The Journal of Pediatrics
Volume 152, Issue 1 , Pages 6-8, January 2008

Pain Still Lords Over Children

  • Justin N. Baker, MD

      Affiliations

    • Department of Oncology, Palliative and End of Life Care, St. Jude Children’s Research Hospital, Memphis, Tennessee
    • ,
  • Doralina L. Anghelescu, MD

      Affiliations

    • Division of Anesthesia, Palliative and End of Life Care, St. Jude Children’s Research Hospital, Memphis, Tennessee
    • ,
  • Javier R. Kane, MD

      Affiliations

    • Department of Oncology, Palliative and End of Life Care, St. Jude Children’s Research Hospital, Memphis, Tennessee
    • Corresponding Author InformationReprint requests: Javier R. Kane, MD, St Jude Children’s Research Hospital, 332 N Lauderdale St, MS 260, Memphis, TN 38105.

Article Outline

 

“We must all die. But that I can save him from days of torture, that is what I feel is my great ever-new privilege. Pain is a more terrible lord of mankind than even death itself.”

—Albert Schweitzer

Despite the remarkable impact of science on the practice of medicine, the “terrible lord” pain, like cancer, remains a formidable foe. In 2002, 8.5% of the 25,820 deaths in children 1 to 19 years old occurred as the result of malignancy.1 Today, although approximately 75% of children with cancer can expect to be cured, 25% of children die from either complications of therapy or progressive disease.2 The death of a child is always difficult and emotionally charged, and few things are more heartrending than the suffering of a vulnerable young patient ravaged by cancer and its treatment. Proper pain management and attention to the suffering of seriously ill children and their families must be one of the most pressing issues for pediatric health care providers in general and pediatric oncologists in particular because pain continues to be among the most prevalent and distressing symptoms in children dying a cancer-related death.3, 4

See related article, p 39

The pursuit of freedom from pain is as old as mankind, but it has not succeeded appreciably until recent years. We have learned much since the ancient Egyptians applied electric fish to painful wounds, the Mesopotamians grew opium poppies, and the Chinese used the willow tree. Since the time of Aesculapius, Hippocrates, and Galen, countless warriors have fought the battle against pain, and many have made remarkable achievements. In the seventeenth century, Sydenham introduced Laudanum, a mixture of opium and sherry, which was used for the relief of pain well into the nineteenth century.5 In the early 1800s, morphine was purified from poppy seeds by F.W.A. Serturner; a few decades later, its effectiveness against pain increased when the hypodermic syringe and hollow needle were invented.6 Advances during the 1900s included Bonica’s concept of interdisciplinary care for patients suffering from pain, the development of the World Health Organization pain management guidelines, and Wong and Baker’s “faces” pain assessment scale for children.7, 8, 9 Modern day medicine uses many special pain management techniques, such as conscious or deep sedation for procedures, epidural analgesia, or ingenious drug delivery systems such as those used in patient-controlled analgesia. These interventions are readily available in tertiary pediatric care centers in most developed countries. Today, we know about the role of receptors, ion channels, and neurotransmitters; we have greater understanding of the differences between acute, chronic, nociceptive, neuropathic, and complex types of pain; and we enjoy the availability of a variety of moderate and high potency opioids, non-steroidal antinflammatory agents, adjuvant drugs, routes of administration, and non-pharmacological approaches.10

Although barriers to proper pain and symptom control remain, a skilled pain management practitioner can ensure effective pain control and a comfortable death for most children with progressive, incurable cancer. In this issue of the Journal, Hewitt et al report a prospective study of the preferred types, routes of administration, and doses of opioids used to treat pain in children with incurable cancer at Children’s Cancer Study Group centers in the United Kingdom.11 Although this study does not address the efficacy of the opioid regimens, it does demonstrate that the liberal use of high-potency opioids is an integral part of interdisciplinary palliative care for advanced cancer. In this study, most patients (89.6%) received a major opioid, and in 72.8% of cases increasing doses of the drug were necessary as the illness progressed. Morphine was the opioid most commonly used, and it was most often administered intravenously at the end of life.

In this series, the authors report a group of 34 patients who required unusually high opioid doses, defined as >20 mg/kg/24 hours (range, 20-1500 mg/kg/24 hours). Thirty of these children reported pain as a major problem that responded to treatment, but 3 patients reported pain as an unresolved symptom. The presence of neuropathic pain in these patients is a real possibility, and the use of medications such as anticonvulsants, tricyclic antidepressants, methadone, or ketamine may supplement and enhance the benefit from opioids.12 The care of children whose pain is unresolved despite increasing doses of opioids and appropriate use of adjuvant drugs is frequently seasoned by the struggle to find a delicate balance between achieving adequate analgesia and avoiding undesirable adverse effects.13 For patients with inescapable suffering despite state-of-the-art treatment, physicians have appealed to the principle of double effect to justify continued treatment on the basis of its intent to achieve comfort.14 The provision of sedation to a level that allows the child to be unaware of suffering is also described.15, 16 Although useful, such approaches are difficult and ethically challenging. Newer and more effective drugs and drug delivery systems should be researched to overcome this obstacle.

The Institute of Medicine recognizes the value and need for improving palliative care and has identified end-of-life care, pain management, care coordination, and care of children with special health care needs as priority areas for quality improvement.17 Proper pain management is only 1 component of palliative care. Our challenge in the care of pediatric oncology patients is to have greater integration of palliative principles and practices into the continuum of care. Caregivers in a wide variety of disciplines must be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice and quality improvement approaches, with special emphasis on the management of pain and other symptoms.18

The goal to alleviate pain and attend to suffering is an ethical imperative for pediatric oncology providers, and the Hewitt et al study provides useful comparator data for the management of pain in modern cancer centers. The pattern of opioid use, dosing, and route of administration described in their report is probably similar to regimens used in other developed countries in which access to tertiary care centers, intravenous high-potency opioids, and an interdisciplinary care team is readily available. Unfortunately, children throughout the developing world lack access to even the most rudimentary cancer treatment and pain relief. It is estimated that 80% of the 250,000 children in whom cancer develops every year around the world die without adequate treatment, and many do not even receive morphine.19 In fact, six countries, the United States, Canada, France, Germany, Britain, and Australia, consume 79% of the World’s morphine. Comparatively, the 80% of the World’s people who live in poor and middle-income countries consume only about 6%.20 The pain and suffering that these children and families experience is a cry for help; it demands a focused and united effort from governments, pharmaceutical companies, hospitals, academic institutions, and individual caregivers. Indeed, humanity’s quest to conquer the “terrible lord” rages on.

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This series was supported in part by NIH Cancer Center Support Core Grant CA21765 and the American Lebanese Syrian Associated Charities (ALSAC). The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the National Cancer Institute.

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References 

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PII: S0022-3476(07)00775-5

doi:10.1016/j.jpeds.2007.08.019

Refers to article:

  • Opioid Use in Palliative Care of Children and Young People with Cancer , 05 November 2007

    Martin Hewitt, Ann Goldman, Gary S. Collins, Margaret Childs, Richard Hain
    The Journal of Pediatrics January 2008 (Vol. 152, Issue 1, Pages 39-44)

The Journal of Pediatrics
Volume 152, Issue 1 , Pages 6-8, January 2008

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