15.1 Pain Assessment and Management

CPHON Test Content Outline (TCO) IV.B.1 tests pain assessment and management as a general acute, chronic, and late effect. It is not the vaso-occlusive crisis (VOC) emergency playbook, not the dinutuximab infusion protocol, and not the gastrointestinal mucositis chapter restated. Those live elsewhere. Here the nurse names the pain type, matches a developmental tool, and runs a pediatric-adapted World Health Organization (WHO) analgesic ladder with nonpharmacologic partners. The Oncology Nursing Certification Corporation (ONCC) does not publish a single mandated pain scale. Do not invent one as exam fact. Match the tool to the child in front of you.

A 14-month-old after laparotomy who cannot self-report, a 5-year-old with mucositis pointing at a FACES card, a 9-year-old whose feet burn after vincristine, and a 16-year-old on patient-controlled analgesia (PCA) after amputation are the same domain at different ages.

Developmental tools: match the child, not a mythical ONCC scale

Pain is what the child—or a validated behavioral score—says it is, trended against that child's baseline. Infants and nonverbal children cannot give a 0–10 number. Use behavioral tools:

• Neonatal Infant Pain Scale (NIPS) and related infant scales for neonates and young infants: facial expression, cry, breathing pattern, arms, legs, and arousal.
• Face, Legs, Activity, Cry, Consolability (FLACC) for infants, toddlers, and nonverbal or developmentally delayed children. Each domain scores 0–2; the total is 0–10.
• Wong-Baker FACES for many preschool and early school-age children who can point to a face that matches how they feel.
• Numeric 0–10 self-report for older school-age children and adolescents who understand ranking.
• Pediatric self-report is the gold standard whenever the child can do it. National Comprehensive Cancer Network (NCCN) adult oncology pain guidance and pediatric practice both emphasize regular screening, reassessment after every intervention, and a documented plan—not a branded instrument ONCC requires you to name.

Reassess after you intervene. A FLACC of 8 that falls to 2 after morphine and a parent in the crib is a plan that worked. A numeric 7 never rechecked after a breakthrough dose is incomplete. Do not withhold analgesia because the child is playing, sleeping between doses, or "should be used to ports." Do not demand a numeric score from a nonverbal 2-year-old because a unit poster shows a 0–10 line. A 4-year-old who says "my mouth is a 10" during methotrexate mucositis gets treatment for that 10, not a debate about whether FACES is too subjective.

Name the pain type

Nociceptive pain is tissue injury: surgical incision, bone metastases or marrow expansion, viscera after laparotomy, inflammatory mucositis. It often responds to acetaminophen, cautiously used nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids.

Neuropathic pain is nerve injury or nerve-targeted therapy. Vincristine produces stocking-glove burning, jaw pain, and dysesthesia (the neurologic-effects chapter owns foot drop and ileus; this chapter owns the burning). Dinutuximab (anti-GD2 for high-risk neuroblastoma) causes expected neuropathic pain that protocols treat with opioids plus a gabapentinoid; the immunotherapy chapter owns capillary leak and stop parameters—this section owns the pain type. Phantom limb pain after amputation for osteosarcoma or Ewing sarcoma is neuropathic, not the child imagining the leg. Burning, shooting, allodynia, and "legs on fire" are neuropathic clues. Opioids help; gabapentin (or another gabapentinoid as ordered) and, in complex or opioid-refractory pain, methadone are the adjuvants to know. Do not withhold dinutuximab analgesia because pain "means it is working."

Procedural pain is needles, lumbar punctures, bone-marrow aspirations, and dressing changes. Treat the event, not only the diagnosis. Mucositis after high-dose methotrexate, anthracyclines, or radiation is inflammatory nociceptive pain that stops eating; oral care and scheduled opioids sit beside the gastrointestinal-effects chapter. Bone metastases and packed marrow produce deep, movement-related pain. VOC in sickle cell disease is ischemic nociceptive pain treated with age-appropriate opioids; avoid meperidine because the metabolite normeperidine lowers the seizure threshold. Full VOC titration, incentive spirometry, and acute-chest watch are signposted to the sickle-cell and later emergency chapters—do not restage the entire SCD pathway here.

WHO ladder, PCA, adjuvants, and opioid safety

A pediatric-adapted WHO analgesic ladder still organizes teaching:

• Mild: acetaminophen on a scheduled or as-needed clock. In neutropenia, document doses so a home caregiver is not "treating fever" instead of coming in; acetaminophen for documented pain remains appropriate as ordered. NSAIDs (ibuprofen, ketorolac as ordered) help bone and inflammatory pain but carry platelet, gastritis, and renal caution. Hold NSAIDs when platelets are critically low, when the child is in a high-dose methotrexate window (clearance risk), or when creatinine is rising. Ketorolac is not automatically safe because it is not an opioid.
• Moderate to severe: opioids—morphine, hydromorphone, fentanyl (including transdermal systems only in selected stable, opioid-tolerant severe pain). Dose by weight, titrate to comfort and respiratory status, and prefer the oral route when the gut works. Do not place a fentanyl patch on an opioid-naive 8-year-old for a one-time procedure. Avoid meperidine in SCD and as a routine pediatric oncology analgesic.
• Around-the-clock (ATC) dosing for continuous pain (mucositis, bone mets, postoperative days) plus breakthrough doses for incident or end-of-dose pain. As-needed-only opioids for around-the-clock mucositis leave the child chasing pain all night.
• PCA in older children and adolescents who understand the button: a continuous rate when indicated plus a lockout bolus. Parents and nurses do not push the button for a sleeping child (no PCA-by-proxy) unless a protocolized authorized-agent pathway exists. Teach the 16-year-old that the button treats pain, not boredom.
• Adjuvants: gabapentin for neuropathic and dinutuximab pain; methadone for complex, escalating, or neuropathic-dominant pain under experienced prescribers (long half-life, QTc watch). Corticosteroids may reduce bone or inflammatory pain as ordered; they are not a secret opioid substitute.

Constipation prophylaxis starts the day the opioid starts: polyethylene glycol, senna as ordered, a stool record. Waiting three days without stool is the failure. Naloxone reverses oversedation and respiratory depression—it is not a first-line analgesic and not a bowel regimen. Dilute or low-dose naloxone infusions are sometimes used for opioid-induced pruritus or ileus as ordered. A child who will not arouse and whose respiratory rate is falling gets prompt naloxone and airway support, then a new pain plan so withdrawal and rebound pain are not the next injury.

Nonpharmacologic partners are interventions

Pharmacology without development is incomplete. Oral sucrose and nonnutritive sucking for infants during heel sticks and line access; positioning and swaddling; parental presence as the default, not a privilege; distraction (bubbles, tablets, music); and Child Life for procedural rehearsal, comfort holds, and medical play. A 3-year-old who watches a tablet during port access still needs a topical anesthetic and an honest warning, not a surprise stick. Cluster painful tasks when possible so the child is not poked hourly.

The CPHON product is a documented score that matches development, a named pain type, an opioid with a bowel plan, naloxone in the drawer for oversedation, and Child Life in the room for the needle—not a single ONCC-branded scale.