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WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnessesWHO guidelines on the pharmacological treatment of persisting pain in children with medical illnessesWHO Library Cataloguing-in-Publication DataPersisting pain in children package: WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. Contents: WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses - Three brochures with important information for physicians and nurses; pharmacists; policy-makers and medicines regulatory authorities, hospital managers and health insurance managers - Dosing card - Pain Scale for children (4 years of age and up) - Pain Scale for children (6 - 10 years) - Wall chart for waiting rooms 1.Pain-drugtherapy.2.Pain-classication.3.Painmeasurement.4.Analgesics,Opioid.5.Drugs,Essential.6.Drug and narcotic control. 7.Palliative care. 8.Child. 9.Guidelines. I.World Health Organization.ISBN9789241548120   (NLMclassication:WL704)© World Health Organization 2012Allrightsreserved.PublicationsoftheWorldHealthOrganizationareavailableontheWHOwebsite (www.who.int)orcanbepurchasedfromWHOPress,WorldHealthOrganization,20AvenueAppia,1211Geneva27,Switzerland(tel.:+41227913264;fax:+41227914857;e-mail:bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensing/copyright_form/en/index.html).Thedesignationsemployedandthepresentationofthematerialinthispublicationdonotimplytheexpressionof any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dottedlinesonmapsrepresentapproximateborderlinesforwhichtheremaynotyetbefullagreement.Thementionofspeciccompaniesorofcertainmanufacturers’productsdoesnotimplythattheyareendorsedorrecommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errorsandomissionsexcepted,thenamesofproprietaryproductsaredistinguishedbyinitialcapitalletters.AllreasonableprecautionshavebeentakenbytheWorldHealthOrganizationtoverifytheinformationcontained in this publication. However, the published material is being distributed without warranty of any kind,eitherexpressedorimplied.Theresponsibilityfortheinterpretationanduseofthemateriallieswiththe reader. In no event shall the World Health Organization be liable for damages arising from its use. Design and layout: paprika-annecy.comPrinted in France<1CONTENTSACKNOWLEDGEMENTS 6Donors 6ABBREVIATIONS AND ACRONYMS 7GLOSSARY 8EXECUTIVE SUMMARY 10Clinical and policy recommendations 10Future research 10Reading guide 11INTRODUCTION 131. CLASSIFICATION OF PAIN IN CHILDREN 161.1 Introductiontoclassicationofpain 171.2 Painclassicationsystems 181.2.1Pathophysiologicalclassication 181.2.2Classicationbasedonpainduration 201.2.3Etiologicalclassication 211.2.4Anatomicalclassication 211.3 Causesandclassicationofpainassociatedwithspecicdiseases 231.3.1CausesandtypesofpaininchildrenwithHIV/AIDS 231.3.2Causesandtypesofpaininchildrenwithcancer 241.3.3Causesandtypesofpaininchildrenwithsicklecelldisease 252. EVALUATION OF PERSISTING PAIN IN THE PAEDIATRIC POPULATION 262.1 Clinicalexamination:painhistoryandphysicalexamination 272.2 Expressionofpainbychildrenandappropriatepainassessmentmeasures 292.3 Documentationofpain:theuseofpainmeasurementtools 302.4 Deningcriteriaandselectingapainmeasurementtoolinclinicalsettings 332.5 Assessmentofotherparametersinchildrenwithpersistingpain 342.6 Overcoming the challenges of assessing persisting pain in children 353. PHARMACOLOGICAL TREATMENT STRATEGIES PATIENT-LEVEL GUIDELINES FOR HEALTH PROFESSIONALS 363.1 Principlesforthepharmacologicalmanagementofpain 373.2 Treatingpainusingatwo-stepstrategy 383.2.1Therststep:mildpain 383.2.2Thesecondstep:moderatetoseverepain 383.2.3Considerationofthetwo-stepapproach 39> 23.3 Treatingpainatregularintervals 403.4 Treatingpainbytheappropriateroute 403.5 Tailoringpaintreatmenttotheindividualchild 403.5.1Non-opioidanalgesics 403.5.2Opioidanalgesics 413.6 Strongopioidsessentialinpaintreatment 423.7 Choiceofstrongopioids 423.8 Immediate-releaseandprolonged-releaseoralmorphine 