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MANAGEMANT OF CANCER PAIN IN CHILDREN

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Title: MANAGEMANT OF CANCER PAIN IN CHILDREN


1
MANAGEMANT OF CANCER PAIN IN CHILDREN
  • Prof. M Badr

2
PHYSIOLOGY OF PAIN
  • Pain is a protective mechanism for the body. It
    causes the individual to remove the painful
    stimuli, so prevent tissue damage. Nociceptors
    are the receptors of pain.
  • Pain pathways
  • The pain pathway includes the following
    components
  • a. Peripheral receptors
  • b. Neural pathways
  • c. Spinal Cord mechanisms long tracts
  • d. Brainstem, thalamus, cortex other areas.
  • e. Descending pathways

3
Pain transmission.
4
  • Pain Nerve Fibers
  • Pain impulses are transmitted to the CNS
    through 2 types of fibers, which are
  • A d fiber These are small myelinated nerve
    fibers 2-5 µm. In diameter. They conduct at
    velocity of 12-30 meter/second. A d fibers
    synapse primarily in lamina I (lamina
    marginalis).
  • C fibers These are unmyelinated nerve fibers
    with a diameter of 0.4-1.2 µm. Their conduction
    velocity is 0.6-2 meter /second. Slow pain is
    claimed to be conducted via these fibers. The C
    fibers synapse in lamina II and III substantial
    gelationsa.

5
Pain pathway
6
Developmental Stages in Pediatric Pain
Perception
7
Types of Cancer Pain
  • Nociceptive
  • Soft tissues.
  • Bone metastasis.
  • Neuropathic.
  • Visceral.
  • Combined.

8
Cancer Pain Syndromes
  • Pain in the cancer patient results from
  • 1- Direct tumor involvement
  • 2- Pain associated with cancer therapy
  • 3- Pain unrelated to the cancer or the cancer
    therapy

9
1- Direct tumor involvement
  • Direct tumor involvement of bone, hollow viscera,
    or nerves is a common cause of pain in pediatric
    cancer patients.
  • Pain caused by tumor occurs in 2546 of
    patients, often as a result of leukemic
    infiltration of bones or joints.
  • a- Somatic pain is typically well localized
    Examples pain associated with primary or
    metastatic bone disease.

10
  • b- Visceral pain is poorly localized, often
    described as "deep", "squeezing" and "pressure"
    and may be associated with nausea, vomiting and
    diaphoresis, particularly when acute. It may
    result from the infiltration, compression,
    distension or stretching of thoracic and
    abdominal viscera by primary or metastatic
    tumors. Example pain associated with tumors of
    the liver primary or metastatic.
  • c- Neuropathic pain results from tumor
    compression or infiltration of peripheral nerves
    or the spinal cord. Chemical- or radiation-
    induced injury also may result in this sort of
    pain.

11
  • 2- Pain associated with cancer therapy
  • It includes pain which occurred in the
    course of, or as a result of, chemotherapy,
    surgery, or radiation therapy. Procedural pain
    occurs in approximately 40 of children. Last,
    pain caused by treatment toxicities (e.g.,
    mucositis) occurs in 4050 of children
  • 3- Pain unrelated to the cancer or the cancer
    therapy.

12
Mediators producing pain
  • Malignant cells produce
  • PGs.
  • Cytokines Growth factors EGF, TGF, PDGF, and
    Endothelin 1.
  • Macrophages (20-30) in malignant tumors
  • TNFa.
  • IL-1

13
Importance of pain relief
  • Elimination of stress response that has an
    influence on
  • Sleep.
  • Appetite and nutrition.
  • Nitrogen balance.
  • Cytokine cascade, towards immuno-suppression.

14
Patient Assessment
  • Assessment of patients pain.
  • Assessment of patients psychological state.
  • Assessment of patients social state.
  • Assessment of patients family care giver state.

15
Pain Assessment in Pediatric
  • Pain assessment in children is difficult and this
    has led to the proliferation of multiplicity of
    pain assessment scales for neonates, infants and
    children. Most of these scales try to assign a
    numerical value to one of these dimensions
    cognitive, physiological, sensory, behavioral,
    and even facial expression.
  • Pain can be assessed by
  • 1- Self-report (what children say).
  • 2- biological markers (how their bodies react),
  • 3- and behavioral methods (what children do).

16
1)Self-Report (e.g. face scale, graphic rating
scale.)
  • Face scales
  • Children are asked to indicate their pain by
    pointing to one of the faces put in a scale.
    Usually the child is trained by asking how he or
    she would feel following some minor pain and then
    a more severe pain. However, it is important to
    be sure that the scale signifies pain and not
    simple misery.

17
2)Biological Measures
  • Heart rate Heart rate initially decreases and
    than increases in response to short, sharp pain.
  • Arterial oxygen saturation Oxygen saturation
    decreases during painful procedures.
  • Stress Hormones Surgery or trauma triggers the
    release of stress hormones (corticosteroids,
    catecholamine, glucagon and growth hormone) into
    the blood with reduction in insulin levels.
  • Cortisol release widely studied in infants and
    children, is not specific to pain and occurs in
    many adverse situations.

18
3-Behavioral methods
  • 1-Behavioral Pain Assessment Scales For Young
    Children (FLACC Scale).
  • Five categories (F) Face (L) Legs (A)
    Activity (C) Cry (C)Consolability
  • 2-The children's Hospital of Eastern Ontario pain
    Scale (CHEOPS)
  • The scale assigns a point score to 6 categories
    of behavior

19
Social and Psychological Assessment
  • This form of assessment is important to define a
    successful plan for management.
  • The response of the patient is highly dependant
    on his attitude to the situation (coping).
  • The family members who are going to carry, and
    held responsibility for executing properly the
    treatment plan, or caregivers.

