FEATURE

Pediatric Palliative Pain and

Symptom Management
Tressia M. Shaw, MD

M
any children with life-limiting
conditions have distressing
symptoms not just at the end
of life, but throughout the course of their
illnesses, which may run years after the
initial diagnosis.1 Because pediatricians
treat these children throughout their dis-
ease trajectory, it is important to have the
basic skills to assess and treat pain and
other distressing symptoms. This article
reviews pain and symptom assessment
and management.
Several studies have shown a high
degree of symptom burden in pediat-
ric populations with terminal illness in
the last few weeks of life. Some com-
monly reported symptoms include pain,

dyspnea, fatigue, poor appetite, nausea,
vomiting, constipation, and change in
sleep patterns.2-5 While much of the focus
in the medical literature has been on end
of life symptoms, many children living
with life-limiting conditions experience
distressing symptoms throughout their
illness. The perception of suffering as a
Tressia M. Shaw, MD, is Pediatric Palliative Care
Program Director, Phoenix Children’s Hospital;
Pediatric Medical Director, Hospice of the Val-
ley; and Clinical Assistant Professor of Pediatrics,
University of Arizona College of Medicine.
Address correspondence to: Tressia M. Shaw,
MD, Phoenix Children’s Hospital, 1919 E. Thomas,
Phoenix, AZ 85016; fax: 602-933-0222; email:
tshaw@phoenixchildrens.com.
Disclosure: Dr. Shaw has no relevant financial
relationships to disclose.
doi: 10.3928/00904481-20120727-13
result of these symptoms may be differ-
ent for each child and family. However,
the need for pain and symptom manage-
ment is clear. Good pain and symptom
control, especially in the last days and
weeks of life, can have a lasting posi-
tive impact on families; failure to achieve
good symptom control, on the other hand,
is associated with complicated grief and
bereavement.6,7 For most children, symp-
tom control can be achieved using stan-
dard dosing protocols with well-known
medications such as opioids and benzo-
diazepines.2 Klick and Hauer identify
several guiding principles for symptom
management, which are outlined in Side-
bar 1 (see page 330).
© 2012 iStockphoto.com
PAIN ASSESSMENT AND CONTROL
Assessment
Treatment of pain starts with its mul-
tifaceted assessment. For young or non-
verbal children, we often rely on the
caregiver’s report. Pain may manifest as
changes in behavior, irritability, or fa-
tigue. A complete pain history includes
namely: location of the pain; and then for
each site the quality, exacerbating/reliev-
ing factors, onset, associated symptoms,
temporal pattern, impact on daily life/
activities, and response to treatments.
An initial pain assessment should also
include a discussion of the child or fam-
ily’s history with pain, pain medications,
and what they perceive as barriers to

PEDIATRIC ANNALS 41:8 | JULY 2012 Healio.com/Pediatrics | 329


SIDEBAR 1.
Guiding Principles for
Symptom Management
• Partner with the child and family to
establish clear goals of therapy. Focus on
improved physical and psychosocial func-
tion, and decreased suffering.
• Recognize that emotional, spiritual, and
social suffering can significantly affect the
experience of symptoms.
• A child’s report of symptoms is the “gold
standard” of assessment. Parental report,
physiologic indicators, and behavioral
indicators are alternate assessments.
• Use developmentally appropriate com-
munication and assessment tools.
• Anticipate symptoms, respond to them
quickly, and re-evaluate the efficacy of
treatment often until the symptom distress
is resolved.
• Consider early referral to a pain or pallia-
tive care specialist for refractory symptoms.
Source: Klick JC, Hauer J1
good pain management. It is important to
understand that pain is a complex experi-
ence impacted not only by physical fac-
tors, but also psychological, social, spiri-
tual, and environmental factors as well.8
There are multiple pain assessment
tools for both verbal and nonverbal chil-
dren. Some common examples of pain
scales include the following: the Infant
FLACC tool (Face, Legs, Activity, Cry,
and Consolability) using behavioral ob-
servation for infants; the Faces Pain Scale
using visual images of faces representing
levels of pain for school age children;
and the Visual Analogue Scale using rat-
ing of a single line with descriptors of
pain at each end for children and adoles-
cents.9 Pain assessment guides the ongo-
ing treatment, as the goal is resolution of
pain. Thus, once a useful tool is picked
for an individual patient, that same tool
should be used to determine the efficacy
of the treatment; much like a blood sugar
level is rechecked to evaluate the effect
of the insulin dose prescribed. It is also
330 | Healio.com/Pediatrics
FEATURE
SIDEBAR 2.
