Marie-Claude Grégoire

Frequency and self-management of pain, dyspnea, and cough in cystic fibrosis.

Cystic fibrosis (CF) has been transformed from a fatal diagnosis in infancy to a chronic disease of children and young adults. Symptom patterns and disease burden in CF may be shifting to reflect the relatively healthier, older population with the disease. Self-management of symptoms is a hallmark of chronic illness, and yet we do not have a good understanding of how CF patients monitor or manage their symptoms. Children and adults were recruited through clinics in three Canadian provinces. Questionnaires with open-ended and close-ended questions in English and French, designed to assess the frequency, severity, and self-management of pain, breathlessness, and cough, were mailed to all the eligible participants. One hundred twenty-three respondents completed the survey, for a response rate of 64%. Eighty-four percent (103 of 123) of participants reported having pain. They reported an average of 2.1 locations of pain, with headache and abdominal pain most frequently described. Sixty-four percent (76 of 123) of participants reported having breathlessness, and 83% (99 of 123) of participants reported experiencing cough. Sixty-three percent (62 of 99) of participants with cough reported that cough always or sometimes interfered with their sleep. A variety of pharmacological and nonpharmacological treatments were used to manage symptoms. Pain and dyspnea are more common than suspected and a wide variety of pharmacological and nonpharmacological measures are used to treat symptoms. Cough is difficult to assess, but disturbed sleep may be an indicator of cough severity and an important symptom to consider when evaluating the overall burden of illness in those with CF.

Drugs for Chronic Pain in Children: A Commentary on Clinical Practice and the Absence of Evidence

Pediatric chronic pain is widespread, under-recognized and undertreated. Best management usually involves a multimodal approach coordinated by a multidisciplinary team. The present commentary specifically discusses common pharmacological approaches to chronic pain in children, identifies gaps in knowledge and suggests several research directions that would benefit future clinical care.

Ensuring Pain Relief for Children at the End of Life

Pain management in the context of pediatric palliative care can be challenging. The present article reviews, through a case-based presentation, the nonpharmacological and pharmacological methods used to ensure adequate pain control in children facing end of life. Details on the impressive range of opioid dosages required and routes of administration are highlighted from published literature and clinical experience. Where available, evidence-based recommendations are provided. Potential side effects of pain medication and barriers to good pain control are discussed. Novel analgesics and innovative delivery methods are presented as future tools enhancing pain relief at the end of life. Some challenges to ethically grounded research in this important context of care are reviewed.

Doctor, I think my baby is in pain: the assessment of infants' pain by health professionals

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Development and Implementation of a Survey to Assess Health-Care Provider’s Competency, Attitudes, and Knowledge About Perinatal Palliative Care

Perinatal palliative care is an emerging area of health care. To date, no published tools assess health-care provider’s knowledge and level of comfort in providing such care. A 2-phase study was undertaken to develop and implement a survey to evaluate the self-assessed competency, attitudes, and knowledge of health-care providers working in perinatal palliative care. Phase 1 included a review of the literature and appraisal of palliative and death-related instruments to inform the initial draft of the Perinatal Palliative Care Survey (PPCS). Twenty-four Canadian pediatric palliative care specialists critiqued the PPCS, establishing its face and content validity. Phase 2 involved administering the PPCS at 4 sites across Canada, resulting in 167 responses from nurses, physicians, and midwives. The majority of participants responded that they possessed a degree of comfort in providing perinatal palliative care, particularly with assessing pain (76%), managing pain (69%), assessing other symptoms (85%), and managing other symptoms (78%). Two areas where participants level of confidence or extreme confidence was diminished included having conversations with families about the possibility of their infant dying (55%) and knowing and accessing community palliative care resources (32%). Responses in the knowledge section identified gaps related to opioid use, pharmacological interventions for breathlessness, pain behaviors, and tolerance developed to opioids and sedatives. Eighty-six percent of respondents stated that if education about palliative care was made available, they would participate with priority topics identified as communication with families (75%), managing symptoms (69%), pain management (69%), and ethical issues (66%). The PPCS provides a useful assessment to determine the educational needs of health-care providers delivering perinatal palliative care.

Ketamine: We need to continue to advocate against scheduling

In the midst of a busy medical practice in Canada, it is easy to forget that access to postoperative pain relief has not always been universal in our country. In this issue of the Journal, Tuchscherer et al. remind us that most patients in developed countries take certain entitlements for granted, which, unfortunately, are far from accessible to all. Their study explored the potential use of subcutaneous ketamine for pain following major surgery in Rwanda; their results showed that ketamine appears to be safe within the range of doses studied. Inadequate postoperative pain management in Rwanda and other low-income countries (LICs) has multiple causes, but one important factor is restricted access to analgesic medications, especially opioids. In the context of limited access to opioids, monitoring equipment (e.g., pulse oximeters), and insufficient personnel, ketamine becomes the natural choice of medication to treat postoperative pain. Ketamine has been used clinically for more than 50 years, its pharmacokinetics are well understood, and its safety and side effect profile are well studied. There is an abundance of experience using this medication, even in more vulnerable populations such as children. What is critical about Tuchscherer et al.’s study is how they used ketamine in the context of very limited resources. They specifically chose the subcutaneous route to avoid the use of an expensive pump and the need for highly trained staff. They used a standard initial dose to simplify the dosing protocol, and they changed doses based on a simple treatment algorithm. The authors note that the cost per injection of subcutaneous ketamine is Can

Opioids for cancer‐related pain in children and adolescents

0.40. To put this cost in context, the average the Rwandan’s hourly salary in 2012 was 450 Rwandan francs (Can

Non‐steroidal anti‐inflammatory drugs (NSAIDs) for cancer‐related pain in children and adolescents

0.75). The use of ketamine represents a creative, apparently safe, efficacious, and inexpensive treatment for postoperative pain, which is clinically relevant and feasible in Rwanda’s current financial landscape. As described by Marcel Durieux in his editorial, ‘‘We need to listen to the providers and governments in lowand middle-income countries. It’s not for the Goose to decide what is good for the Gander.’’ Medical research on issues in LICs, such as Tuchscherer et al.’s study, provides an excellent way to identify strategies for solutions that will address local needs. Despite its limitations, their study could drastically change how postoperative pain is treated in LICs and could improve access to pain relief for thousands of people. Their methodology could be extended to other areas of undertreated pain in the context of limited access to opioids, e.g., cancer-related pain or palliative and end-of-life care. If this scenario were part of a Hollywood movie, this would likely be where the happy story would end. Unfortunately given its use, or abuse, as a recreational drug, the United Nations (UN) is under pressure to classify ketamine as a Schedule 1 psychotropic substance. Under the Convention on Psychotropic Substances, 1971, Schedule 1 substances present a high risk of abuse, pose a threat to public health, and are of very little or no therapeutic value. China has been leading the request for scheduling, as ketamine abuse is particularly frequent there. Adding ketamine to the list of Schedule 1 substances would have a devastating impact on how M.-C. Grégoire, MD, MSc, FRCPC Department of Pediatrics, Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada