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APS Bulletin • Volume 14, Number 3, 2004

Palliative Care

Arthur G. Lipman, PharmD, Department Editor

Progress and Needs in Pediatric Palliative Care Pain Management

Sophie M. Colleau, PhD, and Arthur G. Lipman, PharmD

Pain management is essential for good palliative care, and palliative care is one of the most rapidly growing fields for pain clinicians worldwide. Pain treatment is a priority in palliative care because it often is not possible to address psychosocial, spiritual, and other physical problems until pain is properly controlled.

For a variety of cultural, regulatory, and scientific reasons, progress in pediatric pain management has come about relatively late. The science and practice of pediatric pain management have grown in recent years, however, and we now have a body of knowledge the clinical pain community can—and must—use more effectively. This need is especially acute in palliative care because 80% of children with advanced cancer experience pain.

Cancer Pain Release, the publication of the World Health Organization (WHO) Pain and Palliative Care Communications Program, draws attention to pediatric pain in a special double issue (Volume 16, Nos. 2 & 3, 2003), “Achieving Pain Control in Pediatric Palliative Care.” The issue begins with a stark telling of “the facts.”

Recent evidence shows 25% of children with cancer die of their disease or its complications. When a child is dying, there is also evidence that

• Terminal symptoms and pain are not adequately relieved.
• There are not enough specialists trained in symptom control.
• Palliative care can improve the experience for the pediatric patient and parents, but many do not commonly have access to palliative care services.
• Palliative care specialists are not adequately trained in pediatrics.
• Parents want to give their children every available treatment to extend their lives.
• Parents want their children to be comfortable and pain-free.

New models to deliver pediatric palliative care are needed, incorporating pain and symptom control in routine pediatric oncology.

This special Cancer Pain Release issue highlights a few examples of these new models, and will be useful to all who care for—or about—pediatric pain patients with advanced disease.

The body of knowledge on controlling pain in children safely and effectively is impressive, but too seldom translated into clinical practice. An interview with Patricia McGrath, PhD, director of the Chronic Pain Program at the Hospital for Sick Children, professor of anesthesia at the University of Toronto, and current APS treasurer, describes some of this underused knowledge. Dr. McGrath concluded her interview by saying, “In no particular order, increased education of health professionals, better information for families, cooperation of health professionals with parents and children, documentation of pain, establishment of explicit treatment protocols, and routine institutionalization of protocols—all these factors can improve pain control for children in the palliative care setting.”

The issue proves wrong several important myths and misconceptions about pediatric pain control; truths are presented to replace false beliefs. Examples of such truths are that infants can feel pain; opioids should not be reserved only as a last resort; health professionals often can effectively assess children’s pain; and simple nondrug therapies can be effective in pediatric pain control.

Brief descriptions of the use of NSAIDs, opioids, and local anesthetics in children are provided with citations of key references on these topics. Some clinical “pearls” include

• Children metabolize drugs faster than adults because their liver mass is larger per kilogram of body weight.
• Because drugs clear more rapidly in children than in adults, more frequent drug dosing is required. For example, a sustained-release morphine dosage form that is appropriate for twice-daily dosing in adults may require three-times-daily dosing in children.
• Common pediatric drug dosing errors include milligram-microgram conversions, decimal point errors, confusion between daily dose and fractional dose, and dilution errors.

The Pediatric Pain Profile is described as a tool for understanding pain in children who cannot speak. Online resources on pediatric pain, a course for pediatric oncology nurses, a manual for patient/family education, and U.S. and U.K. guidelines on pediatric palliative care provision are described. This Cancer Pain Release issue includes many useful and timely resources, including tools to improve clinical competency in pediatric pain management, resources to develop pediatric palliative care services, new books and journals about pain in children with cancer, and recent evidence about pain measurement, the relief of surgical pain, and palliative care for newborns.

To read this issue online, visit: www.WHOcancerpain.wisc.edu/eng/16_3-4/16_3-4.html

To receive a print copy of this or any previous issue of Cancer Pain Release, visit www.WHOcancerpain.wisc.edu/feedback.html.

Cancer Pain Release is published quarterly at the WHO Collaborating Center for Policy and Communications in Cancer Care, a program of the Pain and Policy Studies Group at the University of Wisconsin-Madison. The mission of the WHO Pain and Palliative Care Communications program is to improve access to professional education resources in pain control and palliative care on a global scale and actively support the World Health Organization to promote pain relief and palliative care.

Sophie M. Colleau, PhD, is Editor of Cancer Pain Release, Coordinator of the WHO Pain and Palliative Care Communications Program, and a member of the Pain and Policy Studies Group at the University of Wisconsin-Madison. She may be contacted at colleau@med.wisc.edu.

Arthur G. Lipman, PharmD, is Professor of Pharmacotherapy, College of Pharmacy; Adjunct Professor of Anesthesiology, School of Medicine; and Director of Clinical Pharmacology, Pain Management Center, University Hospitals and Clinics; University of Utah Health Sciences Center, Salt Lake City UT. He may be contacted at alipman@hsc.utah.edu.

Please direct your comments or suggestions about this article or department to Arthur G. Lipman, PharmD, Department Editor, at alipman@hsc.utah.edu.

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