Paediatric cancer pain management using the WHO analgesic ladder - results of a prospective analysis from 2265 treatment days during a quality improvement study

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 inpatient 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. (C) 2005 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved.