In this section
Until recently, it was widely believed that children,
particularly young children, experienced less pain than adults.
Many clinical studies have negated these myths showing that
children and adults experience similar degrees of pain. ﾮ1
One of the great fears of children and families in the setting of
terminal illness is that of unrelieved pain. However in the vast
majority of circumstances it is possible to effectively control
pain with analgesic/pain relieving medications. Opioid addiction is
another concern for families, and some health professionals. Again,
this fear can be allayed because it has been shown that patients
receiving properly titrated doses of analgesia do not become
addicted. ﾮ2 Parents and health professionals sometimes confuse
tolerance (the need for escalating doses to achieve the same
therapeutic effect) with addiction. A patient's need for increasing
doses of opioids is related to tolerance and disease progression,
and should not be seen as impending addiction. The dose should be
increased according to an individual's need. It is important to
anticipate and discuss concerns and fears about the use of opioid
analgesics early in the terminal phase of the child's illness to
ensure that misconceptions are addressed.
Self-report of pain levels is the "gold standard" of pain
assessment in older children and adults. The evaluation of pain in
children however is dependent on the child's age and developmental
stage. Pain measurement and pain assessment are not the same thing
and while it may be possible to determine the site of pain and make
some estimation of its severity, understanding its character and
radiation is often more difficult. Children need to understand what
is being asked of them so wherever possible their own terminology
should be used, e.g. using the word 'sore' or 'hurt' instead of
pain. The response they give might also depend on who is asking the
question and what the consequences may be. Children who are fearful
of receiving a painful injection or unpleasant tasting medication
may not admit to pain. Health professionals need to utilise a
number of parameters to adequately assess pain in children. Simple
observation is extremely useful as changes in activity level and
behaviours such as irritability or withdrawal may indicate
discomfort. It is important to remember however that the behaviour
of a child in chronic pain differs from that of a child in acute
pain. The latter tend to be more demonstrative and vocal while
children in chronic pain may appear quiet, withdrawn, lack interest
in activities or surroundings, be reluctant to move, have clingy
behaviour or whinging, or have difficulty sleeping. ﾮ3
Pain assessment in children should be multidimensional taking
The World Health Organisation Analgesic Ladder has provided an
excellent framework for the escalation of analgesia for many years.
A more flexible approach is now advocated with management
strategies customised according to the child's pain, the mechanism
involved, the child's particular needs and response to previous
treatments. The entry level onto the ladder will be influenced by
these factors. Treatment should be frequently reassessed and
modified. An adjuvant analgesic agent (see 'Resistant' pain and
Adjuvant Analgesia.) can be added at any point on the ladder if
indicated by the clinical circumstances eg. bone pain, neuropathic
(nerve) pain, inflammatory pain.
WHO Pain Ladder
Paracetamolﾮ is generally well tolerated in
children and is very useful for mild pain (15mg/kg/dose
4/24 orally. Max 90 mg/kg/day or 6 doses) ﾮ7 It is
available in a variety of oral preparations and for rectal use (not
appropriate for neutropenic patients).
These are powerful anti-inflammatory agents with analgesic and
anti-pyretic activity. They may be helpful in alleviating
musculoskeletal pain such as that induced by bone metastases and
soft tissue inflammation and can be used in combination with
opioids. There are a variety of NSAIDS on the market including
aspirin, naproxen, ibuprofen and diclofenac. Individuals may
respond better to one agent than another. Side effects in children
include nausea and vomiting, bronchospasm, gastric irritation and
ulceration, and interference with platelet function. They should
not be used in children with
Caution should be exercised if using NSAIDS in children with
COX 2 inhibitors such as Celecoxib and Rofecoxib are equally
analgesic when compared with non-selective NSAIDS. They offer
certain advantages in that the risk of gastrointestinal bleeding is
reduced, and they have no effect on platelet function.
If paracetamol is ineffective in controlling pain, a weak opioid
such as codeine phosphate oral 0.5 mg/kg/dose 4/24
ﾮ7 may be used. Codeine however can result in severe constipation,
and has a ceiling effect (that is, a maximum effect is achieved
beyond which further dose increases yield no benefit), so morphine
is preferred in patients who are likely to require escalating
doses. Morphine is still the "gold standard" against which all
other opioid analgesics are measured, and is the drug of preference
unless there are circumstances that prohibit its use.
Where ongoing pain is expected, immediate release morphine in
the appropriate dosage should be prescribed every 4 hours. Prn
dosing of analgesia in the palliative care of children is not
appropriate as "breakthrough pain" resulting from falling plasma
levels of morphine is very distressing to the child and family.
Pain management is more effective if symptoms are anticipated and
prevented with medication administration.
