CPHON Pain Assessment and Management in Pediatric Oncology 1 — Questions and Answers

Question 1: A 3-year-old with ALL is crying, holding her leg, and refusing to walk. The nurse should use which pain assessment tool?

FLACC scale (Face, Legs, Activity, Cry, Consolability) (Correct answer)
Numeric Rating Scale (NRS) 0–10
McGill Pain Questionnaire
Brief Pain Inventory

Correct answer: FLACC scale (Face, Legs, Activity, Cry, Consolability)

The FLACC scale is validated for assessing pain in preverbal and young children (ages 2 months to 7 years) who cannot self-report, using behavioral and physiologic indicators across 5 domains.

The FLACC scale assesses pain in non-verbal patients (infants, toddlers, cognitively impaired children) by scoring 5 behavioral indicators: Face (0–2: no expression to frequent frown/clenched jaw), Legs (0–2: normal position to kicking), Activity (0–2: lying quietly to arching/rigid), Cry (0–2: no cry to constant crying), and Consolability (0–2: content to difficult to console). Total score 0–10. It is validated for acute procedural and postoperative pain. For children ≥3–4 years who can point, the Wong-Baker FACES scale or Oucher scale can be used as self-report tools. For children ≥7–8 years, the numeric rating scale (NRS) 0–10 is appropriate. Choosing the right tool for the developmental level ensures accurate pain assessment.

Question 2: A child with cancer reports a pain score of 8/10 from bone metastases. Current pain management includes acetaminophen 15 mg/kg PO every 6 hours. Per the WHO analgesic ladder for pediatric pain, the next appropriate step is:

Addition of an opioid analgesic (e.g., oral morphine or oxycodone) as the pain has not responded to non-opioid therapy alone (Correct answer)
Adding a second non-opioid NSAID
Increasing the acetaminophen dose beyond the maximum
Waiting to see if the pain resolves spontaneously

Correct answer: Addition of an opioid analgesic (e.g., oral morphine or oxycodone) as the pain has not responded to non-opioid therapy alone

The WHO analgesic ladder calls for step-up to opioid analgesics (Step 2: mild opioids, or Step 3: strong opioids like morphine) when pain is not controlled by non-opioid analgesics. A pain score of 8/10 uncontrolled on acetaminophen requires opioid initiation.

The WHO 2-step analgesic ladder for children (updated from the original 3-step adult ladder) recommends: Step 1: mild pain (1–3) → non-opioids (acetaminophen, ibuprofen); Step 2: moderate to severe pain (4–10) → strong opioids (morphine is the gold standard; oxycodone, hydromorphone, or fentanyl are alternatives). Pain rated 8/10 is severe and uncontrolled on current non-opioid therapy, meeting the indication for opioid initiation. Oral morphine is the preferred first-line strong opioid for pediatric cancer pain per WHO guidelines due to its availability, established dosing, and reversibility. Adjuvant medications (NSAIDs, corticosteroids for bone pain; gabapentinoids for neuropathic pain; bisphosphonates) should be added as appropriate.

Question 3: A 10-year-old receiving IV morphine for cancer pain develops increased drowsiness, respiratory rate of 8 breaths/minute, and pinpoint pupils. The priority nursing intervention is:

Administer naloxone (Narcan) IV per protocol and prepare for airway support (Correct answer)
Hold the next morphine dose and continue monitoring
Administer supplemental oxygen and elevate the head of the bed
Notify the provider and wait for orders before acting

Correct answer: Administer naloxone (Narcan) IV per protocol and prepare for airway support

Respiratory rate of 8 breaths/minute with pinpoint pupils and excessive sedation constitutes opioid-induced respiratory depression — a life-threatening emergency requiring immediate naloxone administration and airway readiness.

Opioid-induced respiratory depression is recognized by the classic triad: altered mental status/sedation, respiratory rate <10–12 breaths/minute, and miosis (pinpoint pupils). This constitutes a medical emergency. Naloxone (Narcan) is an opioid receptor antagonist that rapidly reverses respiratory depression. In non-opioid-tolerant patients, standard IV dose is 0.01 mg/kg; in opioid-tolerant cancer patients on chronic opioids, smaller titrated doses (0.001–0.002 mg/kg) should be used to avoid precipitating severe withdrawal, severe pain, or pulmonary edema from abrupt reversal. Airway support (positioning, supplemental oxygen, bag-valve-mask ventilation if needed) must be immediately available. Monitor closely after naloxone as its duration is shorter than most opioids.

