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Managing Painful Procedures in Children With Cancer

Marilyn J. Hockenberry, PhD, RN-CS, PNP, FAAN,* Kathy McCarthy, BSN, RN,*
Olga Taylor, MPH,* Meredith Scarberry, MS,* Quinn Franklin, MS, CCLS,w

Chrystal U. Louis, MD, MPH,* and Laura Torres, MDz

Summary: Children with cancer experience repeated invasive and
painful medical procedures. Pain and distress does not decrease with
repeated procedures and may worsen if pain is not adequately
managed. In 1990, the first recommendations on the management of
pain and anxiety associated with procedures for children with cancer
were published. Guiding principles described in the recommenda-
tions continue to hold true today: maximize comfort and minimize
pain, use nonpharmacologic and pharmacologic interventions,
prepare the child and family, consider the developmental age of
the child, support family and child involvement, assure provider
competency in performing procedures and sedation, and use
appropriate monitoring to assure safety. This article reviews these
key components for managing painful procedures in children and
reviews the latest pharmacological and nonpharmacological inter-
ventions most effective in minimizing pain and discomfort.

Key Words: procedures in children with cancer, procedure sedation,

managing bone marrow aspirations with sedation, managing

lumbar punctures with sedation

(J Pediatr Hematol Oncol 2011;33:119–127)

There is evidence to support that pain and distress doesnot decrease with repeated procedures and may worsen
if pain is not adequately managed.1,2 In 1990, the first
recommendations on the management of pain and anxiety
associated with procedures for children with cancer were
published by the American Academy of Pediatrics.1

Guiding principles described in the recommendations
continue to hold true today:

� Maximize comfort and minimize pain. The ideal goal for
procedure pain management is to make the experience as
comfortable as possible for the child and parents.
� Use nonpharmacologic and pharmacologic interventions.
Nonpharmacologic interventions like cognitive-behavioral
interventions (CBI) should be taught to every child who is
developmentally able to use these strategies to decrease
anxiety and distress. Pharmacologic therapies are safe and
effective when carefully administered and monitored by
appropriately trained personnel.
� Prepare the child and family. The key to managing
procedure-related pain and distress is preparation and
education. Parents and children should receive appro-
priate information regarding what to expect before, dur-

ing, and after the procedure. Stress reducing techniques
can be taught for use before, during, and after procedures.
� Consider the developmental age of the child. The child’s
cognitive development provides the foundation for esta-
blishing standards of care for children undergoing pain-
ful procedures.
� Support family and child involvement. Families should
be involved in choices offered for pharmacologic and
nonpharmacologic therapies.
� Assure provider competency in performing procedures
and sedation. Procedures must be performed by persons
with technical expertise or by providers directly super-
vised by experts.
� Use appropriate monitoring to assure safety. Sedation
and anesthesia should be administered in a monitored
setting with immediately available resuscitative drugs and

Key components to managing painful procedures in
children with cancer include effective parent teaching and
education, appropriate preparation for the procedure for
both parent and child, and optimal analgesia and sedation.
This article provides a review of child and family preparation
for painful procedures and a review of the latest pharmaco-
logical and nonpharmacological interventions most effective
in minimizing pain and discomfort.


Children and their families should be prepared before
the procedure and well supported during and after painful
procedures.4,5 By first establishing rapport with the child and
family, the clinician is able to assess the family’s knowledge
of the procedure, expectations, and preferred learning style.5

This assessment should include discussion of the child’s
developmental level, coping strategies, and previous experi-
ences with procedures that can greatly impact his/her anxiety
level.2,4 Table 1 provides a developmental overview of
important aspects to consider when preparing children of
all ages and their families for painful procedures.

Inclusion of child life programs in pediatric settings has
become widely accepted and advocated by the American
Academy of Pediatrics.6 With expertise in child development,
child life specialists (CLS) promote effective coping and
adjustment during potentially stressful situations through
play, psychological preparation, education, and support. CLS
prepare children psychologically for medical procedures and
events to increase their sense of mastery, reduce anxiety, and
plan and rehearse coping strategies. Psychological prepara-
tion is patient focused and is defined as a “process of
communicating accurate and developmentally appropriate
information, identifying potential stressors, as well as
planning and practicing coping strategies.”6Copyright r 2011 by Lippincott Williams & Wilkins

Received for publication April 9, 2010; accepted July 9, 2010.
From the *Pediatric Hematology Oncology, Baylor College of

Medicine, Texas Children’s Cancer Center; wEvidence-Based
Outcomes Center; and zAnesthesiology, Texas Children’s Hospital,
Houston, TX..

Reprints: Marilyn J. Hockenberry, PhD, RN-CS, PNP, FAAN, Texas
Children’s Hospital, 6621 Fannin St, Houston TX 77030 (e-mail:
[email protected]).


