Paediatric cancer pain management using the WHO analgesic ladder--results of a prospective analysis from 2265 treatment days during a quality improvement study

Eur J Pain. 2006 Oct;10(7):587-95. doi: 10.1016/j.ejpain.2005.09.002. Epub 2005 Oct 21.


Objective: To collect data on pain management in paediatric oncology with respect to the WHO ladder approach. SETTING, DESIGN, PATIENTS AND METHODS: Eight German tertiary care paediatric oncology centres prospectively documented all their in-patient pain treatment courses from June 1999 to December 2000. Pain was scored using a 1-6 faces scale.

Results: Two hundred and twenty four patients (median age, 9 years; range 0.2-32.1) were enrolled. Three hundred and thirty three pain episodes comprising a total of 2265 treatment days were documented. Pain was mostly therapy associated. The most frequently administered non-opioid analgesics were dipyrone and paracetamol. On WHO step 2, tramadol was almost the only opioid used. During tramadol monotherapy average daily pain scores were lower than with a combination of tramadol and non-opioid analgesics. On WHO step 3, morphine was at least part of the analgesic regimen on most treatment days. Strong opioids were combined with a non-opioid analgesic on 41% of the treatment days. The mean intravenous morphine equivalence dose was 0.034 mg/kg/h. During opioid and non-opioid combination therapy, adverse effects were more frequent, and average pain scored higher than on opioid monotherapy.

Conclusions: WHO-guidelines were closely followed in Germany and seem to provide effective analgesia for children with cancer pain. In our patient group there is no evidence that a combination of an opioid with a non-opioid is more effective than opioid therapy alone in in-patient paediatric oncology pain treatment.

Publication types

  • Clinical Trial
  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acetaminophen / administration & dosage
  • Acetaminophen / adverse effects
  • Adolescent
  • Adult
  • Analgesia / methods*
  • Analgesia / standards
  • Analgesia / trends
  • Analgesics / standards*
  • Analgesics / therapeutic use*
  • Analgesics, Opioid / administration & dosage
  • Analgesics, Opioid / adverse effects
  • Antineoplastic Agents / adverse effects
  • Child
  • Child, Preschool
  • Dipyrone / administration & dosage
  • Dipyrone / adverse effects
  • Drug Therapy, Combination
  • Germany
  • Humans
  • Infant
  • Medical Oncology / methods
  • Medical Oncology / standards
  • Medical Oncology / trends
  • Neoplasms / complications*
  • Neoplasms / drug therapy
  • Pain / drug therapy*
  • Pain / etiology*
  • Pain / nursing
  • Pain Measurement
  • Pediatric Nursing / methods
  • Pediatric Nursing / standards
  • Pediatric Nursing / trends
  • Pediatrics / methods
  • Pediatrics / standards
  • Pediatrics / trends
  • Prospective Studies
  • Quality Assurance, Health Care
  • Treatment Outcome
  • World Health Organization


  • Analgesics
  • Analgesics, Opioid
  • Antineoplastic Agents
  • Acetaminophen
  • Dipyrone