(From Hicks CL, von Baeyer CL, Spafford PA, et al: The faces pain scale—revised: Toward a common metric in pediatric pain measurement. Pain 93:173–183, 2001. Used with permission from IASP.)

Assessing pain in the nonverbal infant or young child requires astute behavioral observation, ideally with input from a parent or someone who knows the child best. Signs to watch for include the quality of cry, body posture, and degree of consolability.

Provide effective pain and symptom management

Suppose Kate reported her pain intensity as 7 out of 10. Applying the universal principles of the World Health Organization’s (WHO) analgesic ladder, codeine (Step 2) is inadequate for Kate’s pain severity. If pain is inadequately relieved with 1 mg/kg per dose, increasing the codeine dose will only result in increased side effects, with inadequate pain relief. This ceiling effect, typical of the Step 2 opioids, further fuels the argument to avoid codeine entirely. A proportion of patients lack the necessary enzyme to convert codeine to the active metabolite and, consequently, receive inadequate relief. Morphine, hydromorphone, or another opioid for moderate-to-severe pain, corresponding with Step 3 of the WHO Analgesic Ladder, is now indicated for Kate.

It is very important to be on a high alert for side effects. Children may forgo analgesia if they feel that the side effects of a medication are more troublesome than the analgesic effects, especially if the side effects are prolonged. Although generally well tolerated, opioids may cause nausea, vomiting, itchiness, urinary retention, sedation, or agitation, which may attenuate several days after starting opioid therapy. A more serious but uncommon side effect is respiratory depression. Constipation is an anticipated side effect, which does not resolve the longer that someone is on opioid therapy. It must be proactively treated by starting a bowel regimen with the initiation of opioid therapy. At the least, these symptoms should be asked about and addressed as they occur. Because the medical conditions that these children have are often complex, with their own constellation of symptoms and polypharmacy for managing their illnesses, it can be difficult on occasion to know whether a symptom, such as nausea, is being caused or contributed to by the opioid. A knowledge of the opioid’s peak, onset of action, duration of effect, and biologic half-life can be helpful. Appropriate titration of dosage or changing between the various opioid options is effective in mitigating adverse effects.

Kate’s codeine was stopped, and morphine, along with a bowel regimen, was started.

Address concerns of addiction and safety

Clinician (speaking with Kate’s mother, Sandi): It seems that our treatments are much more effective now in treating Kate’s pain. I’m really glad. Do you have any questions about where things stand now?

Parent: I’m very glad that her pain is under control, but to be honest, I’m worried about what’s going to happen when its effectiveness wears off. My friend’s son was addicted to drugs, and we watched him spending more and more to keep his habit going. I’m afraid the same thing will happen to Kate—after all, isn’t morphine almost the same as heroin?

Clinician: I can understand your worry. We hear a lot about inappropriate use of certain medications, like opioids, but it’s different for Kate. She’s using them to control her pain. Her needs and experience will be very different from someone using them for an effect other than pain relief. Taking any medication, including opioids like morphine, does not somehow change a child into a different person. We know from studies of hundreds of children and youth who needed such medications for pain control, that the incidence of addiction was no greater than that of the general population.

FIGURE 23–2 The World Health Organization Analgesic Ladder.

(Modified from the World Health Organization: Cancer Pain Relief and Palliative Care in Children. Geneva, Switzerland, World Health Organization, 1998.)

Parent: OK, fair enough, but won’t she continue to need higher doses?

Clinician: I understand that you may be worried about that. What you are describing is called tolerance and that is very different from addiction. Tolerance is not usually the reason that these pain medications need to be increased. Higher doses are more often related to increasing pain as the illness changes. With medications like morphine or hydromorphone, we can continue to adjust the dose to Kate’s comfort. There is really no maximum compared with the codeine she had been taking.

Parent: But I’ve heard that one of the side effects of morphine is to slow down breathing. If Kate needs higher doses, I’m scared the medicine could actually kill her if she gets too much!

Clinician: You are certainly not alone in thinking about this, as many share your concern. I think some more information would help you feel less worried. For example, if Kate were just recovering from major surgery, she would be receiving pain medication, like morphine, at a certain starting dose according to her weight. If Kate has significant pain over a longer period of time, with gradual adjustments, she would be able to tolerate doses that may reach many hundred times higher than the dose we would have started with, and her higher tolerance would mean less risk of respiratory depression. We know this from clinical experience and, more recently, from good research.

Key Point

Opioids are safe when properly prescribed and titrated.

Children rely completely on their caregivers for access to medications and pain relief. Should you or the parent have concerns about addiction, side effects, or other frequently unvoiced concerns, the child could be denied access to appropriate therapy. Just as initiating a bowel regimen (of stool softener and cathartic) is an integral part of starting opioid therapy, a discussion with the child’s family, caregivers, and child (as appropriate) is necessary to proactively address concerns. It is helpful to start such a discussion in the third person, such as, “Many people worry that [insert a common concern/misperception].” Wait for a response, then follow-up with, “Have you heard about this?”

Some parents may also be against the use of opioids because they associate such analgesia with advanced illness and dying. A caring focus on the child’s present suffering and need for adequate pain control can be helpful in addressing this. Acknowledging their role as caring parents, who wish the best for their child, and that ensuring the child’s comfort is congruent with being caring parents, can be helpful. It is particularly effective when parents who have been anxious and reluctant about opioid use can see that their child, who appears to be feeling better, is displaying more of his or her usual behaviors, being playful and interactive when relieved of pain.

Key Point

Relieving a parent’s worries about opioids will ensure their child’s comfort.