Existing Pain Drugs Can Spare Kids Lumbar Puncture Trauma

CRYSTAL CITY, Va--Pain due to cancer or cancer treatments or procedurescan present special problems in pediatric patients, making lifemore difficult for everyone who must deal with the children, includingthe oncologist, Jo Eland, RN, PhD, said at the 25th AnniversaryConference of the Candlelighters Childhood Cancer Foundation.

For example, childhood leukemia patients must undergo lumbar punctureand blood aspiration every month for 18 months. "When youtell children it's time to go to the hospital, many go nuts,"said Dr. Eland, associate professor of nursing, University ofIowa. "They hide in closets. The parents have to drag theminto the car and then they come screaming into the clinic."Following the procedure, the children may have nightmares.

Fortunately, 85% of cancer pain could easily be relieved withexisting knowledge and drugs, Dr. Eland said. For example, atMinneapolis Children's Hospital, at least 1,000 pediatric patientshave undergone lumbar puncture and blood aspiration under theinfluence of pro-pofol (Diprivan), a short-acting general anesthetic.

These children have no frightful memories, and they are very cooperative,she said, recounting how one 4 year old, experienced with thedrug, cheerfully greeted his physician when it was time for theprocedures.

Alternatively, midazolam (Versed), a benzodiazepine, can be usedvery effectively with morphine or fentanyl for bone marrows andlumbar punctures if one does not want to put the patient to sleep,she said.

One method to check pain that is widely used in adult cancer medicine,but neglected in pediatric oncology, is the use of "caines,"nerve blocking agents such as lidocaine and procaine. The problemis that they sting, Dr. Eland said. But a new nerve blocker, EMLA(prilocaine plus lidocaine), comes in ointment form and doesn'tsting. "It's great for port access, PIC lines, and chesttubes," she said.

One application lasts for 4 hours, but it takes an hour to becomeeffective. One child "demanded it before any procedure,"Dr. Eland said, and when the doctor told him he'd have to waitan hour, he said, "Fine, I'll go play."

Although EMLA has been used widely in Europe for nearly 20 years,where it now even comes in bandages, it has only recently beenapproved in the United States, and solely for application on intactskin.

As for major surgery, Dr. Eland recommends considering epiduralsand caudals. "They are even easier to inject into childrenthan into adults," she said. "You can do even a fairlylarge abdominal surgery with none of the risks of an anesthetichangover. Just give them enough Valium or Versed so they're notscared when you do the epidural." For bone pain, Dr. Elandrecommends Trilisate (choline salicylate and magnesium salicylate),a close relative of aspirin that does not inhibit blood clotting.

'Like Being Hit by a Semi'

One of the reasons health-care professionals have trouble dealingwith pain, Dr. Eland said, is that there is no objective way tomeasure it. For toddlers, it may be impossible to obtain evena subjective analysis. But for older children, a little imaginationcan go a long way toward solving the problem.

Frequently, children are asked to assess their pain numericallyor to point to the one face in a series of pain-contorted visagesthat expresses the patient's level of pain. But adolescents oftendon't like to work with numbers and find the faces childish. Dr.Eland recommends letting children come up with their own analogies.One child told her he felt like he'd been hit by a semi trailer,so she invented a pain scale that descended from semi to cargovan, to Chevy S10 pickup, to tiny economy car.

She also urged doctors to encourage kids to keep diaries of theirpain. "It reminds the kid to raise the subject, and in aquick look, it tells the physician what is and isn't working."

Pain May Actually Exacerbate Illness

There are data and case reports to suggest that pain can exacerbateillnesses such as cancer, Dr. Eland said at the Candlelightersconference (see story above).

In a study by Dr. Gayle Page from the University of California,San Francisco, breast cancers introduced into rats spread twiceas quickly in rats that received a sham operation performed withcurare but no pain-relieving medications, as in rats that receivedmorphine before and during the operation (along with an anestheticand curare), she said.

Dr. Eland also described the case of a boy scout who broke severalribs when he collided with a boulder while tubing down a glacier.Upon hospital admission, his PaO2 was 50 (on a scale of 0 to 100,with the 90s considered normal). It rose to 70 immediately followinginjection of 40 mg of morphine.