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Table of Contents
Vol. 16, Suppl. 1, 2007
Issue release date: August 2007
Open Access Gateway
Med Princ Pract 2007;16:10–15
(DOI:10.1159/000104541)

Principles of Pediatric Pain Management during the End-of-Life Period

Friedrichsdorf S.J.a · Collins J.J.b
aPain and Palliative Care Program, Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minn., USA; bPain and Palliative Care Service, Children’s Hospital at Westmead, Sydney, Australia
email Corresponding Author

Abstract

More than 80% of children with a life-limiting condition such as cancer or a neurodegenerative disease suffer from pain during their last week of life. This article reviews the principles of pediatric pain management and addresses characteristics and pitfalls of integrative and pharmacological therapies during the end-of-life period of a child.Providing a good pain management for a dying child is one of the many domains of pediatric palliative care and usually requires a holistic, multidisciplinary approach and the knowledge to apply appropriate analgesic drugs in combination with integrative nondrug therapies.


 goto top of outline Key Words

  • Pediatric palliative care
  • Symptom management
  • Child
  • Terminal care
  • Pain control

 goto top of outline Abstract

More than 80% of children with a life-limiting condition such as cancer or a neurodegenerative disease suffer from pain during their last week of life. This article reviews the principles of pediatric pain management and addresses characteristics and pitfalls of integrative and pharmacological therapies during the end-of-life period of a child.Providing a good pain management for a dying child is one of the many domains of pediatric palliative care and usually requires a holistic, multidisciplinary approach and the knowledge to apply appropriate analgesic drugs in combination with integrative nondrug therapies.

Copyright © 2007 S. Karger AG, Basel


 goto top of outline References
  1. Association for Children with Life-Threatening or Terminal Conditions and Their Families and The Royal College of Paediatrics and Child Health: A Guide to the Development of Children’s Palliative Care Services, ed 2. Bristol, Association for Children with Life-Threatening or Terminal Conditions and Their Families, 2003.
  2. Dangel T: Domowa opieka paliatywna nad dziecmi w Polsce. Warsaw, Department of Palliative Care, Institute for Mother and Child, 2001.
  3. Drake R, Frost J, Collins JJ: The symptoms of dying children. J Pain Symptom Manage 2003;26:594–603.
  4. Goldman A: Symptoms and suffering at the end of life in children with cancer – correspondence. N Engl J Med 2000;342:1997–1999.
  5. Wolfe J, Grier HE, Klar N: Symptoms and suffering at the end of life in children with cancer. N Engl J Med 2000;342:326–333.
  6. Jay SM, Elliott C, Siegal S: Cognitive, behavioral, and pharmacologic interventions for children’s distress during painful medical procedures. J Consult Clin Psychol 1987;55:860–865.
  7. Elliott C, Jay SM, Woody P: An observational scale for measuring children’s distress during medical procedures. J Pediatr Psychol 1987;12:543–551.
  8. Kuttner L, Bowman M, Teasdale M: Psychological treatment of distress, pain and anxiety for children with cancer. J Dev Behav Pediatr 1988;9:374–381.
  9. Denecke H, Hünseler C: Messen und Erfassen von Schmerz; in Zernikow B (ed): Schmerztherapie bei Kindern, ed 2. Berlin, Springer, 2003, pp 51–79.
  10. Solodiuk J, Curley MA: Pain assessment in nonverbal children with severe cognitive impairments: the Individualized Numeric Rating Scale (INRS). J Pediatr Nurs 2003;18:295–299.
  11. Collignon P, Giusiano B: Validation of a pain evaluation scale for patients with severe cerebral palsy. Eur J Pain 2001;5:433–442.
  12. Kuttner L: Integrative methods to relieve pain and suffering; in Goldman A, Hain RDW, Liben S (eds): Oxford Textbook of Palliative Care for Children. Oxford, Oxford University Press, 2006.
  13. Kuttner L: Mind-body methods of pain management. Child Adolesc Psychiatr Clin N Am 1997;6:783–795.

