Pain Management Tips

The following are suggestions from various reliable web sites on dealing with pain related to your child's treatment. They are not meant to be a substitute for discussions with your health care team about managing pain. For help with any of the non-medicine based pain management procedures, you can contact Jeff Ungetheim through the medical team or at 336-713-5984.

General Information:

• Medications may be short-acting and taken on an "as needed" basis or
  long-acting to suppress any pain before it occurs.
• Pain medications may be given as pills, liquids, skin patches, or injections.
• Take charge and become an active participant with the health care team.
• Do not worry that your child will become "hooked" or "addicted" to your pain medication. Studies have shown this is very rare with cancer patients.
• Contact Pediatric Oncology if your child's pain medication is not working.
• Do not wait until the pain is unbearable. It is easier to prevent pain or relieve it when it starts than to wait until it gets really bad.
• Report the severity of your child's pain on a scale from 0 to 10, where 0 is no pain and 10 is the worst pain you can imagine.
• Know how to reach Pediatric Oncology after hours, and when you should contact them. For example, severe pain should be reported right away, not at your next appointment.
• Inform your doctor or nurse that your child is experiencing pain. Don't wait to be asked! Pain should be evaluated at every visit.

Tips about Procedures:

• Explain procedures, or ask team members to explain procedures, such as a fingerstick and blood drawing, internal and external port accessing, spinal tap or lumbar puncture (LP), and bone marrow aspiration or bone marrow biopsy, to your child (know if your child responds best to information or not).
• Be honest about painful procedures, but consider the timing of giving the information as well.
• Use small rewards after procedures such as stickers, small toys, or a special activity.
• Allow the child to have some control such as which finger to stick, to sit in the chair or your lap during a procedure, or allow your child to make a choice between options.

Methods for managing stress due to pain:

Age	Methods
0 - 2 years	Touching, stroking, patting, rocking, playing music, using mobiles over the crib
2 - 4 years	Puppet play, storytelling, reading books, breathing, blowing bubbles
4 - 6 years	Breathing, storytelling, puppet play, talking about favorite places, TV shows, activities
6 - 11 years	Music, breathing, counting, eye fixation, thumb squeezing, talking about favorite places, activities on TV shows, humor
12 and up	Honesty: never say "this won't hurt" unless you are certain that it won't.

• Guided imagery can be a very effective and soothing technique. Tapes are available. (see description below)
• Breathing and relaxation exercises can also help many patients. Tapes and handouts are available.
• Hot or cold packs may also provide symptomatic relief of discomfort.
• EMLA cream -- ask for it.

There are some important points to remember when dealing with cancer pain that include:

• Be honest with your physicians and nurses about your child's pain.
• Keep a diary of the times your child is in pain.
• Note how much medication your child is taking and the time your child
  takes pills.
• Make sure your child is on appropriate medications to prevent constipation if your child is taking any narcotics for pain control.
• Give your child's medications as prescribed.

What Can You Do to Help?

Early treatment for pain is always more effective. As an active participant in your health care, you can take the following steps:

• Keep a diary of your child's pain; where it is, when it begins, when it peaks, when you give medications, and what helps relieve the pain.
• Be precise when describing your child's pain. Use words like sharp, radiating, aching, pounding, prickly, tight, deep, stabbing, dull, pinching, and tingly.
• Give your child's medications exactly as prescribed. Your child may be taking several medications. Be sure you understand when and how to give them, and report any side effects; they can be helped.
• Use the same pharmacy if possible. They will know what pain medicines to keep on hand and can answer questions about the medicines and side effects.
• Consider non-drug interventions that might help your child, including distraction, relaxation techniques, use of heat and cold, massage, and light exercise. Consult members of your health care team (nurse, social worker, psychologist, and physical therapist) for help in these areas.