J Pediatr Hematol Oncol� Volume 33, Number 2, March 2011 | 119

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Whether taught by a CLS or nurse, educational
preparation for the procedure emphasizes sensory aspects
of the procedure: what the child will feel, see, hear, smell,
and touch and what the child can do during the procedure
(eg, lie still, count out loud, squeeze a hand, hug a doll).
Allow for ample discussion during educational preparation
to prevent information overload and confusion and ensure
satisfactory feedback. Allow the child to practice proce-
dures and be comfortable with the sequence of events that
will require cooperation (eg, deep breathing). Teaching
dolls are frequently used to help children understand where
on the body the procedure will be performed. Allowing the
child choices when possible and empowering the child by
giving them specific roles or jobs during the procedure
decreases fear and anxiety. Emphasize that the procedure
will end quickly and stress any pleasurable events afterward
(eg, going home, seeing parents). Provide a positive ending,
praising efforts at cooperation and coping.

Like the child, parents also experience high levels of
stress during procedures, and their anxiety does not
decrease during treatment. However, parent anxiety levels
can be minimized when the child is adequately prepared.7–9

Several studies report a positive impact on parental distress
and satisfaction and no difference in technical complica-
tions when parents remain with children.8,10,11

CBI are techniques intended to alter the procedure

experience by changing the child’s thoughts through

attention diversion, images, and self-determina-
tion.1,2,7,11–19 Examples of common CBI strategies used
with children with cancer include distraction through music
or other pleasant diversions, story telling, deep breathing,
relaxation, guided imagery, massage, and yoga. CBI
techniques are known to decrease anxiety and discomfort
during painful procedures 1,2,12–19 and a variety of
techniques are available to facilitate the child and family’s
coping during the procedure (Table 2). Distraction involves
concentrating on an event or object other than the pain.
Distraction is a powerful coping strategy during painful
procedures.20 Infants and toddlers are easily distracted
because of their short attention span. Distraction is
accomplished by focusing the child’s attention on some-
thing other than the procedure. Singing favorite songs,
listening to music with a headset, counting aloud, or
blowing on a magic wand are effective techniques.

Older children can be distracted with activities such as
video games, television, and music. Guided imagery works
well with school-aged children and adolescents who can
visualize an enjoyable experience or pleasant memory. The
child describes the event in detail as he or she visualizes it.
The child describes details of the event, including as many
senses as possible (eg, “feel the cool breezes,” “see the
beautiful colors,” “hear the pleasant music”). The child
concentrates only on the pleasurable event during the painful
time by enhancing the image, often by reading a script or
playing a tape. The effectiveness of this method is enhanced
by the use of a coach. The coach may be a parent or other
adult who discusses the event with the child and keeps the

TABLE 1. Preparation for Procedures and Development

Infant Toddler/Preschooler School Age Adolescent

Involve parent in procedure
if desired.

If parent is unable to be
with infant, place familiar
object with infant (eg,
stuffed toy).

Have usual caregivers
perform or assist with

Make advances slowly
and in a
nonthreatening manner.

Limit number of
strangers entering room
during procedure.

During procedure use
sensory soothing measures
(eg, stroking skin, talking
softly, giving pacifier).

Cuddle and hug infant
after stressful procedure;
encourage parent to comfort

Perform painful
procedures in a separate
room, not in crib (or bed).

Use same approaches as for
infant, plus the following.

Explain procedure in relation
to what child will see, hear,
taste, smell, and feel.

Use play; demonstrate on doll
but avoid child’s favorite doll.

Emphasize those aspects of
procedure that require cooperation
(eg, lying still).

Tell child it is okay to cry, yell,
or use other means to express
discomfort verbally. Expect
treatments to be resisted; child
may try to run away.

Use firm, direct approach.
Ignore temper tantrums.
Use a few simple terms familiar
to child.

Give child one direction
at a time (eg, “lie down,” then
“hold my hand”).

Prepare child shortly or
immediately before procedure.

Keep teaching sessions short
(about 5-10min).

Tell child when procedure
is completed.

Allow choices whenever possible
but realize that child may still
be resistant and negative.

Allow child to participate in care
and to help whenever possible.

Explain procedures using
correct medical terminology.

Explain procedure using

diagrams and photographs.
Discuss why procedure is

necessary; concepts of illness
and bodily functions are
often vague.

Explain function and

of equipment in concrete

Allow child to manipulate
equipment; use doll or
another person as model to
practice using equipment

Allow time before and after
procedure for questions
and discussion.

Plan for longer teaching
sessions (about 20min).
Prepare up to 1 day in
advance of procedure to
allow for processing of

Include child in decision
making when possible
(eg, time of day to perform
procedure, preferred site).

Encourage active

Discuss why procedure is
necessary or beneficial.

Explain long-term
consequences of procedures;
include information about
body systems working

Encourage questioning
regarding fears, options,
and alternatives.

Provide privacy; describe how
the body will be covered and
what will be exposed.

Discuss how procedure may
affect appearance (eg, scar)
and what can be done to
minimize it.

