Cancer pain management in children

Behavioral physical activity intervention coupled with standard post-cancer directed treatment care to mitigate chronic pain in childhood cancer survivors: A protocol for a single-center, pilot randomized controlled trial

Background

Long term survivors of childhood cancer have a high prevalence of chronic pain. Novel, multidisciplinary approaches to manage pain, are needed to allow for a reduction in the use of opioids for pain management. Physical activity is highly effective in managing chronic pain in children and adolescents, however, evidence about the combination of physical activity intervention and pain medications in chronic pain management in childhood cancer survivors is lacking. The aim of this study is to investigate the feasibility, acceptability and preliminary effects of a behavioral physical activity intervention integrated into standard post cancer directed treatment care to mitigate chronic pain in this unique population.

Methods

This is a single site pilot randomized controlled trial of a 16-week physical activity intervention coupled with standard care. The primary aim is to assess the feasibility and acceptability of the physical activity intervention in childhood cancer survivors with chronic pain. Secondary aims include evaluating the differences in functional and psychosocial outcomes along with self-reported pain scores and cumulative dose of pain medications between the exercise group and standard cancer care group. The physical activity intervention is a home-based program structured to increase patients' physical activity behavior and to favor low intensity bodily movement using aerobic exercise and resistance training.

Conclusions

This study will demonstrate that behavioral supportive measures like physical activity may be a novel means to improve cancer related chronic pain in young survivors of childhood cancer and decrease medication usage for pain along with improvement in functional and psychosocial outcomes.

Chronic pain in children and adolescents diagnosed with cancer: the challenge of mitigating the pain and the potential of integrating exercise into pain management

BACKGROUND

Pain is one of the most common and distressing symptoms experienced by children and adolescents diagnosed with cancer. It is vital that children and adolescents receive adequate pain management early on in their cancer treatments to mitigate pain and cancer-related symptoms. Exercise training shows particular promise in the management of acute and chronic pain among children and adolescents diagnosed with cancer.

METHODS

This position paper comes to outline the challenge of mitigating pain in children and adolescents diagnosed with cancer, and the potential benefits of integrating exercise training to the management of chronic pain in this population in need.

RESULTS

Integrating exercise training into the care and pain management of children and adolescents diagnosed with cancer who have chronic pain would have the advantage of addressing several shortcomings of pain medication. Pain medication aims to temporarily manage or reduce pain; it does not have the potential to directly improve a patient's physical condition in the way that exercise training can. The current paucity of data available on the use of exercise training as a complementary treatment to pain medications to reduce chronic pain in children and adolescents diagnosed with cancer allows only for hypotheses on the effectiveness of this pain management modality.

CONCLUSION

More research on this important topic is necessary and mitigating pain effectively while also reducing the use of opioid pain medication is an important goal shared by patients, their families, clinicians, and researchers alike. Future research in this area has great potential to inform clinical care, clinical care guidelines, and policy-making decisions for pain management in children and adolescents diagnosed with cancer who experience chronic pain.

A Pilot Randomized Controlled Trial of Virtual Reality Distraction to Reduce Procedural Pain During Subcutaneous Port Access in Children and Adolescents With Cancer

OBJECTIVES

We aimed to determine the feasibility of virtual reality (VR) distraction for children with cancer undergoing subcutaneous port (SCP) access. We also aimed to estimate preliminary treatment effects of VR compared with an active distraction control (iPad).

MATERIALS AND METHODS

A single-site pilot randomized controlled trial comparing VR to iPad distraction was conducted. Eligible children and adolescents were aged 8 to 18 years undergoing treatment for cancer with upcoming SCP needle insertions. Intervention acceptability was evaluated by child, parent, and nurse self-report. Preliminary effectiveness outcomes included child-reported pain intensity, distress, and fear. Preliminary effectiveness was determined using logistic regression models with outcomes compared between groups using preprocedure scores as covariates.

RESULTS

Twenty participants (mean age 12 y) were randomized to each group. The most common diagnosis was acute lymphocytic leukemia (n=23, 58%). Most eligible children and adolescents (62%) participated, and 1 withdrew after randomization to the iPad group. Nurses, parents, and children reported the interventions in both groups to be acceptable, with the VR participants reporting significantly higher immersion in the distraction environment (P=0.0318). Although not statistically significant, more VR group participants indicated no pain (65% vs. 45%) and no distress (80% vs. 47%) during the procedure compared with the iPad group. Fear was similar across groups, with ~60% of the sample indicating no fear.