433.9 Opioidswitching 443.10 Routesofadministration 453.11 Treatmentofbreakthroughpain 463.12 Tolerance,withdrawalanddependencesyndrome 463.13 Opioidoverdose 473.14 Adjuvantmedicines 503.14.1Steroids 503.14.2Bonepain 503.14.3Neuropathicpain 513.14.4Painassociatedwithmusclespasmandspasticity 523.15 Researchagenda 534. IMPROVING ACCESS TO PAIN RELIEF IN HEALTH SYSTEMS 544.1 The right to health, the right to be spared avoidable pain 554.2 International regulations on opioid analgesics 554.3 Dimensionsofanationalpaintreatmentpolicy 564.4 Financing pain relief within the national system 564.5 Estimatingneedsforpainrelief 574.6 Saving resources by treating pain 584.7 Pain management coverage 594.8 Human resources for pain management 594.9 What treatment should be available 60ANNEX 1. PHARMACOLOGICAL PROFILES 62A1.1Fentanyl 63A1.2Hydromorphone 66A1.3Ibuprofen 69A1.4Methadone 70A1.5Morphine 73A1.6Naloxone 76A1.7Oxycodone 78A1.8Paracetamol 80<3ANNEX 2. BACKGROUND TO THE CLINICAL RECOMMENDATIONS 82A2.1Developmentprocess 83A2.2Pharmacologicalinterventions 84A2.2.1Atwo-stepapproachversusthethree-stepladder 84A2.2.2Paracetamolversusnon-steroidalanti-inammatorydrugs 86A2.2.3Strongopioidsessentialinpaintreatment 87A2.2.4Choiceofstrongopioids 88A2.2.5Prolonged-releaseversusimmediate-releasemorphine 90A2.2.6Opioidrotationandopioidswitching 91A2.2.7Routesofadministration 92A2.2.8Breakthroughpain 93A2.2.9Adjuvantmedications:steroids 95A2.2.10Adjuvantsinbonepain:bisphosphonates 95A2.2.11Adjuvantsinneuropathicpain:antidepressants 96A2.2.12Adjuvantsinneuropathicpain:anticonvulsants 97A2.2.13Adjuvantsinneuropathicpain:ketamine 98A2.2.14Adjuvantsinneuropathicpain:localanaesthetics 98A2.2.15Adjuvantsforpainduringmusclespasmorspasticity: benzodiazepines and baclofen 99A2.3Non-pharmacologicalinterventions 99ANNEX 3. BACKGROUND TO THE HEALTH SYSTEM RECOMMENDATIONS 100ANNEX 4. EVIDENCE RETRIEVAL AND APPRAISAL 104A4.1 GRADEproles 105A4.2 Studiesretrievedonhealthsystemrecommendations 123A4.3 Studiesretrievedinthethirdstepoftheevidenceretrievalprocess 124ANNEX 5. RESEARCH AGENDA 128ANNEX 6. OPIOID ANALGESICS AND INTERNATIONAL CONVENTIONS 130A6.1 UNdrugconventionsandtheirgovernancesystem 131A6.2 TheSingleConventiononNarcoticDrugsandopioidanalgesics 132A6.3 Drugmisuseversuspatientneed 132A6.4 Competentnationalauthoritiesundertheinternationaldrugcontroltreaties 133A6.5 TheConvention’srequirementsfornationalestimatesofmedicalneedforopioids 133A6.6 Theimportanceofreliableestimates 134A6.7 Domesticmanufactureofstrongopioidanalgesics 134> 4A6.8 Theimport/exportsystemforstrongopioids 135A6.9 Requirementsforimport/exportauthorizationsorcerticates 136A6.10Thereportingsystemfollowingexportation,importationandconsumptionofopioids 137A6.11Distributionofstrongopioids 137A6.12Usualrequirementsforprescribinganddispensingopioids 138ANNEX 7. LIST OF CONTRIBUTORS TO THIS PUBLICATION 140A7.1Guidelinesdevelopmentgroupmeeting 141A.7.2Othercontributors 142A7.3Declarationofinterestandmanagementofpotentialconictofinterest 143SUMMARY OF PRINCIPLES AND RECOMMENDATIONS 146REFERENCES 148INDEX 156<5LIST OF TABLESTable 1.1 Common sensory features suggestive of neuropathic pain 19Table 1.2 Differentiating features of nociceptive and neuropathic pain 22Table 2.1 List of self-report measuring tools for pain intensity 31Table3.1Non-opioidanalgesicsforthereliefofpaininneonates,infantsandchildren 41Table3.2Startingdosagesforopioidanalgesicsforopioid-naiveneonates 48Table3.3Startingdosagesforopioidanalgesicsinopioid-naiveinfants(1month–1year) 48Table3.4Startingdosagesforopioidanalgesicsinopioid-naivechildren(1–12years) 49Table3.5Approximatedoseratiosforswitchingbetweenparenteralandoraldosageforms 50LIST OF BOXESBox0.1DenitionofqualityofevidenceaccordingtoGRADE 14Box0.2Interpretationofstrongandweakrecommendations 14Box2.1Summaryofquestionsbythehealth-careproviderduringclinicalevaluation 29Box2.2Multidimensionalassessmentofepisodicpaininchildrenwithsicklecelldisease 