Page 269 Guide to Pain Management in Low-Resource Settings

Pain Management in Children 257

early stages. Pain means relevant stress in all pediat- Chemotherapeutic agents used can also be a cause of
ric patients, and is associated with an inferior medical pain during treatment. Vincristine, a plant alkaloid, is
outcome. Lower morbidity and mortality have been re- most commonly associated with peripheral neuropa-
ported among neonates and infants who received prop- thies, characterized by dysesthetic pain that presents
er analgesia during and after cardiac surgery. Surgery as a burning sensation, causing pain upon light con-
in young infants who are receiving inadequate treat- tact with the skin. Mucositis is a common side eff ect of
ment for pain evokes an outpouring of stress hormones, chemotherapy, often seen in children receiving anthra-
which results in increased catabolism, immunosuppres- cyclines (e.g., daunorubicin), alkylating agents (e.g., cy-
sion, and hemodynamic instability, among other eff ects. clophosphamide), antimetabolites (e.g., methotrexate),
It is thought that younger children may even experi- and epipodophyllotoxins (e.g., VP-16). Radiation thera-
ence higher levels of distress during painful procedures py to the head and neck area is associated with severe
than older children, because they tend to cope with pain mucositis in children. Postradiation pain may occur in
more behaviorally. certain body regions, caused by skin reactions, fi brosis
or scarring of connective tissues, and secondary injury

Do children become accustomed to nerve structures. Other treatment-related side eff ects
that cause pain include abdominal pain from vomiting,
to chronic pain or repeated
diarrhea, constipation, and infections such as typhlitis,
painful procedures? cellulitis, or sinusitis.

No. Children exposed who are given repeated pain-
ful procedures often experience increasing anxiety and Barriers to eff ective
perception of pain. Th erefore, especially children ex- pain management

periencing chronic or repeated pain, such as in tumor
Do children become addicted to opioids
diseases or HIV, have a high demand for accurate pain
more easily than adults?
management.
Opioids are no more dangerous for children than they
are for adults, when appropriately administered. Th e
Is pain in children with HIV or prevalence of physical dependence (defi ned as an in-
cancer always related directly voluntary physiological eff ect of withdrawal symptoms
to the disease? noted following abrupt discontinuation of opioids, or
administration of a narcotic antagonist such as nalox-
No, not always. In HIV, between 20% and 60% of HIV- one) on opioids in children is comparable to that in
infected pediatric patients have pain daily. Pain in HIV adults. If opioids are given regularly in high doses for
not only reduces quality of life, but is also associated more than a week, do not stop medication abruptly.
with more severe immunosuppression and increased Slow tapering of the opioid is recommended to pre-
mortality, and therefore, it should be treated with care. vent withdrawal symptoms. As a rule of thumb, re-
Pain not directly related to the HIV infection can be duce the opioid to 3/4 of the previous dose over each
caused by (1) adverse drug eff ects, e.g., peripheral neu- 24-hour periods (e.g., day 1: 100 mg/d, day 2: 75 mg/d,
ropathy, drug induced pancreatitis or abdominal pain day 3: 55 mg/day, day 4: 40 mg/d). Sometimes tapering
from vomiting (a common side eff ect of zidovudine), (2) may last 1–2 weeks. If seizures occur during tapering,
invasive medical procedures (it has been estimated that treatment with diazepam (i.v. 0.1–0.3 mg/kg every 6
20–25% of HIV-positive patients will require surgery hrs) is recommended.
during their illness), (3) opportunistic infections such as
esophageal candidiasis, herpes zoster, pneumonia (e.g., Is respiratory depression a common problem
Pneumocystis carinii, Cytomegalovirus, or Cryptococ- in opioid-treated children?
cus), or tuberculosis infections, and (4) additional ma- Respiratory depression is a serious and well-known side
lignancy. For cancer in children additional pain mainly eff ect of opioids; however, it rarely occurs in children
occurs from (1) surgery, (2) chemotherapy, and (3) ra- when opioids are administered appropriately. As chil-
diation therapy. Children undergoing surgery for exci- dren develop a tolerance to the analgesic eff ect of opioids,
sion of a primary tumor experience postoperative pain. they often develop a tolerance to an initial respiratory