Pain in Children With Cancer: Prevalence, Characteristics, and Parent Management

The Critical Role of Parents in Pediatric Cancer-Related Pain Management: a Review and Call to Action

PURPOSE OF REVIEW

Even with optimized medical management, pain remains an inevitable part of pediatric cancer care. The most effective interventions for nonpharmacologic pain management within pediatric psychology include parent skills training. This review specifically explored the role of parents in cancer-related pain management with the goal of defining a set of evidence-based skills that could translate to improved pediatric cancer pain management.

RECENT FINDINGS

Pain is now widely understood to be both a sensory and emotional experience. As a result, within pediatric non-cancer pain management there is increasing application of the biopsychosocial model for pain management, inclusive of evidence-based psychological intervention. This review, specifically focusing on the role of parent training in cancer-related pain management, finds few interventions that systematically included parents. There is a need for continued evidence-based innovation and knowledge dissemination in this area of care. This paper highlights a critical gap in translational science within pediatric cancer pain management, namely, that parents who have a child with cancer are not reliably gaining access to well-established, evidence-based psychological skills training that can help to mitigate pain and pain-related stress. Based on the literature, the authors provide recommendations for generating adaptable, evidence-informed interventions that support and empower parents to help their child with pain management through all phases of cancer treatment.

Quality of Life and Pain Experienced by Children and Adolescents With Cancer at Home Following Discharge From the Hospital

An exploratory study was conducted to examine the quality of life and pain experienced by patients with pediatric cancer at home after discharge. Physical, cognitive, social, and emotional aspects of quality of life were measured and how these may be affected by age, sex, diagnosis, and pain status. The authors also characterized intensity, location, and quality of pain experienced. A sample of 33 patients participating in a larger study was selected on the basis of having pain on the day of discharge and having completed the Pediatric Quality of Life Inventory Generic, Cancer Module, Multidimensional Fatigue Scale, and the Adolescent Pediatric Pain Tool at home. Cancer diagnoses were leukemias/lymphomas (42.4%), brain/central nervous system tumors (27.3%), sarcomas (24.2%), or other (6.1%). More than half of patients reported pain (n=17; 51.5%). Patients with pain had more fatigue affecting the quality of life (P=0.01), and lower physical and emotional functioning, leading to lower overall health-related quality of life scores (P=0.011). Female individuals and adolescents reported worse emotional functioning (P=0.02 and P=0.05, respectively). Physical, cognitive, and social functioning were lowest among patients diagnosed with sarcomas (P=0.00, P=0.01, and P=0.04, respectively). It is important to understand the symptom experience of patients at home as a first step in moving towards optimal discharge teaching and treatment.

Maternal Pain Management at Home in Children with Cancer: A Turkish Sample

PURPOSE

The purpose of the present study was to examine maternal pain management in children with cancer and the associated factors.

DESIGN AND METHODS

The present work is a descriptive and cross-sectional study. Data for the study were obtained from mothers of children in the age group of 0 to 18 years undergoing treatment for solid tumors in Pediatric Oncology Service and Outpatient Clinics (n = 112). We used a questionnaire on parental pain management practices at home, the knowledge about pain and analgesic drugs, Spielberger State-Trait Anxiety Inventory (STAI), and Pain Catastrophizing Scale (PCS) to collect the data.

RESULTS

Several mothers taking part in the study reported various misconceptions about the assessment of children's pain, analgesic drugs, and usage of limited non-pharmacological methods for managing pain in children with cancer. No significant relationships were found between mothers' pain management practices, knowledge of pain assessment and analgesic drugs, and mothers' and children's sociodemographic characteristics or mothers' pain catastrophizing and anxiety about their own pain.

CONCLUSIONS

The findings of the study revealed that the majority of mothers of children with cancer had misconceptions regarding knowledge of pain assessment and analgesic drugs; these misconceptions potentially lead to manage children's pain associated with cancer ineffectively. Findings indicate mothers' information and support needs for children's cancer pain management in the home settings.

PRACTICE IMPLICATIONS

A further understanding of barriers to parental pain management in children with cancer in the home setting will contribute immensely in developing appropriate management practices.

CE: Hematologic Childhood Cancers: An Evidence-Based Review

Every year in the United States, thousands of children and adolescents are diagnosed with a hematologic cancer. That diagnosis and the prescribed course of treatment profoundly affect both the child and the family. This article provides a brief overview of the therapies used to treat such cancers, describes the presentations and diagnoses of the various hematologic cancers, and explains the treatments specific to each. Nursing care of the child and family is discussed, with an emphasis on education and supportive care.