33Box2.3Step-by-stepguidanceforadministeringandinterpretingaself-reportpainscale 34Box3.1Excludedmedicineforpainrelief 39Box3.2FormulationsofmorphinelistedintheWHO model list of essential medicines for children, 2010 43Box3.3Guidanceforselectionandprocurementofmorphineoralformulations 44LIST OF FIGURESFigure 1.1 Diagram showing the many dimensions of pain modifying the transmissionofnoxiousstimulitothebrain 17Figure2.1Algorithmonevaluationofpaininthepaediatricpopulation 28FigureA6.1Stepsinopioidimport/exportprocedures 136(ForGRADETablesseeAnnex4,SectionA4.1(page105).)> 6ACKNOWLEDGEMENTSTheseguidelineswereproducedbytheWorldHealthOrganization(WHO),DepartmentofEssentialMedicinesandPharmaceuticalPolicies,AccesstoControlledMedicationsProgrammeincollaborationwiththeDepartmentofChronicDiseasesandHealthPromotion,theDepartmentofMentalHealthandSubstanceAbuse,theDepartmentofHIV,theDepartmentofEssentialHealthTechnologies(currently:Department of Health Systems Governance and Service Delivery), and the Department of Child and AdolescentHealthandDevelopment.ThesedepartmentswererepresentedontheWHOSteeringGroupon Pain Treatment Guidelines.TheWHOGuidelinesReviewCommitteeprovidedinvaluablesupporttotheAccesstoControlledMedicationsProgrammewhiledevelopingtheseguidelines.The guidelines were developed with contributions from:• theExpandedReviewPanelindeningthescopeoftheguidelinesandinreviewingtheevidenceretrieval report;• the Guidelines Development Group in reviewing and appraising the available evidence, formulating therecommendations,anddeningthecoreprinciplesonassessment,evaluationandtreatmentofpain;• thePeerReviewGroupinprovidingfeedbackonthedraftguidelinesandnalizingthedocument;• theWHOconsultantswho,withtheirexpertise,supportedseveralstepsoftheguidelinesdevelopmentprocess;• the WHO Steering Group on Pain Treatment Guidelines.ForfullmembershiplistsseeAnnex7.DonorsGenerousnancialsupportwasreceivedforthedevelopmentoftheguidelinesfromTheDiana,PrincessofWalesMemorialFund,London,UnitedKingdom;theFoundationOpenSocietyInstitute(Zug),Zug,Switzerland;theInternationalAssociationfortheStudyofPain(IASP),Seattle,WA,USA;theInternationalChildrensPalliativeCareNetwork,Durban,SouthAfrica;theMaydayFund,NewYork,NY,USA;MinistryofHealth,WelfareandSport,TheHague,theNetherlands;theRockefellerFoundation,NewYork,NY,USA;TheTrueColoursTrust,London,UnitedKingdom;andtheUSCancerPainReliefCommittee,Madison,WI,USA.The Rockefeller Foundation hosted the meeting of the Guidelines Development Group at the Bellagio Center,Bellagio,Italy,inMarch2010,andprovidednancialsupportforthetravelofparticipantsfromdeveloping countries.[...]... research In the course of the development of these guidelines, the gaps in research on pharmacological interventions in neonates, infants and children have been noted and mapped The majority of the studies considered in these guidelines have been conducted in children with acute pain and do not appropriately address research questions regarding children requiring long-term pain treatment Therefore, the. .. be a reason to conclude that the pain is simulated 1.2.2 Classification based on pain duration A commonly used definition of acute pain is pain lasting less than 30 days, and a commonly used definition of chronic pain is pain lasting more then three months However, these definitions are arbitrary and not essential for deciding on treatment strategies Symptoms and causes of the two types of pain may overlap... for treatment (Chapter 1) and an introduction to assessment of pain in children (Chapter 2) are presented In particular, good assessment of pain is essential for the appropriate treatment of pain Potential conflicts of interest and their management are mentioned in Annex 7, List of contributors to this publication 15 < WHO guidelines on the pharmacological treatment of persisting pain in children with. .. of this type of pain include migraine, episodic sickle cell