**3. Pain control methods**

The necessary nature of pain treatment has long been categorized among other basic human rights, and in 1999 the Joint Commission on Accreditation of Healthcare Organizations formalized pain standards to ensure to all patients their right to appropriate assessment and management of their pain, describing pain as the "fifth vital sign" (Lanser, 2001). Intrinsic to our capacity to treat pain is possession of perspective of themany cultural beliefs, philosophical ideologies, and scientific discoveries that have influenced and evolved into the modern Western conceptualization of pain. Cancer pain can not be treated sufficiently. In analysis of 11 reports including 2000 cancer patients in 1986, it was found that pains could not be healed in 50-80% of the patients in developed country. Pain may be healed with simple methods in 90% of cancer patients. However, it was also detected that pains could not be healed with acceptable methods in 10% of these patients. American National Cancer Institute attracted attention to be importance of issue with message that "being unable to treat cancer pain is a serious and unacceptable community health problem" (Aslan, 2006).

The other methods depend on behaviour pattern (such as tone of voice, facial expression and gestures) and biological parameters (such as heart rate, falling of peripheral oxygen saturation). Personal expression is the best measurement method if can be obtained and is accepted as "golden rule" in pain measurement (Unuvar, 1999). Behavioral pain assessment

> Occasional grimace or frown, withdrawn, disinterested

Squirming, shifting back

and forth, tense

Moans or whinpers; occasional complaint

touching, hugging or being talked to, distractible

Table 4. Behavioral pain assessment scales for young children (Hockenberry-Eaton et al., 1999)

Adolescents; adolescents give reactions similar to adults. They may look calm, have sleeping problems, loss of appetite, avoid from friends or family, be nervous or angry. They may not say when they have pain since they are afraid of getting addicted to narcotics. The best method determine the pain of adolescent patients is scales which have assessment criteria ranging 0 to 5 (0= presence of no pain, 5= presence of intense unbearable pain). Expression

The necessary nature of pain treatment has long been categorized among other basic human rights, and in 1999 the Joint Commission on Accreditation of Healthcare Organizations formalized pain standards to ensure to all patients their right to appropriate assessment and management of their pain, describing pain as the "fifth vital sign" (Lanser, 2001). Intrinsic to our capacity to treat pain is possession of perspective of themany cultural beliefs, philosophical ideologies, and scientific discoveries that have influenced and evolved into the modern Western conceptualization of pain. Cancer pain can not be treated sufficiently. In analysis of 11 reports including 2000 cancer patients in 1986, it was found that pains could not be healed in 50-80% of the patients in developed country. Pain may be healed with simple methods in 90% of cancer patients. However, it was also detected that pains could not be healed with acceptable methods in 10% of these patients. American National Cancer Institute attracted attention to be importance of issue with message that "being unable to treat cancer pain is a serious and unacceptable community health problem" (Aslan, 2006).

Uneasy, restless, tense Kicking, or legs

Frequent to constant quivering chin, clenched jaw

drawn up

jerking

comfort

Arched, rigid or

Crying steadily, screams or sobs, frequent complaints

Difficult to console or

scale for young children was given in the Table 4.

expression or smile

position, moves easily

of pain according to age groups was given Table 5.

Consolability Content, relaxed Reassured by occasional

Categories 0 1 2

**FLACC Scale Scoring** 

Total is scored from 0-10.

**3. Pain control methods** 

Face No particular

Legs Normal position or relaxed

Cry No cry (awake or asleep)

Activity Lying quietly, normal


Table 5. Expression of pain in children

Pain Management and Nursing Approaches in Pediatric Oncology 107

Fig. 6. Medical management of cancer pain (Gindrich, 2006)

The word "opioid" contains all components associated with opium. Use of pure alkaloids has become widespread in whole world since second half of 19th century after Serturner isolated morphine from opium for the first time in 1806 (Cizmeci& Babacan, 2007). The first preference should be oral route in implementation of analgesic drugs, which is the first pain control method in algorithms used in treatment of chronic pains. Where oral intake is not possible, intravenous, intramuscular, subcutaneous, transdermal, intrathecal, or epidural route might be used (Golianu et al., 2000). Opioids are used for removal of severe pains. Opioids such as morphine, meperidine, methadone, fentanyl, codeine and hydromorphone are included in this group and are the most frequent used morphines. Gradually increasing

**3.1.1 Opioid (narcotic) analgesics** 

The WHO Analgesic Stepladder is a multi-step approach to treating pain, and is a guide for initiating analgesic drugs and dosages that correspond to the patient's reported level of pain (Fig. 5). The ladder starts with non-opioid oral drugs for mild pain and progresses to strong opioids, adjuvants and invasive therapies for severe and/or intractable pain (Hockenberry-Eaton et al., 1999).

