Pain Management and Children

What are the causes and effects of pain?

Pain management is an important concern for a child with cancer or other pain-causing diseases. When a child has cancer, one of his or her greatest fears, and the fear of parents, is pain. Every effort should be made to ease the pain during the treatment process.

Because pain is unique to each individual, a child's pain cannot be measured with a lab test or imaging study. Health care providers can evaluate a child's pain by observing him or her and asking about it. The family can also help describe a child’s pain. There are a number of tools and techniques available to help assess pain in children.

Pain may be acute or chronic. Acute pain is severe and lasts a relatively short time. It is usually a signal that body tissue is being injured in some way, and the pain generally disappears when the injury heals. Chronic pain may range from mild to severe, and is present to some degree for long periods of time.

Many people believe that if an individual has been diagnosed with cancer, they must be in pain. This is not necessarily the case, and even when cancer pain is present, it can be reduced or even prevented. Pain management is an important area to discuss with your child's doctor as soon as a cancer diagnosis is made or suspected.

Pain may occur as a result of the cancer or for other reasons. Children can normally have headaches, general discomfort, pains, and muscle strains as part of being a child. Not every pain a child expresses is from the cancer, or is being caused by the cancer.

Cancer pain may depend on the type of cancer, the stage (extent) of the disease, and your child's pain threshold (or tolerance for pain). Cancer pain that lasts several days or longer may result from:

• Pain from a tumor that is enlarging, or pain from a tumor that is pressing on body organs, nerves, or bones.
• Poor blood circulation because the cancer has blocked blood vessels.
• Blockage of an organ or tube in the body.
• Metastasis. Cancer cells that have spread to other sites in the body.
• Infection or inflammation.
• Side effects from chemotherapy, radiation therapy, or surgery.
• Stiffness from inactivity.
• Psychological responses to illness, such as tension, depression, or anxiety.

Specific treatment for pain will be determined by your child's doctor based on:

• Your child's age, overall health, and medical history
• Type of cancer
• Extent of disease
• Your child's tolerance for specific medications, procedures, or therapies
• Your opinion or preference

The two categories of pain management are pharmacological and nonpharmacological.

What is pharmacological pain management?

Pharmacological pain management for cancer refers to the use of medications. Pediatric oncology clinics usually offer several pain management options for any procedure that may be painful, such as a bone marrow aspiration or lumbar puncture. There are many types of medications and several methods used in administering them, from very temporary (10 minute) mild sedation, to full general anesthesia in the operating room. Pain medication is usually given in one of the following ways:

• Orally (by swallowing)
• Intravenously (IV), through a vein
• By a special catheter in the back
• Through a patch on the skin

Examples of pharmacological pain relief include the following:

• Mild pain relievers, such as acetaminophen and ibuprofen
• Opioid analgesics, such as morphine and oxycodone
• Sedation (usually given by IV)
• General anesthesia
• Topical anesthetics (cream or patches put on the skin to numb the area)

Some children build up a tolerance to sedatives and pain relievers. Over time, doses may need to increase or the choice of medications may need to change. Fear of addiction to narcotics is common among families. It is important to understand that the ultimate goals are comfort, function, and overall quality of life, which means taking appropriate measures to assure the child is free from pain. There is no evidence of addiction to pain medications in children being treated for cancer.

What is nonpharmacological pain management?

Nonpharmacological pain management is the management of pain without medications. This method utilizes ways to alter thinking and focus to decrease pain. Methods include

Psychological. The unexpected is always worse because of what one imagines. If the child is prepared and can anticipate what will happen to him or her, his or her stress level will be much lower. Ways to accomplish this include:

• Explain each step of a procedure in detail, utilizing simple pictures or diagrams when available.
• Meet with the person who will perform the procedure and allow your child to ask questions ahead of time.
• Tour the room where the procedure will take place.
• Adolescents may observe a videotape, which describes the procedure, while small children can "play" the procedure on a doll, or observe a "demonstration" on a doll.

Hypnosis. With hypnosis, a professional (such as a psychologist or doctor) guides the child into an altered state of consciousness that helps him or her to focus or narrow his or her attention, in order to reduce discomfort.

Imagery. Guiding a child through an imaginary mental image of sights, sounds, tastes, smells, and feelings can often help shift attention away from the pain.

Distraction. Distraction can be helpful particularly for babies by using colorful, moving objects. Singing songs, telling stories, or looking at books or videos can distract preschoolers. Older children find watching TV or listening to music helpful. Distraction should not be a substitute for explaining what to expect.

Relaxation. Children can be guided through relaxation exercises, such as deep breathing and stretching, to reduce discomfort.

Other nonpharmacological pain management may utilize alternative therapies, such as acupuncture, massage, or biofeedback, to eliminate discomfort.

Each child experiences pain differently. It is important to tailor a pain treatment plan based on each child’s needs. Finding the best plan often requires trying a variety of treatments to see what works best.