The starting dose of oral morphine for opioid
nave children aged over six months is 0.2-0.5 mg/kg/dose
q4-6h orally. ﾮ8 Neonates have a higher relative volume of
distribution and lower clearance than older children, leading to a
longer half life. This, combined with the increased permeability of
the blood brain barrier, means that infants may have a heightened
sensitivity to the respiratory depressant effects of opioids. A
paediatric pain specialist or neonatologist should be approached
for advice when dealing with infants under the age of 6 months. The
onset of analgesic activity is approximately 30 minutes with peak
activity reached at 60-90 minutes. The average plasma half-life is
3 hours so steady state plasma concentration is achieved in 15
hours. Thus, the dose may be increased by 30-50% every 12-24 hours
if pain control is suboptimal and more rapidly for a severe
exacerbation of pain. The child should be frequently reassessed to
ensure pain is controlled with minimal side effects. Once the pain
is under control and the appropriate 24-hour dose of morphine
determined, a switch to a sustained release formulation of morphine
is appropriate. This continuous release form has a slower onset of
action but a much longer duration and offers the advantages of less
frequent dosing and improved sleep. Preparations are available for
once and twice daily dosing. Provision for breakthrough pain should
be made with a 'rescue' dose of immediate release form of morphine.
Breakthrough pain is a flare of pain that is above the usual or
background pain that the child experiences.
Dosing regimens for continuous release morphine are calculated
using the total daily amount of immediate release morphine
required. For example, if 5 mg of oral morphine has been
administered every 4 hours the total dose is 30 mg (6 x 5 mg) and
this is converted to 15mg of sustained release morphine every 12
hrs. The "breakthrough" dose is equivalent to one sixth of the
total daily dose of immediate release morphine, in this example
If the child regularly requires repeated breakthrough or rescue
doses of morphine (ie more than two per day), the dose of sustained
release morphine needs to be increased. This is accomplished by
calculating the total dose of morphine (both immediate and
sustained release) required in the previous 24 hours and dividing
the dose. For example, if the child in the example above required 4
breakthrough doses of 5mg each then it would be appropriate to
increase the dose of sustained release morphine to 25 mg BD. The
breakthrough dose of morphine will also need to be adjusted
accordingly. To continue the example this would need to be
increased to 8mg.
Alternative routes of delivery
(subcutaneous, intravenous, spinal and epidural) may be required in
the following circumstances
The intravenous route is most practical in children with
long-term venous access devices. For other children, the
subcutaneous route is relatively simple and safe. In the setting of
acute pain in an opioid nave patient aged over six months, the
parenteral dose of morphine is 0.05-0.1mg/kg 4/24
ﾮ8 For children who have been taking morphine orally, the
parenteral dose is one third of the oral dose. Subcutaneous
infusions of morphine are manageable at home with appropriate
equipment and support (see "parenteral infusions"). The 24-hour
dose is determined by totaling the doses required in the previous
24 hours. For children switching to subcutaneous morphine from oral
morphine, the dose is one third of the total oral dose. For
example, a child who received a total oral dose of 72 mg, would
require 24 mg per day of morphine as a continuous subcutaneous
infusion. This serves as a starting point only. The dose may need
titrating up or down according to the patient's need. Breakthrough
doses may be required and these are 1/6 of the total daily
subcutaneous dose. In this example the breakthrough dose would be
It is important when delivering morphine via the subcutaneous
route that the volume of the infusion is considered, and every
attempt made to keep infusion volumes as low as possible. There may
be technical limitations with the type of syringe driver used that
make this difficult.
Fentanyl has become available in a transdermal
formulation and provides an effective and convenient alternative to
oral opioids in situations where pain is stable. Unfortunately,
fentanyl patches are very expensive and not available on the PBS
for children under the age of 16. The lowest dose form of patch
currently available is 2.5mg which delivers 25mcg/hr of transdermal
fentanyl. As this equates to 1mg/hour of continuous IV morphine or
75mg of oral morphine, the child has to have a high opioid
requirement for this therapy to be an option. Transbuccal dosettes
are also available for severe pain flares in patients on high dose
opioid therapy and have the advantage of being rapidly acting. The
lowest dosette size available is 200mcg and therefore is usually
only appropriate for prescription for adults. The assistance of
paediatric pain specialists should be sought prior to commencing
treatment with either of these forms of fentanyl.
A variety of other opioid medications are available and may
offer advantages over morphine in certain situations. The advice of
pain management specialists should be sought if pain is not
The most frequently encountered side effects are:
Depending on the circumstances, side effects can be treated with
appropriate medication or managed expectantly as many will settle
as tolerance develops. If persistent, a reduction in dose, switch
to an alternative opioid or change to a different route of delivery
may be required.