Commonly Misunderstood Terms
• Addiction — compulsive behaviors of seeking out a drug despite adverse consequences or
self-harm. Extremely uncommon in patients receiving palliative care in the absence of a pre-
existing addiction disorder.
• Pseudoaddiction — behaviors such as clock-watching, loud moaning, or multiple requests for
pain medications that may be mistaken for addiction, but are actually a response to inadequate
pain control. Titration of medication to resolution of distress extinguishes this behavior.
• Tolerance — a physiologic need for increased dose of a drug to achieve the same clinical effect
due to receptor down-regulation.
• Dependence — a physiologic response of the body with long-term medication use, leading to
withdrawal if the medication is suddenly stopped, reversed, or if the dose is tapered too rapidly.
It is not the same as addiction and can be avoided by slowly tapering the medication.
Source: Weissman D10,11
important to remember that pain assess- Lane Handbook, are often sufficient for
ment tools should be used in the context mild to moderate pain, but titration may
of treatment, reassessment, and review of be needed for more severe pain.15 Medi-
other factors influencing pain. cation doses for severe pain should be ti-
trated until good pain control is achieved
Barriers to Pain Management or significant side effects are manifest.
Misconceptions and myths surround Side effects are the only limitation to dos-
the use of pain medications, creating ing for pure opioid medications, as op-
barriers to adequate pain control. Some posed to non-opioid medications, which
commonly misunderstood terms and usually have a clear upper limit. It is criti-
their meaning are reviewed in Sidebar 2. cal to keep in mind that the final goal is
Additional myths include disproportion- improved comfort.
ate fear of respiratory depression and has- Recommendations for pain manage-
tening death, or the belief that children do ment can be found in the World Health
not experience pain as much as adults Organization (WHO) guidelines. Basic
do.12,13 Adequate pain management does principles are outlined in Sidebar 3 (see
not hasten death, but on the contrary can page 331).16 New WHO guidelines have
improve and prolong the child’s quality eliminated step two medications (codeine
and even duration of life.14 and tramadol) moving from a three-step
ladder to a two-step approach. Due to
Treatment of Pain concerns about the safety, efficacy, and
The treatment of pain for a child with variable metabolism of codeine, its use is
a life-limiting condition depends on the no longer recommended. The guidelines
comfort of the child as reported by the called for additional research with trama-
child or family caregiver. Many times, dol to determine its safety and efficacy
control of pain can be achieved simply in children. The safety of using low dose
by using nonpharmacologic techniques, strong opioids, such as morphine, for
including positioning, distraction, appli- moderate pain was felt to be safer than
cation of heat and ice, as well as prescrib- use of the previous step two medications.
ing medications well-known to the pedia- The choice of which opioid to start de-
trician. Usual starting doses, as found in pends on factors such as severity and type
commonly used references, such as the of pain, medication history, preferred
drug dosing formulary in The Harriet route, and preferred schedule.
PEDIATRIC ANNALS 41:8 | JULY 2012

Morphine
Morphine is the WHO-preferred an-
algesic and is most frequently prescribed
world-wide for moderate to severe pain.
It has been well studied in children and
can be given by multiple routes includ-
ing oral, intravenous, subcutaneous, rec-
tal, peridural, and spinal.17 In addition,
morphine is inexpensive, readily avail-
able, and can be given in long-acting
form if needed. Morphine is metabo-
lized by the liver and excreted by the
kidney. Dose adjustment or use of an
alternate opioid should be considered in
the face of severe renal insufficiency or
failure since poor renal clearance leads
to buildup of toxic morphine metabo-
lites, resulting in irritability, myoclonus,
seizures, increased pain and rarely respi-
ratory depression.17
Oxycodone
Oxycodone is another commonly used
opioid. There is no intravenous prepara-
tion of oxycodone in the United States,
but long acting oral forms are available.
