title: Paediatric cancer pain management using the WHO analgesic ladder--results of a prospective analysis from 2265 treatment days during a quality improvement study.
abstract: OBJECTIVE
  To collect data on pain management in paediatric oncology with respect to the WHO ladder approach. SETTING, DESIGN, PATIENTS AND METHODS: Eight German tertiary care paediatric oncology centres prospectively documented all their in-patient pain treatment courses from June 1999 to December 2000. Pain was scored using a 1-6 faces scale.
  
  
  RESULTS
  Two hundred and twenty four patients (median age, 9 years; range 0.2-32.1) were enrolled. Three hundred and thirty three pain episodes comprising a total of 2265 treatment days were documented. Pain was mostly therapy associated. The most frequently administered non-opioid analgesics were dipyrone and paracetamol. On WHO step 2, tramadol was almost the only opioid used. During tramadol monotherapy average daily pain scores were lower than with a combination of tramadol and non-opioid analgesics. On WHO step 3, morphine was at least part of the analgesic regimen on most treatment days. Strong opioids were combined with a non-opioid analgesic on 41% of the treatment days. The mean intravenous morphine equivalence dose was 0.034 mg/kg/h. During opioid and non-opioid combination therapy, adverse effects were more frequent, and average pain scored higher than on opioid monotherapy.
  
  
  CONCLUSIONS
  WHO-guidelines were closely followed in Germany and seem to provide effective analgesia for children with cancer pain. In our patient group there is no evidence that a combination of an opioid with a non-opioid is more effective than opioid therapy alone in in-patient paediatric oncology pain treatment.
authors.affiliation: Children's Pain Therapy and Pediatric Palliative Care, Children's Hospital Datteln, Witten/Herdecke University, Dr. Friedrich-Steiner Strasse 5, D-45711 Datteln, Germany. Boris.Zernikow@t-online.de <Boris.Zernikow@t-online.de>
authors.forename: Boris
authors.initials: B
authors.lastname: Zernikow
authors.forename: Helen
authors.initials: H
authors.lastname: Smale
authors.forename: Erik
authors.initials: E
authors.lastname: Michel
authors.forename: Carola
authors.initials: C
authors.lastname: Hasan
authors.forename: Norbert
authors.initials: N
authors.lastname: Jorch
authors.forename: Werner
authors.initials: W
authors.lastname: Andler
mesh_terms: D000082:Acetaminophen / Q000008:administration & dosage / Q000009:adverse effects; D000293:Adolescent; D000328:Adult; D000698:Analgesia / Q000379:methods* / Q000592:standards / Q000639:trends; D000700:Analgesics / Q000592:standards* / Q000627:therapeutic use*; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000009:adverse effects; D000970:Antineoplastic Agents / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D004177:Dipyrone / Q000008:administration & dosage / Q000009:adverse effects; D004359:Drug Therapy, Combination; D005858:Germany; D006801:Humans; D007223:Infant; D008495:Medical Oncology / Q000379:methods / Q000592:standards / Q000639:trends; D009369:Neoplasms / Q000150:complications* / Q000188:drug therapy; D010146:Pain / Q000188:drug therapy* / Q000209:etiology* / Q000451:nursing; D010147:Pain Measurement; D010371:Pediatric Nursing / Q000379:methods / Q000592:standards / Q000639:trends; D010372:Pediatrics / Q000379:methods / Q000592:standards / Q000639:trends; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D016896:Treatment Outcome; D014944:World Health Organization
chemical_list: D000700:Analgesics; D000701:Analgesics, Opioid; D000970:Antineoplastic Agents; D000082:Acetaminophen; D004177:Dipyrone