Pediatric Pain and Palliative Care Update
Jimmie P Leleszi, DO Jeanne Lewandowski, MD 117th Annual Osteopathic Medical Conference & Exposition AOA Public Health Seminar October 7, 2012
Total pain four components: • • • • • •
physical pains, usually multiple emotional or psychic pain social or interpersonal pain spiritual or existential pain each interacts with others can result in all-encompassing pain or suffering
Eric Cassel: • “Suffering is a state of severe distress associated with events that threaten the intactness of the person.”
Physical Body Family
Behaviors Secret Lives
“A person is a person no matter how small” - Horton
Misperceptions about Pain: in children • children do not feel pain or... • children remember pain differently • valid assessment of child’s pain not possible • risks of respiratory depression greater • side effects of opioids greater • risk of addiction outweigh opioid benefit • medications ineffective in ped pain
Cancer Pain Relief and Palliative Care in Children WHO, Geneva, 1998 • “unlike adults children cannot independently seek pain relief and are therefore vulnerable, they need adults to recognize their pain before they can receive appropriate treatment”
WHO: 1998 • “ Nothing would have a greater impact on the quality of life of children with cancer than the dissemination and implementation of the current principles of palliative care, including pain relief and symptom control.”
WHO: 1998 • “In the developed world, the major source of pain in children’s cancer are diagnostic and therapeutic procedures. In the developing world, most pain is disease related.”
“To Cure Sometimes, To Relieve Often, To Comfort Always” Anonymous 15TH Century
Types of pediatric pain: • • • • • •
disease related (cancer metastases) treatment related (chemo, radiation) treatment or disease unrelated (fracture) procedure related (bone marrow aspiration) incidental (positional joint stress) breakthrough (insufficient pain coverage)
To Assess Pain, just ask
Controlling Pain in Children: • • • • •
by the mouth by the clock by the ladder by the individual with attention to detail
The Gold Standard
By the child By the mouth By the clock
Infant: no sense of time – death is separation Toddler: links time with concrete events – dead things disappear, temporary, rescue possible School age: can tell time, but the future is far in the distant - death selective, only the old die, physical limitations Age 8-9: Death is final Adolescence: future understood - death final, irreversible, can’t happen to them
Pain management concepts children same as adults: • • • • • • • •
tolerance physical dependence addiction pseudo-addiction scheduled breakthrough incidental procedural
Tolerance: • A change in the dose-response relationship induced by exposure and manifest as a need for a higher dose to maintain an effect.
Physical Dependence: • defined solely as the development of an abstinence syndrome following dose reduction or the administration of an antagonist.
Addiction: • defining characteristics are compulsive and continued use despite harm and loss of control.
Pseudo-addiction: • Aberrant behavior in response to unrelieved pain. • Insufficient medication dosage, frequency, duration and professional fear of causing ‘addiction’-but really prolonging the pain and suffering. • With better pain management the seeking of pain medications ceases.
Analgesics for severe pain: • mu agonists are indicated for severe pain • opioids have no upper dose limit • rate of elimination of opioids reaches and exceeds adult values within the first year of life
Morphine: metabolism • morphine clearance is delayed in the first 1-3 months of life • starting doses in infants should be lower than those recommended for older children ( usually 1/3 or 1/2) • infants are more sensitive to the respiratory depressant effects of opioids than older children
Pediatric (>6 months) initial oral opioid dosage: • 0.5 - 1.0 mg/kg Q 3-4 hours – codeine (methylated morphine)
• 0.2 mg/kg Q 3-4 hours hydrocodone or oxycodone
• 0.3 mg/kg Q 3-4 hours - morphine • 0.06 mg/kg Q 3-4 hourshydromorphone
Equianalgesic table Oral
q 2 -3 h
Combination opioid / NSAID preparations
Oxycodone (Roxicodone, also in Percocet, Percodan, Tylox)
Codeine (with aspirin or acetaminophen )
180 -200 mg
q 3 -4 h
Hydrocodone (in Lorcet, Lortab, Vicodin)
q 3 -4 h
*Fentanyl should not be used in opioid naive patients. Use manufacturer's table for dosing after patient is established on another opioid.
