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INTRODUCTION

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The prognosis of cancer in children has improved dramatically over the past 40 years. Unlike many adult cancers, pediatric malignancies are often responsive to initial aggressive chemotherapy, radiation, and surgery. Currently, the estimated survival rate for a child (age 0-19) with cancer is 80%. However, these therapies often produce acute and chronic pain problems, such as mucositis, graft versus host disease (GVHD), peripheral and central neuropathic pain, phantom limb pain, prolonged postdural puncture headache, radiation dermatitis, and visceral hyperalgesia. Although treatment-related pain generally exceeds tumor-associated pain in pediatric cancer patients, tumor-associated pain is prevalent and may involve bone, viscera, nerves, and other tissues. In the most common diagnostic category of pediatric cancer, leukemia, presenting in children 2 to 6 years of age, bone pain is secondary to rapid growth of precursor cells in the bone marrow. In adolescents, malignant bone tumors and lymphomas produce most tumor-related pain. The most common solid tumor diagnosed during childhood, central nervous system (CNS) tumor, may induce headache caused by increased intracranial pressure (ICP).

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Following the often successful treatment protocols for children with cancer, there is increasing risk of delayed and chronic complications of treatment, such as secondary malignancies, skeletal disorders, cardiac and pulmonary insufficiency, neurocognitive disability, and pain. At present, the estimated number of childhood cancer survivors in the United States is greater than 300,000, and there is a 75% risk of a chronic health disorder 30 years postdiagnosis. Early recognition and treatment of medical and psychological issues in children treated for cancer are a public health care concern.

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As the assessment of pain in children is guided by the child's cognitive and behavioral development and individualized coping skills,1 the treatment of cancer pain in children should involve a multidimensional approach that uses medications for pain and symptom management and also cognitive-behavioral interventions and other nonpharmacologic therapies. This approach provides optimal pain control and addresses patients’ complex emotional needs related to grief and sense of loss.

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TREATMENT-RELATED PAIN

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In contrast to adults, children with cancer experience pain more frequently related to aspects of cancer treatment. This is in part because of higher rates of remission in children after initial chemotherapy induction and improved long-term survival rates in childhood cancers.1,2

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Procedures such as bone marrow biopsies and aspirates, lumbar punctures, and central venous line insertions are common sources of distress and pain in children with cancer. Pain related to the treatment of cancer includes painful mucositis, amputation pain, and painful neuropathies from surgery and chemotherapeutic agents.

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Every attempt should be made to minimize distress, fear, and pain in children undergoing brief needle procedures and more invasive procedures because traumatic experiences with initial procedures make subsequent procedures more distressing. Treatment of procedure-related pain is combination of cognitive-behavioral interventions, local anesthesia, conscious sedation, and general anesthesia.

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Evidence supports the use of cognitive-behavioral strategies ...

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