disease pain, recurrent abdominal pain Persisting and recurrent pain can coexist, especially in conditions such as in sickle cell disease Breakthrough pain is characterized as a temporary increase in the severity of pain over and above the pre-existing baseline pain level, e.g if a child is taking pain medicines and has good pain control with. .. (27) 25 < WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses 2 EVALUATION OF PERSISTING PAIN IN THE PAEDIATRIC POPULATION > 26 Optimal pain management begins with accurate and thorough pain assessment Pain assessment enables health-care providers to treat pain and alleviate needless suffering It should be carried out at regular intervals because the disease... referring to the level of pain experienced and reported by the patient Pain severity: term is used interchangeably with pain intensity and referring to the level of pain experienced and reported by the patient Persisting pain: term as used in these guidelines is intended to cover long-term pain related to medical illness, for example pain associated with major infections (e.g HIV), cancer, chronic neuropathic... with HIV include headache, oral cavity pain, abdominal pain, neuromuscular pain, chest pain, earache, odynophagia (pain while swallowing), myalgia and arthralgia (16, 17) In older children, the type of pain is often a function of the clinical stage of the infection In early HIV, most pain occurs as a result of opportunistic conditions and is, therefore, somatic and transient in nature During the later... included and excluded It also describes the patients to which they apply and the audience for whom the guidelines were developed Chapter 1 Classification of pain in children provides a description of pain classification systems Chapter 2 Evaluation of persisting pain in the paediatric population gives general guidance and key concepts on the assessment and evaluation of pain in children Chapter 3 Pharmacological. .. experiencing persisting pain related to medical diseases They can also be applied to adolescents as the majority of the evidence retrieved and appraised refers to studies in populations comprising patients from 0 to 18 years The guidelines deal specifically with the pharmacological management of persisting pain in children with medical illnesses, where persisting pain refers to any long-term pain and medical. .. by intestinal infections, urinary tract infection, pancreatitis, hepatitis and colitis Diarrhoea and vomiting are commonly associated with abdominal pain Cramping or episodic pain is often seen in settings where there is intestinal infection or bowel obstruction (e.g secondary to inflammation) Children with HIV can also develop abdominal sepsis and present with an acute abdomen where pain is continuous, . WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses WHO guidelines on the pharmacological treatment. treatment of persisting pain in children with medical illnesses WHO Library Cataloguing -in- Publication Data Persisting pain in children package: WHO guidelines
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Xem thêm: WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses docx, WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses docx, WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses docx, 1Clinical examination: pain history and physical examination, 3Documentation of pain: the use of pain measurement tools, 12Tolerance, withdrawal and dependence syndrome, 1The right to health, the right to be spared avoidable pain, ANNEX 2. BACKGROUND TO THE CLINICAL RECOMMENDATIONS, ANNEX 3. BACKGROUND TO THE HEALTH SYSTEM RECOMMENDATIONS, ANNEX 4. EVIDENCE RETRIEVAL AND APPRAISAL, A4.3Studies retrieved in the third step of the evidence retrieval process, ANNEX 7. LIST OF CONTRIBUTORS TO THIS PUBLICATION, A7.3 Declaration of interest and management of potential conflict of interest

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