Fig. 5. Therpeutic ladder for pain management (Hockenberry-Eaton et al., 1999)

#### **3.1 Pharmacological pain management**

Western oncology group states that although cancer patients have taken analgesic, 67% of them have pain, 36% of them have so severe pains as to deteriorate their daily functions, 42% of them have not taken sufficient analgesic treatment. Tolerance and fear of addiction prevents cancer treatment (Aslan, 2006). While planning pain treatment, location, level, quality of pain, presence and features of the diseases causing pain, age of patient, present clinical facilities should be taken into consideration. In the light of all these features, treatment method is decided (Bedre& Sethna, 2002; Krauss& Gren, 2000). Drug treatment is the most frequently used method in treatment of acute and chronic pains in children. Analgesic drugs can be used singly or in a drug combination way (Golianu et al., 2000). For this purpose, non-opioid analgesics, opioid analgesics and adjuvant analgesics are used. In recent years, significant developments have been made in this field by adjustment of doses of these drugs and knowing their efficiency and pharmacologic differences in children. The most significant steps in this field have been taken by WHO. In consequence of studies concerning drug use especially in children with cancer pain, WHO published a guide book titled cancer pain treatment and palliative care (WHO, 1998). Medical management of cancer pain was given Fig. 6.

The WHO Analgesic Stepladder is a multi-step approach to treating pain, and is a guide for initiating analgesic drugs and dosages that correspond to the patient's reported level of pain (Fig. 5). The ladder starts with non-opioid oral drugs for mild pain and progresses to strong opioids, adjuvants and invasive therapies for severe and/or intractable pain (Hockenberry-

Fig. 5. Therpeutic ladder for pain management (Hockenberry-Eaton et al., 1999)

Western oncology group states that although cancer patients have taken analgesic, 67% of them have pain, 36% of them have so severe pains as to deteriorate their daily functions, 42% of them have not taken sufficient analgesic treatment. Tolerance and fear of addiction prevents cancer treatment (Aslan, 2006). While planning pain treatment, location, level, quality of pain, presence and features of the diseases causing pain, age of patient, present clinical facilities should be taken into consideration. In the light of all these features, treatment method is decided (Bedre& Sethna, 2002; Krauss& Gren, 2000). Drug treatment is the most frequently used method in treatment of acute and chronic pains in children. Analgesic drugs can be used singly or in a drug combination way (Golianu et al., 2000). For this purpose, non-opioid analgesics, opioid analgesics and adjuvant analgesics are used. In recent years, significant developments have been made in this field by adjustment of doses of these drugs and knowing their efficiency and pharmacologic differences in children. The most significant steps in this field have been taken by WHO. In consequence of studies concerning drug use especially in children with cancer pain, WHO published a guide book titled cancer pain treatment and palliative care (WHO, 1998). Medical management of cancer

**3.1 Pharmacological pain management** 

pain was given Fig. 6.

Eaton et al., 1999).

Fig. 6. Medical management of cancer pain (Gindrich, 2006)

#### **3.1.1 Opioid (narcotic) analgesics**

The word "opioid" contains all components associated with opium. Use of pure alkaloids has become widespread in whole world since second half of 19th century after Serturner isolated morphine from opium for the first time in 1806 (Cizmeci& Babacan, 2007). The first preference should be oral route in implementation of analgesic drugs, which is the first pain control method in algorithms used in treatment of chronic pains. Where oral intake is not possible, intravenous, intramuscular, subcutaneous, transdermal, intrathecal, or epidural route might be used (Golianu et al., 2000). Opioids are used for removal of severe pains. Opioids such as morphine, meperidine, methadone, fentanyl, codeine and hydromorphone are included in this group and are the most frequent used morphines. Gradually increasing

Pain Management and Nursing Approaches in Pediatric Oncology 109

inflammatory (Bedre&Sethna, 2002; Golianu et al., 2000). Pharmacodynamic and pharmacokinetic features of paracetamol, salicylates and nonsteroid anti-inflammatory drug (NSAID) in children are not different from adults except for neonatal period. Drug selection changes depending on various factors such as action time of drug, whether asked for antiinflammatory effect or not, oral or IV route preference and adverse effects of drug. While majority of drugs in this group have both three of analgesic, antipyretic, anti-inflammatory effects, the others have just analgesic and antipyretic effects. Selections of analgesic are made in line with pain level according to step principle. According to WHO's three steps principle, nonsteroid anti-inflammatory drugs are given in light pains, weak opioids in addition to NSAIDs are given in mild pains, strong opioids are also given additionally in severe pains. Moreover, adjuvant drugs can be added in all steps (Eyigor et al., 2007).

