Pain Management for Children during Bone Marrow and Stem Cell Transplantation

A Narrative Review of Pain in Pediatric Oncology: The Opioid Option

Opioid therapy is the mainstay for managing pain in pediatric oncology. This narrative review describes the current literature regarding opioids for pediatric cancer pain. The review explores the multifaceted landscape of opioid utilization in this population, including the role of opioids in certain clinical circumstances, modalities of opioid delivery, unique opioids, outpatient and at-home pain management strategies, and other key concepts such as breakthrough pain. This review highlights the importance of individualized dosing and multimodal approaches to enhance efficacy and minimize adverse effects. Drawing from a wide range of evidence, this review offers insights to optimize pediatric oncology pain management.

The management of pain during pediatric hematopoietic stem cell transplantation: A qualitative study of contextual factors that influenced pain management practices

BACKGROUND

Children hospitalized following hematopoietic stem cell transplantation (HSCT) experience complex and prolonged pain in response to the intensity of this treatment.

OBJECTIVES

To describe how pain was managed for children during HSCT therapy and how contextual factors related to the clinical environment influenced healthcare providers' and parents' pain management practices.

METHODS

A qualitative case study was conducted and involved semi-structured interviews at two time points following transplantation (30 and 90 days) with parents (n = 10) and naturalistic observations of pain-related care provided to children (n = 29) during HSCT therapy by their healthcare providers (n = 10). Semi-structured interviews were also conducted with healthcare providers (n = 14).

RESULTS

The effectiveness of pain management interventions was hindered by the multifactorial nature of pain children experienced, a gap in the provision of psychosocial interventions for pain and a lack of evidence-based guidelines for the sustained, and often long-term, administration of opioids and adjuvant medications. Misconceptions were demonstrated by healthcare providers about escalating pain management according to pain severity and differentiating between opioid tolerance and addiction. Parents were active in the management of pain for children, especially the provision of nonpharmacological interventions. Collaboration with external pain services and the impact of caring for children in protective isolation delayed timely management of pain.

CONCLUSIONS

There is a pressing need to create evidence-based supportive care guidelines for managing pain post transplantation to optimize children's relief from pain. If parents and children are to be involved in managing pain, greater efforts must be directed toward building their capacity to make informed decisions.

Symptoms of Survivors of Pediatric Hematopoietic Stem Cell Transplant by Age, Sex, and Transplant Type

Purpose: The purpose of this study was to describe symptoms experienced by survivors of pediatric hematopoietic stem cell transplant (HSCT), and demographic and treatment-factors associated with ongoing symptomology. Methods: Fifty pediatric survivors completed a cross-sectional pilot study. Questionnaires were administered online via REDCap to assess symptoms experienced in the last week. Survivors also consented to a medical record chart review. Results: Survivors were on average 5.4 years post-HSCT (range 1.1 to 9 years), male (58%), and Caucasian (80%) who received an allogeneic HSCT (92%). The most commonly reported symptoms were difficulty concentrating (42.5%), pain (38%), worry (38%), nervousness (37.5%), and lack of energy/fatigue (34%). Survivors reported up to 14 symptoms, with 90% of the sample experiencing at least one symptom in the previous week. Average number of symptoms varied by age group between 2.1 (8-9 years) and 6.8 (18 and older). Age and female gender were associated with higher levels of fatigue. Conclusions: The majority of survivors experienced at least one symptom in the previous week. Neuropsychological symptoms and pain endure well into survivorship that can influence outcomes such as function and health-related quality of life (HRQOL). Research is needed on biological mechanisms of ongoing symptomology, effective interventions to prevent or mitigate symptoms, and the impact of symptoms on patient outcomes including daily functioning and HRQOL. Implications Survivors of pediatric HSCT continued to experience symptoms for up to nine years. Survivors should be frequently screened for symptoms, as symptoms may affect function, learning/employment outcomes, and HRQOL.

Safety and Acceptance of Acupuncture and Acupressure in Children, Adolescents, and Young Adults Undergoing Hematopoietic Stem Cell Transplant

BACKGROUND

Hematopoietic stem cell transplant (HSCT) is associated with significant morbidity and high symptom burden including mucositis pain, nausea, and vomiting. There is little documentation in the literature regarding acupuncture or acupressure for children undergoing HSCT.

OBJECTIVE

The purpose of this study was to determine the safety and acceptance of acupuncture and acupressure in children undergoing HSCT in a large tertiary care children's hospital.

METHODS

This is a descriptive retrospective study that evaluated 80 admissions to the HSCT unit over a 24-month period. Every child admitted for HSCT was offered acupuncture or acupressure as part of their care.