The management of respiratory depression associated with opioid use
warrants special mention and may vary according to the child's
overall condition. Drowsiness and respiratory slowing may be part
of the dying process and in the terminal setting no specific
intervention may be required. In the early phases of palliative
care where the child may enjoy a reasonable quality of life, active
intervention may be warranted. Excessive slowing of respiration
rate may be managed by rousing the child, slowing the rate of the
opioid infusion, administering oxygen as required and if necessary
giving small doses of naloxone 0.01-0.1
microgram/kg every few minutes. Caution is required as
rapid reversal may cause withdrawal, hypotension or the reemergence
of severe pain.
Patients with significant hepatic or renal dysfunction should
start at lower initial doses and be monitored closely for side
effects as the drug and its metabolites may accumulate and result
in respiratory depression. An alternative opioid such as fentanyl
may be more appropriate for patients with renal failure.
Most pain can be controlled with adequate doses of opioid
medication and much of what is regarded as "resistant" pain can be
managed with a dose increase or an alternative route of delivery
(eg. parenteral, spinal). In some circumstances however, the
addition of an adjuvant agent can greatly enhance pain control by
targeting particular pain mechanisms. Adjuvants include
antispasmodics, anxiolytics, corticosteroids, antidepressants,
anti-epileptics, clonidine, ketamine, baclofen and others. For
example, the addition of non-steroidal anti-inflammatory drugs may
help in relieving pain due to bony or soft tissue metastases.
Neuropathic pain has characteristic features (eg electric
shock-like quality, lancinating, burning, paresthesia) and may
respond to antidepressants or antiepileptic agents.
Amitriptyline 1-2mg/kg oral nocte ﾮ8 is a useful
agent and may be especially helpful for children with nocturnal
pain, neuropathic pain or sleeping difficulties.
Nerve blocks or ablation, the use of chemotherapy or
radiotherapy and the use of opioids delivered via the intrathecal
or epidural routes are all techniques that may be of benefit in
controlling pain in difficult circumstances. These techniques
should be discussed with an appropriate specialist skilled in their
application prior to discussion with the family.
The provision of accurate information to patients and families
about their symptoms and treatment will greatly allay their fears
and help with compliance and the control of pain. For children with
chronic illness, minimising pain should be a priority from the time
of the first procedure. The use of topical anaesthetics and other
strategies will help prevent bad pain memories and reduce their
detrimental effect on experiences during future procedures.
Children may be greatly empowered and assisted by the use of
complementary techniques such as acupuncture, guided imagery,
relaxation training, meditation and distraction (stories, videos,
music, bubble blowing, singing). Children can also be taught
techniques to use during painful procedures and staff members with
expertise in this area are available to provide guidance in this
A range of physical therapies may be of use to the child in pain.
Touch, massage warmth, cold and electrical therapies are all used
in the management of various types of pain.
The authors gratefully acknowledge the kind assistance of Dr.
Greta Palmer, anesthetist Royal Children's Hospital, Melbourne in
reviewing this manuscript.
1/ Anand KJS, Grunau RVE, Oberlander TF. Developmental character
and long-term consequences of pain in infants and children. Child
Adolesc Psychiat North Am 1997; 6: 703.
2/ Woodruff R. Palliative Medicine: Symptomatic and supportive care
for patients with advanced cancer and AIDS. Asperula.
3/ Gauvain-Piquard A, Rodary C, Lemerle J. L'atonie psychomotrice:
signe majeur de doleur chez l'enfant de moins de 6 ans. J
Parisiennes Pediatrie 1988;249-52.
4/ Bieri D, Reeve RA, Champion GD, et al. The faces pain scale for
the self-assessment of the severity of pain experienced by
children: development, initial validation, and preliminary
investigations for ratio scale properties. Pain 1990; 41:
5/ Beyer JE, Wells N. The assessment of pain in children. Pediatr
Clin North Am 1989; 36: 837-54.
6/ Chambers CT, Reid G, Craig KD, McGrath PJ, Finley GA. Agreement
between child and parent reports of pain. Clin J Pain 1998; 14:
7/ Therapeutic Guidelines, Palliative Care. Therapeutic
8/ Kemp CA, McDowell JM (Eds). Paediatric Pharmacopoeia. 13th
Edition. Royal Children's Hospital. Melbourne. 2002.
McGrath P. Pain in Children: Nature, Assessment and Treatment.
Guildford Press. New York.1990.
World Health Organisation and International Association for the
Study of Pain. Cancer Pain Relief and Palliative Care in Children.
World Health Organisation. Geneva. 1998.
Franck LS, Greenberg CS, Stevens B. Pain Assessment in Infants
and Children. Pediatr Clin North Am 2000; 47: 487-512.
Therapeutic Guidelines, Palliative Care. Therapeutic Guidelines.
Royal College of Paediatrics and Child Health. Prevention and
Control of Pain in Children: a Manual for Health Care
Professionals. British Medical Journal Publishing Group London
Goldman A. ABC of Palliative care: Special problems of children.
British Medical Journal 1998; 316: 49-52.