Pharmacological management of pain in children

[Headache in children: also a problem for child and adolescent psychiatry? Pathogenesis, comorbidity, therapy]

Headache is a recurrent somatic complaint in childhood and adolescence. In recent decades headache prevalence has increased while the age of onset has decreased. In most cases headache can be categorized as migraine or tension-type headache without significant organic pathology, i.e. head trauma, structural lesion, etc. Diagnosis according to the criteria of the International Headache Society is based on subjective reports by patients and their parents. The basic tools of clinical assessment are history, physical examination and a headache diary. Laboratory tests, including electroencephalography and imaging studies should not, as a rule, be undertaken routinely. Pathophysiological models with an impact on therapeutic interventions will be discussed. Childhood headache is often treated inappropriately in daily practice despite the availability of various options (including environmental, drug, and psychological therapy). Psychological therapy (relaxation training, biofeedback, stress management, etc.) as well as medication can be applied for prophylaxis. Minimal therapeutic interventions have been shown to be equally effective in a remarkable number of patients. Chronic Headache shows relevant comorbidity with anxiety and depression and is associated with somatization and school disorders. A careful investigation and an adequate therapy of eventual psychiatric comorbidity is therefore strongly recommended.

Long-acting morphine for pain control in paediatric oncology

BACKGROUND

Guidelines for treatment of paediatric cancer pain recommend the usage of long-acting morphine. However, published paediatric experience with this drug is restricted to 147 children not systematically evaluated, and thus insufficient. We aimed to systematically analyse the age-dependent effects and adverse effects of long-acting morphine in paediatric cancer patients.

PROCEDURE

Ninety-five children aged 1 to 19 years were enrolled in a collaborative retrospective study conducted over seven-and-a-half years. Pain was scored according to a numeric rating scale (NRS, range 0 to 5), and the corresponding medication was recorded.

RESULTS

In 83 children documentation period started during morphine treatment (71, oral long-acting; 1, rectal; 11, IV). Mean oral/equivalent morphine starting dose was 1.3 mg/kgbw/d (SD 0.9). Mean end dose was 2.8 mg/kgbw/d (SD 2.7). Infants aged < 7 years received the highest average dose (2.6 mg/kgbw/d, SD 2.8), while patients > 12 years received the lowest dose (1.4 mg/kgbw/d, SD 1.1). Median pain intensity decreased from score 1.0 (mean 1.2) NRS at the beginning to 0 (mean 0.6) NRS at the end. The proportion of patients scoring > 2 NRS (severe or most severe pain) under morphine treatment decreased from 26 to 12% (P = 0.08). In children > 12 years pruritus was frequently observed (23% of patients). In all age groups, there were no severe adverse effects during the study period.

CONCLUSIONS

In paediatric haematology/oncology, pain control by oral long-acting morphine proved to be safe and effective even in the very young patients. The pharmacological properties of long-acting morphine are ideally suited for paediatric use, combining efficacy and compatibility.