Report
of the Subcommittee
on the
Management
of Pain Associated
With
Procedures
in Children
with Cancer
L. K. Zeltzer
(co-ordinator),
A. Altman,
D. Cohen,
S. LeBaron,
E-L. Munuksela,
and N. L. Schechter
The ideal goal of pain management for pediatric
procedures is to make the procedure comfortable for the child and his or her parents. Success will be manifested by the child who is not afraid of
subse-quent procedures and not merely by a child who can be held still for procedures. This goal is often
difficult to achieve entirely, but at least an attempt
to achieve it should be considered as evidence for
an adequate standard of care. The orientation of
this section will be a developmental one, with
spe-cific recommendations for five age categories: 0 to
6 months of age, 6 months to 2 years of age, 2 to 5 years of age, 5 to 12 years of age, 12 years of age. Initially, we discuss general principles of pain
man-agement (Table 5). The painful procedures include bone marrow aspiration and biopsy (Table 6);
lum-bar puncture (Table 7); and needle sticks including intravenous and intramuscular injection, phlebo-tomy, finger sticks, heel lances, and suturing (Table 8). Nonpainful radiographic diagnostic and
thera-peutic procedures that require patient cooperation in remaining still (eg, computed tomographic scan,
magnetic resonance imaging, radiation therapy) are also discussed (Table 9).
GENERAL PRINCIPLES OF MANAGEMENT
There are several principles of management that are applicable for all age groups and procedures.
These points need to be highlighted because
pedi-atric procedures currently are not being managed
in an organized fashion at many hospitals and
oncology units. In a survey of the major pediatric oncology centers, more than 75% of the centers had no defined protocol for procedures of pain
manage-ment (Hickman et al. 1988. Unpublished manu-script). Of those who did, the majority suggested
use of the DPT (Demerol, Phenergan, Thorazine), a combination associated with a high incidence of
side effects. Other popular protocols involved the
use of chloral hydrate and diazepam, which are sedatives and have no analgesic properties.
Specific measures to control pain and anxiety, other than a local anesthetic, are often an after-thought typically occurring after a child becomes unmanageable. We believe that procedures for the management of pain and anxiety in children with cancer should be considered as an integral part of the diagnostic and treatment protocol beginning with the process of diagnosis. Evaluation and plan-ning for pain management should be part of “front-line” treatment. The diagnostic process should not be so aversive that the child becomes fearful of treatment. For this reason, we recommend adequate preparation of the child and parents for all
diag-nostic evaluation and maximal, intense pharmaco-logic sedation and analgesic management of the initial bone marrow aspiration and lumbar punc-ture. The initial experiences of the child will “set the stage” for the child’s reaction to further medical contact, and “catch-up” at a later date is more difficult to accomplish and takes more time and effort than that spent in initial planning and prep-aration. For example, there should be coordination of blood work to minimize the number of “sticks” a child receives. When possible, we recommend delaying the diagnostic bone marrow aspiration so that an anesthesiologist can be present to provide general anesthesia or appropriate deep sedation.
There is now evidence from numerous
investi-gations that psychologic/behavioral techniques can
reduce significantly the pain and anxiety of painful procedures in children (Table 10). Therefore,
psy-chologic preparation of the child and parents for
procedures should become part of the “induction” phase of treatment. This includes providing
infor-mation about the procedures in age-appropriate
TABLE 5. General Principles of Medical Procedure for the Management of Pain and Anxiety
1. Preparation of child and parents with specific roles for parent(s).
2. Maximum treatment of pain and anxiety for the initial procedure to reduce the development of subsequent
anticipatory anxiety symptoms.
3. Adequate knowledge of behavioral and pharmacologic treatment of acute pain and anxiety by medical staff
responsible for medical procedures.
4. Appropriate monitoring and rescusitative equipment in the procedure room. 5. Adequate mechanical skill in individuals who plan to perform pediatric procedures. 6. Ongoing evaluation of the child to assess efficacy of treatment for pain and anxiety.