    External Resources

  14. World Health Organization: Cancer Pain Relief and Palliative Care in Children. Geneva, World Health Organization, 1999.
  15. Yaster M, Kost-Byerly S, Maxwell LG: Opioid agonists and antagonists; in Schechter NL, Berde CB, Yaster M (eds): Pain in Infants, Children, and Adolescents, ed 2. Philadelphia, Lippincott Williams & Wilkins, 2003, pp 181–224.
  16. Galinkin JL, Fazi LM, Cuy RM, Chiavacci RM, Kurth CD, Shah UK, Jacobs IN, Watcha MF: Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia. Anesthesiology 2000;93:1378–1383.
  17. Manjushree R, Lahiri A, Ghosh BR, Arpita L, Handa K: Intranasal fentanyl provides adequate postoperative analgesia in pediatric patients. Can J Anaesth 2002;49:190–193.
  18. Peng PWH, Sandler AN: A review of the use of fentanyl analgesia in the management of acute pain in adults. Anesthesiology 1999;90:576–599.
  19. Borland ML, Jacobs I, Geelhoed G: Intranasal fentanyl reduces acute pain in children in the emergency department: a safety and efficacy study. Emerg Med (Fremantle) 2002;14:275–280.
  20. Collins JJ, Dunkel IJ, Gupta SK, Inturrisi CE, Lapin J, Palmer LN, Weinstein SM, Portenoy RK: Transdermal fentanyl in children with cancer pain: feasibility, tolerability, and pharmacokinetic correlates. J Pediatr 1999;134:319–323.
  21. Christensen ML, Wang WC, Harris S, Eades SK, Wilimas JA: Transdermal fentanyl administration in children and adolescents with sickle cell pain crisis. J Pediatr Hematol Oncol 1996;18:372–376.
  22. Friedrichsdorf S: Fentanyl in pediatric pain management – Novel routes of administration. Suffering Child 2004;8:24–29.
  23. Portenoy RK, Payne R, Coluzzi P, Raschko JW, Lyss A, Busch MA, Frigerio V, Ingham J, Loseth DB, Nordbrock E, Rhiner M: Oral transmucosal fentanyl citrate (OTFC) for the treatment of breakthrough pain in cancer patients: a controlled dose titration study. Pain 1999;79:303–312.
  24. Heubi JE, Barbacci MB, Zimmerman HJ: Therapeutic misadventure with acetaminophen: hepatotoxicity after multiple doses in children. J Pediatr 1998;132:22–27.
  25. Hain RDW, Miser A, Devins M, Wallace HB: Strong opioids in pediatric palliative medicine. Paediatr Drugs 2005;7:1–9.
  26. Drake R, Longworth J, Collins JJ: Opioid rotation in children with cancer. J Palliat Med 2004;7:419–422.
  27. Galer BS: Individual variability in the response to different opioids. Pain 1992;49:87–91.
  28. Portenoy RH, Gebhart GF, Hammond DI, Jensen TS: Opioid tolerance and responsiveness: research findings and clinical observations; in Gebhart (ed): Progress in Pain Research and Management. Seattle, IASP Press, 1994, pp 615–619.
  29. Schechter NL, Berde CB, Yaster M: Pain in infants, children, and adolescents – An overview; in Schechter NL, Berde CB, Yaster M (eds): Pain in Infants, Children, and Adolescents, ed 2. Philadelphia, Lippincott Williams & Wilkins, 2003, pp 3–18.
  30. Hicks CL, von Baeyer CL, Spafford P, van Korlaar I, Goodenough B: The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain 2001;93:173–183.

 goto top of outline Author Contacts

Stefan J. Friedrichsdorf, MD
Pain and Palliative Care Program, Children’s Hospitals and Clinics of Minnesota
2525 Chicago Avenue South, Minneapolis, MN 55404 (USA)
Tel. +1 612 813 6246, Fax +1 612 813 6358
E-Mail stefan.friedrichsdorf@childrensmn.org


 goto top of outline Article Information

The authors have made extensive efforts to ensure that treatments, drugs and dosage regimens in this article are accurate and conform to the standards accepted at the time of the publication. However, changes in information through continuing research and clinical experience and the possibility of human error warrant that the authors do not accept any responsibility for any loss or damage arising from actions or decisions based on information in this article: the ultimate responsibility for the treatment of patients and interpretation of published material lies with the medical practitioner.

