PAEDIATRIC PALLIATIVE CARE PAIN MANAGEMENT

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PAEDIATRIC PALLIATIVE CAREPAIN MANAGEMENT

• Lynette Thacker
• Clinical Nurse Specialist
• Paediatric Palliative Care
• 07773281621

Disclaimer Whilst every effort has been made to
ensure that the information in this presentation
is accurate and referenced the author does not
accept any responsibility for the use by any
third parties.
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Definition of Palliative Care

• Palliative care is the active, total care of the
  patient whose
• disease is not responsive to curative treatment.
  Control of
• pain, of other symptoms, and of social,
  psychological and
• spiritual problems is paramount. Palliative care
  is
• interdisciplinary in its approach and encompasses
  the patient,
• the family and the community in its scope. In a
  sense,
• palliative care is to offer the most basic
  concept of care that
• of providing for the needs of the patient
  wherever he or she is
• cared for, either at home or in the hospital.
  Palliative care
• affirms life and regards dying as a normal
  process it neither
• hastens nor postpones death. It sets out to
  preserve the best
• possible quality of life until death.
• (European Association for Palliative Care 1998)

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What is Pain

• Pain is an emotion experienced in the brain,
  it is not like touch, taste, sight, smell or
  hearing. Pain can be perceived as a warning of
  potential damage, but can also be present when no
  actual harm is being done to the body.
• Pain is what the individual tells us they are
  experiencing, where it is, when it occurs, what
  it feels like, what makes it better and when its
  disappeared.
• It is categorised into
• Acute pain - less than twelve weeks duration and
  may serve as a warning of injury and tissue
  damage, this pain may not necessarily be
  associated with major or persistent changes in
  lifestyle or relationships.
• Chronic pain - of more than twelve weeks, which
  may be persistent or recurrent, is often
  associated with substantial alterations in
  behaviour and in relationships.

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Definitions of Types of Pain Experienced in
Palliative Care

• Allodynia - Pain due to a stimulus that does not
  normally provoke pain. For example, stroking the
  skin lightly with clothes or cotton wool will
  produce pain.
• Causalgia - Disruption in normal flow of sensory
  information along nerve to brain, creating a
  confusion for the brain, which is interpreted as
  a constant , uniquely disabling pain state which
  is highly resistant to normal forms of medical
  therapy.
• Deafferentation pain - Pain that occurs, often
  after trauma or surgery, presenting as
  neuropathic pain in an area of numbness or loss
  of sensation.
• Hyperalgesia - The perception of a painful
  stimulus as more painful than normal.
• Neuralgia - Pain in the distribution of a nerve
  or nerves
• Neuropathic pain - Is pain initiated or caused by
  a primary lesion or dysfunction in the peripheral
  or central nervous system. For example pain
  following shingles, or an amputation, or spinal
  cord trauma.
• (The
  British Pain Society 2006-2007-2008)

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TYPES OF PAIN
NOCICEPTIVE
Somatic
Viscera

• Organs heart, liver, pancreas, gut, etc.
• Constant or crampy
• Aching
• Poorly localized
• Referred

• bones, joints
• connective tissues
• Muscles
• Aching, often constant
• May be dull or sharp
• Often worse with movement
• Well localized

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NEUROPATHIC
Deafferentation
Sympathetic Maintained
Peripheral
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When Do Children Experience Pain

• Pains experienced by children with palliative
• care conditions are a result of
• Investigations
• Treatment
• Disease
• Disability secondary to the disease process
• Coincidental to the disease.
• Both acute and chronic.

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Palliative Care Approach To Pain Control

• Thorough assessment of the pain experience by
  skilled and
• knowledgeable professional.
• Assessment of pain includes history, location,
  intensity or
• severity, quality (description), duration,
  pattern, current
• treatment and response to treatment
  (pharmacological and
• non-pharmacological interventional analgesia),
  physical
• examination.
• Discuss with child (if cognitively appropriate)
  and family the
• goals of care, hopes, expectations, anticipated
  course of
• illness.
• Refer to medical team who may wish to undertake
  further
• investigations X-Ray, CT, MRI, etc. For
  treatment of
• reversible causes of pain.
• Ongoing reassessment and review of options,
  goals,
• expectations, etc.