Local Anesthesia With General Anesthesia for Pediatric Bone Marrow Procedures

BACKGROUND

Pediatric patients with cancer undergo repeated painful procedures, including bone marrow aspirations and biopsies (BMABs). Optimal management of procedure-related pain can reduce discomfort, anxiety, and distress.

METHODS

Children with neuroblastoma were randomly assigned to 1 of 2 arms on a prospective, single-blind, crossover trial conducted at Memorial Sloan Kettering Cancer Center from October 2016 to January 2018 (www.clinicaltrials.gov, identifier NCT02924324). Participants underwent 2 sequential BMABs: one with general anesthesia (GA) alone, the other with GA plus local anesthesia (LA) (GA + LA). The objective was to assess procedure-related pain and its interference with quality of life (QoL) with GA versus GA + LA. Primary outcome was percentage of participants requiring postprocedural opioids. Secondary outcomes were total opioid and nonopioid analgesics, pain scores, time to first analgesic, QoL, and toxicity. Management of postprocedural pain was standardized.

RESULTS

Of 56 participants randomly assigned (3-16.5 years old), 46 completed both procedures. There was no significant difference in percentage of participants requiring opioids with GA versus GA + LA (24% vs 20%, P = .5). Pain scores in the recovery room were significantly lower for GA + LA versus GA (median [IQR]: 0 [0-2] vs 2 [0-4], P = .002). There were no statistically significant differences in total opioid or nonopioid analgesic, 6- and 24-hour pain scores, median time to first analgesic, or pain interference. No adverse events occurred.

CONCLUSIONS

LA was associated with significant improvement in pain scores in the immediate recovery period. LA did not reduce postprocedural opioid use, nor did it improve QoL for patients undergoing BMAB with GA.

When "a headache is not just a headache": A qualitative examination of parent and child experiences of pain after childhood cancer

OBJECTIVE

Today, more than 80% of children diagnosed with cancer are expected to survive. Despite the high prevalence of pain associated with the diagnosis and treatment of childhood cancer, there is a limited understanding of how having cancer shapes children's experience and meaning of pain after treatment has ended. This study addresses this gap by exploring childhood cancer survivors' (CCS') experiences of pain from their perspective and the perspective of their parents.

METHODS

Twenty semi-structured interviews were completed with CCS (50% female; mean age = 13.20 y, range = 8-17 y) and their parents (90% mothers). Data were analyzed using interpretive phenomenological analysis.

RESULTS

Analyses revealed three superordinate themes present in the data: (a) pain is a changed experience after childhood cancer; (b) new or ambiguous pains may be interpreted by CCS and parents as a threat of disease recurrence, late effects, or a secondary cancer; and (c) pain interpretation occurs within the broader context of how CCS and parents appraise their cancer experience. Parents generally appraised their child's cancer and pain as more threatening and were influential in guiding their child's interpretations.

CONCLUSIONS

The cancer experience played an important role in shaping CCS' and their parents' experience and interpretation of pain in survivorship. This study provides novel data to inform the development and refinement of new and existing conceptual models of pain and symptom perception after cancer. The results also point to key areas for future investigation and clinical intervention to address the issue of pain in cancer survivorship.

Perspectives on Cancer Pain Assessment and Management in Children

OBJECTIVE

To report evidence regarding pain assessment and management for children and adolescents receiving treatment for cancer.

DATA SOURCES

Published research and clinical guidelines.

CONCLUSION

Children and adolescents experience multiple sources of pain across the cancer continuum. They require developmentally relevant approaches when assessing and managing pain. This review suggests that consideration of the developmental stage and age of the child are essential in both pain assessment and pain management.

IMPLICATIONS FOR NURSING PRACTICE

Pediatric oncology nurses play a key role in developmentally appropriate pain assessment, identification of potential strategies to manage pain, and delivery of pharmacologic and nonpharmacologic therapies.