Received: June 29, 2005
Revised: April 2, 2006
Number of Print Pages : 6
Number of Figures : 2, Number of Tables : 1, Number of References : 30


 goto top of outline Publication Details

Medical Principles and Practice (International Journal of the Kuwait University Health Sciences Centre)

Vol. 16, No. Suppl. 1, Year 2007 (Cover Date: August 2007)

Journal Editor: Owunwanne, A. (Kuwait)
ISSN: 1011–7571 (print), 1423–0151 (Online)

For additional information: http://www.karger.com/MPP


Open Access License / Drug Dosage / Disclaimer

Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

More than 80% of children with a life-limiting condition such as cancer or a neurodegenerative disease suffer from pain during their last week of life. This article reviews the principles of pediatric pain management and addresses characteristics and pitfalls of integrative and pharmacological therapies during the end-of-life period of a child.Providing a good pain management for a dying child is one of the many domains of pediatric palliative care and usually requires a holistic, multidisciplinary approach and the knowledge to apply appropriate analgesic drugs in combination with integrative nondrug therapies.



 goto top of outline Author Contacts

Stefan J. Friedrichsdorf, MD
Pain and Palliative Care Program, Children’s Hospitals and Clinics of Minnesota
2525 Chicago Avenue South, Minneapolis, MN 55404 (USA)
Tel. +1 612 813 6246, Fax +1 612 813 6358
E-Mail stefan.friedrichsdorf@childrensmn.org


 goto top of outline Article Information

The authors have made extensive efforts to ensure that treatments, drugs and dosage regimens in this article are accurate and conform to the standards accepted at the time of the publication. However, changes in information through continuing research and clinical experience and the possibility of human error warrant that the authors do not accept any responsibility for any loss or damage arising from actions or decisions based on information in this article: the ultimate responsibility for the treatment of patients and interpretation of published material lies with the medical practitioner.

Received: June 29, 2005
Revised: April 2, 2006
Number of Print Pages : 6
Number of Figures : 2, Number of Tables : 1, Number of References : 30


 goto top of outline Publication Details

Medical Principles and Practice (International Journal of the Kuwait University Health Sciences Centre)

Vol. 16, No. Suppl. 1, Year 2007 (Cover Date: August 2007)

Journal Editor: Owunwanne, A. (Kuwait)
ISSN: 1011–7571 (print), 1423–0151 (Online)

For additional information: http://www.karger.com/MPP


Open Access License / Drug Dosage

Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Association for Children with Life-Threatening or Terminal Conditions and Their Families and The Royal College of Paediatrics and Child Health: A Guide to the Development of Children’s Palliative Care Services, ed 2. Bristol, Association for Children with Life-Threatening or Terminal Conditions and Their Families, 2003.
  2. Dangel T: Domowa opieka paliatywna nad dziecmi w Polsce. Warsaw, Department of Palliative Care, Institute for Mother and Child, 2001.
  3. Drake R, Frost J, Collins JJ: The symptoms of dying children. J Pain Symptom Manage 2003;26:594–603.
  4. Goldman A: Symptoms and suffering at the end of life in children with cancer – correspondence. N Engl J Med 2000;342:1997–1999.
  5. Wolfe J, Grier HE, Klar N: Symptoms and suffering at the end of life in children with cancer. N Engl J Med 2000;342:326–333.
  6. Jay SM, Elliott C, Siegal S: Cognitive, behavioral, and pharmacologic interventions for children’s distress during painful medical procedures. J Consult Clin Psychol 1987;55:860–865.
  7. Elliott C, Jay SM, Woody P: An observational scale for measuring children’s distress during medical procedures. J Pediatr Psychol 1987;12:543–551.
  8. Kuttner L, Bowman M, Teasdale M: Psychological treatment of distress, pain and anxiety for children with cancer. J Dev Behav Pediatr 1988;9:374–381.
  9. Denecke H, Hünseler C: Messen und Erfassen von Schmerz; in Zernikow B (ed): Schmerztherapie bei Kindern, ed 2. Berlin, Springer, 2003, pp 51–79.
  10. Solodiuk J, Curley MA: Pain assessment in nonverbal children with severe cognitive impairments: the Individualized Numeric Rating Scale (INRS). J Pediatr Nurs 2003;18:295–299.
  11. Collignon P, Giusiano B: Validation of a pain evaluation scale for patients with severe cerebral palsy. Eur J Pain 2001;5:433–442.
  12. Kuttner L: Integrative methods to relieve pain and suffering; in Goldman A, Hain RDW, Liben S (eds): Oxford Textbook of Palliative Care for Children. Oxford, Oxford University Press, 2006.
  13. Kuttner L: Mind-body methods of pain management. Child Adolesc Psychiatr Clin N Am 1997;6:783–795.