Compared to morphine, it has a slightly
longer half-life; for some patients every
6-hour dosing may be possible. In ad-
dition, it is more expensive and in some
settings may be less available than mor-
phine. The conversion ratio from mor-
phine to oxycodone is approximately
1-2:1, which means the equivalent daily
dose of oxycodone would be 50% to
100% of the daily morphine dose. 18
Clearance of oxycodone is also affected
by severe renal insufficiency or failure.19
Hydromorphone
Hydromorphone is 5 to 7.5 times more
potent than morphine,17,18 meaning much
lower does are needed to obtain the same
analgesic efficacy. Hydromorphone may
be administered by all routes other than
rectally. There is no long-acting form of
hydromorphone available for pediatric
use in the US. Hydromorphone is a good
alternative if morphine or oxycodone is
not well tolerated.
PEDIATRIC ANNALS 41:8 | JULY 2012
FEATURE
SIDEBAR 3.
WHO Principles of Pain
Management in Children
Analgesic Two-Step Approach pected for some duration of time.
Step 1 – Nonopioids (acetaminophen,
ibuprofen)
Step 2 – Opioids (morphine, oxycodone,
fentanyl, hydromorphone)
Consider adjuvant medications when ap-
propriate. an opioid-naïve child.
Principles of Pain Management
• By the clock: at a regular interval
• By the child: based on child’s pain level
and response to treatment
• By the appropriate route: use least inva-
sive route possible
WHO = World Health Organization.
Source: World Health Organization16
Fentanyl
Fentanyl is available in intravenous,
transdermal, intranasal, and transbuccal
routes and is useful in patients with renal
insufficiency or failure.18 The transder-
mal patch cannot be titrated quickly nor
does it give quick pain relief at time of
initiation due to its long half-life and slow
absorption, respectively. Other analgesic
medications, such as morphine or oxyco-
done should first be titrated to relief prior
to conversion to a transdermal patch for
chronic, stable pain control. Transbuccal
or intranasal routes can be used for acute
or breakthrough pain. These medication
delivery systems can be expensive and
are not widely available; therefore, use
of a complementary medication, such as
morphine, for breakthrough pain, is often
a reasonable option. Appropriate doses
must be calculated.
Methadone
Methadone is a long-acting, inexpen-
sive opioid. It is available as an oral and
parenteral medication and it acts on nu-
merous classes of pain receptors; it can
therefore be very useful in refractory,
SIDEBAR 4.
Dosing Tips for Opioids
• Consider scheduled medications, plus
breakthrough (prn) doses if pain is ex-
• The easiest and least invasive route is
always preferred.
• For infants less than 6 months of age,
decrease starting dose by 30%-50%.
• Consider lower end of starting doses for
• Rescue doses can be given for break-
through pain at 25%-50% of the scheduled
interval dose or (alternatively) 10% of the
total daily dose.
• If there is an indwelling IV catheter con-
sider using it. Subcutaneous administration
is an option for many medications if no
other route is possible.
• Avoid intramuscular dosing.
Source: Shaw TM
chronic, or neuropathic pain.1 Metha-
done should be prescribed carefully and
by an experienced practitioner. Frequent
communication with the patient must be,
especially in the first weeks of treatment,
until a stable regimen is reached. Consul-
tation with a pain or palliative care spe-
cialist is recommended for those unfamil-
iar with methadone and its side effects.
Correct Dosage
Starting doses for commonly used opi-
oids are outlined in the Table (see page
332), along with dosing tips in Sidebar
4. Changing from one opioid to anoth-
er to reduce the build-up of metabolites
(“opioid rotation”) can be accomplished
using equianalgesic dosing charts. Dos-
age calculations for opioid rotation can
be confusing because they account for
incomplete cross-tolerance, meaning that
the reduced efficacy of a medication over
time that is related to tolerance does not
translate completely to the new alternate
medication, rendering it more potent than
predicted when using the standard con-
version table. If a practitioner is inexpe-
rienced with this paradigm, consulting
Healio.com/Pediatrics | 331
 FEATURE

TABLE.