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How Do We Assess Pain

• Choosing a pain assessment tool
• Pain Scales
• Use appropriate tool for the childs age and
  cognitive development
• Use the same pain scale for the child

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Self-report of pain

• The ability of children to describe and rate
  their own pain
• varies with their age, developmental stage, and
  health.
• Wong-Baker FACES Pain Rating Scale

Numeric Rating Scale
0 1 2 3 4 5
6 7 8 9 10 No Pain
Mild Moderate Severe
Worst Possible
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Behavioural Pain Tools

• Paediatric Pain Profile
• The Paediatric Pain Profile is a behaviour rating
  scale
• developed to assess pain in children with severe
  motor and
• learning disabilities. The tool is envisaged as a
  parent held
• document, and contains documentation of the
  child's pain
• history, baseline, and on-going pain assessments.
• Consists of
• Pain history
• Current pain problems
• Childs behaviour on a good day
• Current pain behaviour
• Ongoing assessment of pain

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Treating Pain

• The treatment of pain should not be
• about just giving medications.

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Care Planning Components

• Pharmacological component
• Non pharmacological component
• Monitoring component

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Non-Pharmacologic Treatments

• Exercise
• Immobilisation
• Transcutaneous Electrical Nerve Stimulation
  (TENS)
• Acupunture
• Relaxation and Imagery
• Distraction
• Psychotherapy
• Hypnosis
• Peer support groups
• Counselling

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W.H.O. ANALGESIC LADDER
Strong opioid
/- adjuvant
Weak opioid
Severe Pain Morphine Diamorphine Fentanyl
/- adjuvant
Non-opioid
Moderate Pain Codeine Transaxmic Acid
/- adjuvant
Pain persists or increases
Mild Pain Paracetamol NSAID Ibuprofen
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Key Steps to Improving Pain Control

• Step 1 Administer medications routinely, not as
  required
• Step 2 Use the least invasive route of
  administration first
• Step 3 Begin with low dose titrate up
• Step 4 Monitor and document effectiveness of
  medication each shift
• Step 5 Reassess and adjust dose to optimise
  pain relief while monitoring and managing side
  effect

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• Opioids
• Safe effective analgesic
• Oral route effective as injectable
• No ceiling effect
• 7 10 population lack CYP2D liver enzyme
  codeine cannot be metabolised and therefore will
  not be effective

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• Side Effects of Opioids
• Constipation need proactive laxative use
  (Movicol)
• Nausea/vomiting consider treating with dopamine
  antagonists and/or prokinetics (Metoclopramide,
  Prochlorperazine Stemetil, Haloperidol)
• Urinary retention (warm bath may help)
• Itch/rash worse in children. May try
  antihistamines, however not great success
• Dry mouth
• Respiratory depression uncommon when titrated
  in response to symptom
• Drug interactions
• Neurotoxicity (OIN) delirium, myoclonus
  seizures

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Adjuvant Analgesics

• first developed for non-analgesic indications
• subsequently found to have analgesic activity in
  specific pain scenarios
• Common uses
• pain poorly-responsive to opioids (eg.
  neuropathic pain), or
• with intentions of lowering the total opioid dose
  and thereby mitigate opioid side effects.

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Adjuvants Used In Palliative Care

• General / Non-specific
• corticosteroids
• cannabinoids (trial in adults with MS in ABMU)
• Neuropathic Pain
• gabapentin
• antidepressants
• ketamine
• Bone Pain
• bisphosphonates
• (calcitonin)

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Professional Barriers to Effective Opioid Pain
Control

• Fear of causing addiction
• Fear of regulatory and legal barriers
• Lack of experience with opioid analgesia
• Side effects

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Parent Barriers to Effective Opioid Pain Control

• Parent and family fear of addiction which is rare
  when given for pain less than 1.
• Misconception about side effects
• Reluctance to report pain
• Professional parent relationship

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