DISCUSSION

VR was feasible and acceptable to implement as an intervention during SCP access. Preliminary effectiveness results indicate that VR may reduce distress and distress compared with iPad distraction. These data will inform design of a future full-scale randomized controlled trial.

The effect of playing games with toys made with medical materials in children with cancer on pain during intravenous treatment

OBJECTIVE

This research aims to examine the effect of playing games with toys made of medical materials in children with cancer on pain that occurs during intravenous (IV) treatment.

METHODS

The randomized controlled clinical trial was conducted between May 2016 and February 2018. The study sample comprised 110 children (experimental group 55; control group 55), determined using power analysis from the study population. The data were collected by the researcher, using face-to-face interview techniques, the Information Form, and Wong-Baker FACES Pain Rating Scale (WBS).

RESULTS

The pre- and post-test pain mean scores of patients in the experimental group were 2.27 ± 0.91 and 0.43 ± 0.66, respectively (p = 0.0001). The pre- and post-test pain mean scores of patients in the control group were 1.72 ± 0.82 and 3.34 ± 0.77, respectively (p = 0.0001).

SIGNIFICANCE OF RESULTS

The experience of playing with toys made from materials used for invasive procedures relieves pain the during IV treatment.

[The management of pain in the child with cancer]

C'est une étude prospective étalée sur une année (Juin 2007 à Mai 2008) portant sur une série de 140 malades (84 garçons et 56 filles), hospitalisés à l'unité d'hémato-oncologie du service de pédiatrie III à l'hôpital d'enfant de Casablanca. L'objectif de l’étude est de reconnaître la douleur chez l'enfant, l’évaluer en fonction des échelles internationales, et d’ assurer sa prise en charge globale en rapportant l'expérience du service. L’évaluation de la douleur a concerné différentes pathologies cancéreuses: quatre vingt enfants avaient des leucémies aigues lymphoblastiques (57%), 24 enfants présentaient des lymphomes (17%), 10 enfants avaient des neuroblastomes (7%) et 10 autres des néphroblastomes (7%). Parmi les 140 malades évalués, 100 présentaient des douleurs et qui ont fait l'objet de notre étude, donc on peut estimer la prévalence de la douleur ressentie au cours de l'hospitalisation à 71,4%. Plusieurs types d’échelles en fonction de l’âge de l'enfant, et de sa capacité à exprimer par lui-même, ou non, sa douleur, ont été mises à la disposition pour une mesure chiffrée et reproductible mais aussi une base à l'adaptation du traitement antalgique et pour assurer un suivi évolutif sous traitement. Le Traitement anticancéreux reçu par les malades à but curatif: dix malades soit 7,2% ont bénéficié d'une chirurgie curative et une chimiothérapie, cent vingt cinq enfants (89,2%) ont reçu une chimiothérapie seule et cinq malades (3,6%) ont bénéficié d'une association chirurgie, chimiothérapie et radiothérapie. La douleur ressentie avait en lien direct avec la maladie cancéreuse chez 30% des cas (30 enfants), secondaire au traitement anticancéreux chez 30% (30 enfants), et elle était surtout induite par des actes invasifs à visée diagnostique ou thérapeutique chez 40% des cas (40 enfants). Le traitement antalgique a été instauré en fonction de l’évaluation clinique: 67% des patients ont nécessité des antalgiques niveaux I ou II, l'usage des antalgiques niveaux III a eu lieu dans 20% des cas alors que dans 13% des cas le seuil de la douleur n'exigeaient aucun traitement. La prise en charge de la douleur est une étape fondamentale dans le traitement du cancer de l'enfant, elle doit être évaluée dès l’étape diagnostique et surveillée tout au long du traitement.

A smartphone-based pain management app for adolescents with cancer: establishing system requirements and a pain care algorithm based on literature review, interviews, and consensus

BACKGROUND

Pain that occurs both within and outside of the hospital setting is a common and distressing problem for adolescents with cancer. The use of smartphone technology may facilitate rapid, in-the-moment pain support for this population. To ensure the best possible pain management advice is given, evidence-based and expert-vetted care algorithms and system design features, which are designed using user-centered methods, are required.

OBJECTIVE

To develop the decision algorithm and system requirements that will inform the pain management advice provided by a real-time smartphone-based pain management app for adolescents with cancer.