on patient response to treatment. Patient
monitoring should include assessment
Recommended Starting Doses for Opioids of vital signs and level of consciousness,
Drug Dosing Interval Starting Adult Doses as well as pain relief. Breathing may be
Morphine slowed when adequate pain control is
IV, SC 0.1 mg/kg/dose Every 2-4 h 2-6 mg achieved and should not be mistaken for
Oral 0.15-0.3 mg/kg/dose Every 4 h as scheduled 5-15 mg a medication’s side effect.1 Respiratory
Every 1 h as needed
depression caused by opioids will also
Oxycodone include an unexpected decreased level
Oral 0.1-0.2 mg/kg Every 4-6 h 5-10 mg
of consciousness. The use of naloxone
Hydromorphone to treat respiratory depression should be
IV, SC 0.02 mg/kg Every 2-4 h 0.5-1 mg
avoided as it may lead to an increase in
Oral 0.04-0.08 mg/kg Every 2-4 h 2-4 mg
pain and possibly even opioid withdraw-
Fentanyl
al. Usually holding or decreasing the opi-
IV 0.5-1 mcg/kg Every 1-2 h 25-50 mcg
Transdermal Convert from IV dose oid dose with close monitoring is effec-
tive in reversing respiratory depression in
IV = intravenous; SC = subcutaneous.
Data from Klick JC and Hauer J,1 Wolfe J,12 and Zernikow et al17 this setting.

with a pain or palliative care specialist
may be beneficial.
Combination medications, such as ac-
etaminophen with codeine or oxycodone
and acetaminophen with hydrocodone
should be used with caution, if at all, in
children. It is easy to exceed maximal
recommended doses of the acetamino-
phen and ibuprofen when using these.
Optimally, the nonopioid analgesic will
be prescribed concurrently but separately
from the opioid to ensure safe dosing of
each medication. In addition, use of hy-
drocodone in the pediatric population car-
ries concerns similar to codeine regarding
safety, metabolism, and efficacy.20
Side Effects of Opioids
Constipation
The most common side effect of opi-
oid treatment, constipation, should be
managed proactively. A bowel regimen
including a stool softener and an osmotic
or motility agent should be started at the
initiation of opioid treatment unless the
patient is experiencing diarrhea. As opi-
oid doses escalate, so must the intensity
of the bowel regimen.
Pruritis
Often mistaken for an allergic reac-
tion, pruritis is an expected side effect of
opioids due to their histamine releasing
properties; the itching usually resolves
within a few days of treatment initiation
or increased dosage.1 Treatment with di-
phenhydramine or hydroxyzine can be
helpful until resolution. If pruritis is se-
vere or refractory to treatment consider
rotating to another opioid.
Nausea and vomiting
Nausea and vomiting usually are tem-
porary symptoms occurring at the time of
initiation or escalation of opioid medica-
tion doses and can be treated with anti-
emetics until resolution. Sedatives such
as promethazine should be avoided if
possible.
Urinary retention
An uncommon side effect of opioid
treatment, urinary retention can be man-
aged with nonpharmacologic techniques
such as running water, manual pressure
on the bladder (Crede’s maneuver) or, if
needed, intermittent catheterization may
be used until resolution.
Respiratory depression
Though commonly feared, respira-
tory depression is a rare complication of
opioid treatment, particularly with ap-
propriate titration of medications based
Myoclonus
Myoclonus can be seen with higher
and longer term doses of opioids, due
to the build-up of neuroexcitatory meta-
bolic byproducts which can also lead to
seizures and personality changes. The
appearance of such side effects should
prompt consideration of opioid rotation,
as described above.
Adjuvant Medications
A pain assessment may reveal differ-
ent types of pain such as nociceptive as
well as neuropathic pain; the latter is dis-
tinguished by its associated sensations of
shooting pain, burning, or allodynia (non-
painful stimuli, such as light touch result-
ing in pain perception). Adjuvant medi-
cations, in conjunction with opioids, can
be useful for the treatment of neuropathic
pain. Some common adjuvant medica-
tion classes include: anti-inflammatories;
antidepressants (particularly tricyclics);
anticonvulsants (commonly gabapentin);
steroids; and muscle relaxants.
