Multimodal analgesia in paediatric palliative care

Regarding World Health Organization ۲۰۱۸ guideline for healthcare workers deliveringpaediatric pallia-tive care ; making palliative care accessible to all children in need and theirfamilies is emphasised and medically and morally is necessity . (۱)Symptom management is an essential part of palliative care, and as a minimum standard ofpalliative care, it is vital that healthcare providers understand the multi- faceted nature ofsymptoms and their contextual impact on the child with serious illness. It is therefore helpful toidentify accurately those children with life- limiting and life- threatening conditions, and torecognize subpopulation- specific patterns of symptom presentation. This may improve accessto expertise for good symptom management.In the past, judging the severity of symptoms relied on obser-vational variables such as heartrate, respiratory rate, and changes in posture. At best, those observations were elaborated byverbal reports from relatives, other carers, or the child herself. In the twenty- first century,however, symptom evaluation has become more sophisticated, harnessing software that canbe easily installed on smartphones (۲). These improvements enable more accurate symptomassessment in real time and better patient/ professional interface for planning managementstrategies. There has also been recognition of the diversity of symptom reporting by the child,carer, and healthcare professional and this combined viewpoint provides a valuable globalperspective to the patient’s symptom experience, enabling more accurate planning of acceptableinterventions (۳).The most distressing and one of the most common symptom children who are living with anunderlying serious illness commonly is pain (۴-۶). Selfreports from verbal with malignanciesshowed high distress from pain in ۳۹% of paediatric patients with advanced cancer, whichincreased to ۵۸% during the end- of- life period (۷).Children and adults are not wholly different from one another, but they are certainly not exactlythe same. While the pharmacological action of most drugs is largely the same in children and inadults, some of the differences between adults and children are significant when it comes todeciding how to use medications in a way that optimizes safety and effectiveness.A medication must be acceptable to the child in order for it to be ingested, and needles ormedicines that taste unpleasant should be avoided as far as possible. The distribution,metabolism, effect, and elimination of drugs all depend on parameters such as functionalphysiology and body composition that develop over the course of childhood. All might plausiblyinfluence the relationship between the dose of a medication and the child’s response. It isdifficult to be sure, as there is often little research evidence on which to base clinical decisions.‘Multimodal analgesia’, aims to highlight the key concepts of multimodal analgesia, including:۱. Basic analgesia: acetaminophen (paracetamol) plus a non- steroidal anti- inflammatorydrug (NSAID), such as ibuprofen.If bleeding side effects or stomach discomfort occur, analternative to consider might be a cyclooxygenase- ۲ (COX- ۲) inhibitor, such as celecoxib.۲. Opioids: including medications such as tramadol, morphine, fentanyl, hydromorphone,oxycodone, or methadone carefully titrated to effect. However, ‘if Coke doesn’t work, switch to Pepsi’— In other words a significant number of children or adults may experience opioid- induced side- effect (which might be mitigated by a low- dose naloxone infusion) or poor analgesia on one opioid and then need to be ‘rotated’ or switched to an-other strong opioid for better control.۳. Adjuvant Analgesia: such as gabapentinoids, (e.g. gabapentin, pregabalin) alpha- agoninists, (e.g. dexmedetomidine, clonidine) n- methyl- d- aspartate receptor (NMDA)- channel blocker, (e.g. low- dose ketamine, methadone) sodium- channel blocker, (e.g. lidocaine) tricyclic antidepressants (e.g. low- dose amitriptyline).۴. Interventional modalities: or neuroxial analgesia, including (e.g. nerve blocks, paravertrebral blocks, or epidural pain pumps).In practice, those working in paediatric palliative care have found ways to prescribe and administer medications to children safely and effectively. This chapter sets out some of the theoretical concerns about using medications in children and some of the practical ways in which clinicians have overcome challenges.