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 childs 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