Emphasize any physical
benefits of procedure.

Involve adolescent in decision
making and planning.

Impose as few restrictions
as possible.

Explore what coping strategies
have worked in the past;
they may need suggestions
of various techniques.

Accept regression to more
childish methods of coping.

Hockenberry et al J Pediatr Hematol Oncol� Volume 33, Number 2, March 2011

120 | r 2011 Lippincott Williams & Wilkins

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image alive during the procedure. Muscle relaxation is
another CBI that is useful in children and adolescents. The
child is asked to take a deep breath and “go limp as a rag
doll” while exhaling slowly; then ask child to yawn. Begin
progressive relaxation by starting with the toes, and system-
atically instructing the child to let each body part “go limp”
or “feel heavy”; if child has difficulty relaxing, instruct child
to tense or tighten each body part and then relax it. The child
can keep eyes open, as children may respond better if eyes
are open rather than closed during relaxation.

As parent participation plays a major role in reducing
a child’s anxiety associated with procedures,4,5 when
possible, parents should have the option to remain with
their child during the procedure and be involved in the CBI
techniques used.

There are 3 main categories of sedation used for

painful procedures: minimal sedation, moderate sedation,
and deep sedation/general anesthesia. CBI should be used
in combination with sedation/analgesic agents. Table 3
provides a brief description of each sedation category.

Minimal Sedation
Children receiving minimal sedation are able to

respond to verbal commands; airway, spontaneous ventilation,

and cardiovascular function are unaffected.3 This type of
sedation is achieved by administering agents to treat
symptoms of anxiety (Table 4). The benefits of anxiolytic
therapy should be carefully considered as there are side
effects including paradoxical effects resulting in agitation.
It remains important to work with each child, using CBI
during their procedure so they develop coping skills over
time. Once the child’s anxiety lessens, nonpharmacologic
interventions may become sufficient and anxiolytics may no
longer be needed.

Moderate Sedation
Moderate sedation is a drug-induced depression of

consciousness during which the patient responds purposefully
to verbal command, either alone or accompanied by light
tactile stimulation.3 Usually no interventions are necessary to
maintain a patent airway. Spontaneous ventilation is
adequate and cardiovascular function is maintained. Numer-
ous studies report midazolam, fentanyl, and ketamine as safe
and effective agents for moderate sedation for painful
procedures in children with cancer (Table 5).22–29 Two agents
are often combined to provide both sedation and analgesia.
Ketamine, fentanyl, and midazolam can be administered by a
nonanesthesiologist outside of the operating room when
proper monitoring and trained personnel are avail-
able.7,24–27,29–32 It is essential to continue using CBI with
these children to develop coping skills over time, even when
moderate sedation is used.

Midazolam is a benzodiazepine with no analgesic
properties of its own. Fentanyl is an opioid analgesic, and
ketamine is a dissociative anesthetic/analgesic. These drugs

TABLE 2. Cognitive-Behavioral Interventions and Development

Age Range Techniques

Infants (0-12mo) Parent’s voice (eg, talking, singing on tape), touching (eg, holding and rocking),
pacifier, music, swaddling, massage

Toddlers (12-36mo) Same as infants in addition to: pinwheels, storytelling, peek-a-boo, busy box
Preschoolers (3-5 y) Pinwheels, party blowers, feathers, pop-up books storytelling, comfort item,

music, singing, manipulatives
School agers (6-12 y) Electronic toys (eg, Nintendo DS, PSP, IPOD), pop-up books, I Spy books,

participation in procedure, imagery, storytelling, breathing techniques, muscle relaxation
Adolescents (13-18 y) Music, comedy tapes, imagery massage, muscle relaxation, TV, video, other electronics

TABLE 3. Categories of Sedation21

Minimal sedation (anxiolysis)
Patient responds to verbal commands
Cognitive function may be impaired
Respiratory and cardiovascular systems unaffected

Moderate sedation (previously conscious sedation)
Patient responds to verbal commands but may not respond to
light tactile stimulation

Cognitive function is impaired
Respiratory function adequate; cardiovascular unaffected

Deep sedation
Patient cannot be easily aroused except with repeated or painful

Ability to maintain airway may be impaired
Spontaneous ventilation may be impaired; cardiovascular
function is maintained

General anesthesia
Loss of consciousness, patient cannot be aroused with painful

Airway cannot be maintained adequately and ventilation is

Cardiovascular function may be impaired

TABLE 4. Anxiolytic Agents*

Agent Dose

Diazepam Children:
Oral: 0.12-0.8mg/kg/d in divided doses every 6-8 h
IV: 0.04-0.3mg/kg/dose every 2-4 h;
a maximum of 0.6mg/kg, OR 10mg within 8 h

Oral: 2-10mg given 2-4 times/d
IV: 2-10mg, may repeat in 3-4 h if needed

Neonates, infants, and children:
Oral, IV: 0.05mg/kg/dose every 4-8 h;
Max: 2mg/dose

Lorazepam Adults:
Oral: 1-10mg/d in 2-3 divided doses;
usual dose: 2-6mg/d in divided doses

*Dosages from Lexicomp online.
IV indicates intravenous; Max, maximum dose; OR, operating room.