Nonpharmacologic (non-medicine based) interventions in the management of pain have been found to be highly effective for some children and for some procedures. These techniques are easy to learn and should be used when possible to give the child some control in the management of pain. The examples given for distraction, muscle relaxation, and guided imagery are easy techniques to learn and can be used with young children. However, non-drug based interventions are an adjunct to, not a substitute, for medications.

Distraction

• Distraction is used to focus the child's attention away from the pain. For children, simple distraction techniques can be very effective in decreasing pain. Simple measures such as looking at books, blowing bubbles, and counting are favorite distraction techniques for children. Touch can be an important distraction technique by stroking, patting and rocking infants as well as children who are in distress.
• Deep breathing is the easiest technique to use with young children. The child is instructed to take a deep breath through the nose and blow it out through the mouth. Making a conscious effort to count the child's respirations focuses attention on the breathing. For school age children, asking them to hold their breath during a painful procedure transfers their focus to their breathing and not on the procedure. Asking children to "blow away their pain" has also been discussed as an effective distraction tool (French, Painter and Coury, 1994).
• Parents should be taught distraction techniques and encouraged to hold their children for comfort as much as possible. Parent coaching gives them a way to participate in decreasing their child's pain and also may provide some benefit in decreasing parent anxiety and worry.

Guided Imagery

• Guided imagery engages the child by focusing on a pleasant activity, providing distraction from the pain, or changing the perception of the painful experience. Guided imagery is used to give the child the opportunity to imagine being in a more pleasant situation. Effective use of imagery involves all of the child's senses. When imagining a favorite place the child is asked to feel the warmth all around, see the colors, smell the odors, and hear the sounds. This helps the child create a clear scene in their mind. It is important to stress that every child needs a favorite place to go that is safe. This safe place provides a means of escape. Children often like to imagine they are watching a favorite TV show or movie. The child can be involved in this type of imagery by asking the child to discuss what is happening on the TV show like a cartoon. The child can sometimes imagine being a particular character in the cartoon. A guided imagery exercise can be used with school age children and adolescents.
• Favorite Imagery Scenes for Children

Visual Imagery

Favorite places
Animals
Flower gardens
TV or movies
Favorite room
Favorite sport

Auditory Imagery

Conversations with significant others
Favorite song
Playing a musical instrument
Listening to music
Environmental sounds (waves, etc.)

Movement Imagery

Flying
Swimming
Skating
Amusement rides
Any activity

Relaxation Exercises

Relaxation exercises are a variety of physical exercises which can be used lying down or sitting in a chair, usually in conjunction with deep breathing. There are good tapes and workbooks describing how to do these, some of which are available from Jeff Ungetheim (336-713-5984).

Comfort Measures

• Comfort measures can be a useful treatment option for reducing pain. Comfort measures can be used as a distraction to help to relieve the anxieties and fears associated with painful procedures. These measures generally allow the child to feel more relaxed and at ease.
• Comfort Measure

Quiet presence - Sitting quietly and displaying a sense of calmness.

Massage - Includes stroking, rubbing or deep manipulation of muscles.

Music - Can help to provide the child with a familiar environment; children often come to the hospital with their own music.

Heat - Warm compress or use of a heating pad, to the painful site (moist or dry heat).

Cold/Ice - Cold compress or ice pack. Precaution: assure ice pack is wrapped allowing comfortable sensation of cold without damaging the skin by freezing tissue. Limit ice application to 10 minutes, then rotate site. If skin becomes blanched, discontinue cold treatment.

Baths - Warm soak; can include whirlpool/jacuzzi.

Vibration - Over the counter massage devise. May be used to stimulate skin and muscle tissue.

Menthol Product - (e.g., Ben-Gay) Apply to skin, however caution must be used to avoid areas of open wounds or irritated skin. Product selection is important as some contain salicylates which may be inappropriate for some patients.

References

Pain Management for the Cancer Patient
James Metz, MD
University of Pennsylvania Cancer Center
http://oncolink.upenn.edu/
http://www.childcancerpain.org/home.cfm