RESULTS

Of 80 patients, 46 were male patients (ages range, 0-32 years; mean, 8 years). Diagnoses include leukemia/lymphoma, sickle cell disease, aplastic anemia, neuroblastoma, and other metabolic, other solid tumor, or other hematologic disorders. Both allogenic and autologous were represented. Sixty-six patients (82.5%) agreed to treatment with acupuncture, acupressure, or both. There were no adverse effects or safety concerns noted. Symptoms addressed by acupuncture or acupressure included pain from mucositis, nausea, constipation, diarrhea, anxiety, insomnia, and general wellness or healing.

CONCLUSION

This study demonstrates that acupuncture and acupressure are well accepted by children and their families admitted for HSCT and are safe even when performed in the first 4 weeks following transplant when the patient is likely to have thrombocytopenia.

IMPLICATIONS FOR PRACTICE

These findings suggest that there may be more therapies for patients undergoing HSCT to help with symptom control.

The influence of contextual factors on children's communication of pain during pediatric Haematopoietic Stem Cell Transplantation: A qualitative case study

PURPOSE

The aim of this study was to describe how contextual factors related to the clinical setting of a pediatric HSCT unit influenced children's communication of pain to their health-care providers and parents during hospitalization.

DESIGN AND METHODS

A qualitative case study design was conducted in two-phases in a tertiary level pediatric HSCT unit. The Social Communication Model of Pain provided the conceptual framework for the study. In phase one participants were parents and phase two participants were health-care providers and children in a pediatric HSCT unit. Parents participated in semi-structured interviews at 30- and 90-days post-transplantation regarding their child's communication of pain. Naturalistic observations of children receiving clinical care were conducted and health-care providers participated in semi-structured interviews.

RESULTS

Children extensively denied pain to their parents and health-care providers. When children did communicate pain, they were motivated by a need to seek interventions for their pain. Children's willingness to communicate pain was influenced by the physiological impact of HSCT therapy, their previous experiences of pain, their relationship with parents and health-care providers and parents and an environment of fear and uncertainty.

CONCLUSIONS

There is a pressing need for child-centric approaches to support children to communicate their pain experiences to overcome the limitations imposed by the complexity of their medical treatment and the clinical environment in which they receive healthcare.

PRACTICE IMPLICATIONS

In the context of HSCT therapy children may not communicate pain until pain is severe, and no longer bearable, or outright deny the presence of pain.

Addressing Common Pain Syndromes in Pediatric Stem Cell Transplant: A Review

Assessment and management of pain for pediatric patients receiving stem cell transplants can be challenging for a health care team. Diagnostic evaluation and interventions vary between institutions and individual provider practices. In this review, we investigate and describe approaches to pain management for the most common sources of pain in pediatric patients undergoing stem cell transplants. Mucositis pain, abdominal pain, and hemorrhagic cystitis emerged as the most frequent sources of acute pain in children during conditioning and transplantation periods. Furthermore, psychosocial distress and psychological pain or distress constitute significant components of the total pain experienced by children undergoing stem cell transplantation. We will expand upon appropriate usage and escalation of opioids, as well as complementary interventions and timely initiation of interventions, in order to help control pain in these clinical syndromes.

Intravenous opioids for chemotherapy-induced severe mucositis pain in children: Systematic review and single-center case series of management with patient- or nurse-controlled analgesia (PCA/NCA)

BACKGROUND

Chemotherapy-induced oral mucositis can result in severe pain. Intravenous (IV) opioids are recommended, but management protocols vary. We systematically reviewed studies reporting IV opioid use for pain related to chemotherapy-induced severe oral mucositis in children and conducted a large single-center case series.

METHODS

Ovid MEDLINE, PubMed, and Cochrane databases were searched for studies reporting IV opioid duration and/or dose requirements for severe mucositis. Secondly, our pain service database was interrogated to describe episodes of opioid administration by patient- or nurse-controlled analgesia (PCA/NCA) for children with mucositis and cancer treatment-related pain.

RESULTS

Seventeen studies (six randomized trials, two prospective observational, three retrospective cohort, six retrospective case series) included IV opioid in 618 patients (age 0.3-22.3 years), but reported parameters varied. Mucositis severity and chemotherapy indication influenced IV opioid requirements, with duration ranging from 3 to 68 days and variable dose trajectories (hourly morphine or equivalent 0-97 mcg/kg/h). Our 7-year series included PCA/NCA for 364 episodes of severe mucositis (302 patients; age 0.12-17.2 years). Duration ranged from 1 to 107 days and dose requirements in the first 3 days from 1 to 110 mcg/kg/h morphine. Longer PCA/NCA duration was associated with: higher initial morphine requirements (ρ = 0.46 [95% CI 0.35, 0.57]); subsequent increased pain and need for ketamine co-analgesia (118/364 episodes with opioid/ketamine 13.9 [9.8-22.2] days vs opioid alone 6.0 [3.9-10.8] days; median [IQR]); but not with age or sex.