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are administered in combination to provide both sedation
and analgesia. However, combining midazolam and keta-
mine in some childhood cancer patients is associated with
hypoxia, hypertension, tachypnea, vomiting, and hallucina-
tions.25,28,29 Combining midazolam and fentanyl may cause
decreased heart rate and blood pressure, oxygen desatura-
tion, and emesis.24 Administering ondansetron with the
analgesia agents reduces vomiting or retching after the

The risk for ketamine complications is dose and age
dependent. In a 2009 meta-analysis on emergency depart-
ment procedural sedation, ketamine caused increased airway
or respiratory adverse events, emesis, and recovery agitation
when administered in an unusually high intravenous dose
(initial dose Z2.5mg/kg or total dose Z5.0mg/kg).22,23

Ketamine was associated with adverse airway and respira-
tory events in children younger than 2 years and those 13
years and older, as well as increased emesis in younger

adolescents. Older children have less distress with procedures
than younger children when moderate sedation is used.7,33

Distress is further reduced by adding nonpharmacologic
interventions to the sedation drug regimen.7,32,34–37

Nitrous oxide (N2O) is an anesthetic gas that provides
moderate sedation and is most commonly used for painful
dental procedures in children.38,39 In a small number of
studies, N2O was effective in reducing pain and anxiety in
children undergoing various painful nondental procedures
[eg, venous cannulation, lumbar puncture (LP), bone mar-
row aspiration (BMA), and dressing change].40–42 In these
studies, concentrations of N2O varied (ranging from 0% to
70% N2O in oxygen) and were administered by certified
nurses or physicians in a controlled setting such as a clinic,
procedure room, or operating room. Patients who received
N2O before procedures had lower levels of distress, lower
pain scores, were more relaxed, and many had no
recollection of the procedure.40–42

TABLE 5. Sedation Agents*

Agent Moderate Sedation Deep Sedation Onset/Duration Adverse Effects Comments

Fentanyl <12 y
IV: 1-2mg/kg/dose,
may repeat full
dose in 5min if
needed. MAX
cumulative dose:
50 mg

Z12 y or >50kg
IV: 0.5-1mg/kg/
dose or 25-50mg/
dose, may repeat
full dose in 5min if
needed, MAX
cumulative dose:

Neonates, infants,
children, and
IV: >2mg/kg/dose
or >MAX
cumulative dose

Onset: IV: 4-5min

Respiratory depression,
apnea; muscle rigidity
and chest wall spasm
occur after rapid IV
bradycardia, seizures,

Provides rapid onset of
action with a short
duration of action;
minimal hemodynamic

Midazolam >6mo-<12 y IV:
dose; MAX
cumulative dose:

Z12 y
IV: 0.5-2mg/dose;
MAX cumulative
dose: 10mg

NA Onset: IV: 1-2min
Duration: 2-6 h

Respiratory depression,
bitter taste, amnesia,
blurred vision,
headache, hiccoughs,
nausea, vomiting,
coughing, sedation;
cardiac arrest, and
hypotension have
occurred after
premedication with
a narcotic

Provides no analgesia;
effective anxiolytic,
sedative, amnesic; fewer
cardiac complications

Ketamine Children and adults
IV: 0.5-1mg/kg/
dose over 2-3min;
may repeat as
needed up to MAX
cumulative dose of
100mg or 2mg/kg
in a 30min time

Children and adults
IV: >1mg/kg/
dose, or cumulative
dose of 100mg or
2mg/kg in a 30min
time period

Onset: IV: 1-2min

Hypertonicity, nystagmus,
contraindicated in
patients in which a
rapid rise in blood
pressure would be
detrimental and in
patients with increased

Good sedative, amnesic,
analgesic; provides
bronchial smooth
muscle relaxation;
airway protective
reflexes remain intact;
eyes usually open with
blank stare; administer
by slow IV push to
decrease risk of
respiratory depression

Propofol NA Children and adults
IV bolus: 1mg/kg/
dose IV infusion:
MAX: 200mg/kg/

Onset: IV: <1min

Hypotension, injection
site burning, apnea,
arrhythmia, pruritus,

Children and adults
>50 kg should be dosed
in 20-50mg increments

*Dosages from Lexicomp online.
IV indicates intravenous; ICP, increased intracranial pressure; MAX, maximum dose; NA, nonavailable.

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A small percentage of patients (ranging from 5% to
15%) experienced minor side effects from N2O; the most
common included nausea, vomiting, excitement, dysphoria,
and oxygen desaturation.40,41 More serious complications
such as inhibition of the methionine pathway, hematologi-
cal, neurological, and/or myocardial injury were associated
with prolonged N2O use (>6h) and higher concentrations
(>70% N2O in oxygen).

