When a child has cancer, one of their greatest fears, and the fear of parents, is pain. Every effort is made to ease the pain during the treatment process.

Because pain is unique to each person, a child's pain can't be measured with a lab test or imaging study. Doctors can assess pain by watching a child and asking them questions. There are a number of tools and methods to help assess pain in children.

Pain may be acute or chronic. Acute pain is severe and lasts a short time. It is usually a sign that body tissue is injured in some way. The pain generally goes away when the injury heals. Chronic pain is ongoing. It may range from mild to severe.

Many people believe that if a child has been diagnosed with cancer, they must be in pain. But this may not be true. And when a child has pain, it can often be reduced or even prevented. Pain management is an important topic to talk about with your child's doctor as soon as a cancer diagnosis happens.

Pain may be the result of the cancer, or it may be from other reasons. For example, children can normally have headaches, general discomfort, pains, and muscle strains as part of being a child. Not every pain a child expresses is caused by the cancer.

Cancer pain may depend on the type of cancer, the stage of the disease, and how well your child can tolerate pain. Cancer pain that lasts several days or longer may result from:

• A tumor that is growing or pressing on organs, nerves, or bones
• Poor blood flow because the cancer has blocked blood vessels
• Blockage of an organ or tube in the body
• Cancer cells that have spread to other sites in the body (metastasis)
• Infection or inflammation
• Side effects from chemotherapy, radiation therapy, or surgery
• Stiffness from inactivity
• Emotional responses to illness, such as tension, depression, or anxiety
• Severe developmental delay, which increases the risk for sensory and neuropathic pain and the inability of doctors to recognize unique pain symptoms. These include types of sounds (crying, moaning), facial expressions, movements, aggression, or laughing.

There are many types of medicines to treat pain. Pediatric oncology clinics usually offer several choices for any procedure that may be painful, such as a bone marrow aspiration or lumbar puncture. There are many types of medicines and several methods used in giving them. They range from very short-term (10-minute) mild sedation to full general anesthesia in the operating room. Pain medicine is usually given in one of these ways:

• By swallowing (orally)
• By I.V. (intravenous, through a needle in a vein or in the marrow in a long bone)
• By a catheter in the back
• On the skin

Examples of pain medicine include:

• Mild pain relievers, such as acetaminophen and ibuprofen
• Opioid medicines, such as morphine and oxycodone
• Sedation (usually given by I.V.)
• General anesthesia
• Cream or patches put on the skin to numb the area
• Antidepressants or anticonvulsants for nerve pain
• Steroids to reduce inflammation, such as for an enlarged liver or swelling in the brain
• Radiation or bisphosphonates for bone pain

Some children build up a tolerance to sedatives and pain medicines. This means that over time, doses may need to increase, or the choice of medicines may need to change. Fear of addiction to pain medicine is common. But it's important to understand that the goals are comfort, function, and overall quality of life. This means taking steps to assure the child is free from pain. There is no evidence of addiction to pain medicines in children being treated for cancer.

Other types of pain management use ways to alter thinking and focus to decrease pain. Methods include:

• Gently explaining in advance. If a child is prepared and can understand what will happen, their stress level may be lower. Ways to do this include:
  • Explaining each step of a procedure in detail in a way that the child will understand, using simple pictures or diagrams when available
  • Meeting with the person who will do the procedure and giving your child time to ask questions
  • Touring the room where the procedure will take place
  • Watching a video that describes the procedure based on the child's level of understanding
  • Small children can do the procedure on a doll, or watch a demonstration on a doll
• Hypnosis. With hypnosis, a mental doctor guides the child into a changed state of awareness. This helps them focus their attention to reduce discomfort.
• Guided imagery. This means guiding a child through a pleasant mental image of sights, sounds, tastes, smells, and feelings. It can often help shift attention away from the pain.
• Distraction. This means moving a child's attention. You can distract babies by using colorful, moving objects. Singing songs, telling stories, or looking at books or videos can distract preschoolers. Older children find watching TV or listening to music helpful. Distraction should not be a substitute for explaining what to expect.
• Relaxation. Children can be guided through relaxation exercises, such as deep breathing and stretching, to reduce discomfort.
• Alternative therapies. Acupuncture, massage, and biofeedback can also help ease discomfort.

Each child experiences pain differently. It's important to tailor a pain management plan based on each child's needs. Finding the best plan often means trying different things to see what works best.

In children with severe developmental delay, this increases the risk for untreated sensory and neuropathic pain. Input from the child's caregiver is important. This may be insight from a parent who knows their child's usual behavior.