Fig. 8. Scheme of using nonsteroidal antiinflamatory drugs (Alanmanou, 2006b)

Adjuvant analgesics are used for potantializing analgesic effects and improving symptoms accompanying pain. In this group, drugs such as anticonvulsants, antidepressants, oral local

**3.1.3 Adjuvant agents** 

Schema related to using NSAIDs was given Fig. 8.

doses might be needed in order to prevent pain due to tolerance occurring against opioids. Tolerance and development of addiction dependent on morphine use occur in children less than in adults. Morphine, intravenous, intramuscular are used with oral route, while nasal, intratecal are used with epidural route (Bedre& Sethna 2002).

The most commonly used 2 drugs;


The combined use of opioids and benzodiazepines should be evaluated for for efficacy and for any potential adverse effects at the peak of their action to guide subsequent titration (WHO, 1998). Schema related to using opiods was given Fig. 7.

Fig. 7. Scheme of using opioid (Alanmanou, 2006a)

### **3.1.2 Non-opioid analgesics**

Non-opioid analgesics are used singly in light pains or by combining with opioids in mild pains. The most frequent used non-opioids are paracetamol, aspirin and nonsteroid anti-

doses might be needed in order to prevent pain due to tolerance occurring against opioids. Tolerance and development of addiction dependent on morphine use occur in children less than in adults. Morphine, intravenous, intramuscular are used with oral route, while nasal,

• Morphine, given at 0,1 mg/kg IV 5-10 minutes before the procedure or 0,3 mg/kg

The combined use of opioids and benzodiazepines should be evaluated for for efficacy and for any potential adverse effects at the peak of their action to guide subsequent titration

Non-opioid analgesics are used singly in light pains or by combining with opioids in mild pains. The most frequent used non-opioids are paracetamol, aspirin and nonsteroid anti-

intratecal are used with epidural route (Bedre& Sethna 2002).

• Fentanyl, 0.5-2 µg/kg given 5-10 minutes before the procedure.

(WHO, 1998). Schema related to using opiods was given Fig. 7.

Fig. 7. Scheme of using opioid (Alanmanou, 2006a)

**3.1.2 Non-opioid analgesics** 

The most commonly used 2 drugs;

orally 1 hour before the procedure.

inflammatory (Bedre&Sethna, 2002; Golianu et al., 2000). Pharmacodynamic and pharmacokinetic features of paracetamol, salicylates and nonsteroid anti-inflammatory drug (NSAID) in children are not different from adults except for neonatal period. Drug selection changes depending on various factors such as action time of drug, whether asked for antiinflammatory effect or not, oral or IV route preference and adverse effects of drug. While majority of drugs in this group have both three of analgesic, antipyretic, anti-inflammatory effects, the others have just analgesic and antipyretic effects. Selections of analgesic are made in line with pain level according to step principle. According to WHO's three steps principle, nonsteroid anti-inflammatory drugs are given in light pains, weak opioids in addition to NSAIDs are given in mild pains, strong opioids are also given additionally in severe pains. Moreover, adjuvant drugs can be added in all steps (Eyigor et al., 2007). Schema related to using NSAIDs was given Fig. 8.

Fig. 8. Scheme of using nonsteroidal antiinflamatory drugs (Alanmanou, 2006b)

#### **3.1.3 Adjuvant agents**

Adjuvant analgesics are used for potantializing analgesic effects and improving symptoms accompanying pain. In this group, drugs such as anticonvulsants, antidepressants, oral local

Pain Management and Nursing Approaches in Pediatric Oncology 111

Fig. 10. Pain assessment and treatment practices (Weidner et al,. 2006)

anesthetics, neuroleptics, myorelaxants, ntihistaminics, psychostimulants, corticosteroids and calcium channel blockers are used (Bedre&Sethna, 2002, Eyigör et al., 2007). Unless drugs are useful in removing pain in children, invasive attempts might be applied. The fundamental reason for childhood regional anaesthesia and analgesia implementations' not attracting attention might be listed as lack of experience in this field, adverse effect fear and not establishing dialog with the patient during attempt. Anatomical differences such as being different heights and anatomical structures of children during adolescence, extension of dura and spinal cord to lower segments in newborn children, being tight of epidural field, not yet completing of myelination following the birth, being thin of ligaments and fascias might lead to technical difficulties in regional implementations (Yaster&Hardart 2002; Desparment-Sheridan, 2000). Schema related to using steroids was given Fig. 9.

Fig. 9. Scheme of using steroids (Ramamurthy&Alanmanou, 2006)

In general, pain assessment and treatment steps were given in fig. 10.

anesthetics, neuroleptics, myorelaxants, ntihistaminics, psychostimulants, corticosteroids and calcium channel blockers are used (Bedre&Sethna, 2002, Eyigör et al., 2007). Unless drugs are useful in removing pain in children, invasive attempts might be applied. The fundamental reason for childhood regional anaesthesia and analgesia implementations' not attracting attention might be listed as lack of experience in this field, adverse effect fear and not establishing dialog with the patient during attempt. Anatomical differences such as being different heights and anatomical structures of children during adolescence, extension of dura and spinal cord to lower segments in newborn children, being tight of epidural field, not yet completing of myelination following the birth, being thin of ligaments and fascias might lead to technical difficulties in regional implementations (Yaster&Hardart 2002;

Desparment-Sheridan, 2000). Schema related to using steroids was given Fig. 9.

