NEWS

Cancer Pain Management Guidelines Issued for Children; Adult Guidelines Updated

Ed Susman

Getting relief from pain for children with cancer may require not just adequate medication but also considerable patient and family education.

"It is important to get important messages across to family members," said Doralina Anghelescu, M.D., director of the pain management service at St. Jude Children's Research Hospital in Memphis, Tenn., who presented the first-ever guidelines for pediatric cancer pain management to the National Comprehensive Cancer Network (NCCN) at its 10th annual meeting in Hollywood, Fla., in March. "Pediatric patients are always at risk for underestimation of pain," Anghelescu said.

The guidelines state that doctors need to make sure that their patients and their patients' families understand that relief of pain is important to the clinician, there is no benefit to suffering pain, and that pain can usually be controlled with oral medications, but if relief fails with those drugs, other options are available. In addition, the guidelines note that doctors should clarify that morphine and morphine-like drugs can control pain, and if that pain is caused by cancer, addiction to these drugs is rarely a problem.

Anghelescu added that clinicians also have to make sure that their patients understand that communication is vital. "Doctors and nurses cannot tell how much pain you have unless you tell them," she said. The guidelines also suggest that patients be encouraged to tell their doctors about any side effects that may be caused by the medication because those side effects can also be eased.

To evaluate pain levels in children, the guidelines suggest several methods, including a visual analog scale that pairs a 0–10 pain rating scale with pictures of faces—a happy face indicating no pain (a 0 on the 0–10 scale) up to a crying face indicating severe pain (a 10 on the 0–10 scale). Doctors are encouraged to show the scale to their young patients to help them report their pain.

If a child reports pain in the 7–10 range on visual analog scales, the guidelines suggest that the treatment should be considered a pain emergency and suggest that doctors rapidly begin to titrate short-acting opioids, begin a bowel regimen to relieve constipation that often occurs with opioid use, use antinausea medications and co-analgesics as needed, and provide psychosocial support.



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The National Comprehensive Cancer Network recently issued new guidelines for treating pediatric cancer pain. One method for assessing a child's pain is to show the patient a visual analog scale such as the Wong-Baker FACES pain rating scale shown above and ask the patient to point to the face that best describes the intensity of his or her pain. (Source: From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St, Louis, 2001, p. 1301.)

 
Pain intensity can also be judged by the observed pain intensity scale (a 0–3 scale), as described in the guidelines for children under the age of 3 or for patients who are unable to self-report pain levels with the visual analog or other scoring scales. For example, a pain intensity level of 0 would be a patient whose face showed no particular expression, whose legs were in a normal position, and is lying quietly not crying and appears to relax when consoled. On the opposite end, a level 2 pain intensity could be observed if the patient has a frequent to constant quivering chin or clenched jaw; is kicking or had legs drawn up; is arched, rigid, or jerking; is crying steadily or frequently screams, sobs or complains and is difficult to console.

Although pain relief is a priority, Anghelescu reminded doctors that they also must determine the etiology of the pain. "We don't want to ignore an oncological emergency while focusing on the relief of pain," she said.

In prescribing opioids in the pediatric setting, the guidelines list several general principles, Anghelescu said, with the primary rule that "the appropriate dose is the dose that relieves the patient's pain throughout [the] dosing interval without causing unmanageable side effects." The guidelines for pediatric patients are directed at children that weigh less than 50 kilograms (110 pounds). Children that weigh more than that are treated according to adult pain relief guidelines.

She said the main differences between the pediatric pain guidelines and the adult guidelines, aside from obvious differences in how to dose patients, is that the algorithm suggests that reassessment of the pain in the pediatric patient be performed sooner and more frequently than in adults. Whereas the adult guideline suggests a 50% increase in dose if pain increases or is not reduced with the present schedule, the pediatric guidelines suggest a 20% increase in dose, again acknowledging that the pediatric patient may respond to lower doses of medication.

Along with the presentation of the new pediatric pain management guidelines, there were some changes made to the algorithm for pain management in adults.

The new algorithm begins with a requirement that all cancer patients be screened for pain and that clinicians attempt to achieve the patient's goals for pain relief. A key item in the guidelines also specifies how pain is to be assessed in follow-up visits and also suggests formulas for determining the likelihood that the patients will experience breakthrough pain, said Sunil Panchal, M.D., director of interventional pain medicine at the University of South Florida in Tampa.

He also suggested a change in thinking about pain relief and abandoning the idea of a stepwise approach to pain relief that begins with over-the-counter drugs and eventually can reach surgical approaches.

"We think that pain relief should be diagnosis-driven," Panchal said, allowing for more objective, rather than subjective, treatment of pain with opioid analgesia if warranted without waiting for weaker analgesics to fail to provide relief first.



             
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