Elsevier

Journal of Pediatric Nursing

Volume 39, March–April 2018, Pages e11-e20
Journal of Pediatric Nursing

Pain and its Impact on the Functional Ability in Children Treated at the Children's Cancer Center of Lebanon

https://doi.org/10.1016/j.pedn.2017.12.004Get rights and content

Highlights

  • Pain was relatively infrequent and of moderate intensity.

  • The most painful areas were the forehead, abdomen and lower-back.

  • The children used sensory words (aching) and temporal phrases (comes and goes) to describe pain.

  • Time since diagnosis, past surgeries, radiotherapy, pain duration and frequency predicted pain intensity.

  • Inability to participate in strenuous sports activities was the major physical limitation reported by the children.

Abstract

Purpose

The purpose of this study was to describe the characteristics of pain in children under treatment at the Children Cancer Centre of Lebanon at the American University of Beirut Medical Centre.

Design and Methods

A cross-sectional correlational survey was used. The Adolescent Pediatric Pain Tool and the Functional Disability Inventory were used to examine the characteristics of pain experienced in a consecutive sample of children treated at the CCCL and its impact on their functional abilities.

Results

The mean age of the 62 participants was 12.3 (SD 2.9). The overall mean pain intensity rating for the sample was 5.06 (SD 1.87) on a 10 cm Word Graphic Rating Scale. More than one-half of the children in the sample (57.4%) reported having pain “sometimes” with a median duration of two hours per pain episode. The most frequently reported locations of pain were the forehead, the abdomen, and the lower back. For the most part, the children used sensory words to describe their pain experience. The children reported moderate levels of functional disability (mean FDI score 25.04, SD 13.81). Multivariable linear regression analysis identified frequency, duration, location, use of affective descriptors, and treatments as statistically significant predictors of pain intensity.

Conclusion

Regrettably, the findings reported attest once again to unrelieved pain in a pediatric oncology population.

Practice Implications

Policy makers can contribute to pain control by introducing legislation and national policies to ensure adequate pain management for children with cancer in Lebanon.

Introduction

Cancer in children is a significant and worldwide health problem and major cause of death, ranking second in child mortality after accidents (National Cancer Institute 2014). In 2017, an estimated 10,270 new cases of cancer were diagnosed in U.S. children aged 0 to 14 years and 1,190 children were expected to die from cancer (American Cancer Society 2017). In Lebanon, the National Cancer Registry (NCR) reported 281 new cases of cancer in children and adolescence aged 0 to 19 in 2010 (National Cancer Registry 2010). This number constitutes around 5% of the newly diagnosed cancer cases in Lebanon. More recent data have not been published by NCR due to political instability in the country. The Children Cancer Center of Lebanon (CCCL) at the American University of Beirut Medical Center (AUBMC) registry reported 125 new pediatric cases in 2016. The lack of recent data for Lebanon limits international comparisons. Similarly, there is a lack of data on cancer pain and its management in Lebanon.

Although the incidence rates of cancer in U.S. children have increased in recent decades, the mortality rate has declined by 50% since 1975. This significant improvement in the survival rates, approximately 83%, is thought to be related to advances in cancer treatment (American Cancer Society. Cancer facts and figures 2012). Comparable survival rates, 80%, were stated in the CCCL registry. The CCCL is an affiliate of St. Jude Children's Research Hospital in Memphis, Tennessee and uses the same treatment modalities and protocols as those used at leading treatment centers in the U.S. The majority of oncologists treating patients at CCCL are board certified in the U.S, which might explain the comparable survival rates achieved in Lebanon. Although international studies show that children with cancer are living longer, the majority are experiencing unnecessary pain. Almost 87% of children with cancer report moderate to severe pain (Jacob et al., 2007, Jacob et al., 2008, Ljungman et al., 1999, Mathews, 2011), are undertreated and suffer unrelieved pain (Daher et al., 2002, Jacob et al., 2007, Mathews, 2011).

Pain is the most common and fearful symptom reported by children with cancer (Beretta et al., 2009, Forgeron et al., 2005, International Association for the Study of Pain, 2009, Jacob et al., 2007, Jacob et al., 2008, Miller et al., 2011, Uman et al., 2013; Van Van Cleve, Muñoz, Riggs, Bava, & Savedra 2012). Unrelieved cancer pain in children has negative physiological and psychological effects that have been linked to changes in functional ability (International Association for the Study of Pain, 2009, Ruccione et al., 2013). Pain severity delays treatment effectiveness and recovery and has a negative impact on quality of life (Huijer et al., 2013, Miller et al., 2011). Thus, a comprehensive approach to pain assessment (sources, location, quality, intensity, frequency, duration) is essential for timely intervention.

Studies of the characteristics of pediatric cancer pain are scarce and have mostly been conducted in the West (Forgeron et al., 2005, Jacob et al., 2008, Mathews, 2011, Twycross et al., 2015, Van Cleve et al., 2004, Windich-Biermeier et al., 2007, Zernikow et al., 2005). With this study we fill a gap in the literature by identifying the characteristics of pain in children and adolescents with cancer in Lebanon and its impact on functional ability.

Section snippets

Culture and Pain

Early in childhood, children learn how to react to pain (Abu-Saad 1984). However investigations of the relationship between culture and pain are scarce, especially in the Eastern Mediterranean Region. Generalizations based on cultural stereotypes can be made, but caution is needed before attributing the characteristics of pain to cultural factors. Although there are people in Lebanon and in the Arab world more generally who believe that illness and, therefore, pain is a punishment from God, or

Design

A cross-sectional correlational survey was designed to meet the study objectives.

Setting

The study was conducted at the American University of Beirut (AUBMC) affiliated

CCCL. Lebanon is a small middle-income country in Western Asia on the Eastern coast of the Mediterranean Sea with a surface area of 10, 452 km2, and an estimated population of four million (Daher et al. 2002). AUBMC, a 420 bed academic medical center is Joint Commission International accredited and Magnet designated. The CCCL was

Demographic Characteristics

Sixty-two children participated in the study. Forty-seven children (75.8%) were recruited from outpatient departments and 15 children (24.2%) from the inpatient department. The mean age of the children was 12.3 ± 2.9 years. The children were evenly distributed between those of school age and adolescents, with 34 (54.8%) living in urban areas and 28 (45.2%) living in rural areas. The majority of the children had leukemia and was primarily admitted for chemotherapy (n = 30, 48.4%). Almost all of the

Discussion

The findings of this study depart in important respects from those reported by other investigators.

Limitations of the Study

The relatively small sample size of 62 children limited the power of the study and may have concealed differences in the pain experience of girls and boys and children in different age groups. None of the children in the study were aged < 8 years so we have no information to report on younger children with cancer. There was likely interaction between data collection methods and children's reports of the sources of pain. The study needs to be repeated with a larger and more diverse sample of

Conclusion

This study has filled a gap in the knowledge of pain and its impact on the functional ability on Lebanese children with cancer. The pain experience in the Lebanese pediatric oncology population was not different from that in other pediatric oncology populations, which strongly suggests that cancer pain is a universal experience. We compare the findings of the study with those of international studies and shed light on the functional ability of children with cancer, a variable barely searched in

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