43 Serious side effects are not found
in the review of studies using N2O for procedures that
involve short-term sedation. Adequate room ventilation
and effective scavenging systems are required when using
N2O to reduce exposure to ambient gas.

39,44,45 In addition,
the N2O system must be capable of administering 100%
oxygen (never <30% oxygen), and be regularly checked
and calibrated.39,44

Dexmedetomidine has also received recent attention as
a moderate sedation agent. Dexmedetomidine, an a-2
agonist with analgesic properties that control stress,
anxiety, and pain, is effective as a single agent for sedation
for noninvasive procedures and is used most often for
lengthy radiological imaging such as magnetic resonance
imaging.46–50 However, when used alone it does not provide
deep enough sedation to be beneficial for painful proce-
dures such as BMA or LP.

Deep Sedation
Deep sedationis a drug-induced depression of con-

sciousness when the child cannot be easily aroused but
responds purposefully after repeated or painful stimulation.
Medications used for moderate sedation can cause deep
sedation and the trained sedation specialist should be able
to manage any complications as the ability to indepen-
dently maintain ventilatory function may be impaired.
Children may require assistance in maintaining a patent
airway, and spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained.3

General Anesthesia
General anesthesia is a drug-induced loss of con-

sciousness when the child is not arousable, even by painful
stimulation. Children often require assistance in maintain-
ing an airway, and positive pressure ventilation is often
used because of depressed spontaneous ventilation or drug-
induced depression of neuromuscular function. Cardiovas-
cular function may be impaired.3

Propofol, a short-acting sedative hypnotic, is one of
the most widely used agents for brief invasive procedures
preformed on children with cancer. It is administered
intravenously either by continuous infusion or intermittent
boluses (Table 5). Propofol, when administered slowly over
at least 1 minute, provides rapid anesthesia induction,
amnesia; during recovery this agent causes less agitation
and has a lower incidence of nausea and vomiting.51,52

Propofol has no analgesic properties and short-acting
opioids such as fentanyl may be used in combination to
alleviate pain. The addition of an analgesic agent such as
fentanyl can result in lower propofol doses (median 3.1mg/
kg vs. 4.6mg/kg), fewer adverse effects (18% vs. 50%), and
a shorter recovery period (37min vs. 26min).53–55 When
remifentanil, an ultra-short-acting opioid, was used in
combination with propofol in 80 children undergoing
BMAs, it allowed for an overall propofol dose reduction
and decreased time to discharge, but it increased the risk of
respiratory depression.56

Whether used alone or in combination, propofol can
cause apnea, hypotension, and airway obstruction. There-
fore, this agent must be administered in a controlled setting
with experienced personnel trained in advanced airway
management skills with resuscitative equipment readily

There are several choices for sedation that can be

administered in outpatient and inpatient cancer settings.
Minimal sedation can be safely administered in the clinic or
an inpatient unit. Moderate and deep sedation can also be
administered in similar areas, but require the immediate
availability of resuscitation drugs and equipment and
trained personnel who are competent in airway manage-
ment and sedation.

General anesthesia is administered by anesthesiologists
in the operating room and sites outside the operating room
specifically established for safe delivery of general anesthetics.

Practitioners administering sedative agents and mon-
itoring patients should have documented sedation compe-
tency. For all patients receiving moderate deep sedation,
recommended monitoring includes continuous pulse oxi-
metry, observation of ventilation, and blood pressure
measurement. For patients whose ventilation cannot be
observed directly during moderate or deep sedation, either
exhaled/end-tidal carbon dioxide can be monitored or
capnography can be used. Level of consciousness should be
assessed at regular intervals throughout the sedation
process. During deep sedation, practitioners must be
proficient in airway management and advanced life support
to rescue patients from a deeper level of sedation than
intended to reduce the risk of hypoxia, hypoventilation,
and hypotension. Advanced life support equipment must be
immediately accessible and supplemental oxygen should be
administered unless contraindicated.

The American Society of Anesthesiologists describes
monitored anesthesia care as an assortment of postproce-
dure responsibilities, beyond the expertise of practitioners
providing moderate sedation, that assures a return to full
consciousness, relief of pain, management of adverse
physiological responses, or side effects from medications
administered during the procedure, while considering coex-
isting medical problems.59 A clinical algorithm developed to
guide the decision making process for the type of sedation
based on the specific procedure is found in Figure 1.
Considerations for deep sedation or general anesthesia
should include the:

� Type of procedure
� Length of procedure
� Number of procedures
� Newly diagnosed oncology patients
� Downs syndrome/cognitively impaired patients
� Patients who had problems with procedures or obtaining
adequate sedation in the clinic or inpatient setting
� Patients with allergic reactions to sedative medications
� Patients with medical conditions requiring an anes-
thesiologist to administer sedation or general anesthesia.

Any child with unusual circumstances should be
discussed with an anesthesiologist before determining the
type of sedation. Children at risk for difficult airways may
include morbidly obese patients (body mass index Z35)

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and patients with craniofacial anomalies (eg, Treacher-
Collins, Pierre Robin) and patients with mucopolysacchar-
idoses (eg, Hurler, Hunter, Morquio). It is recommended
that the following types of patients be managed by an
anesthesiologist in the operating room:

� Infants <6 months of age
� Patients who have an oxygen requirement
� Patients in shock, hypotensive, impending septic shock
(eg, patients with high fevers and unstable volume status
requiring fluid boluses on the day of the procedure)

FIGURE 1. Clinical Algorithm for Managing Painful Procedures. BMA indicates bone marrow aspirates; BMI, body mass index; BMX,
bone marrow biopsies; LPs, lumbar punctures.

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BMA and Biopsy
When possible, all first time BMAs and biopsies

should be performed under deep sedation or general
anesthesia, regardless of age. As children do not habituate
to this painful procedure, deep sedation/general anesthesia
is recommended for all bone marrow biopsies. However,
there are selected children who can undergo BMA without
sedation, and each child’s management should be indivi-
dualized. A local anesthetic using 1% buffered-lidocaine
should always be used for the BMA and biopsy. The use of
a local anesthetic, when carried out properly is key to
minimizing discomfort (Table 6).

Children receiving frequent LPs during the first few

months of cancer therapy may require sedation. Options
for having LPs performed without sedation should be
discussed with the parents and child after the initial
diagnostic period. A topical anesthetic should be used for
all LPs, especially when sedation is not administered. For
children with suspected leukemia, a practitioner experi-
enced at procedures should perform the first diagnostic LP,
as well as the first procedure in which the patient is
transitioning from moderate to minimal sedation. Deep
sedation or general anesthesia should always be considered
for children undergoing more than one procedure (eg, both
BMA and LP).

Although significant advances in procedure manage-

ment have been made in the last 25 years since the days of
chloral hydrate and the demoral, phenergan and thorazine
cocktail, there remains a continued need to explore more
effective agents that provide short-term sedation with
minimal side effects. There is limited research on the use
of newer agents such as remifentanyl, a short-acting opioid,
or short-term sedation with agents such as N2O. Continued
use of CBI for all children should be a standard of care and
creative interventions developed and tested to increase
children’s coping skills are still needed.

The guiding principles established 20 years ago for

effectively managing painful procedures in children with
cancer hold true today.1 Essential components for a
procedure management program must include effective
parent teaching and education, procedure preparation for
both parent and child, and appropriate analgesia and
sedation. Although new and better pharmacologic agents
now exist, management of painful procedures in children
with cancer must be tailored to the individual patient by
effective communication between the child, parents, and
medical staff of successful multimodal interventions.


1. Zeltzer LK, Altman A, Cohen DL, et al. Report of the
subcommittee on the management of pain associated with
procedures in children with cancer. Pediatrics. 1990;86:

2. Katz ER, Kellerman J, Siegel SE. Behavioral distress in
children with cancer undergoing medical procedures: develop-
mental considerations. J Consult Clin Psychol. 1980;48:

3. Continuum of depth of sedation: definition of general
anesthesia and levels of sedation/analgesia [American Society
of Anesthesiologists Web site]. October 21, 2009. Available at:
Accessed on: January 5, 2010.

4. Dahlquist LM, Power TG, Cox CN, et al. Parenting and child
distress during cancer procedures: a multidimensional assess-
ment. Child Health Care. 1994;23:149–166.

5. Koller D. Child life council evidence-based practice statement:
preparing children and adolescents for medical procedures
[Child Life Council Web site]. November 2007. Available at:
cfm. Accessed on: January 5, 2010.

6. American Academy of Pediatrics. Committee on Hospital
Care. Child life services. Pediatrics. 2006;118:1757–1763.

7. Kazak AE, Penati B, Brophy P, et al. Pharmacologic and
psychologic interventions for procedural pain. Pediatrics.

8. Cline R, Harper F, Penner L, et al. Parent communication and
child pain and distress during painful pediatric cancer
treatments. Soc Sci Med. 2006;63:883–898.

9. Crock C, Olsson C, Phillips R, et al. General anaesthesia
or conscious sedation for painful procedures in childhood
cancer: the family’s perspective. Arch Dis Child. 2003;88:

10. Piira T, Sugiura T, Champion GD. The role of parental
presence in the context of children’s medical procedures:
a systematic review. Child Care Health Dev. 2005;31:233–243.

11. Christensen J, Fatchett D. Promoting parental use of
distraction and relaxation in pediatric oncology patients
during invasive procedures. J Pediatr Oncol Nurs. 2002;19:

12. Blount RL, Sturges JW, Powers SW. Analysis of child and
adult behavioral variations by phase of medical procedure.
Behav Ther. 1990;21:33–48.