7. Creation of as pleasant an environment as possible in the treatment room.
TABLE 6. Bone Marrow Aspirations*
Age Recommendations
0-6 mo I.
6-24 mo
2-5 y
5-12 y
Procedure should be performed on an infant who is warmed appropriately and “settled” (ie, not on a crying infant immediately after another procedure).
II. Local anesthesia with 1% lidocaine. III. Use of a “lumbar puncture” needle.
IV. The use of opioids and sedatives in this age group for conscious sedation is difficult. Further studies need to be performed before firm recommendations can be made. If analgesics are deemed necessary,
the use of small doses of single medications (not combined with other drugs) should be considered.
I. Preparation. The parent should carry the infant to the treatment room and maintain physical and
eye contact with him or her during the procedure. The parent can be instructed to talk soothingly to child and to stroke or rub a part of the child’s body.
II. Establish IV access if an IV line not already present.
III. To provide adequate pain control, either general anesthesia or conscious sedation using sedatives,
opioids, and local anesthesia is necessary. A. Sedatives
1. Diazepam 0.2-0.3 mg/kg maximum of 10 mg orally 45-60 mm before the procedure (Diazepam
burns when given IV), or
2. Midazolam 0.2-0.4 mg/kg maximum to 15 mg (IV solution) orally 30-45 mm or 0.05 mg/kg
IV 3 mm before the procedure B. Opioids
1. Morphine sulfate 0.05-0.10 mg/kg IV over 1-2 mm given 5 mm before the procedure (skin
can be cleansed, draped, etc, during this time), or
2. Fentanyl 1-2 tg/kg (0.001-0.002 mg/kg) IV 3 mm before procedure, or
3. Meperidine (if morphine sulfate or fentanyl is not available) 0.5-1.0 mg/kg IV for 1-2 mm
given 2-5 mm before the procedure.
4. With the above opioids, half of original dose can be repeated if the child does not appear adequately comfortable during the local anesthetic needle.
C. Local anesthetics: 1% lidocaine given slowly intradermally then slowly subcutaneously to the periosteum and wait 4-5 mm
IV. After the procedure, the child should be placed on his or her side, observed, and discharged when
fully conscious (see American Academy of Pediatrics guidelines’2); a nurse should monitor the child until he or she can be easily aroused. Oxygen saturation monitoring should be continued during the recovery period. Supplemental oxygen should be administered if the oxygen saturation is less than 95%.
V. General anesthesia should be considered if conscious sedation efforts are inadequate. I. Environment/psychologic preparation:
A. See “6-24 mo” regarding parent’s physical presence
B. Preparation. Play preparation and practice with models, stuffed animals, and dolls can be used
to let child know what to expect and what is expected of him or her. The child life worker, parent, nurse, etc can do this for many children with proper instruction.)
C. Enhancing coping skills. Concrete objects are needed for distraction: pop-up books, bubbles,
toys, dolls, etc. Can use imagination (especially 4-5 y) to supplement the physical distractions.
II. Suggest pharmacologic measures for all BMAs, and use of psychologic measures as adjuncts. III. Use recommendations discussed above (6 mo to 2 y) for pharmacologic intervention. General
anesthesia should be considered if psychologic measures and attempts at conscious sedation fail.
I. First BMA. IV sedation and analgesia or general anesthesia. The doses recommended for sedatives and analgesics are mentioned above. With children entering adolescence, the lowest recommended
dose should be used as the starting dose. Supplemental doses, if necessary, that titrate to effect are
encouraged.
