Pathophysiology

• Rare in paediatric palliative medicine.
• Often results from inexpert opioid titration and adjuvant prescription in early stages of pain.
• Always has major anxiety and fear component.

Signs and symptoms

• Pain suddenly becoming worse, often with no obvious cause.
• Apparent ineffectiveness even of large doses of opioids.

Management

• Involve specialist palliative care team as soon as diagnosis of uncontrolled pain is made.
• Use parenteral route to secure control as soon as possible.
• Palliative care team will administer slow injection of opioid until pain goes.
• Calculation of regular and breakthrough opioid dose is made on basis of dose required to control pain.