Research Article ISSN 2689-1085

Journal of Pediatrics & Neonatology

A Survey of Pain Management and Procedural Sedation Practices by

Pediatric Hematology/Oncology Practitioners in China
Cuixia Yan BPh1, Cho Lee Wong PhD2, Celeste LY Ewig PharmD3, Jingqi Zhang MS1, Haiying Huang BN1,
Feng-Gui Wei MD4, Chi-kong Li MBBS, MD5, Hui Zhang MD, PhD1* and Yin Ting Cheung PhD3*
Department of Pediatric Hematology/Oncology, Guangzhou
1

Women and Children’s Medical Center, Guangzhou, China.

The Nethersole School of Nursing, Faculty of Medicine, The Chinese

2 Correspondence:
*

Yin Ting Cheung, Ph.D., School of Pharmacy, Faculty of

University of Hong Kong, Hong Kong SAR.
Medicine, The Chinese University of Hong Kong, Hong Kong.
School of Pharmacy, Faculty of Medicine, The Chinese University of
3
Hui Zhang, M.D, Ph.D., Department of Pediatric Hematology/
Hong Kong, Hong Kong SAR. Oncology, Guangzhou Women and Children's Medical Center, 9
Jinsui Road, Guangzhou, China.
Department of Pediatrics, The First Affiliated Hospital of Guangzhou
4

Medical University, Guangzhou, China. Received: 28 April 2020; Accepted: 25 June 2020

Department of Paediatrics, Faculty of Medicine, The Chinese

5

University of Hong Kong, Hong Kong SAR.

Citation: Cuixia Yan, Cho Lee Wong, Celeste LY Ewig, et al. A Survey of Pain Management and Procedural Sedation Practices by
Pediatric Hematology/Oncology Practitioners in China. J Pediatr Neonatal. 2020; 2(1): 1-13.

ABSTRACT
Background: The provision of supportive care is increasingly a priority of quality care in pediatric oncology
settings. In China, the quality of supportive care services may vary among regions because of differences in social
and health indicators.

Objectives: To evaluate Chinese pediatric oncology practitioners’ pain management practices, and identify barriers
to optimal pain control in children with cancer undergoing invasive procedures in China.

Methods: Oncology practitioners were recruited from pediatric cancer centers and professional groups in Hong
Kong and mainland China through convenience sampling. Respondents completed a paper-based or electronic
structured questionnaire. Chi-square test was conducted to compare practitioners’ responses across geographical
regions of their practices.

Results: The sample (n=304) consisted of pediatric oncologist/hematologists (n=149, 49%) and allied health
professional (n=155, 51%), who practiced in the South China region (n=189, 62%) and North China/other regions
(n=115, 38%). As compared to practitioners from the South China region, practitioners from the North/other
regions were less likely to administer procedural sedation during lumbar puncture (78% vs 48%; P<0.0001) and
bone marrow aspiration (72% vs 46%; P=0.0012). Regardless of region, practitioners identified the lack of formal
training (72%) and dedicated staff (77%), and restricted access to sedative drugs (70%), as major barriers to
adopting procedural sedation. Physicians who practiced in South China were more likely than those in North China/
other regions to report the use of opioids for moderate-to-severe pain, such as morphine (70% vs 49%; P=0.013)
which is the recommended first-line strong opioid for persistent pain in children. Practitioners indicated parents’
concerns with opioid addiction (73%), safety (76%) and stigma (63%). Practitioners also reported inadequate
knowledge in dosing opioids (48%) and side effects management (48%). Overall, 37% of practitioners perceived
that even with existing measures, children still experienced severe pain (pain score of 5-10) during procedures.

Conclusion: Our results suggest the relative inadequacy of procedural control in certain regions of China. We

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 have identified potential institutional barriers and gaps in physicians’ knowledge and education about the use of
procedural sedation and strong analgesics. There is an urging need to empower oncology practitioners and review
policies to facilitate implementation of procedural sedation for children in China.

