Paediatric Palliative Care Guidelines
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Edition/Revision: 1.0
Archived

Adjuvant pain therapies - Archived

At all steps of the analgesic ladder, an adjuvant therapy should be introduced as soon as the nature of the pain is clear.

An adjuvant is not usually analgesic, but is capable of relieving pain in certain specific pain situations.  Selection of an appropriate adjuvant is a key element of a rational and evidence based approach to management of pain in children.  It depends on diagnosis of the type of pain (see below).

Adjuvants are more specific, but not necessarily more potent, than analgesics.

There are many different ways to classify pain.  For the purposes of selecting adjuvant mediations, the most useful is:

Neuropathic pain

Characterised by disordered sensation (numbness, allodynia, dysaesthesia, hyperaesthesia) a plausible nerve distribution such as a dermatome or, in the case of sympathetic mediated pain, with a vascular distribution.  Central or thalamic pain, resulting from direct damage to the thalamus, is a special example of neuropathic pain that may be difficult to identify and treat.

  • Adjuvants could include: anti-convulsants (e.g. Gabapentin, Carbamazepine), anti-depressants (particularly Amitriptyline), and NMDA receptor antagonists (such as Methadone and Ketamine).
Bone pain

Characteristically:  focal, deep seated, intense, occurring in the context of conditions causing metastasis or osteopenia.  Where these are complicated by pathological fracture or joint dislocation, may present as incident pain.

  • Adjuvants could include:  non-steroidal anti-inflammatory drugs, bisphosphonates (e.g. Pamidronate) and radiotherapy.
Muscle spasm or colic

Typically intense but short lived, often occurs in children without the cognitive or verbal ability to identify its location.  Between painful episodes, the child may be pain free.

  • Adjuvants could include:  muscle relaxants such as benzodiazepines or Phenobarbitone.
Cerebral irritation

Typically:  Follows acute brain inury such as perinatal asphyxia or intra-cerebral bleed.   Caused by amplification of pain and anxiety.  Occurs in the neonatal period, but may also result from trauma, infection or malignancy in older children.

  • Steroids can be useful in managing inflammatory mediated pain or pain mediated by oedema round a tumour.
  • Chemotherapy.  Some chemotherapeutic agents, particularly oral Etoposide and Vincristine, can reduce the size of a tumour enough to relieve symptoms, without themselves causing major side effects.
Incident pain

Incident pain is breakthrough pain from an intermittent cause (e.g. fracture) rather than from inadequate background analgesia.  It can be difficult to treat and specialist paediatric (or, if that is not available, adult) palliative medicine advice should be sought.

Edition/Revision: 1.0
Created 18 Jul 2013 - Archived
Validated 19 Jul 2013 by Ian Back
Last modified 15 May 2021
Mon 17 May 2021 01:56:48 GMT +0100 (DST)
Last modified 15 May 2021