1. PAEDIATRIC PALLIATIVE CARE PAIN MANAGEMENT
Lynette Thacker
Clinical Nurse Specialist
Paediatric Palliative Care
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.

2. 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)

3. 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.

4. 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 )

5. TYPES OF PAIN NOCICEPTIVE Somatic Viscera bones, joints
connective tissues
Muscles
Aching, often constant
May be dull or sharp
Often worse with movement
Well localized
Organs – heart, liver, pancreas, gut, etc.
Constant or crampy
Aching
Poorly localized
Referred

6. NEUROPATHIC
Deafferentation
Sympathetic Maintained
Peripheral

7. 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.

8. 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.

9. How Do We Assess Pain Choosing a pain assessment tool Pain Scales
Use appropriate tool for the child’s age and cognitive development
Use the same pain scale for the child

10. No Pain Mild Moderate Severe Worst Possible
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
No Pain Mild Moderate Severe Worst Possible

11. 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

12. Treating Pain The treatment of pain should not be
about just giving medications.

13. Care Planning Components
Pharmacological component
Non – pharmacological component
Monitoring component

14. Non-Pharmacologic Treatments
Exercise
Immobilisation
Transcutaneous Electrical Nerve Stimulation (TENS)
Acupunture
Relaxation and Imagery
Distraction
Psychotherapy
Hypnosis
Peer support groups
Counselling

15. 3 2 1 Strong opioid +/- adjuvant Weak opioid +/- adjuvant
W.H.O. ANALGESIC LADDER
By the
Clock 3
Strong opioid
+/- adjuvant 2
Weak opioid
Severe Pain
Morphine
Diamorphine
Fentanyl
+/- adjuvant 1
Non-opioid
Moderate Pain
Codeine
Transaxmic Acid
+/- adjuvant
Pain persists or increases
Mild Pain
Paracetamol
NSAID – Ibuprofen

16. 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

17. 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

18. 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

19. 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.

20. 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)

21. 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

22. 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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