The Power of Reiki: Feasibility and Efficacy of Reducing Pain in Children With Cancer Undergoing Hematopoietic Stem Cell Transplantation

Purpose: Reiki is a growing complementary therapy in pediatric oncology that needs evidence to become more credible among the health community. A within-subject design experiment was conducted to pilot testing the feasibility and efficacy of Reiki to provide pain relief among pediatric patients undergoing hematopoietic stem cell transplantation (HSCT). Method: Pediatric patients undergoing HSCT during the inpatient phase in the Stem Cell Transplantation Unit were eligible to participate to the pilot study. Short and medium effects were assessed investigating the increase or decrease of patient's pain during three specific time periods ("delta") of the day: morning of the Reiki session versus assessment before Reiki session (within subjects control period), assessment before Reiki session versus assessment after Reiki session (within subjects experimental period) and assessment after Reiki session versus morning the day after Reiki session (within subject follow-up period). The long-term effects were verified comparing the pain evolution in the day of the Reiki session with the following rest day. Results: The effect of 88 Reiki therapy sessions in nine patients (M_age = 12; Female = 61%) was analyzed following a short, medium, and long-term perspective. Repeated-measures analysis of variance revealed a significant difference among the three periods (F = 17,17 p < .0001): A decrease of the pain occurred in the experimental period in short and medium term, while in the follow-up period, the pain level remained stable. Conclusions: This study demonstrates the feasibility of using Reiki therapy in pediatric cancer patients undergoing HSCT. Furthermore, these findings evidence that trained pediatric oncology nurses can insert Reiki into their clinical practice as a valid instrument for diminishing suffering from cancer in childhood.

Pain, sleep patterns and health-related quality of life in paediatric patients with cancer

PURPOSE

To compare sleep and health-related quality of life (HRQOL) in children and adolescents with cancer who had pain, with those who had no pain during hospitalisation.

METHOD

A prospective comparative study was used to collect data from paediatric oncology units in three countries (Portugal, Brazil, USA). Participants (n = 118; 8-18 years) completed the Quality of Life Inventory (PedsQL) Cancer module, which includes a pain subscale, and wore a wrist actigraph for at least 72 hr.

RESULTS

Almost half of the participants (48.3%) reported having pain. Sleep patterns were not affected by pain. Girls, adolescents and patients diagnosed with leukaemia/lymphoma who reported pain, had significantly lower HRQOL scores. Low sleep duration and HRQOL were found, irrespectively of pain status.

CONCLUSIONS

The low sleep duration and HRQOL score in children and adolescents with cancer highlight the importance of physical and psychosocial nursing interventions during hospitalisation. The mediating effect of gender, age and diagnoses on the relation between pain and HRQOL needs to be further understood.

The Implementation Effectiveness of a Freely Available Pediatric Cancer Pain Assessment App: A Pilot Implementation Study

Background

Pain Squad is an evidence-based, freely available iOS app designed to assess pain in children with cancer. Once research-based technologies such as Pain Squad are validated, it is important to evaluate their performance in natural settings to optimize their real-world clinical use.

Objective

The objective of this study was to evaluate the implementation effectiveness of Pain Squad in a natural setting.

Methods

Parents of 149 children with cancer (aged 8-18 years) were contacted to invite their child to participate. Participating children downloaded Pain Squad on their own iOS devices from the Apple App Store and reported their pain using the app twice daily for 1 week. Participants then emailed their pain reports from the app to the research team and completed an online survey on their experiences. Key implementation outcomes included acceptability, appropriateness, cost, feasibility, fidelity, penetration, and sustainability.

Results

Of the 149 parents contacted, 16 of their children agreed to participate. More than a third (6/16, 37.5%) of participating children returned their pain reports to the research team. Adherence to the pain assessments was 62.1% (mean 8.7/14 assessments). The 6 children who returned reports rated the app as highly feasible to download and use and rated their overall experience as acceptable. They also reported that they would be willing to sustain their Pain Squad use over several weeks and that they would recommend it to other children with cancer, which suggests that it may have potential for penetration.

Conclusions

While Pain Squad was well received by the small number of children who completed the study, user uptake, engagement, and adherence were significant barriers to the implementation of Pain Squad in a natural setting. Implementation studies such as this highlight important challenges and opportunities for promoting the use and uptake of evidence-based technologies by the intended end-users.