Nonpharmacologic Treatments
Pain management should include an
integrated strategy of medications as
well as nonpharmacologic therapies or
techniques. These strategies may include
biofeedback, guided imagery, hypnosis,

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massage, acupuncture, herbals, or art
therapy. Fifty-nine percent of parents
whose children have cancer reported
using complementary therapies.21 The
evidence for these therapies is still be-
ing explored, but appears to have benefit
for some patients. Most clinicians en-
courage the use of complementary tech-
niques unless there is evidence of harm
to the patient, to the family’s budget, or
in the literature. Their use often enables
the parents to feel they are meaningfully
contributing to the child’s well-being.
Therefore, care plans should be devel-
oped based on individual response and in
partnership with the family.
In addition, it is important to consider
that psychosocial distress or other envi-
ronmental factors may play a role in pain
generation. Recognition and discussion
of these factors can result in significant
benefit with few side effects. Interdis-
ciplinary care team members such as
psychologists, psychiatrists, counselors,
spiritual leaders, or social workers may
be helpful in this regard.
OTHER SYMPTOMS
Respiratory Symptoms
Dyspnea is one of the most common
respiratory symptoms among children
with life-limiting conditions, especially
at the end of life. The treatment of dys-
pnea often requires an interdisciplinary
approach and the use of relaxation tech-
niques and deep breathing, distraction, or
hypnosis. First line medication treatment
of nonspecific dyspnea from an irrevers-
ible condition includes scheduled opioid
medications, with one-quarter to one-half
oral starting doses for pain.1,12 Patients
with dyspnea who are already receiving
opioids for pain control will, of course,
need higher doses and should not be re-
verted to starting doses. Administering
opioids for breathing distress often fright-
ens both families and health care provid-
ers due to the association of opioids with
respiratory depression.
Recent evidence has shown both
PEDIATRIC ANNALS 41:8 | JULY 2012
FEATURE
safety and efficacy for the use of these
medications.12 Benzodiazepines can also
be considered in the treatment of dyspnea
and can be helpful if there is associated
anxiety or agitation.18 Oxygen can be
considered for patients with hypoxia. A
fan blowing on the face is also effective
for managing the sensation of breathless-
ness, based on its stimulation of the V1
branch of the facial nerve. Anticipatory
education of families about end-of-life
It is important to consider
that psychosocial distress or
other environmental factors
may play a role in pain
generation.
changes in respiratory patterns (apnea, ir-
regular breathing rates, and noisy breath-
ing) can help alleviate their distress.
Secretion Control
Secretions are another common re-
spiratory problem, often presenting well
before end of life in children with se-
vere neurologic impairment. Excessive
or poorly controlled salivary secretions
can be managed chronically with medi-
cations such as anticholinergic agents,
glycopyrrolate, or the use of a suction
machine.1 Management can include edu-
cating the family, a reduction of artificial
fluid intake, and in long term settings,
possibly the use of botulinum toxin in
the gland itself.22
Gastrointestinal Symptoms
Nausea, vomiting, anorexia, constipa-
tion, and diarrhea are all common symp-
toms that may be disease-related or a side
effect of treatments.23 Management of
these symptoms is directly related to the
presumed cause, with an effective treat-
ment plan based on a good history, exam,
and review of current medications.
Antiemetics are targeted at specific re-
ceptors and mechanisms; they should be
chosen based on the underlying reason for
the nausea. For example, ondansetron, a
serotonin receptor antagonist, works well
for nausea caused by chemotherapeutic
and anesthetic agents. For opioid-induced
nausea, dopaminergic (eg, haldoperidol),
anticholinergic (eg, scopolamine), or pro-
kinetic (eg, metoclopramide) agents may
be more effective. Benzodiazepines (eg,
lorazepam) are helpful when anxiety is
contributing to nausea.23 If the antiemetic
medication chosen is ineffective in reliev-
ing symptoms, a second antiemetic with a
different mechanism of action should be
either added or substituted to the current
regimen.1
Constipation is another common
symptom.1,23 Medications used to treat
constipation fall into three categories:
stool softeners, osmotic agents, and stim-
ulants. Stool softeners, such as docusate,
are usually ineffective when used alone
for this population; a stool softener plus
either an osmotic agent or stimulant is
indicated. Osmotic agents include poly-
ethylene glycol 3350, lactulose, and mag-
nesium sulfate. Stimulant medications in-
clude senna or bisacodyl.
Appetite Changes
Redirecting the parent to focus on pro-
viding companionship and love, rather
than food, and offering anticipatory guid-
ance as appetite, physical activity, and
metabolic activity typically decrease can
be helpful. Earlier in the course of ill-
ness, high calorie supplements or phar-
macologic therapy may be of benefit. In
the case of early satiety, small frequent
meals may be appropriate and if the taste
of food is altered by the illness or its treat-
ment, soliciting the child’s preferences
can lead to improved nutritional intake. It
is important to exclude remediable causes
of decreased appetite, such as pain, nau-
sea, and depression.23 Many children
with profoundly debilitating neurologic
conditions are dependent on medically
Healio.com/Pediatrics | 333

administered enteral feedings through-
out their lives. At the end of life, it is the
normal course of most conditions to have
loss of appetite and intolerance of feed-
ing.24 Continuing artificial hydration and
nutrition at this point may worsen symp-
toms.12,25 How this is addressed may de-
pend on the family’s beliefs and goals.
Mood Lability
Anxiety, depression, insomnia, and ag-
itation are symptoms typically associated
with psychosocial or spiritual distress, in
addition to underlying physical causes.
Their management often benefits from an
interdisciplinary approach and nonphar-
macologic treatments. Reversible medical
causes, such as pain, and medication side
effects should be investigated as well.26
Selective serotonin reuptake inhibitors
(SSRIs) can be helpful for depression and
anxiety, but must be taken for 4 to 6 weeks
before they reach their full effectiveness.
For children at end of life with only days
or weeks remaining, more immediate
acting medications should be considered
such as benzodiazepines and haloperidol
for anxiety and agitation;26 psychostimu-
lants have been used in adult patients for
rapid resolution of depression and asthe-
nia in the palliative setting and may be
beneficial in children as well.27
Fatigue Management
Fatigue can be related to disease pro-
cess, treatments, medications, nutrition,
anemia, pain, depression, anxiety, or
other causes. Other than with reversible
causes such as anemia, fatigue is very
difficult to treat. Structuring activities to
include rest time may be helpful.
CONCLUSION
The pediatrician is at the front line of
symptom assessment and management
for children living with life-limiting con-
334 | Healio.com/Pediatrics
FEATURE
ditions, starting from time of diagnosis
and extending all the way to the end of
life. With just a few basic tools, the pe-
diatrician can help prevent and manage
many symptoms that may be experienced
by these children and families. For symp-
toms that are difficult to control, consider
consulting a physician who specializes in
pain or palliative care.
REFERENCES
1. Klick JC, Hauer J. Pediatric palliative care.
Curr Probl Pediatr Adolesc Health Care.
2010;40(6):120-151.
2. Drake R, Frost J, Collins JJ. The symptoms
of dying children. J Pain Symptom Manag.
2003;26(1):594-603.
3. Pritchard M, Burghen E, Srivastava DK, et.
al. Cancer-related symptoms most concerning
to parents during the last week and last day of
their child’s life. Pediatrics. 2008;121(5):e1301-
1309.
4. Wolfe J, Grier HE, Klar N, et. al. Symptoms and
suffering at the end of life in children with can-
cer. N Engl J Med. 2000;342(5):326-333.
5. Theunissen JM, Hoogerbrugge PM, van Achter-
berg T, Prins JB, Vernooij-Dassen MJ, van den
Ende CH, Symptoms in the palliative phase of
children with cancer. Pediatr Blood Cancer.
2007;49(2):160-165.
6. Contro N, Kreicbergs U, Reichard RW, Sourkes,
B. Anticipatory Grief and Bereavement. In:
Wolfe J, Hinds P, Sourkes B, eds. Textbook of In-
terdisciplinary Pediatric Palliative Care. Phila-
delphia: Elesvier Press; 2011:41-54.
