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Several years after the introduction of morphine for pain control, its use in pediatrics is limited by the fear of side effects. "Titration" represents a new way of management with a faster pain relief, and low risk of narcotic induced complication, the doses of morphine being self limited to the minimal pain relieving dosage. It consists in administering small doses of morphine every few minutes (10 in intravenous treatment or 30 orally) until total disappearance of pain; the total amount necessary for four hours is the sum of the initial dose and all the additional doses.

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Stomatodynia is a difficult disease for both patients and clinicians. When facing true stomatodynia, i.e., idiopathic burning mouth, patients are offered poorly effective treatment. This open study reports the results of local application of clonazepam (0.5 or 1 mg) two or three times daily in 25 subjects who suffered from idiopathic stomatodynia. At the first evaluation, 4 weeks after the beginning of treatment, a visual analogue scale (VAS) that represented the intensity of pain decreased significantly from 6.2 +/- 0.3 to 3.0 +/- 0.5. At the second evaluation, 3 to 29 months after the first consultation, the VAS scores dropped significantly further to 2.6 +/- 0.5. Analysis of the individual results showed that 10 patients were totally cured and needed no further treatment, 6 patients had no benefit at all, and the remaining 9 patients had some improvement but were not considered to be cured since they did not wish to stop the treatment. Blood level tests that were performed 1 and 3 hours after the topical application revealed the presence of small amounts of the drug (3.3 ng/mL +/- 0.66 and 3.3 ng/mL +/- 0.52, respectively). The hypothesis that clonazepam acts locally to disrupt the neuropathologic mechanism that underlies stomatodynia is proposed. The risk factors that are recognized for this condition could decrease the density and/or ligand affinity of peripheral benzodiazepine receptors. This, in turn, could cause spontaneous pain from the tissues concerned.

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All patients with cancer invariably experience pain during the course of their disease. Treatment- and diagnosis-related acute pain and persistent pain caused by the disease itself or treatment sequellae are involved. Pain should be suspected, diagnosed and evaluated as a first line symptom. The physician should recognized its different components and pathophysiological mechanisms. Treatment should be prescribed according to the needs of each patient and regularly verified to obtain maximal efficacity with the least side effects. Opiate drugs are frequently used for nocipeptive pain. Neurogenic pain requires selective use of psychotropes.

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BACKGROUND: Lumbar puncture is a common procedure in pediatric onco-hematology. Repeated invasive painful procedures may contribute to increase distress displayed during medical treatment, and cause regression, depression and other psychological disorders. MATERIAL AND METHODS: A two-year workshop of the Société française d'oncologie pédiatrique was reviewed through a questionnaire assessing changes in technical management of lumbar puncture, local anesthesia, sedation and cognitive-behavioral interventions. RESULTS: Significant changes were found for pain assessment, local anesthesia procedures, and nitrous oxide administration. The extensive use of the Emla cream largely contributed to reduce pain. Anxiety however remained an unsolved problem, particularly among young children. CONCLUSION: Pain in pediatrics remains a major challenge. This workshop is a model of reflexion to achieve a better management of pain during invasive medical procedures.

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Most children with cancer will experience pain during their illness, whether it may be cured or not. They may suffer from acute pain related to treatments or to invasive procedures, or from prolonged pain due to the evolution of cancer or sequellae of treatment. Pain must be considered as a major symptom and must be suspected, diagnosed and evaluated. Physicians have to analyse the different components, the physiopathologic data, and causes of pain. Treatments have to be prescribed, adjusted to each patient and monitored in conformity with rigorous guidelines in order to obtain the best analgesic efficacy and the lowest side effect levels. The use of opioids is frequent and their doses are higher as those used in adults. Neuropathic pain is frequent in children suffering from cancer and requires treatment by means of antidepressant drugs if clinical signs of neuropathic pain are predominant.

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All cancer patients will inevitably experience pain during their illness, whether it is cured or not: acute pain induced by the treatment and examinations required for diagnosis; chronic pain associated with the evolution of the disease or sequelae caused by treatment. These pains must be treated imperatively as accompanying symptoms. The practitioner should be able to analyse the components, the physiopathological, the cause(s) and the way in which they occurred. Treatment will then be prescribed, adapted and monitored according to stringent criteria so that optimal efficacy is achieved with a minimum of side effects.

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To assess the contribution of pharmacological tolerance to increasing doses of morphine, 29 cancer patients requiring oral morphine to treat pain were studied by two teams working independently. The first team assessed physical impairment, pain intensity and pain treatment. The second team assessed depressive disorders (DSM III criteria), emotional and behavioural depressive patterns (Retardation Depressive Scale, Polydimensional Mood Scale). All patients were seen at the initiation of morphine therapy and followed to the first morphine dose modification. Evaluations were carried out in out-patient clinics except staging investigations which were undertaken at the beginning and at the end of the study. Our results showed that (1) in 24 of the 25 patients for whom morphine doses were increased, progressive disease was recorded; (2) in 4 patients, morphine doses were not increased and in these patients their disease was stable or in remission; and (3) changes in depressed mood were not correlated with pain intensity. These data strongly suggest that, instead of pharmacological tolerance, the main factor resulting in increasing oral morphine requirement in cancer pain management is pain increase due to disease progression.

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