20
Cancer Pain management
  • Although improved, it is considered up-till now
    as an empirical treatment, hopes in the future to
    have specific antagonists to each type of
    mediator released.
  • Should be considered always as an adjuvant
    treatment to anticancer therapy to improve the
    outcome and prognosis.
  • Care is also paid for psychological, and
    para-neoplastic syndromes.

21
Aim of Management
  • To prevent pain from coming rather than to relief
    pain when it comes, this will
  • provide a better quality of life.
  • Better monitor the clinical state of cancer
    growth and dissemination.
  • decrease the total analgesic dose.
  • prevent tolerance.
  • improve patients immunity and suppress stress
    response, and give a better response to
    anti-cancer therapy.

22
General roles for management
  • Optimization of drug therapy
  • Right analgesic.
  • Right dose.
  • Right schedule.
  • Right co-analgesic.
  • Individualization for each patient.
  • Opioid Rotation if there is side effects.
  • Anticipation of breakthrough pain.
  • Prevention of side effect.

23
  • Management of cancer pain can be divided
    according to causes into
  • 1. Management of Procedure related pain
  • This includes topical local anesthetics,
    intravenous sedation, transmucosal drug and
    nitrous oxide.
  • 2. Management of Treatment related pain
  • This is includes treatment of mucositis, post
    operative pain, infection.

24
  • 3-Management of cancer related pain
  • This includes a complex mechanism which
    depend on severity of pain followed by choose
    the appropriate drugs which depend on what is
    called stepladder of WHO which divide pain into 3
    categories
  • Step 1 Mild pain NSAIDs and Paracetamol are the
    drugs of choice.
  • Step 2 Moderate pain where weak opioid with
    NSAIDs are used as codeine or hydrocodone
  • Step 3 Severe pain strong opioid and
    intervention therapy are used morphine,
    hydromorphone, methadone, fentanyl, or
    levorphanol.

25
Step ladder WHO
26
Oral Analgesics
  • Easier.
  • Desired.
  • Remember that
  • Concentrations unpredictable
  • Constant serum level is important to keep the
    patient not in pain.
  • Higher levels of metabolites
  • Higher incidence of side effects.
  • Burden on the kidney More ionized.
  • The oral route cannot be used in patients
  • Who are unable to swallow.
  • Have a bowel obstruction or.
  • Have persistent nausea and vomiting.

27
Analgesics are given by
  • Oclock, and not when needed.
  • Full clinical dose.
  • In sustained release formula.
  • By step ladder system.
  • With an adjuvant.

28
Recommended dose for mild pain for pediatrics
29
Opioids
  • Problem of addiction
  • Presence of pain protects against addiction.
  • Side effects are mainly
  • Tolerance.
  • Constipation.
  • Nausea / vomiting.
  • Sedation / dizziness.
  • Rash.
  • Respiratory depression.

30
Weak OpioidsSecond Step in WHO Ladder
  • They can relief pain when we increase the dose
    but with significantly higher incidence of side
    effects.
  • Members are
  • Codeine and dihydro-codeine.
  • Tramadol.
  • Dextro-propoxyphene.

31
Strong Opioids
  • Morphine available in.
  • Immediate release( 4 hourly).
  • Controlled release (12-hourly).
  • Sustained release (24-hour dosing).
  • Oxycodone.
  • Fentanyl (available in a transdermal, and
    transmucosal formulation).
  • Methadone.
  • Hydromorphone.
  • Oxymorphone (available in a rectal formulation).
  • Meperidine is not used.

32
Principles of Dosing
  • Opioid naive patients should start on weak
    opioids.
  • An immediate release formulae are only used for
    dose titration, and break through pain.
  • Maintenance should be with sustained release
    formulae.
  • Switching opioids is done with half or 2/3 of
    equi-analgesic doses.

33
Transdermal Route
  • Transdermal drug systems deliver a drug to the
    skin surface at a rate less than the maximum rate
    of transport through the skin .
  • This enables to control the drug to remain within
    the delivery system and not within the skin.
  • The stratum corium is difficult to penetrate.
  • Stores a drug depot that prolong drug action.

34
Transdermal Therapy System TTS
Drug Reservoir Alcohol is added
35
Minimizing Side Effects
  • Constipation
  • Around the Oclock laxatives.
  • Should be monitored as pain.
  • Nausea and vomiting
  • Secondary causes should be excluded.
  • Anti-emetics.
  • Sedation
  • Psychostimulants.
  • Opioid rotation may improve side effects

36
Adjuvant Drugs
  • Their presence is crucial in the success of
    management.
  • They can promote sleep, relief anxiety,
    potentiate pain relief, smooth side effects.

37
Drugs for Bone Pain
  • Nonsteroidal Anti-Inflammatory Drugs
  • Corticosteroids
  • Bisphosphonates
  • Pamidronate, alendronate)
  • Calcitonin
  • Radiopharmaceuticals
  • Strontium-89.

38
Drugs Used for Bowel Obstruction
  • Anticholinergics
  • Scopolamine reduces peristalsis and secretions,
    subjective reports of analgesic effects
  • Octreotidereduces peristalsis and secretions,
    subjective reports of analgesic effects
  • Corticosteroidssubjective reports of analgesic
    effects

39
Conclusion
  • Cancer Pain can greatly influence patients
    prognosis and should be managed early, and
    specifically.
  • Drug therapy is still the corner stone in cancer
    pain management.
  • If properly scheduled, drug therapy can achieve
    90 success.

40
  • No injectable forms are used for maintenance
    except through a pump.
  • Sustained release formulae is the role.
  • Oral formulations generally have more side
    effects particularly with kidney affection.
  • Recently introduced fentanyl patch, and oxycodone
    got their success from the less side effects they
    produced.
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