Most children with cancer experience pain (McGrath, 1990b), which, as does the progression of cancer in children, differs from that of adults. After diagnosis, the common childhood malignancies generally respond rapidly to treatment, and disease-related pain often remits.- If the tumor recurs and is resistant to treatment, the disease progresses rapidly, resulting in early death (Miser, 1993). Pain in children with cancer arises more often from the treatment than from the disease (Miser, Dothage, Wesley, et al., 1987). Aggressive multimodal treatment protocols for children have increased survival rates markedly for most types of cancer, but they often involve treatment toxicity that results in painful conditions, e.g., mucositis, peripheral neuropathy, and infection.
Children with cancer undergo procedures ranging from venipunctures to bone marrow aspirations and biopsies. Children with aggressive treatment protocols may have one or more venipunctures daily, lumbar punctures weekly, and bone marrow aspirations monthly. Unlike adults, infants and children do not provide consent for these procedures and often do not understand the reasons for them or realize their short duration. Although appropriate preparation and adequate analgesia are crucial for children undergoing procedures, often neither occurs or they occur in a haphazard fashion (Schechter, 1989).
The optimal treatment of a child's cancer-related pain requires an awareness of the many factors that shape that pain. Among these are the child's developmental level, emotional and cognitive state, personal and physical condition, and past experiences; the meaning of the pain for the child; the stage of the disease; the child's fears and concerns about illness and death; issues, attitudes, and reactions of the family; cultural background; and the environment (Hester, Foster, and Beyer, 1992). Clinicians should be aware that children with cancer experience many distressing symptoms such as pain, depression, anxiety, panic, pruritus, fatigue, nausea, constipation, insomnia, dyspnea, and the fear of abandonment and death.
Getting to know the child and having knowledge of developmental norms and behavioral competencies are important in the assessment and management of pain. Clinicians should tailor assessment and management strategies to the child's developmental level, personality style, and emotional and physical resources and to the context; tailoring is particularly necessary for children with developmental delays, learning disabilities, emotional disturbances, and language barriers.
Assessment is not only diagnostic but also therapeutic. Assessing the meaning of the pain to the child and the family, the effect of the pain on the activities of daily living and on mood, and the concurrent concerns and symptoms helps clinicians understand pain from the perspective of the child and the family. Asking about pain underscores the clinician's desire to ease pain and suffering and builds a therapeutic alliance with the child and family.
It is easier for clinicians to understand inherently subjective experiences, such as pain, anxiety, and despair, when the child can verbalize, but for some children, verbal communication is difficult or impossible. Therefore the clinician should recognize the potential for pain and discomfort or suspect that the child is in pain even if the signs are not immediately apparent.
PROCEDURE-RELATED PAIN IN ADULTS AND CHILDREN
PAIN IN SPECIAL POPULATIONS
Assessing the Adequacy of Pain Management Strategies (Children)
MONITORING THE QUALITY OF PAIN MANAGEMENT