Cancer pain
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Cancer Pain Management in Pediatric Cancer Patients

ByMichelle Byrd, RN, CMCN

Pain Management and Its Effects on Children with Cancer 

The perception of cancer pain is unique. Everyone experiences pain differently. The same is true for children who have been diagnosed with cancer. Children express pain differently depending on age and other barriers such as cognitive ability, verbal communication, etc. Minimizing or eliminating the pain a child experiences is the overall goal of parents and caregivers.  Studies suggest that children who experience adequate pain management during their illness and/or treatment achieve better outcomes and quality of life. Various medications and non-pharmacologic techniques are available to assist in helping a child with cancer experience as little pain as possible.  

Pediatric cancer pain is one of the most challenging types of pain to manage. According to The World Health Organization (WHO), nearly every child diagnosed with cancer will experience some degree of pain.  Pain can come from the tumor itself or the prescribed treatment regimen. Children diagnosed with cancer who experience pain that is not well controlled can have a negative impact on their overall emotional, social, and physical health. Uncontrolled pain puts children at risk for developing anxiety, depression, social isolation, learning delays, or physical disabilities. 

The Many Faces of Cancer Pain  

Cancer pain can be associated with several causes. These include tumors themselves, cancer treatments, or even underlying illnesses. Pain can come on suddenly or come and go intermittently. It can last weeks to months. It can disappear after treatment with a mild pain reliever like Tylenol or come back, lasting a long time. Cancer pain comes in many forms, depending on the size and location of the tumor.

Discomfort can manifest as a headache, backache, stomachache, or soreness in the legs, arms, joints, or mouth. It can be intense, taking the form of sharp, stabbing, or burning sensations, or it can be more subtle, like a dull ache or an area that’s tender to the touch. Such discomfort may arise from medical tests prescribed by doctors, which might involve needles for blood drawing, bone marrow aspiration, or spinal fluid extraction. Additionally, biopsies of the skin or tissue, ordered by the doctor to rule out cancer, can also be sources of discomfort. Cancer treatments, such as chemotherapy, radiation therapy, or surgery, are other factors that can contribute to a child’s pain.   

Impacts of Pain on the Mind and Body  

Physical

Physical – Cancer pain can be debilitating. It can limit movement and mobility, leading to an inability of children to complete otherwise regular activities. Normal daily activities may include bathing, dressing, eating, walking, running, riding a bike, or attending school. Children with cancer are at risk of developing a physical disability related to the tumor or treatment. Nutrition plays a key factor in pain management.  Pain oftentimes can cause nausea, extreme fatigue, weight loss, and loss of muscle mass in the arms or legs.

A child may not choose to eat due to mouth or throat pain stemming from radiation irritation or blisters. Children may have trouble with sleep due to pain caused by IV site location and muscle or joint discomfort. Surgical site pain may make it difficult for children to find comfortable positions to fall asleep. Infection from illness or treatment can also cause severe pain. Children undergoing cancer treatment often develop weakened immune systems, making it hard for them to fight off illnesses. Children who have a weakened immune system can become extremely ill very quickly. This may limit their ability to attend school, participate in school functions, and visit family or public places.  

Cognitive

Cognitive—Pain can become a child’s primary focus, affecting their ability to concentrate on other things. Pain may hinder a child’s ability to comprehend simple commands or complete simple tasks like brushing teeth or writing names. In some instances, pain may be so severe that children are unable to verbalize their needs.  

Emotional

Emotional – Fear is one of the most significant emotional experiences a child and their family face after cancer is diagnosed. Fear may be related to pain from cancer, illness, procedures, and/or medication administration. Fear may lead to anxiety, depression, isolation, withdrawal, and emotional distress. Children often blame themselves for their parents feeling sad or scared. This is especially true when they witness their parents struggling with overwhelming emotions such as fear, sadness, or helplessness. Parents play a vital role in the recovery of a child with cancer. Helping parents understand they are not alone in their child’s cancer battle is crucial. The Sassy Carmen Foundation offers parents educational tools and resources to support and help them through challenges they may face during their child’s cancer journey.  

Evaluation of Pain in Children  

The first step in managing pain in a child with cancer is to understand the need to assess it correctly. Caregivers and parents should be educated in the different ways to assess pain. Caregivers can better understand a child’s pain through observation of body language and active listening while interacting with the child.  The ability to act quickly to assess and treat pain can positively impact a child’s recovery and outcome.   Many types of pain scales are used with pediatric patients to help them express the level of pain they are experiencing. These pain assessment tools help healthcare providers and parents better understand and treat the child’s pain accordingly. These assessment tools include:  

The Numerical Rating Scale (NRS: A numeric scale of 0 to 10; zero means no pain, and 10 means extremely severe pain.  

The Revised Face Legs Activity Cry and Consolability (r-FLACC) scale: Assesses pain in verbal and nonverbal patients. In infants and children, observation is made to note changes in facial expression, increased activity, restlessness, or tension in the arms/legs. Assesses for change or intensity of crying and how easily the patient can be comforted or consoled.  

The Revised Premature Infant Pain Profile (PIPP-R): Evaluates pain in neonates by observing the infant’s heart rate, oxygen use, facial expression, and crying.  

The Faces Pain Scale (including the Oucher and Wong-Baker Scales): Assesses pain using cartoon facial drawings as a scale.  Starting with a face with a neutral expression, the scale progresses as facial expressions change to reflect pain intensity. The faces can include numbers 0, 2, 4, 6, 8, and 10 and words describing each facial expression’s pain. 

Treatments for Cancer Pain 

There are various methods available to help control pain. Treatment depends on the child’s age, description of pain, and location. Their caregiver may also observe it. Some include medications such as Acetaminophen (Tylenol) and nonsteroidal anti-inflammatories (NSAIDs), such as ibuprofen (Advil), for mild or acute pain. Moderate or more severe and/or chronic pain may require stronger medications to be prescribed. These may include codeine, tramadol, morphine, fentanyl, and oxycodone. If a child reports experiencing nerve pain (a sensation of numbness, tingling, or burning sensation), gabapentin may be prescribed.  

There are also ways to help ease a child’s pain without the use of medication. Some methods include passive massage, hot or cold compresses, warm baths, and repositioning. Pain may be relieved by sitting in a chair, walking short distances, or  

standing for short periods. Other ways to help a child manage pain include imagery, yoga, hypnosis, or distraction through music and play.  Laughter can also be a great distraction from pain. Parents can comfort their child through touch, i.e., holding, cuddling, gentle rocking, swaying, humming, or singing.  

Collaboration is Key 

The importance of pain control in the pediatric cancer population is a priority. If pain is uncontrolled, it can have a negative impact on the patient’s disease course, treatment, and outcome. Pain can have adverse effects on not only the physical quality of a child but also have long-standing effects psychologically and emotionally. Caregivers and Parents play a vital role in the struggle to help manage a child’s cancer pain. Parents are the best advocates for their children. They also know their child’s behaviors, strengths, and fears.  Through communication and working closely with their child’s provider, plans to help pain control are created.  Establishing rapport between the provider and parents sends a strong message to a child, building their trust that they will be well cared for. This sets the groundwork to provide a child with cancer with a brighter outcome for their future health and well-being.  

References

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