METHODS

A systematic approach to algorithm development and system design was utilized. Initially, a comprehensive literature review was undertaken to understand the current body of knowledge pertaining to pediatric cancer pain management. A user-centered approach to development was used as the results of the review were disseminated to 15 international experts (clinicians, scientists, and a consumer) in pediatric pain, pediatric oncology and mHealth design, who participated in a 2-day consensus conference. This conference used nominal group technique to develop consensus on important pain inputs, pain management advice, and system design requirements. Using data generated at the conference, a prototype algorithm was developed. Iterative qualitative testing was conducted with adolescents with cancer, as well as pediatric oncology and pain health care providers to vet and refine the developed algorithm and system requirements for the real-time smartphone app.

RESULTS

The systematic literature review established the current state of research related to nonpharmacological pediatric cancer pain management. The 2-day consensus conference established which clinically important pain inputs by adolescents would require action (pain management advice) from the app, the appropriate advice the app should provide to adolescents in pain, and the functional requirements of the app. These results were used to build a detailed prototype algorithm capable of providing adolescents with pain management support based on their individual pain. Analysis of qualitative interviews with 9 multidisciplinary health care professionals and 10 adolescents resulted in 4 themes that helped to adapt the algorithm and requirements to the needs of adolescents. Specifically, themes were overall endorsement of the system, the need for a clinical expert, the need to individualize the system, and changes to the algorithm to improve potential clinical effectiveness.

CONCLUSIONS

This study used a phased and user-centered approach to develop a pain management algorithm for adolescents with cancer and the system requirements of an associated app. The smartphone software is currently being created and subsequent work will focus on the usability, feasibility, and effectiveness testing of the app for adolescents with cancer pain.

SIOP PODC: recommendations for supportive care of children with cancer in a low-income setting

These supportive care recommendations were prepared to guide doctors who practice in areas with significantly limited resources but who have sufficient infrastructure and training to treat children with cancer with curative intent. The success of any cancer treatment regimen depends largely on the availability and quality of supportive care and this also determines the intensity of treatment that can be delivered. We present practical recommendations on how to prevent infections, general nursing care, management of febrile neutropenia, nutritional assessment and support, treatment of co-infections and the social support to help prevent failure to complete treatment in resource poor settings.

Main Caregivers’ Experiences of Managing Pain for Children With Neuroblastoma in Taiwan

Neuroblastoma is a common malignant tumor among children. Seventy percent of children with neuroblastoma have metastatic disease when the diagnosis is established. The aim of this study was to understand the main caregivers’ lived experiences in managing pain for children with neuroblastoma. A descriptive qualitative design was used. Twelve main caregivers of children with neuroblastoma were interviewed. Two themes evolved: experiences of pain and coping with pain. Three subthemes were found under the theme “experience of pain”: pain assessment based on language expressions and behavioral observations, tendency of misdiagnosing tumor metastasis–related pain, and unique manifestations of pain at various phases. Four subthemes evolved under the theme “coping with pain”: utilization of pharmacological and nonpharmacological modalities for pain management, learning to confront pain, seeking mental and emotional support, and adjustment of family lifestyle. The results provide a description regarding the expression of pain in children with neuroblastoma and the pain management modalities used by the main caregivers. The findings serve as a reference for health care providers in Taiwan as they manage pain for children with neuroblastoma and seek to understand the needs of the main caregivers.

Bereaved parental evaluation of the quality of a palliative care program in Lebanon

BACKGROUND

Palliative care (PC) is important in Pediatric Oncology as more than 20% of children with cancer still die despite modern treatment. As a significant number of children reside in countries with limited resources; more research in PC is needed there. This study aimed at evaluating the quality of care provided to children with cancer at the Children's Cancer Center of Lebanon (CCCL) during their last month of life as perceived by the bereaved parents.

PROCEDURE

Between 2002 and 2007, 76 children with cancer treated at CCCL succumbed to their disease. Twenty-nine of the bereaved parents were interviewed at home about the symptoms and suffering experienced by their children during the last month of life, communication with the healthcare team, quality of care delivered, and recommendations for improving care.

RESULTS

Fatigue, anorexia, and pain were the most prevalent symptoms and edema was the most distressing. The overall communication with the healthcare team and the overall quality of care delivered was rated as "very good" to "excellent" by 86.2% and 93.1% of the participants, respectively. Parents suggested improving the organization of care, the communication, and the availability of human and material resources.

CONCLUSIONS

This study is the first conducted in Lebanon to evaluate the quality of pediatric palliative care (PPC). The parents' experiences in our country were similar to those described in other countries, religions, and cultures. Significant strengths and weaknesses in the management of the dying children, from the parents' perspective, were uncovered and recommendations for improving practice were made.