13. Ellis JA, Spanos NP. Cognitive-behavioral interventions for
children’s distress during bone marrow aspirations and lumbar
punctures: a critical review. J Pain Symptom Manage. 1994;

14. McCarthy AM, Cool VA, Hanrahan K. Cognitive behavioral
interventions for children during painful procedures: research
challenges and program development. J Pediatr Nurs. 1998;

15. Chen E, Joseph MH, Zeltzer LK. Behavioral and cognitive
interventions in the treatment of pain in children. Pediatr Clin
North Am. 2000;47:513–525.

TABLE 6. How to Administer a Local Anesthetic for Bone Marrow

� Draw up 2-3mL of 1% lidocaine solution, always use buffered
lidocaine except in PACU or OR settings.
� Insert a 27 gauge needle at a 45 degrees angle just under the
skin and create a small bleb with <0.2-0.3mL of fluid.
� Straighten needle to a 90 degrees angle and insert all the way to
the periosteum. Begin administering the lidocaine. Use a
technique of pushing the needle down to the periosteum and
pulling back the needle gently while continuing to administer
provides better effect. There is no need to enter the skin more
than once and gentle movements using the push/pull needle
method off the periosteum should always be used.
� When using buffered lidocaine in patients receiving mild-to-
moderate sedation, administer very, very slowly to minimize
discomfort. In the PACU or OR the local anesthetic can be
performed quickly.

OR indicates operating room; PACU, post anesthesia care unit.

J Pediatr Hematol Oncol� Volume 33, Number 2, March 2011 Managing Painful Procedures in Children With Cancer

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16. FavaraScacco C, Smirne G, Schiliró G, et al. Art therapy as
support for children with leukemia during painful procedures.
Med Pediatr Oncol. 2001;36:474–480.

17. Dahlquist LM, Busby SM, Slifer KJ, et al. Distraction for
children of different ages who undergo repeated needle sticks.
J Pediatr Oncol Nurs. 2002;19:22–34.

18. Kuppenheimer WG, Brown RT. Painful procedures in
pediatric cancer: a comparison of interventions. Clin Psychol
Rev. 2002;22:753–786.

19. Kwekkeboom KL. Music versus distraction for procedural
pain and anxiety in patients with cancer. Oncol Nurs Forum.

20. Uman LS, Chambers CT, McGrath PJ. Psychological inter-
ventions for needle-related procedural pain and distress in
children and adolescents. Cochrane Database Syst Rev.
2006;4:CD005179. Review.

21. Holdsworth M, Ralsch D, Winter S, et al. Pain and distress
from bone marrow aspirations and lumbar punctures. Ann
Pharmacother. 2003;37:17–22.

22. Green SM, Roback MG, Krauss B, et al. Predictors of
airway and respiratory adverse events with ketamine
sedation in the emergency department: an individual-patient
data meta-analysis of 8282 children. Ann Emerg Med. 2009;54:

23. Green SM, Roback MG, Krauss B, et al. Predictors of emesis
and recovery agitation with emergency department ketamine
sedation: an individual-patient data meta-analysis of 8282
children. Ann Emerg Med. 2009;54:171–180.

24. Mantadakis E, Katzilakis N, Foundoulaki E, et al. Moderate
intravenous sedation with fentanyl and midazolam for invasive
procedures in children with acute lymphoblastic leukemia.
J Pediatr Oncol Nurs. 2009;26:217–222.

25. Bhatnagar S, Mishra S, Gupta M, et al. Efficacy and safety of a
mixture of ketamine, midazolam and atropine for procedural
sedation in paediatric oncology: a randomised study of oral
versus intramuscular route. J Paediatr Child Health. 2008;44:

26. Evans D, Turnham L, Barbour K, et al. Intravenous ketamine
sedation for painful oncology procedures. Paediatr Anaesth.

27. Meyer S, Aliani S, Graf N, et al. Inter- and intraindividual
variability in ketamine dosage in repetitive invasive procedures
in children with malignancies. Pediatr Hematol Oncol.

28. Pellier I, Monrigal JP, Le Moine P, et al. Use of intravenous
ketamine-midazolam association for pain procedures in
children with cancer. A prospective study. Paediatr Anaesth.

29. Marx CM, Stein J, Tyler MK, et al. Ketamine-midazolam
versus meperidine-midazolam for painful procedures in pedia-
tric oncology patients. J Clin Oncol. 1997;15:94–102.

30. Nagel K, Willan AR, Lappan J, et al. Pediatric oncology
sedation trial (POST): a double-blind randomized study.
Pediatr Blood Cancer. 2008;51:634–638.

31. Ljungman G, Kreuger A, Andréasson S, et al. Midazolam
nasal spray reduces procedural anxiety in children. Pediatrics.

