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Dr. Mahay is a clinical oncology/hematology pharmacist at Banner Desert Medical Center in Mesa, Arizona.
Over the past 20 years, pain in infants has gained considerable attention. Infants are capable of experiencing pain from birth, and infants who are diagnosed with cancer are almost certain to experience pain due to the multiple diagnostic and therapeutic procedures that they must endure. These procedures can include repeated blood tests, bone marrow biopsies, and drug administration (eg, via intravenous, intramuscular, and intrathecal routes). Parents report that pain associated with these procedures is the worst or most negative part of the cancer experience. It is therefore vital that the entire health care team take responsibility in relieving and ameliorating cancer pain and its related procedures in infants.
To achieve this end point, an understanding of the following is needed: (1) consequences of pain in infants; (2) assessment and reassessment of pain in infants; and (3) effective pharmacologic, behavioral, and physical pain management throughout the diagnosis and treatment of cancer, including palliative care.
Understanding Pain in Infants
Unlike adults and adolescents, infants do not have the cognitive skills or communicative abilities that enable conveyance about pain. Therefore, parents play an essential role in identifying pain problems in children as well as providing comfort and consolation. Parents are much more adept at understanding their child’s responses to distressing situations. For infants who cannot express their pain or need for intervention, this decision falls on nurses, parents, and other members of the health care team. Consequently, parents should be included in the initial and ongoing evaluation of their child’s pain.1
Based on curious myths, the undertreatment of pain and underuse of pain medications—especially narcotics—in infants have been documented. These myths include the idea that children’s nervous systems are not the same as adults and they do not experience pain with the same intensity; children will become addicted to narcotics; and narcotics always depress respirations in children—all of which have been proven false.1,2
Consequences of Pain in Infants
Recent studies have shown that by 26 weeks of gestation, neonates have substantial maturation of afferent pain transmission, and they respond to tissue injury with specific behavior and signs of distress.1-3 Many studies have shown pain that occurs early in life during critical periods of development may lead to long-term consequences. Animal studies have illustrated that pain experience early in development has resulted in potential changes to pain thresholds, behavioral and physiologic pain, and stress-related responses later in life; however, human studies have yielded conflicting results.1
Among children newly diagnosed with cancer, those who experienced inadequate analgesia during their first bone marrow aspiration showed more pain during subsequent procedures than those who received an opioid during the first procedure.1,3 Nonetheless, additional research is needed to determine how pain experienced in the neonatal years affects future cognition, behavior, and development in children who have experienced prolonged or persistent pain associated with cancer and the procedures that accompany it.
Assessing pain in infants is one of the most difficult challenges facing clinicians and parents. This is largely due to the infant’s inability to communicate verbally, individual attitudes and beliefs, and insufficient provider knowledge. Many well-validated infant pain measures have been developed; however, only a few take the conditions of the pain experience or the environment into consideration. Factors associated with the infant, such as severity of the illness, the observer’s attitude and beliefs toward pain, and the time and instruments available to measure pain in the environment, influence individual pain indicators.1,4-6
To treat pain effectively, continuous assessment of the presence and severity of pain and the infant’s response to treatment is essential. Reliable and valid assessment tools are available for infants. Pain and response to treatment, as well as adverse effects, should be monitored routinely and documented clearly, such as on a vital sign sheet to help facilitate treatment and communication among health care professionals. Clinicians can recognize the immediate physiologic consequences of pain in infants, which include increases in heart rate, respiratory rate, blood pressure, changes in skin tone, dilated pupils, palmar sweating, diaphoresis, nausea, and vomiting. Pain assessment is the initial step in determining the effectiveness of management strategies and remains an enormous challenge.
Pain management in infants remains vague, which leads to discrepancies in pain management strategies. Clinicians try to avoid pain through the prevention of painful procedures and conditions; however, in infants with cancer, this is not always feasible. Pain management in the infant should be multifaceted.
Pharmacologic strategies involve opioid analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, and sucrose.
Acetaminophen and NSAIDs
For infants with bone pain–related cancer, an NSAID may be effective; however, NSAIDs can often cause gastric irritation, platelet dysfunction, and, with long-term use, nephrotoxicity. Therefore, acetaminophen, which does not have these side effects, has been considered a preferable choice. It is one of the most widely used antipyretic and mild analgesics for children. NSAIDs can be used with good effects, as long as they are monitored carefully.7 In infants unable to take oral pain agents, parenteral NSAIDs are available. Ketorolac is available parenterally and, when used judiciously, can be used safely in infants.1,7
Morphine and fentanyl are the most commonly used opioids in hospitalized neonates and infants and are considered the mainstay of systemic analgesia. Morphine has a rapid onset of action, within 5 minutes of administration, and peaks at 10 to 30 minutes. The duration of action is variable, but usually lasts between 3 and 8 hours. Fentanyl is approximately 50 to 100 times more potent than morphine, with a peak effect within 5 to 15 minutes; however, the duration of action is usually <2 hours.1,8,9
Sucrose, both alone and with pacifiers, has been studied in relieving procedural pain in neonates and young infants. Several randomized controlled trials have demonstrated that 24% sucrose solution either with or without a pacifier given approximately 2 minutes before a procedure such as a blood draw reduces pain and was more effective than lidocaine/ prilocaine (EMLA) cream.1,10
For infants, comfort measures such as cuddling, swaddling, auditory and tactile stimulation, and suckling may reduce behavioral and physiologic responses to pain.10 Swaddling of infants enhances their feelings of security during painful procedures. Suckling has been shown to decrease heart rates and crying times in infants during painful procedures. Many of these behavioral and physical interventions are good alternatives that can be used alone or in conjunction with pharmacologic agents.
Pain at the end of life must combine the perspectives of the clinicians and parents. In pain assessment in infants, both physiologic and behavioral signs need to be addressed. Parents’ perspectives are important, as they understand their child’s usual activities, behaviors, and can recognize any deviations from normal. Pain in this population needs to be reassessed regularly, especially with changes in activities and treatment. Pain can increase with a worsening of the infant’s condition. Pharmacologic as well as nonpharmacologic strategies need to be used and reevaluated constantly by the parents as well as providers.9,11
Optimal pain management in infants is a challenge as well as a common goal for parents and health care workers. The past decade has provided much more evidence and knowledge for health care providers in understanding infants’ capacity for pain. In infants with cancer, it is only ethical and moral that caregivers use pharmacologic as well as nonpharmacologic means to relieve and prevent their suffering. Parents and health professionals are essential for understanding how to better address pain in this population.
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