CONCLUSIONS

Management of severe mucositis pain can require prolonged IV opioid therapy. Individual and treatment-related variability in analgesic requirements highlight the need for regular review, titration, and management by specialist services.

Nursing diagnosis after hematopoietic stem cell transplant due to Fanconi anemia

OBJECTIVES

to identify nursing diagnoses in patients who underwent hematopoietic stem-cell transplants due to Fanconi anemia, according to the NANDA-I taxonomy.

METHODS

exploratory study using a retrospective analysis of 85 records from patients who underwent hematopoietic stem-cell transplants due to Fanconi anemia, developed in a specialize transplant center in the South of Brazil. The results were analyzed using descriptive statistics.

RESULTS

73 different diagnoses were found in 9 out of the 13 domains from the NANDA-I taxonomy. From these, 22 were in 50% or more of the patients investigated, and most of them are related to the domain Safety/Protection.

CONCLUSIONS

it was possible to identify the nursing diagnosis in the patients who underwent hematopoietic stem cell transplants due to Fanconi anemia, contributing to design a plan for the care of these patients. The same was true for those with other syndromes of chromosomal instability that need to undergo this transplant.

Nursing care for patients in post-transplantation of hematopoietic stem cells: an integrative review

OBJECTIVES

to analyze the available evidence on the nursing care provided to patients after hematopoietic stem cell transplantation.

METHODS

integrative review with the search for primary studies in four databases and a virtual health library. A broad search strategy was used, including research published in English, Brazilian Portuguese, or Spanish, between 2008 and 2018, totaling a sample of 42 studies.

RESULTS

the studies were grouped into three categories: multiple nursing care (n=19), first-line care (n=18), and self-management of care (n=5).

CONCLUSIONS

nursing care is critical, comprising patients' physical, psychological and social aspects. It occurs in hospital and home contexts, mainly involving technical actions and health guidance. The evidence identified provide subsidies for decision-making; however, most studies are of the non-experimental type, indicating the need for conducting intervention research.

Irradiation free conditioning regimen is associated with high relapse rate in Egyptian patients with acute lymphoblastic leukemia following allogeneic hematopoietic stem cell transplantation

Background

Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) is a curative treatment for adult patients with acute lymphoblastic leukemia (ALL). Cyclophosphamide plus total body irradiation (TBI/Cy) or plus busulfan (Bu/Cy) is a widely used pre-transplant conditioning regimen for ALL. We retrospectively compared the overall survival (OS), disease-free survival (DFS), and other transplant outcomes of allo-HSCT in 119 adult patients with ALL who received an HLA-matched sibling allo-HSCT using TBI-based versus non-TBI-based conditioning regimens. Patients were divided into two groups by their conditioning regimen: TBI/Cy or Bu/Cy.

Results

Median OS was 11 months in the TBI/Cy group and 6.2 months in the Bu/Cy group. Median DFS was 11.1 months in the TBI group versus 6.8 months in the Bu group, without a statistically significant difference. A higher risk of relapse was observed with the Bu/Cy regimen (HR 2.709, CI 95% 1.106 to 6.638, p = 0.029). Patients who received a transplant in ≥ CR2 were associated with poor DFS.

Conclusion

Despite the high relapse rate in the non-TBI regimen (Bu/Cy), both regimens had no statistically significant differences in OS, DFS, and NRM. Additional prospective studies are indeed warranted to evaluate the long-term outcomes of radiation-free regimens, including oral and intravenous busulfan, and compare these regimens with TBI-based ones.

Mobile Health Technology for Pediatric Symptom Monitoring: A Feasibility Study

BACKGROUND

Pediatric blood and marrow transplant (PBMT) patients experience significant symptom distress. Mobile health (mHealth) technologies can be leveraged to improve understanding of the patient's symptom experience by providing continuous, real-time, in situ, patient-generated symptom data. This rich data stream can subsequently enhance symptom management strategies. However, limited research has been conducted in this area.

OBJECTIVES

This pilot study seeks to (a) explore the feasibility of integrating mHealth technologies to monitor symptom data for PBMT patients and (b) evaluate the study design, measures, and procedures.