7. McCarthy M, Clarke N, Ting C. Conroy R,
Anderson V, Heath J. Prevalence and predic-
tors of parental grief and depression after the
death of a child from cancer. J Palliat Med.
2010;13(11):1321-1326.
8. McSherry M, Kehoe K, Carroll JM, Kang TI,
Rourke MT. Psychosocial and spiritual needs of
children living with a life-limiting illness. Pedi-
atr Clin N Am. 2007;54(5):609-629, ix-x.
9. Franck L, Greenberg C, Stevens B. Pain assess-
ment in infants and children. Pediar Clin N Am.
2000;47(3):487-512.
10. Weissman, D. Is it pain or addiction?, 2nd ed.
Fast Facts and Concepts #68. EPERC website.
Available at: www.eperc.mcw.edu. Accessed
July 3, 2012.
11. Weissman, David. Pseudoaddiction, 2nd ed.
Fast Facts and Concepts #69. EPERC website.
Available at: www.eperc.mcw.edu. Accessed
July 3, 2012.
12. Wolfe J. Easing Distress When Death is Near.
In: Wolfe J, Hinds P, Sourkes B. Textbook of In-
terdisciplinary Pediatric Palliative Care. Phila-
delphia: Elsevier Press; 2011:284-310;368-384.
13. Gregoire MC, Frager G. Ensuring pain relief
for children at the end of life. Pain Res Clin
2006;11(3):163-171.
14. Friedrichsdorf SJ. Pain management in children
with advanced cancer and during end-of-life
care. Pediatr Hematol Oncol. 2010;27(4):257-
261.
15. Tschundy M, Arcara K. John Hopkins Hospital
The Harriet Lane Handbook, 19th ed. Philadel-
phia, PA. Elsevier; 2012.
16. World Health Organization. Pharmacological
Treatment Strategies. In: Persisting pain in chil-
dren package: WHO guidelines on the pharma-
cological treatment of persisting pain in children
with medical illnesses. WHO 2012.
17. Zernikow B, Michel E, Craig F, Anderson
BJ. Pediatric palliative care: use of opioids
for the management of pain. Paediatr Drugs.
2009;11(2):129-151.
18. Watson M, Lucas C. Hoy A, Back I. Oxford
Handbook of Palliative Care. New York: Ox-
ford Press; 2005:191-195;520-533.
19. Hain RD, Miser A, Devins M, Wallace WH.
Strong opioids in pediatric palliative medicine.
Paediatr Drugs. 2005;7(1):1-9.
20. Madadi P, Hildebrandt P, Gong I, et al. Fatal
hydrocodone overdose in a child: pharma-
cogenetics and drug interactions. Pediatrics.
2010;126:e986.
21. Post-White J, Fitzgerald M, Hageness S, Sencer
SF. Complementary and alternative medicine
use in children with cancer and general and
specialty pediatrics. J Pediatr Oncol Nurs.
2009;26(1):7-15.
22. Little SA, Kubba H, Hussain SS. An evidenced-
based approach to the child who drools saliva.
Clin Otolaryngol. 2009;34(3):236-239.
23. Santucci G, Mack JW. Common gastrointesti-
nal symptoms in pediatric palliative care: nau-
sea, vomiting, constipation, anorexia, cachexia.
Pediatr Clin N Am. 2007;54(5):673-689.
24. Siden H, Tucker T, Derman S, et al. Pediatric
enteral feeding intolerance: a new prognostica-
tor for children with life limiting illness. J Palliat
Care 2009;25(3):213-217.
25. Wagner B, Ersek M, Riddell S. HPNA position
statement: artificial hydration and nutrition in
end of life care. Available at: www.hpna.org.
Accessed July 6, 2012.
26. Wusthoff CJ, Shellhaas RA, Licht DJ. Manage-
ment of common neurologic symptoms in pedi-
atric palliative care: seizures, agitation, and spas-
ticity. Pediatr Clin N Am. 2007:54(5):709-733.
27. Homsi J, Walsh D, Nelson KA. Psychostimu-
lants in supportive care. Support Care Cancer.
2000:8(5):385-397.
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