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 induction chemotherapy.
The most common childhood cancer, acute lymphoblastic leukemia (ALL),
was an almost uniformly fatal disease in the early 1950s. Long-term
survival rates in children with ALL now exceed 70%. Children
with cancer, however, frequently experience a variety of acute and
chronic pains, which can be a result of cancer treatment or of the
tumor itself.1 The treatment of cancer pain in
children should involve a multidimensional approach that relies not
only on medications for pain and symptom management, but also on
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.
In contrast to adults, children with cancer more frequently experience
pain 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
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. Other sources of pain
related to the treatment of cancer include painful mucositis, amputation
pain, and painful neuropathies from surgery and chemotherapeutic
Every attempt should be made to minimize distress, fear, and
pain in children undergoing brief needle procedures and other more
invasive procedures, since initial traumatic experiences with procedures
tend to make subsequent procedures more distressing. In general,
treatment of procedure-related pain should consist of the individualized
use of combinations of cognitive-behavioral interventions, local
anesthesia, conscious sedation, and general anesthesia.
There is ample evidence to support the use of cognitive-behavioral
strategies in managing procedure-related pain in children with cancer.
Through guided imagery, progressive muscle relaxation, and hypnosis,
patients can direct their focus away from pain and the procedure
and help reduce their experience of pain, fear, and discomfort.
Young children or those with developmental deficiencies, however,
may not have the cognitive abilities to use these techniques. Explaining
the procedure in age-appropriate terms often helps to gain the child’s
trust and confidence.
The use of local anesthetics and conscious sedation combined
with cognitive-behavioral techniques can make procedures less terrifying
for children. Applying EMLA (eutectic mixture of lidocaine and prilocaine)
to the skin overlying intravenous catheter-insertion sites or lumbar puncture
sites can reliably decrease the pain from needle insertion into
the skin. This can allow less painful infiltration of local anesthetics
deep to the dermis. For more invasive procedures or for children
who experience significant distress with brief needle procedures,
conscious sedation or general anesthesia should be used. Conscious
sedation refers to a level of sedation where a child is comfortable
but is able to maintain airway reflexes and spontaneous ventilation.
Conscious sedation is often performed by ...