hours |
|
| Methadone | 10mg | 20mg | 0.1mg/kg IV or SC every 4-8 hours |
1:2 | 0.2mg/kg every 4-8 hours |
12-50 |
(a) Equianalgesic doses are based on single-dose studies
in adults.
(b) Usual starting dose is the commonly used standard dose and not always
based on equianalgesic principles (ie. starting dose of hydromorphone may be 2mg despite
the parenteral:oral ratio of 1:5). For infants under 6 months of age, starting doses
should be one-quarter to one-third the suggested dose and titrated to effect.
(c) Pethidine is not recommended for chronic use because of its long
half-life and the possibility of accumulation of a toxic metabolite.
(d) Continuous infusion of fentanyl at 100µg/hour is approximately
analgesic to a morphine infusion of 2.5mg/hour.
(e) Methadone may cause some irritation when administered SC. Extreme care
is needed when using methadone, both for initiation of therapy and when doses are
increased, because of the extremely long biological half-life.
N/R = not recommended; N/A = not applicable.
* Reproduced with permission from: WHO. Cancer Pain Relief and Palliative Care in
Children, Geneva: WHO, 1998.
Treatment of opioid side effects
Children often do not voluntarily report all side effects
(constipation, dysphoria, pruritis), so they should be asked specific questions about
these problems. [...] If side effects persists despite appropriate
interventions, a different opioid should be tried whose side effects may be better
tolerated.
It is important to anticipate and treat side effects aggressively. [...]
Addiction is not a problem in children with cancer who receive opioids for pain control.
"New information about the nature of pain had led to an improved understanding of how children experience it and how their suffering can be alleviated. Children with cancer will experience pain, because of the disease, the side-effects of treatments or because of psychological distress. The new WHO-IASP guidelines offer a comprehensive guide to pain management and should be made available for educational purposes to health professional in both developed and developing countries." --Jean-Marie Besson, DSc, President, IASP |
The use of nondrug therapies
Techniques such as distraction, attention, imagery, relaxation
and behavioral management can enable children to understand what is happening and to
lessen their anxiety.[...]
Cancer treatment involves increasingly aggressive protocols with the potential for causing pain and suffering. Health care professionals, institutions and countries must support the humane and competent treatment of suffering, particularly for the dying child. No one should have to witness and remember that the child's final days were filled with physical pain."
| The WHO-IASP guidelines express the consensus that pain relief is
an essential component of cancer care. Most children with cancer throughout the world
should receive pain relief and palliative care. All of us need to integrate these
guidelines with the daily care of children with pain. --Kathleen M. Foley, MD, Chair, WHO Expert Committee on the Comprehensive Management of Cancer Pain in Children |