II. Subsequent BMAs. An attempt should be made to individualize the treatment approach for each child. Some children will benefit from behavioral intervention alone (with local anesthetic) while
Adolescents
(>12 y
or pubertal)
6-24 mo
2-5 y
TABLE 6-(continued)
Age Recommendationst
III. If an oral sedative has not been given, but sedation becomes necessary just before the procedure, the following can be administered IV:
A. Midazolam: 0.05 mg/kg 3-4 mm before BMA; repeat if necessary X2.
B. Diazepam: 0.1 mg/kg 3-5 mm before BMA (only give IV if have central line); repeat if necessary
X2.
C. Pentobarbital: 2 mg/kg 5-10 mm before BMA; repeat if necessary xl.
I. Same as school age, but the sedation/analgesia maximal doses should be limited to the following: A. Benzodiazepine
1. Diazepam: orally 10 mg, IV 5 mg; half-dose can be repeated. 2. Midazolam: 0.5 mg IV every 3-4 mm until effect achieved. 3. Triazolam: 0.25-mg tablet orally.
B. Opioids
1. Morphine sulfate: 3-4 mg IV and repeat in 5 mm if necessary.
2. Fentanyl: 25-50 cg IV (0.025-0.05 mg) (0.5-1 mL of 50 sg/mL solution); full dose can be
repeated in 5 mm if necessary; and, if needed, repeat four to five times with 25 g at 5-mm intervals.
3. Meperidine: 40 mg IV repeated one to two times at 5-mm intervals
C. Barbiturates: 100 mg IV pentobarbital (Nembutal) or same dose orally, if planning BMA with other procedures and need prolonged sedation.
II. Encourage more participation by the adolescent in the decision-making process regarding how to best manage pain during procedures and to provide an opportunity to learn behavioral procedures, including rehearsal.
* Protocol also applies for other invasive procedures such as Brov iac removal,
incision, and drainage. Abbreviations: IV, intravenous; BMA, bone marrow aspiration.
TABLE 7. Lumbar Punctures
Age Recommendations
O-6mo 1. Procedure should be performed on an infant who is warmed
appropriately and “settled” (ie, not on a crying infant imme-diately after another procedure).
2. Local anesthesia using 1% lidocaine.
3. The use ofopioids and sedatives in this age group for conscious sedation is difficult. Further studies need to be performed
before firm recommendations can be made. If analgesics are deemed necessary, the use of small doses of single medications
(not combined with other drugs) should be considered. 1. Preparation. A parent should carry the infant to the treatment
room and maintain physical contact during the procedure.
The parent can be instructed to talk soothingly to the child and to stroke or rub a part of the child’s body.
2. Local anesthetic should be used. Administer 1% lidocaine intradermally and then subcutaneously and wait 4-5 mm before insertion of LP needle.
3. If sedation and analgesia are deemed necessary, recommen-dations are the same as for this age group in Table 2. 4. Attach flexible tubing (ie, T-connector) to spinal needle to
enable easier injection of intrathecal medications.
1. Preparation should be included for all children in this age
group. In addition to the parent maintaining physical and verbal contact with the child throughout the procedure, the parent can be given specific instruction regarding the use of
story-telling, pop-up books, bubbles, and dolls for distraction during the procedure. The 3- to 5-year-old child can also
benefit from preprocedure preparation regarding what to
ex-pect. (See Table 10 for more details.)
2. For guidelines regarding the need for sedation, past behavior
during other procedures and a rating (0-10 scale) by parents of how cooperative and manageable they expect their child to be should be used.
3. If sedation is used, diazepam 0.2-0.3 mg/kg orally or
intra-venous preparation of midazolam 0.2-0.4 mg/kg orally 45 mm
TABLE 7-(continued)
Age Recommendations
4. Local anesthetic recommendation is same as for the 6- to 24-mo age group.
5. If the above interventions are unsuccessful, consider deep sedation or general anesthesia under the supervision of an anesthesiologist.
5-12 y and l2 y 1. For a majority of children in these age groups, psychologic preparation and behavioral intervention should suffice (com-bined with the technical skill of the performer, good position-ing of the child, and local anesthesia).