METHODS

An exploratory longitudinal design was employed to assess the feasibility of monitoring 10 PBMT patients' symptoms using data from two mHealth technologies: (a) a smartphone mHealth application (app) to collect symptom data and (b) a wearable tracking device (Apple watch) to collect physiological data. Feasibility was measured as usability and acceptability. Monthly patient interviews and an end-of-study feasibility survey were employed and analyzed to further understand reasons for sustained interest in and attrition from the study.

RESULTS

Overall usability of the wearable was 51%, and app was 56%. Children reported devices were easy to use and acceptable. The study demonstrated acceptability with an enrollment rate of 83% and an attrition rate of 30%, with 70% of the children remaining in the study for at least 40 days.

DISCUSSION

This pilot study is among the first to explore the feasibility of using mobile technologies to longitudinally obtain patient-generated symptom data to enhance understanding of the PBMT symptom experience. In addition, it will improve our understanding of how these data present, interact, and cluster together throughout the posttransplant period.

A Protocol to Assess Feasibility, Acceptability, and Usability of Mobile Technology for Symptom Management in Pediatric Transplant Patients

BACKGROUND

Pediatric blood and marrow transplant (PBMT) patients experience significant symptom distress, and the use of mobile health (mHealth) technologies may enhance symptom management by providing patient-generated health data to foster personalized health strategies.

OBJECTIVES

The aim of this study was to present a study protocol to explore feasibility, acceptability, and usability of integrating mHealth technologies to collect and monitor symptom data for PBMT patients.

METHODS

An exploratory mixed-methods design is employed for 20 PBMT patients to monitor symptoms using real-time data from two mHealth devices: (a) a self-developed mHealth application and (b) a wearable tracking device. Patient-Reported Outcomes Measurement Information System surveys for fatigue, pain, and sleep disturbance are obtained monthly. Interviews are conducted to obtain further feasibility and usability data.

RESULTS

The study began in October 2017; data collection should be completed in 2018. Feasibility and usability results to monitor and record symptom-related data daily via mobile devices will be reported. Patient-Reported Outcomes Measurement Information System surveys and interviews will further explore patients' symptoms and experiences with the mobile devices.

DISCUSSION

This study will be among the first to explore the feasibility, acceptability, and usability of integrating multiple mHealth technologies to obtain patient-generated symptom data for the PBMT population. Results will enhance our understanding of how these data present, interact, and cluster together throughout the posttransplant period for these children and lead to symptom management strategies. Results will focus on a high-risk population that potentially stands to benefit from the use of mobile technologies.

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.

The Power of Massage in Children with Cancer-How Can We Do Effective Research?

Children with cancer experience multiple troubling symptoms. Massage offers a safe, non-pharmacological approach to address these symptoms. Numerous studies of massage in children and adults with cancer have been performed, yet most are unable to demonstrate significant benefit. This review aims to summarize what we know about the role of massage and sets goals and challenges for future massage research. This paper descriptively reviews the existing literature available in PubMed (both prior reviews and select papers) and the holes in prior research studies. Prior research on massage has been limited by small sample size/insufficient power, inappropriate outcome measures or timing, heterogeneous patient populations, inconsistent intervention techniques, and other design flaws. Based on the findings and limitations of previous work, numerous suggestions are made for future studies to increase the potency of findings, including thoughts about appropriate dosing, control groups, type of intervention, outcome measures, patient selection, feasibility, and statistics.

Customization of the TRU-PBMT App (Technology Recordings to better Understand Pediatric Blood and Marrow Transplant)

PURPOSE

Our investigative team is integrating mobile health technologies into pediatric blood and marrow transplant (PBMT) care. We aim to evaluate whether patient-generated health data can be used to monitor health status and enhance symptom management. While there are numerous health-related apps, none address the symptoms or care needs specific to PBMT patients. This article describes development of the Technology Recording to better Understand Pediatric Blood and Marrow Transplant (TRU-PBMT) mobile application.

DESIGN AND METHODS

A one-time survey was distributed to PBMT clinicians, caregivers, and outpatients to elicit feedback and suggestions for the app's design.

RESULTS

Feedback from clinicians (n = 23), caregivers (n = 5), and PBMT outpatients (n = 4) indicated the app would be acceptable and useable with this group of patients between eight and eighteen years of age. Suggestions from respondents included: making the app language and graphics more child-friendly; adding symptoms such as fatigue, mucositis, bleeding; and a visual stool chart.

CONCLUSION

Patient, caregiver, and clinician feedback was valuable in creation of the TRU-PBMT app. We designed a pediatric friendly, PBMT-symptom-specific app, which we will test in future studies.

IMPLICATIONS FOR PRACTICE

This app facilitates patient-generated health data collection and informs health care plans.