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Pain and symptom control in paediatric palliative care
M M Stevens1, L Dalla Pozza, B Cavalletto
1Oncology Unit, Royal Alexandra Hospital for Children, Camperdown, Sydeny.
Insights
Effective pediatric cancer pain management requires accurate assessment and multidisciplinary approaches, addressing unique challenges in children, including opioid side effects and procedural pain. Continued research and improved palliative care practices are essential for optimal symptom control.
Area of Science:
- Pediatric Oncology
- Palliative Care
- Pain Management
Background:
- Cancer pain in children differs significantly from adults due to developmental immaturity and dependence.
- Despite advancements, optimal pain management in children, especially preverbal ones, remains a challenge.
- Opioid side effects like sedation and tolerance require specific management strategies in terminally ill children.
Purpose of the Study:
- To highlight key differences in cancer pain management between children and adults.
- To review current practices and identify areas for improvement in pediatric palliative pain care.
- To discuss challenges and strategies for managing various types of pain, including neuropathic and procedural pain, in children with cancer.
Main Methods:
- Comparative analysis of pediatric versus adult cancer pain management approaches.
- Review of advancements in pain assessment techniques for children.
- Discussion of pharmacological and non-pharmacological interventions for pediatric cancer pain.
- Exploration of challenges in palliative care, including home nursing and psychosocial support.
Main Results:
- Pediatric pain management is often multidisciplinary, relying more on systemic therapy than invasive measures.
- Accurate pain assessment is crucial, though challenging in preverbal children.
- Opioid side effects (sedation, tolerance) and neuropathic pain require specific attention and advanced techniques like regional anesthesia.
- Procedural pain is common, with nitrous oxide showing benefit, and non-pharmacological methods warrant further evaluation.
Conclusions:
- Optimizing pediatric cancer pain management necessitates accurate assessment, multidisciplinary care, and addressing unique pediatric challenges.
- Further research is needed for effective treatment of neuropathic pain and procedural pain in children.
- Improving palliative care services, including home support and staff training, is vital for holistic care.
- Ethical considerations like euthanasia are complex, with optimal symptom control being the priority.
Abstract:
Important differences become evident in a comparison of cancer pain between children and adults. Management of pain in children is commonly multidisciplinary, is less dependent on invasive measures and relies more on systemic therapy. Children are not little adults: their immaturity, developing cognition and dependence all influence their experience and interpretation of pain. Much progress has been made in altering practices such as under-prescribing and underdosing that have adversely affected adequate control of pain in children. The challenge for paediatric health care providers in the mid 1990s is not only to be informed of current practices in pain and symptom control in paediatric palliative care, but also to remember to establish those practices in day to day management. Even though pain and its effects in children are now better understood, it is often still not managed optimally. Good management of pain in children depends on accurate assessment. In the past 10 years, assessment of pain in children has advanced considerably. However, assessment of pain in the preverbal child is still inadequate and in need of attention. Sedation, tolerance and involuntary movements may occur as side effects of opioids in children and may cause significant problems in management of the dying child. Psychostimulants can diminish sedation to some extent, but there is little information as yet on the value of these drugs in children. Tolerance to opioids may develop quickly, leading to poor control of pain and distress for the child. Strategies to improve management of tolerance include use of regional anaesthetic techniques such as the epidural/intrathecal route for opioid administration. Involuntary movements induced by opioids are uncommon but have the potential to cause significant distress. The mechanisms underlying these side effects of opioids need to be established. Strategies are needed for the effective treatment and prevention of these side effects. Neuropathic pain can be severe, distressing and difficult to treat. Experience of its treatment in terminally ill children is limited. Effective use of tricyclic antidepressants and systemically administered local anaesthetics is still to be determined. Regional anaesthetic techniques may be of great benefit when neuropathic pain cannot be controlled with systemic therapy. Procedural pain is more common than pain related to disease in the management of paediatric cancer. Further research is needed to identify the best approach to its management. We have found nitrous oxide to be of great benefit in management of procedural pain in children. Non-pharmacological methods of treatment of pain in children, such as transcutaneous electrical nerve stimulation or acupuncture, may also be useful and should receive continuing evaluation. There are significant and current issues in paediatric palliative care besides management of pain. There are difficulties in the provision of home nursing care for children with cancer in the terminal phase of their illness, including lack of community nursing services at night and on weekends and lack of adequate home help for parents. Attitudes of staff involved in the care of the child and family and their commitment to working as a multidisciplinary team strongly influence the quality and success of care given. Pain control and palliative medicine are evaluable by measures of quality assurance or outcome, and adoption of such evaluations should improve standards of care. Euthanasia in children is even more difficult as an ethical dilemma than in adults. Optimum symptom control with current techniques should almost always obviate its consideration. We are opposed to euthanasia. Psychosocial and cultural issues all influence the family's experience of palliative care. Further research is necessary in all of these areas.(ABSTRACT TRUNCATED)