Pain Management: Pediatric Chronic Illness

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Pain Management Pediatric Chronic Illness

• Gregory Kirkpatrick, MD
• Pediatric Hematology/Oncology

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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).
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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.
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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.
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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 PainInvolves the
peripheral or central nervous system. Does not
respond predictably to conventional analgesics.
May respond to adjuvant analgesic drugs. Mixed
or undetermined pathophysiologyTreatment is
unpredictable requires various approaches.
Psychologically based pain syndromesTraditional
analgesia is not indicated.
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Assessing Pain
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Assessing Pain
Age variations in abilty to identify Location Qu
ality Time element Source
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Assessing Pain

• Wong/Baker FACES Pain Rating Scale
• FLACC
• Pain Intensity Rating

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Assessing Pain
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Assessing Pain
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Assessing Pain
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Assessing Pain
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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.
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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
Opioid Medications
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Managing Pain
Non-steroidal Anti-inflammatory
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Managing Pain
Adjuvant Medication for Pain Corticosteroids De
cadron Prednisone Most specific indication for
brain metastasis and spinal cord compression.
May add benefit for painassociated with
inflammatory process. Side effects common
hunger and weight gain,stretch marks, muscle
weakness
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Managing Pain
Adjuvant Medication for Pain Anticonvulsants Ca
rbamazepime Gabapentin Neuropathic pain May
be helpful as antidepressant
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Managing Pain
Adjuvant Medication for Pain Antidepressants Am
ytriptyline Doxepin Trazadone Serotonin
re-uptake inhibitors May be helpful as
antidepressant
Neuropathic pain of peripheral nerve injury
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Managing Pain
Adjuvant Medication for Pain Diphenhydramine Trans
dermal clonidine (0.1 to 0.2 mg/day)
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Managing Pain
Wisconsin Cancer Pain Initiative
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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
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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
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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)
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Managing Pain
Psychological Intervention
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Managing Pain
Painful Procedures
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Perceived Pain
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Specific Disease States
Sickle Cell Anemia Bone Infarction Pneumonia A
bdominal Crisis
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Specific Disease States
Cancer Bone Pain Primary Bone Tumors Bone
Metastasis Bone Marrow Metastasis
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Specific Disease States
Cancer Nerve Pain Spinal Cord Compression Increa
sed Intracranial Pressure Peripheral Nerve
Compression/Injury
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Specific Disease States