2. Psychologic preparation includes giving the child information and a chance to practice the procedure. Behavioral interven-tion includes distraction methods such as counting, deep breathing, story-telling, and helping the child to engage in an imaginary fantasy based on something with which the child is familiar (TV show, pets, friends, past experiences, etc). The use of “props” (eg, favorite doll) and parental physical and verbal presence (with specific instructions) should be dictated by the child’s age and anxiety level. The adolescent should be given the choice regarding parental presence during the LP. 3. It is our bias that, if pharmacologic intervention is deemed necessary, sedatives alone (with local anesthetic) should suf-fice. The sedative doses in Table 2 are appropriate.
TABLE 8. Intravenous/Intramuscular/Fingersticks/Heel Lances (All Ages)
1. Consolidate blood drawing using indwelling catheter when possible. If a central line is present, consider using it for blood drawing. View the entire day’s plans to avoid multiple attempts (“sticks”) for blood and intravenous access. When attempting intravenous access (especially if using an “intracath”), use local anesthetic or saline intradermally for analgesia.
2. The child older than 2 y of age should be told what will be done and distraction methods should be used during the procedure (see Table 10).
3. Intramuscular injections should be avoided unless needed for chemotherapy. Distraction and counter irritant methods should be used during the intramuscular injection. Analgesics or sedatives should never be given intramuscularly.
TABLE 9. Nonpainful Procedures Requiring Sedation (All Ages)
1. For a majority of children 5 y, psychologic preparation and behavioral intervention alone should suffice (see Table
10), or:
2. If sedation is necessary, especially for the younger child or infant, use oral chloral hydrate 60-75 mg/kg and repeat the dose to a maximum of 120 mg/kg total if the child is not sleeping within 30 mm after the first dose; give first dose 30-60 mm before the procedure, or:
3. Intravenous pentobarbital 1-3 mg/kg boluses to a maximum of 100 mg until asleep. Requires pulse oximetry and physician in attendance, or:
4. Deep sedation or general anesthesia under the supervision of an anesthesiologist.
There are procedures that require the patient to lie still and quietly, such as computed tomographic scanning, magnetic
resonance imaging, and ultrasonographic examination. Both behavioral and pharmacologic interventions are appro-priate for these instances, although they may be more difficult in the younger age groups. A physician must be
responsible for the care of the patient, and he or she must be identified. If deep sedation is necessary, a trained individual must be present. This individual should be able to watch for signs of obstruction and oversedation, manage an obstructed airway until other more skilled individuals arrive, and be able to observe the patient until he or she can
be easily aroused. In this instance, a pulse oximeter and blood pressure monitor should be used. Airway equipment as well as resuscitation equipment should be easily accessible.
that coordination of procedure timing must take If adequate pharmacologic pain control is to be a into account the need for psychologic preparation. service provided on the inpatient and outpatient
This preparation should not be an afterthought. units where the procedures take place, then certain
Available studies suggest that parents are good requirements must be met. These follow the
guide-predictors of how the child will handle the discom- lines for conscious sedation published by the Amer-fort associated with these procedures. Their predic- ican Academy of Pediatrics’2 and include: oxygen
TABLE 10. Behavioral Management of Pediatric Procedures
1. General considerations
a. Initial preparation ideally is done on a day when no painful procedures are to be performed. It should be conducted in a quiet, comfortable room. All children should receive some initial preparation. Specific intervention approaches (described below) depend on the situation and the patient.
b. The parent who will be present during the medical procedure should participate in the behavioral preparation. The parent is given a specific role such as holding the child’s hand. For adolescents, this is applicable if the
patient requests it.