Fig. 9. Scheme of using steroids (Ramamurthy&Alanmanou, 2006)

In general, pain assessment and treatment steps were given in fig. 10.

Fig. 10. Pain assessment and treatment practices (Weidner et al,. 2006)

Pain Management and Nursing Approaches in Pediatric Oncology 113

child and family. Some children and families seek out information; others may find that too much information increases their anxiety. Health care provides should therefore try to individualize their dealings with families. An empathic approach is essential, and information should be given a little at a time, repeated as frequently as needed. Booklets, videos, drawings, and dolls can be useful tools in this process. Children should never be lied to about painful procedures; they will distrust and fear what will be done to them in the future. Health-care workers must be genuinely fond of children and know how to deal with them. Ideally, children should be given choices about which techniques to use to control pain. They should be given choices about which techniques to use to control pain. They should also be allowed to make decisions that do not interfere with treatment, such as which finger to prick for blood samples. Play is an essential part of every child's daily life and even the sickest child can be helped to play. Playing enables children to understand their world and to relax and forget their worries. All children must therefore have the time and place to play, and painful procedures must not be carried out in play areas. Normal activities such as school, hobbies, and visits by friends should be encouraged. Psychosocial treatment is an integral part of cancer pain treatment. It should be used in all painful or potentially painful

Cognitive treatment methods are intended to influence a child's thoughts and images. Parents are often very skilled at using these methods because they know their children's preferences (WHO, 1998). Distraction is used to focus the child's attention away from the pain (Hockenberry-Eaton, 1999). Active distraction of children's attention is important: the more involved a child becomes in an activity, the greater the distraction from pain (WHO, 1998). For children, simple distraction techniques can be very effective in decreasing pain (Hockenberry-Eaton, M 1999). Infants and young children require concrete events or objects to attract their attention; interesting toys that provide something to see, hear, and do are best. Older children benefit from concentrating on a game, conversation, or special story (WHO 1998). In studies conducted, it was reported virtual reality was useful in distracting attention in painful medical interventions and decreasing pain and distress and child's selection should be attached importance in implementation ( Gershon et al., 2004, Nilsson et al., 2009). Music, even as simple as a mother's lullaby, is a universal soother and distractor (WHO, 1998). Listening to music is an important tool which decreases heart rate, body temperature, blood pressure and breathing rate, distracts patient's attention, lowers the nausea depending on chemotherapy and especially increases the life quality of the patients in terminal period (Chase, 2003; Deng et al., 2004; Halstead&Roscoe, 2002; Hiilliard, 2003; Kaminski&Hall, 1996; Mccaffery, 2000). In a study performed by Burns et al. (2001) on cancer patients, it was reported that well-being and relaxion increased in the patients in music listening process, and tension decreased. In the study carried out by Chan et al. (2003) on the patients to whom colposcopy was applied, pain and anxiety level of the group listening to music was found lower. Nguyen et al. (2010) found that pain score, heart and breathing rate were lower in the group listening to music during and after lumbar puncture implementation in children with cancer. Listening to music was found to increase endorphin secretion by inducing alpha wands and to play a role in not only decreasing the pain by creating a state of relaxion but also in decreasing blood pressure, heart rate and

situations, often combined with analgesic drug therapy (WHO, 1998).

**3.2.2 Cognitive methods** 

#### **3.2 Nonpharmacologic pain management**

Nonpharmacologic methods must be integral part of the management of children's cancer pain, beginning at the time of diagnosis and continuing throughout treatment (WHO, 1998). Nonpharmacologic methods in the management of pain have been found to be highly effective for some children and for some procedures. These techniques are easy to learn and should be used when possible to give the child some control in the management of pain. The examples given for distraction, muscle relaxation, and guided imagery are easy techniques to learn and can be used with young children (Hockenberry-Eaton, M et al; 1999). Non-drug approaches should supplement, but not replace, appropriate drug treatment (Hockenberry-Eaton et al., 1999; WHO, 1998). In selection of nonpharmacologic method use, child's age, behavioral factors, coping ability, fear/anxiety and type of pain experience play role. Nonpharmacologic pain management implementations are divided into 4 groups as supportive, cognitive, behavioral and physical methods. In Table 6, non-pharmacologic methods used in relieving pain are summarized (WHO, 1998).


\*Heat and cold should not be used with infants because of the risk of injury

Table 6. Nonpharmacologic methods of pain relief (WHO 1998)