Síntomas en niños con cáncer y estrategias de cuidado familiar

Introducción: Los síntomas de dolor y náusea vómito en los niños con cáncer son ocasionados por la enfermedad o tratamiento de quimioterapia. El manejo de estos síntomas es un reto en los familiares. Objetivos: Describir y analizar la relación entre los síntomas de dolor y náusea vómito en los niños con cáncer y describir las estrategias de cuidado familiar ante estos síntomas. Materiales y Métodos: Estudio descriptivo correlacional, con muestra de 31 niños y familiares de una clínica oncopediatrica de Veracruz México. Diligenciaron los instrumentos Escala de dolor con caras-Revisada, Clasificación de Náusea-Vómito Inducido por Quimioterapia y Cuestionario de estrategias de cuidado familiar para el manejo de síntomas. Los datos se analizaron con estadística descriptiva e inferencial con Rho de Spearman, utilizando el programa SPSS 20.0. Resultados: Los niños padecen dolor moderado (48%), leve (29%) e intenso (23%).  Tienen náusea-vómito agudo (74%), anticipatorio (16%) y retardado (10%). Existe asociación entre la náusea-vómito retardado con el anticipatorio (r =435<0,05). Los familiares contrarrestan el dolor del niño con estrategias de espiritualidad, distracción y fármacos. Ante la náusea-vómito evitan ambientes con olor a comida y consumo de líquidos calientes. Discusión: Según el tipo de cáncer y tratamiento, es la intensidad del dolor en el niño. La náusea-vómito se considera el síntoma más problemático durante la quimioterapia. Conclusiones: La investigación aporta datos científicos para indagar a futuro estos síntomas y posibles secuelas físicas y psicológicas (depresión, ansiedad) en los niños con cáncer, así como la efectividad de las estrategias familiares para tratar estos síntomas.Como citar este artículo: Díaz-Morales K, Reyes-Arvizu J, Morgado-Nájera K, Everardo-Domínguez D. Síntomas en niños con cáncer y estrategias de cuidado familiar. Rev Cuid. 2019; 10(1): e597. http://dx.doi.org/10.15649/cuidarte.v10i1.597

Improving Children's cancer pain management in the home setting: Development and formative evaluation of a web-based program for parents

BACKGROUND AND METHODS

Despite advances in health care, the majority of children undergoing cancer treatment experience pain, particularly in the home setting. Mobile health tools provide a promising avenue to deliver pain management education and information to parents of children receiving cancer treatment. The current study describes the development and formative evaluation of a novel intervention, Cancer-Tailored Intervention for Pain and Symptoms (C-TIPS), which provides empirically-based pharmacological and non-pharmacological pain management information and coping skills training to parents of pediatric cancer patients. C-TIPS is a web-based application including a tailoring algorithm, customization tools, guided diaphragmatic breathing training, relaxation practice, and educational material (COPE modules). Thirty parents of children undergoing chemotherapy treatment for cancer participated in this initial mixed methods pilot study. Participants completed quantitative measures assessing their stress and relaxation ratings and satisfaction with C-TIPS. Formative evaluation and qualitative data were collected using individual and group interviews.

RESULTS

Parents reported high satisfaction with both the educational and skills training modules of C-TIPS (ps < 0.001). Parent self-reported stress significantly reduced (p = 0.004) and relaxation increased (p = 0.05) following participation with the skills training module.

CONCLUSIONS

C-TIPS is a feasible and well-received web-based intervention that promises to improve pain management in children undergoing cancer treatment, improve stress management in parents, and increase parents' knowledge and understanding of their child's cancer treatment. Results from the current study will help make improvements to C-TIPS in preparation for a randomized-controlled trial of this innovative program.

Parents' Voice in Managing the Pain of Children with Cancer during Palliative Care

Context:

Pain experienced by children can adversely affect their growth and development. Pain is a major health problem for cancer patients and remains an unresolved problem.

Aim:

To know how the experiences of mothers managing their children's pain during palliative care following cancer diagnosis.

Background:

Pain experienced by children can adversely affect their growth and development.

Subject and Methods:

Using qualitative methods within a descriptive phenomenological approach, in-depth interviews were conducted with parents (mostly mothers) of eight children diagnosed with cancer. The data were collected using the snowball sampling method.

Results:

Participants experienced in managing the pain of children with cancer. Analysis of the results identified 8 themes: the dimensions of pain experienced by children undergoing palliative care; mothers' physical and psychological responses; mothers' emotional responses; barriers encountered by mothers when taking care of their child at home; mothers' interventions to reduce their child's pain; mothers' efforts to distract their child from pain; giving encouragement when the child is in pain; and mothers' efforts and prayers to make their child comfort.

Conclusion:

It can be concluded that the child's pain is the main cause of mothers' stress and pressure and also affects the daily lives of mothers and children. Along with the most effective intervention, nurses need to provide mothers and children with adequate information about cancer pain.