C. Children vary widely from one day to another in their responsiveness to psychologic techniques. If a child is obviously too anxious, angry, or sick to respond to psychologic intervention, be prepared to offer adequate pharmacologic relief rather than unduly prolonging the child’s anxiety and/or discomfort.
d. These psychologic techniques can be provided by physicians, psychologists, social workers, child life workers, and nurses. At present, information regarding workships in these techniques are available from The Society for Behavioral Pediatrics, 241 East Gravers Lane, Philadelphia, PA 19118, 215-248-9168 or from The Society for
Clinical and Experimental Hypnosis, 128-A Kings Park Avenue Drive, Liverpool, NY 13090, 315-652-7299.
2. Preparation
a. Find out child’s interests, such as favorite hobbies, games, TV programs, and pets. This information is useful
material for intervention.
b. Find out child’s expectations and fears regarding the procedure. c. Give cognitive information (eg, what will happen).
d. Give sensory information (what it may feel like, described in terms of other sensory options besides “hurt”: eg, “cool,” “pressure,” “warm”).
3. Modeling
a. With film showing another child successfully coping with the procedure. b. Talking with another child who has coped with same procedure.
4. Desensitization/rehearsal: Gradually approximate feared situation while helping child to remain calm; eg, at first the child may just visualize having a bone marrow aspiration, then go through steps of a bone marrow aspiration in an examining room with no needles present, then in treatment room with no needles.
5. Distraction: During desensitization/rehearsal the child will learn that objects present in the room can help to focus his or her attention away from potentially fearful situations or thoughts. Such objects may include colorful pictures in a book, an interesting toy, or bubbles floating through the air. Some children are able to focus their attention on taking slow deep breaths or counting.
6. Imaginative involvement: Help child to focus attention on imagined activities, eg, flying in a rocket ship, petting a
kitten. The “therapist-helper” (who can be a patient) continues to suggest pleasant activity and sensory experience throughout the fantasy, eg, “This is so fun and exciting flying through space. How many stars can you see?” This is practiced during desensitization/rehearsal so that child learns how to interact with the therapist during the fantasy. Some children undergoing intravenous cannulation or finger sticks find it helpful to imagine that their
hand has fallen asleep, or to imagine that pain is conducted in wires that they can turn off with a switch.
self-inflating resuscitation bag, naloxone, and other appropriate resuscitative equipment. A pulse oxi-meter should be considered for children receiving any sedative and/or analgesic drugs. Additionally, a member of the medical team who is not perform-ing the procedure should be responsible for moni-toring the child from the time drugs are given until drug effects have dissipated. Attention must be paid to level of consciousness, respiratory rate and effort, skin color, and oxygen saturation.
The child should never have a bone marrow aspiration or lumbar puncture performed in his or her bed, and the treatment room environment should be a relatively calm one, with the adults present speaking softly to each other and to the child. Background music that calms the adults can be helpful in this regard. Parents should be asked if they wish to accompany their child to the treat-ment room and should be provided with
instruc-tions that, at a minimum, include physical contact with their child and, ideally, offer them a role in the procedure. If the parent chooses not to enter
the treatment room, then another individual should be designated as a “parent substitute” to support the child during the procedure. Ongoing discussions with the child and parents throughout treatment and observation of the child during chemotherapy
administration and blood-drawing will provide the data necessary for determining the best approach to pain and anxiety management for each child (which may change through time).
Those performing the diagnostic procedures should have a documented level of skill at the
start-ing intravenous lines, drawing blood) performed on children in hospitals can be reduced by proper staff training and that it is not ethical to practice on children. Also, the appropriateness of house officers performing bone marrow aspirations at all is open
to serious question. These procedures should be performed only by specially trained nurses,
oncol-ogy fellows, or oncologists who perform them fre-quently.
In summary, we feel that the discomfort associ-ated with diagnostic procedures should be
ad-dressed in a formal manner. Pharmalogic ap-proaches, behavioral interventions, or both should be considered and individualized for each child. In general, an aggressive pharmacologic approach is recommended for the first diagnostic procedure to minimize negative experience associated with the
illness and hospitalization. Personnel should be
appropriately trained and the environment appro-priately modified. With such an approach, some of the burdens associated with these procedures for
