Pediatric Oncology: Managing Pain at the End of Life

Abstract

Pain is a common and highly distressing symptom in pediatric patients with advanced malignancies. Prompt recognition, assessment, and treatment of pain are necessary, especially at the end of life. Opioid medications remain the mainstay of treatment of malignant pain in children at the end of life and the amount of opioids required for adequate pain control in patients is highly variable. Nonpharmacological approaches including behavioral and physical approaches in addition to non-opioid pain medications should be used when possible to augment pain control. Identification and treatment of any underlying pathology is important and use of adjuvant medications based on pathophysiology and source of pain should be considered. In cases where adequate pain control is not achieved through these multiple modalities, an interdisciplinary approach including potential interventional techniques and alternative treatments is required. This multimodal approach to pain management is best provided by interdisciplinary teams, as these teams can best address the complex causes of pain and associated distress that occurs in patients and within families.

Neuropathic Pain in Pediatric Oncology: A Clinical Decision Algorithm

“…While NP is well characterized in adults with cancer [3][4][5][6][7][8][9][10][11][12][13][14][15], it is less well described in pediatric oncology [16][17][18][19][20][21][22]. In the setting of pain in pediatric oncology patients, NP can be caused by a variety of types of somatosensory system injuries including chemotherapyrelated NP [19,23], tumor-related NP [24][25][26], post-surgical NP [27,28], and the complex circumstances of NP at the end-of-life [29]. The most commonly incriminated chemotherapy agent related to neurotoxicity and NP in children is vincristine.…”

“…Post-surgical NP related to mechanical nerve trauma in pediatric oncology has a prevalence of 81.6% after surgery for osteosarcoma with either postamputation phantom limb pain (PLP) or as NP after limb sparing surgery [27]. NP at the end of life is often related to complex circumstances and may include mixed nociceptive and neuropathic mechanisms [29].…”

Electronic Assessment and Tracking of Pain at Home: A Prospective Study in Children With Hematologic or Solid Tumors

“…Pain may result not only from primary cancer and/or metastasis but also from treatment procedures and side effects (Bukola & Paula, 2017;Duffy et al, 2019;Twycross et al, 2015). In other cases, pain is associated with endstage or terminal disease (Snaman et al, 2016;Ye et al, 2019).…”

Provision of Adequate Pain Management to a Young Adult Oncology Patient Presenting with Aberrant Opioid-Associated Behavior: A Case Study

“…[6][7][8][9] Interdisciplinary teams are best equipped to provide such treatment because they can complement medical pain management by addressing the complex issues underlying pain. 10 Although nonopioid analgesics and nonpharmacologic approaches are used to manage cancer pain, opioids remain a mainstay of treatment. 10,11 Indeed, a retrospective review conducted at St. Jude Children's Research Hospital found that 23.6% of AYAs with cancer are prescribed opioids.…”

“…10 Although nonopioid analgesics and nonpharmacologic approaches are used to manage cancer pain, opioids remain a mainstay of treatment. 10,11 Indeed, a retrospective review conducted at St. Jude Children's Research Hospital found that 23.6% of AYAs with cancer are prescribed opioids. 12 Although most patients used opioid medications as prescribed, 11.7% exhibited aberrant opioid-associated behavior (AOB).…”