The complexity of symptoms and problems experienced in children with cancer: a review of the literature

To adequately help children with cancer, care providers need to understand the complexity of symptoms and problems associated with the illness that children are experiencing, which can enable them to better tailor patient care individually to each child. In this integrative literature review, we identified the types of symptoms and problems that children with cancer can experience during treatment and rehabilitation; the terms/expressions they use to describe their symptoms and problems; how children's symptoms and problems vary during the course of their illness; and how they vary and co-vary with age, gender or race. Of the 1175 titles identified, 110 articles met the inclusion criteria and were included in the review. Seventy-eight were research-based. A total of 219 distinct symptoms or problems were identified in the literature either as the main problem or a symptom of the main problem. There is significant evidence that children and adolescents experience numerous and complex symptoms, and problems during and after treatment for cancer. Children use many different expressions to talk about their symptom experiences. However, few articles looked at how children's symptoms and problems varied during the course of their illness or the variations in symptom severity and degree of bother, or examined the relationship between children's symptom experience and age, gender, or race. Most instruments that were used to measure symptoms were interviewer-administered questionnaires, often adaptations from adult versions, and in younger children, symptoms were often obtained from adult informants. The insights gained from this review can be helpful to researchers and clinicians who wish to better understand how symptoms and problems are experienced from the children's own perspective. However, more research is needed: to better understand differences in symptom experiences among different age groups; to identify differences among children from distinct cultural, ethnic, or socio-economic backgrounds; to clarify how symptoms and problems interfere with daily life; and to refine assessment methods that allow even younger children to communicate their symptom experiences in an age-adjusted manner.

Cancer pain management in children

Unrelieved pain may have a major impact on the care of children with cancer. The type and severity of pain experienced by children with cancer varies from acute, procedure-related pain to progressive chronic pain associated with the progression of the disease or sequelae of treatment. Drugs are the mainstay of treatment. Regular pain assessments combined with appropriate analgesic administration at regular dosing intervals, adjunctive drug therapy for control of adverse effects and associated symptoms, and nonpharmacological interventions are recommended. Although standard dosing of opioids adequately treats most cancer pain in children, more complex treatment is required by a significant group. Strategies to improve analgesia include the use of epidural or intrathecal infusions of a combination of opioids and other adjuvants, or other regional anaesthesia techniques. Procedure- and treatment-related pain is an even greater problem than cancer pain. Recommendations have been published with regard to the monitoring and personnel required when children are sedated which aim to set the standard of care and minimize both physical discomfort or pain and negative psychological responses, by providing analgesia; and to maximize the potential for amnesia; and to control behaviour.

Intravenous Ketamine Infusion as an Adjuvant to Morphine in a 2-Year-Old With Severe Cancer Pain From Metastatic Neuroblastoma

A 2.8-year-old female patient (11.6 kg) was admitted to the hospital for uncontrolled pain and swelling in the left leg relating to a metastatic neuroblastoma. Initially, her pain was managed with oral morphine 2 mg (approx. 0.2 mg/kg) every 4 hours. Because she was quite somnolent but still in significant pain, analgesia was then changed to methadone 1 mg orally every 6 hours (approximately 0.1 mg/kg/dose) and was eventually increased over 36 hours to 2 mg every 6 hours (approximately 0.2 mg/kg/dose). She received oral methadone 0.6 mg (approximately 0.05 mg/kg) every 4 hours as needed for breakthrough pain. She continued to have severe pain and experienced side effects, including respiratory depression, sedation, visual hallucinations, and vomiting. An intravenous ketamine infusion was started at 100 μg/kg/hour. Regular opioid administration was ceased, but she was given intravenous morphine 0.5 to 0.75 mg for breakthrough pain. She required only zero to three doses of breakthrough morphine per day, initially. After starting the ketamine infusion, her pain control improved and her symptoms of opioid toxicity abated. She was more alert and able to partake in limited activities. As a result of pain from progressive disease, the ketamine infusion was increased to 200 μg/kg/hour after 6 days with positive results. Her condition continued to deteriorate. An intravenous morphine infusion was initiated 2 weeks after starting the ketamine infusion and was eventually increased to 50 μg/kg/hour. One week later, she died with reasonable pain control. This case illustrates the use of ketamine as an effective analgesic in an adjuvant setting in a pediatric patient with advanced poorly controlled cancer pain. Ketamine not only eased the child's suffering while preserving life but also improved her quality of life by maintaining the child's ability to communicate and engage in activities.