    External Resources

  14. World Health Organization: Cancer Pain Relief and Palliative Care in Children. Geneva, World Health Organization, 1999.
  15. Yaster M, Kost-Byerly S, Maxwell LG: Opioid agonists and antagonists; in Schechter NL, Berde CB, Yaster M (eds): Pain in Infants, Children, and Adolescents, ed 2. Philadelphia, Lippincott Williams & Wilkins, 2003, pp 181–224.
  16. Galinkin JL, Fazi LM, Cuy RM, Chiavacci RM, Kurth CD, Shah UK, Jacobs IN, Watcha MF: Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia. Anesthesiology 2000;93:1378–1383.
  17. Manjushree R, Lahiri A, Ghosh BR, Arpita L, Handa K: Intranasal fentanyl provides adequate postoperative analgesia in pediatric patients. Can J Anaesth 2002;49:190–193.
  18. Peng PWH, Sandler AN: A review of the use of fentanyl analgesia in the management of acute pain in adults. Anesthesiology 1999;90:576–599.
  19. Borland ML, Jacobs I, Geelhoed G: Intranasal fentanyl reduces acute pain in children in the emergency department: a safety and efficacy study. Emerg Med (Fremantle) 2002;14:275–280.
  20. Collins JJ, Dunkel IJ, Gupta SK, Inturrisi CE, Lapin J, Palmer LN, Weinstein SM, Portenoy RK: Transdermal fentanyl in children with cancer pain: feasibility, tolerability, and pharmacokinetic correlates. J Pediatr 1999;134:319–323.
  21. Christensen ML, Wang WC, Harris S, Eades SK, Wilimas JA: Transdermal fentanyl administration in children and adolescents with sickle cell pain crisis. J Pediatr Hematol Oncol 1996;18:372–376.
  22. Friedrichsdorf S: Fentanyl in pediatric pain management – Novel routes of administration. Suffering Child 2004;8:24–29.
  23. Portenoy RK, Payne R, Coluzzi P, Raschko JW, Lyss A, Busch MA, Frigerio V, Ingham J, Loseth DB, Nordbrock E, Rhiner M: Oral transmucosal fentanyl citrate (OTFC) for the treatment of breakthrough pain in cancer patients: a controlled dose titration study. Pain 1999;79:303–312.
  24. Heubi JE, Barbacci MB, Zimmerman HJ: Therapeutic misadventure with acetaminophen: hepatotoxicity after multiple doses in children. J Pediatr 1998;132:22–27.
  25. Hain RDW, Miser A, Devins M, Wallace HB: Strong opioids in pediatric palliative medicine. Paediatr Drugs 2005;7:1–9.
  26. Drake R, Longworth J, Collins JJ: Opioid rotation in children with cancer. J Palliat Med 2004;7:419–422.
  27. Galer BS: Individual variability in the response to different opioids. Pain 1992;49:87–91.
  28. Portenoy RH, Gebhart GF, Hammond DI, Jensen TS: Opioid tolerance and responsiveness: research findings and clinical observations; in Gebhart (ed): Progress in Pain Research and Management. Seattle, IASP Press, 1994, pp 615–619.
  29. Schechter NL, Berde CB, Yaster M: Pain in infants, children, and adolescents – An overview; in Schechter NL, Berde CB, Yaster M (eds): Pain in Infants, Children, and Adolescents, ed 2. Philadelphia, Lippincott Williams & Wilkins, 2003, pp 3–18.
  30. Hicks CL, von Baeyer CL, Spafford P, van Korlaar I, Goodenough B: The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain 2001;93:173–183.