Impact of Pain Management Using the WHO Analgesic Ladder in Children with Cancer in South Egypt Cancer Institute, Assiut University

Salah Abdel-Hadi (1, 2) , Mohammed M. Ghazaly (3, 4) , Montaser A. Mohamed (3, 5) , Ahmed Mohammed Morsy (3, 6)

1 Cairo University
2 National Cancer Institute, Department of Pediatric Oncology
3 Assiut University
4 Faculty of Medicine, Department of Pediatrics
5 South Egypt Cancer Institute, Department of Anesthesiology
6 South Egypt Cancer Institute, Department of Pediatric Oncology

Background: The 2012 WHO guidelines recently recommended the 2 – step strategy in managing pediatric cancer pain. There is little experimental evidence to support this practice. Objectives: To describe characteristics & causes of pain in department of pediatric oncology in South Egypt Cancer Institute, to ascertain the effectiveness of WHO analgesic ladder in these pediatric cancer patients & to address side-effects occurred under treatment with opioid therapy in accordance with step 2 & 3 of the ladder. Methods: During 30 months duration from (1 Jan 2011 till 30 June 2013), A prospective study was conducted on pediatric cancer patients who complained of pain & fulfilled all the inclusion criteria for enrollment in this study. Data collected were: patients' demographics, pain characteristics & pain intensity scores. The 1st24h average intensity pain scores after change of pain therapy & reduction of > 30 % from their initial levels were used to calculate the adequacy of pain control. All patients who had persisting pain after treatment with step – 1 (paracetamol) divided into 2 groups: "group 1" received step – 2 (tramadol) & "group 2" moved directly to step – 3 of WHO analgesic ladder (Low dose of morphine). Results: The study included 133 pain cycles comprising a total of 1028 treatment days. Step – 1 analgesia was effective in 50.6% of all documented treatment days, while Step – 2 analgesia was effective in 17.02% of all documented treatment days and Step – 3 analgesia was required in 23.6% of all documented treatment days. After failure to obtain adequate pain control on non-opioid analgesics, it was found that median average intensity pain scores in the 1st24h after administration of low dose morphine as a two-step strategy (step – 3) was 1.33, which was lower compared to those obtained after tramadol therapy (step – 2), which was 3.33 and the difference was statistically significant (p value = 0.002). Adverse effects which included somnolence, constipation, nausea &/ or vomiting and pruritis were found to be less frequent in weak opioid drugs compared to strong opioid drugs and these differences were statistically significant (p value < 0.05). Conclusions: Efficacy of WHO analgesic ladder was ascertained in managing pain in children with cancer in our department. Disease-related pain was the most frequent cause of pain cycles and somatic type of pain was the most frequently occurring type. Use of low dose morphine in a two-step strategy was associated with lower pain scores, fewer drug changes for pain therapy when treatment was initiated & shorter duration of pain, but associated with more frequent side-effects than the conventional three-step WHO ladder.

Mots clés: Pediatric Oncology; Pain Management; Opioids; Tramadol; Low Dose Morphine; Pediatric Cancer Pain; WHO Analgesic Ladder; Childhood Cancer

Domaines: Cancer; Pédiatrie; Organes des sens

Salah Abdel-Hadi, Mohammed M. Ghazaly, Montaser A. Mohamed, Ahmed Mohammed Morsy. Impact of Pain Management Using the WHO Analgesic Ladder in Children with Cancer in South Egypt Cancer Institute, Assiut University. SECI Oncology, 2014, 2014 (1), pp.2-8. ⟨10.18056/seci2014.1⟩. ⟨hal-01465346⟩