32. Hedén L, von Essen L, Frykholm P, et al. Low-dose oral
midazolam reduces fear and distress during needle procedures
in children with cancer. Pediatr Blood Cancer. 2009;53:

33. Ljungman G, Gordh T, Sorensen S, et al. Lumbar puncture in
pediatric oncology: conscious sedation versus general anesthe-
sia. Med Pediatr Oncol. 2001;36:372–379.

34. American Academy of Pediatrics Committee on Drugs.
Guidelines for monitoring and management of pediatric
patients during and after sedation for diagnostic and ther-
apeutic procedures. Pediatrics. 1992;89:1110–1115.

35. Cote CJ, Wilson S. Guidelines for monitoring and manage-
ment of pediatric patients during and after sedation for
diagnostic and therapeutic procedures: an update. Pediatrics.

36. Cote CJ, Wilson S; Work Group on Sedation. Guidelines for
monitoring and management of pediatric patients during and
after sedation for diagnostic and therapeutic procedures: an
update. Paediatr Anaesth. 2008;18:9–10.

37. Committee on Drugs and Psychosocial Aspects of Child and
Family Health. The assessment and management of acute pain
in infants, children, and adolescents. Pediatrics. 2001;108:793.

38. Quarnstrom FC, Mar RS. A premix of 50% nitrous oxide—
50% oxygen for sedation during dental procedures. Anesth
Prog. 1983;30:197–198.

39. Howard WR. Nitrous oxide in the dental environment: assess
ing the risk, reducing the exposure. J Am Dent Assoc. 1997;128:

40. Henderson JM, Spence DG, Komocar LM, et al. Admini-
stration of nitrous oxide to pediatric patients provides
analgesia for venous cannulation. Anesthesiology. 1990;72:

41. Kanagasundaram SA, Lane LJ, Cavalletto BP, et al.
Efficacy and safety of nitrous oxide in alleviating pain and
anxiety during painful procedures. Arch Dis Child. 2001;84:

42. Slagerman K, Livingston M. (2008, September 27, 2008).
Nurse-directed program to assess patient/parent satisfaction
using nitrous oxide during lumbar punctures for pediatric
leukemia and lymphoma patients. Paper presented at the
APHON 32nd Annual Conference, Albuquerque, NM.

43. Sanders RD, Weimann J, Maze M. Biological effects of nitrous
oxide. Anesthesiology. 2006;109:707–722.

44. Clinical guideline on appropriate use of nitrous oxide for
pediatric dental patients [American Academy of Pediatric
Dentistry Web site] 2009. Available at:
media/Policies_Guidelines/G_Nitrous.pdf. Accessed on: Janu-
ary 11, 2010.

45. McClothlin J, Crouch K, Mickelsen RL. Control of nitrous
oxide in dental operatories [National Institute for Occupa-
tional Safety and Health Web site] September, 1994. Avai-
lable at:
Accessed on: January 11, 2010.

46. Phan H, Nahata MC. Clinical uses of dexmedetomidine in
pediatric patients. Paediatr Drugs. 2008;10:46–69.

47. Mason KP, Zurakowski D, Zgleszewski SE, et al. High dose
dexmedetomidine as the sole sedative for pediatric MRI.
Paediatr Anaesth. 2008;18:403–411.

48. Koroglu A, Teksan H, Sagir O, et al. A comparision of the
sedative, hemodynamic, and respiratory effects of dexmedeto-
midine and propofol in children undergoing magnetic reso-
nance imaging. Anesth Analg. 2006;103:63–67.

49. Berkenbosch JW, Wankum PC, Tobias JD. Pros-
pective evaluation of dexmedetomidine for noninvasive proce-
dural sedation in children. Pediatr Crit Care Med. 2005;6:

50. Mason KP, Zgleszewski SE, Dearden JL, et al. Dexmedeto-
midine for pediatric sedation for computed tomography
imaging studies. Anesth Analg. 2006;103:57–62.

51. Gottschling S, Meyer S, Krenn T, et al. Propofol versus
midazolam/ketamine for procedural sedation in pediatric
oncology. J Pediatr Hematol Oncol. 2005;27:471–476.

52. Hertzog J, Dalton H, Anderson B, et al. Prospective evaluation
of propofol anesthesia in the pediatric intensive care unit for
elective oncology procedures in ambulatory and hospitalized
children. Pediatrics. 2000;106:742–747.

53. Cechvala M, Christenson D, Eickhoff J, et al. Sedative
preference of families for lumbar punctures in children with
acute leukemia: propofol alone or propofol and fentanyl.
J Pediatr Hematol Oncol. 2008;30:142–147.

54. Hollman G, Schultz M, Eickhoff J, et al. Propofol-fentanyl
versus propofol alone for lumbar puncture sedation in children
with acute hematologic malignancies: propofol dosing and
adverse events. Pediatr Crit Care Med. 2008;9:616–622.

55. Jayabose S, Levendoglu-Tugal O, Giamelli J, et al. Intravenous
anesthesia with propofol for painful procedures in children
with cancer. J Pediatr Hematol Oncol. 2001;23:290–293.

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