Question 4: What is the primary advantage of using a patient-controlled analgesia (PCA) pump for pain management in pediatric oncology patients?

Allows the patient to self-administer small bolus doses on demand, improving pain control and sense of autonomy (Correct answer)
Eliminates the need for any scheduled opioid doses
Removes nursing responsibility for pain assessment
Guarantees that the patient will not develop opioid tolerance

Correct answer: Allows the patient to self-administer small bolus doses on demand, improving pain control and sense of autonomy

PCA gives the patient direct control over administering small demand doses within safety lockout parameters, enabling timely analgesia matched to pain peaks (e.g., procedural pain, movement) while maintaining a sense of agency.

Patient-controlled analgesia (PCA) delivers IV opioid (most commonly morphine, hydromorphone, or fentanyl) via a programmable infusion pump. The patient (or nurse/parent in nurse-controlled or parent/nurse-controlled analgesia [NCA/PNCA] for younger children) presses a demand button to receive a pre-programmed bolus dose. Key features: (1) Demand dose — activated by patient for breakthrough pain; (2) Lockout interval — minimum time between doses, preventing overdose; (3) 1-hour maximum — limits total dose per hour; (4) Optional basal rate — continuous background infusion for baseline cancer pain. Benefits: improved pain control (doses timed to need rather than nursing availability); reduced anxiety; increased patient autonomy (particularly important for adolescents); less nursing burden. PCA requires adequate patient cognition; in younger children, PNCA with parental/nurse control is used.

Question 5: A nurse notes that a child's cancer pain is described as burning, shooting, electric-shock-like, and worsens at night. This presentation is most consistent with which type of pain?

Neuropathic pain from tumor invasion or chemotherapy-induced peripheral neuropathy (Correct answer)
Somatic pain from bone metastases
Visceral pain from organ involvement
Procedural pain from repeated lumbar punctures

Correct answer: Neuropathic pain from tumor invasion or chemotherapy-induced peripheral neuropathy

Burning, shooting, electric-shock, tingling, or allodynia pain descriptors are classic features of neuropathic pain — caused by nerve injury from tumor compression, chemotherapy (vincristine, platinum agents), or radiation.

Neuropathic pain results from injury to or dysfunction of the peripheral or central nervous system. In pediatric oncology, causes include: direct tumor nerve invasion or compression; chemotherapy-induced peripheral neuropathy (vincristine, cisplatin, oxaliplatin, taxanes); and radiation-induced nerve injury. Characteristics: burning, shooting, electric-shock-like, stabbing, or lancinating quality; allodynia (pain from non-painful stimuli like touch); hyperalgesia (exaggerated pain response); paresthesias (tingling, numbness); often worse at night. Standard opioids are often inadequate alone — neuropathic pain responds best to adjuvant agents: gabapentin or pregabalin (first-line for pediatric neuropathic pain), tricyclic antidepressants, duloxetine, or topical lidocaine.

Question 6: Which non-pharmacologic intervention is most evidence-based for reducing procedure-related pain and anxiety in pediatric oncology patients during bone marrow aspiration?

Virtual reality (VR) distraction combined with guided imagery or hypnosis techniques (Correct answer)
Having parents leave the room to prevent reinforcing anxiety behaviors
Telling the child 'this won't hurt' before the procedure
Using restraint to ensure the child stays still

Correct answer: Virtual reality (VR) distraction combined with guided imagery or hypnosis techniques

Virtual reality, guided imagery, and hypnosis are among the most evidence-based non-pharmacologic techniques for reducing procedure-related pain and anxiety in children with cancer, activating endogenous pain modulation pathways.

Procedure-related pain and anxiety are major quality-of-life concerns in pediatric oncology. Evidence-based non-pharmacologic interventions include: (1) Virtual reality (VR) distraction — immerses the child in a virtual environment, activating competing sensory channels and reducing procedural distress; (2) Guided imagery and hypnosis — alter pain perception by engaging the child's imagination; (3) Distraction (music, video games, tablets) — effective for younger children; (4) Parent coaching — training parents in comfort-promoting behaviors (vs. reassurance-giving which increases distress); (5) Deep breathing and relaxation; (6) Preparation and coping skills training. These interventions reduce not only pain scores but also analgesic and sedation requirements, anticipatory anxiety, and long-term procedure-related trauma. They should be used as adjuncts to pharmacologic pain management, not as replacements.

CPHON Pain Assessment and Management in Pediatric Oncology 1

A 3-year-old with ALL is crying, holding her leg, and refusing to walk.
The nurse should use which pain assessment tool?