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Chronic Pain and Palliative Care in the Pediatric Patient
Introduction
Pain is a common and troubling symptom among pediatric cancer patients in both the inpatient and outpatient settings. , In this chapter we will provide a comprehensive overview of chronic pain and its management in pediatric cancer patients. We will also discuss pediatric palliative care and how it can be of great benefit to this vulnerable population.
Pain Presentations
Pain is a complex entity that can manifest in many ways even within the same patient. It can present as acute or chronic pain. Acute pain is typically related to a specific insult and is self-limited, lasting no more than 3–6 months. Specifically, in cancer, it is usually related to tumor invasion or invasive interventions such as procedures or surgery. Acute pain occurs when the body sends signals to the brain to indicate injury, and it also occurs during the processes of preservation and repair. Treatment of acute pain is aimed at minimizing the pain perception while primarily treating the underlying etiology. Chronic pain can develop from long-standing tumor expansion, compression, or destruction of surrounding structures or their treatment. Chronic pain is generally defined as lasting for greater than 6 months and the treatment goals are markedly different, as often the underlying etiology cannot be reversed. While acute pain focuses on alleviating pain and treating the root cause, management of chronic pain focuses on maintaining function, while decreasing pain to a tolerable level. There is also an acute on chronic pain presentation that is unique to chronic conditions such as malignancy. Also called breakthrough pain, acute on chronic pain presents as an episodic, significant increase in pain above the patient’s baseline chronic pain. It is usually exacerbated by a specific event such as a surgical intervention, side effect of treatment, or progression of disease. The treatment for this type of pain is similar to that of acute pain, in which decreasing pain to baseline is the goal. In this chapter we will focus on chronic pain presentations, as these are common in the pediatric cancer population.
Types of Pain
Nociceptive pain is subdivided into somatic and visceral types and is caused by direct injury to anatomic structures, including internal organs (visceral pain) or connective tissues, muscles, and bone (somatic pain). Patients, who experience nociceptive visceral pain describe it as achy, crampy, and poorly localized. Examples of visceral pain are pancreatitis secondary to chemotherapy or bowel obstruction from tumor growth. Nociceptive somatic pain is described as sharp, stabbing, throbbing, or a pressure sensation and can be seen with bone metastases or leukemic skin infiltration. Neuropathic pain is characterized as sharp, electrical, shooting, tingling, or numbness and is the result of damage to the central and/or peripheral nervous system by direct tumor invasion, surgical trauma to nerves, or medication-induced neurotoxicity that leads to abnormal processing of somatosensory stimuli.
It is important to note that there are other types of pain, such as spiritual, psychologic, and social, that may manifest or be interpreted as physical pain by the child or their caregivers. Dame Cicely Saunders, the founder of modern hospice and palliative care, described a holistic concept of total pain in which pain affects different aspects of quality of life (physical well being and functioning, psychologic well being, social well being, and spiritual well being), and these aspects, in turn, affect the perception and presentation of pain. This is well established in the literature, and other authors have built on this work. A consequence of undertreated, nonphysical pain is usually an increase in the expression of physical pain. Early assessment and treatment of nonphysical pain may be helpful in minimizing confounding factors during the management of physical pain.
Chronic Pain Etiologies
Chronic pain can be the result of the malignancy or the treatment of the malignancy. Tumor extension can cause pain, as it puts pressure on solid organs or adjacent nerves. Direct infiltration into connective tissues, bone marrow, bones, or muscles can also produce long-standing pain, especially in patients with refractory, metastatic, or inoperable disease. Blockage of blood flow or lymphatics can lead to accumulation of fluid in the form of peripheral edema, ascites, or pleural effusions, which can also cause pain. Chronic neuropathic pain can also present after surgical interventions such as limb amputation (phantom limb), limb salvage, hemipelvectomies, or thoracotomies.
Pathologic fractures secondary to tumor invasion can produce chronic pain. Multimodal cancer therapy with a combination of chemotherapy, radiation, and/or surgery can be a source of great pain burden for patients. Chemotherapy can have painful side effects. For example, vincristine or paclitaxel can cause peripheral neuropathy that can lead to chronic pain. Osteopenia or osteoporosis secondary to chronic steroid use can result in vertebral body fractures, which in turn leads to chronic back pain. Radiation can produce many painful side effects, such as dermatitis and mucositis, which can be significant and prolonged. Iatrogenic procedures, such as indwelling catheters for pleural or ascitic fluid drainage or G-tubes for venting/feeding, can also be sources of chronic pain for patients. Central lines, which are commonplace for cancer treatment, can lead to thrombus or nerve damage.
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