transdermal patches: q 3 days
Infant (< 6 months) initial opioid dosage: • START WITH 1/4 TO 1/3 OF THE PEDIATRIC DOSAGE • TITRATE TO EFFECT • PAIN RELIEF
Breakthrough Pain: • • • • •
common anticipated vs. incidental analogous to insulin carbohydrate coverage “booster” dose, as needed 1/2 the usual 4-hour opioid dose or 10% of the 24-hour dose • regular use (>3-4 times qd) may signal need to increase basal dose &/or need for coanalgesic
Anti-inflammatories: children doses • • • • •
10 mg/kg ibuprofen q 6-8 hr 5 mg/kg naproxen q 8-12 hr 5-10 mg/kg tolmentin q 6-8 hr 10-15 mg/kg trisalicylate q 8-12 hr 0.6 mg/kg load dexamethasone then 0.25 mg/kg q 6 hr (airway and ICP) • 1-2 mg/kg load methylprednisolone and 0.5 mg/kg q 6 hr (acute bronchospasm)
Symptoms in dying children: Wolfe et al, NEJM, 342,#5, 2000 • 89% suffered “a lot” or “ a great deal” from at least one symptom in their last month of life • pain, fatigue, dyspnea • of those treated (%): – tx (76%) successful for pain: 27% – tx (65%) successful for dyspnea: 16%
• suffering pain more likely when physician not actively involved in EOL
Symptoms in dying children: Wolfe continued: • 53% had little or no fun • 61% were more than a little sad • 63% were not calm or peaceful most of the time • 21% were often afraid • treatment related complication deaths had poorer QoL than those with disease progression (degree of fun, sadness, mood)
Jimmy: Jimmy is a 7 yo 30 kg child who is actively dying and has been on 15 mg morphine per gastrostomy tube (GT) every four hours for pain, but has needed five rescue doses for breakthrough pain in the past 24 hours. His respiratory rate is 8, he is in apparent discomfort, and his next dose of morphine is due. Which of the following is the best course of action?
Jimmy: A. Do not give any more morphine because his respirations are depressed. B. Give half of his usual dose of morphine, which would be 7.5mg per GT. C. Continue to give the regularly scheduled dose, 15 mg per GT, with additional rescue dosed PRN for breakthrough pain. D. Increase both his every four hour maintenance dose and his PRN breakthrough dose by at least 50%.
Jimmy: D. Increase both his every four hour maintenance dose and his PRN breakthrough dose by at least 50%.
Jimmy: Which of the following is the best indicator that Jimmy is not experiencing pain? A. Jimmy is asleep. B. Jimmy has normal blood pressure. C. Jimmy has a normal respiratory rate. D. Jimmy says he does not have pain.
Jimmy: Which of the following is the best indicator that Jimmy is not experiencing pain? D. Jimmy says he does not have pain.
Sleep: • • • • •
Newborn: > 20 hours per day Infant: 2 hours noc and two - 2 hour naps Toddler: 10-12 hours noc and 2 hour nap School Age: 10 hours noc Adolescent: sleep debt, alert after noon hour, growth associated with increased need • Dying adds profound fatigue
Leonardo: Leonardo, an 18 year old with end-stage cystic fibrosis, is being treated with antibiotics and his usual regimen of inhaled bronchodilators and enzymes. He has been receiving morphine for relief of breathlessness. For the past 2 days he has needed daily rescue doses totaling 90mg of immediate release morphine, in addition to his usual dose of sustained release morphine 15mg bid. Which of the following would be an appropriate change in his opioids?
Leonardo: A. 60 mg of sustained-release morphine bid, with rescue doses of 15 mg immediaterelease morphine B. 30 mg of sustained-release morphine bid, with rescue doses of 15 mg immediaterelease morphine C. No change: continue his 15 mg dose bid to avoid the possibility of tolerance D. Use a different opioid because he is approaching his maximally tolerated dose
Leonardo: A. 60 mg of sustained-release morphine bid, with rescue doses of 15 mg immediaterelease morphine
Kelly: A one month old term infant undergoes open thoracotomy to ligate a patent ductus arteriosus. When calculating the appropriate dose of IV morphine to give this infant immediately post operatively the following concepts are true:
Kelly: A. Infants metabolize opioids faster than older children and adults. B. Assessing opioid toxicity in an infant is more difficult than in older children, due to their sleep wake cycles and behavior. C. The starting doses needed are for infants are larger than older children for similar analgesic effect. D. The dosing interval for infants is longer than older children and adults due to delayed clearance
Kelly: B. Assessing opioid toxicity in an infant is more difficult than in older children, due to their sleep wake cycles and behavior.