F’ ain, 68 (1996) 385-394 Q 1996 Intcrnalirrnal Association for the Study nf Pain, t,t304-3959/ 96 / $15.00 385 PAIN 3193 Treatmentof pain in pediatric oncology:a Swedishnationwide survey Gustaf Ljungman’*, Anders Kreuger~,Torsten Gordhb,Torsten Bergc, Stefan Sorensend and Narinder Rawalc alkysurtmertt ot Pediatric Oncology and Henwtology and ‘Department qJAnesthe.Tiolo~yand Intensive Care, University Hospital, Uppsala (Sweden), cDepartmenf @Perfiatric,~and ‘Department of Rarearch, Central Hospital, Viislerfis (Sweden) and ‘Depurtmenf ot”Anesthesiologyand Intensive Care, c%ebroMedical Center H{mpita[,&ebrw (Sweden) (Received 20 February 1996, revised version reccivecl 14 May 1996, accepted 23 May 1996) Summary Paintreatment is a crucial aspect in the care of children with cancerand thereare manystudiesdemonstratinginefficient pain treatment.In this study, questionnaires dealing with pain lrcatment of chikkcn with malignant diseases were sent to all (47) pediatric departments in Sweden. The aims of this nationwide survey were to evaluate the extent and causes of pain, the use of methods for pain evaluation (e.g. analysis of type of pain and monitoring of pain intensity), principles of pain management, side effects of pain treatment and lhe educationalneeds of physicians and nurses regarding these issues. The response rate was IOOYO. Answers from physicians and nurses reveal that pain is a commonsymptomduring differentperiods of cancer treatment. Pain due to treatment and procedures is a greater problem than pain due to the malignant disease itself. Instruments for the measurement of pain intensity and analysis of the type of pain are still rarely used. Most physicians (63%) follow the analgesic ‘ladder’ principle recommended by World Health Organization (WHO). Accordingto a majorityof physiciansandnurses(72%), pain could bc treated more effectively than it is presently, and 64% state that they need more time for the management of pain. Both physicians and nurses state that they need additional education in different areas of pain evaluation and pain treatment. Swedish treatment practices for the management of pediatric cancer pain roughly follow the published guidelines, but many improvements are still necessary. Keywords: Children; Neoplasm’s; Cancer; Pain; Educational needs Introduction Pain is a common problem in the care of children with cancer. Numerous studies have documented a high inci- dence of pain in adults with cancer (Oster et al. 1978; Daut and Cleeland 1982; Coyle et al. 1990; Vainio 1992; Rawal et al. 1993; Vainio 1995; Zech et al. 1995). These data can not be extrapolated to children in that adults have a differ- ent panorama of malignant diseases and a different situa- tion owing to such factors as growth and development. Although there have been improvements in pain treatment in the last decades, there is a host of studies that conclude that pain is a common problem in pediatric oncology (Cornaglia et al. 1984; Miser et al. 1987; McGrath et al. 1990; Elliott et al. 1991). This is also the case in pediatric patients in general where pain has been almost universally * Corresponding author: Dr. Gustaf Ljungman, Department of Pediatric Oncology and Hematology, Children’s University Hospital, S-751 85 Uppsala, Sweden. Tel: (46) 18-665804; Fax: (46) 18-500949; E-mail: gustaf.ljungman @ped.uas.se underestimated and, therefore, poorly treated (Arm$ and Olsson 1988; Schechter 1989). It was previously believed that young children experienced less pain than older chil- dren and adults. This notion has now been rejected (Anand et al. 1987). Pain in children with cancer can be reduced to one or more of four basic etiologies: cancer related (e.g. pain due to infiltration of the tumor in various organs or tissues), treatment related (e.g. pain as side effects of chemotherapy and radiation), procedure related (e.g. pain due to lumbar puncture (LP), bone marrow aspiration (BMA), or postop- erative pain), and pain of other etiology. In earlier pediatric studies, treatment related and procedure related pain pre- dominated (Miser et al. 1987; McGrath et al. 1990; Elliott et al. 1991) in contrast to the preponderance of tumor re- lated pain found in series with adult patients (Oster et al. 1978; Daut and Cleeland 1982; Coyle et al. 1990; Rawal et al. 1993;Zech et al. 1995). The aims of this nationwide inquiry on pain in children with cancer were to evaluate the extent and causes of pain, the use of methods for pain evaluation (e.g. analysis of type PII S0304-3959(96)03 193-4