Keywords anecdotal experiences and revealed that poor pain management

Cancer, Children, Suboptimal pain management, Oncology. was largely due to a lack of awareness about the long-term effects
of uncontrolled pain in children, inadequate knowledge of the use
Introduction of analgesia and sedation and a lack of anesthesiology support
Children with cancer are repeatedly exposed to treatment-related regarding general analgesia [13]. Few data are available on
pain and invasive medical procedures [1-3]. According to many pain management and procedural sedation practices in pediatric
studies, treatment-related and procedural pain are often the worst oncology units across China. Although China is a unified country,
causes of pain experienced by children with cancer [3]. Suboptimal the quality of supportive care services may vary among regions
pain management can lead to acute physiological responses such because of differences in social and health indicators. Increasingly,
as tachycardia and perspiration, psychological distress and a fear emphasis is placed on the delivery of cost-effective and optimal
of needles [1,4], which may have adverse effects on the child’s clinical care on curative intent. Therefore, it is important to
quality of life from diagnosis until long-term survivorship. determine the procedural sedation practices used in hospitals
Therefore, procedural pain treatment is now considered an across China and thus identify the barriers to implementing quality
integral part of care for a cancer patient, especially in the context pain services, as well as strategies to overcome these limitations.
of pediatric procedures such as bone marrow aspiration (BMA),
lumbar puncture (LP), peripherally inserted central catheter Advances in risk stratification and risk-based treatment strategies
(PICC) insertion and endoscopic procedures [2,5]. have led to a gradual improvement in childhood cancer survival
rates in China [14]. Accordingly, the provision of supportive care
The literature describes multiple cultural, language and is increasingly a priority of quality care in pediatric oncology
neurodevelopmental factors contributing to poor pain management settings. This study was designed to evaluate the perceptions of
in children with cancer [1,2,5]. Children may receive suboptimal pediatric oncology practitioners regarding the pain experienced
pain treatment because of difficulties in the perception and by children with cancer in association with invasive diagnostic/
articulation of painful sensations [6,7]. Therefore, it is important therapeutic procedures. The overarching aim of this study was to
to use appropriate pain assessment tools to avoid underestimating unite clinicians and policymakers throughout China in achieving
the child’s complaints and enable an accurate evaluation of his/ the shared goal of delivering effective pain management practices
her pain symptoms and intensity. Unfortunately, oncology in children with cancer. We also examined the current pain
practitioners have a limited understanding of pain assessment management practices of pediatric oncology practitioners across
tools, and the available methods for identifying pediatric pain China and identified barriers to the use of procedural sedation and/
often fail to recognize the associated symptoms [5,6,8]. or strong analgesics.

Many international organizations now recommend the use of Methods

procedural sedation, which is broadly defined as the administration This multicenter, cross-sectional survey was conducted between
of sedatives or dissociative agents (with or without analgesics) to April and October 2019. Prior to study initiation, approval was
induce a state that will allow the child to tolerate unpleasant painful obtained from the Survey and Behavioral Research Ethics
procedures while maintaining cardio-respiratory function [5,9- Committee of the Chinese University of Hong Kong and from
11]. However, the administration of procedural sedation is often the Institutional Review Board of the Guangzhou Women and
complex and demanding of resources and training. Strong opioids Children’s Medical Center in Guangzhou, China.
and benzodiazepines, the most commonly used sedation agents,
can increase a patient’s risk of drug-related adverse events such Respondents
as hemodynamic and respiratory instability, prolonged mechanical A convenience sampling approach was used to recruit oncology
ventilation, withdrawal symptoms, delirium and hallucination practitioners from major pediatric oncology and hematology centers
[12]. Despite mounting evidence supporting the use of procedural and through key professional study groups in mainland China and
sedation, oncology practitioners may not be adequately trained to Hong Kong. Respondents considered eligible for this survey met
provide proper sedation care [13]. the following criteria: (1) status as a practicing physician, nurse
or pharmacist; (2) current practice in a pediatric cancer center or
China encompasses a broad geographic area with a diversity of pediatric oncology department of a medical institution located
cultures and traditions. Cultural factors may influence beliefs, in Hong Kong or mainland China; and (3) current provision of
behavior, perceptions and emotions related to pain, all of which clinical care to and interactions with pediatric cancer patients for
have important implications for healthcare practices [6]. In a recent at least 50% of the work shift. These criteria enabled us to target a
qualitative study, 11 Chinese pediatric hemato-oncologists from an homogenous sample of practitioners who were involved directly in
academic hospital in a remote city of Northwest China related their the management of cancer patients.
J Pediatr Neonatal, 2020 Volume 2 | Issue 1 | 2 of 13
Questionnaire Design Practitioners were asked to rate the perceived degree of pain (on
We designed a questionnaire based on the existing literature to assess a scale of 0–10) experienced by children during each of the above
the pain management practices applied to children with cancer, medical procedures both without pharmacological intervention
with a specific focus on the use of strong analgesics and procedural and after the administration of pain control measures. The fourth
sedation (Table 1). The questionnaire, which began with a short section began with a definition of procedural sedation (Table
paragraph describing the overall objective of the study, comprised 2) [9-11], and the practitioners were asked to indicate whether
five sections. The first section collected information about the they applied procedural sedation for LP, BMA, bone marrow
respondents’ demographic details and clinical experiences, biopsy and PICC insertion. The respondents were also asked
including age, sex, profession, rank and specialization, as well as about the level of sedation (minimal, moderate or deep sedation
the region, setting and years of healthcare practice. The second or general anesthesia) and the pharmacological agents used for
section comprised four questions designed to gather information each of these medical procedures. Furthermore, the respondents
about the respondents’ general pain management practices, methods were asked to identify challenges associated with administering
of pain assessment, common drugs used to manage moderate procedural sedation from a list of common practitioner-related and
to severe pain in children and perceived barriers to the use of institutional barriers. The last section concerned the practitioners’
opioids in children. The third section concerned the practitioners’ practices and the perceived effectiveness of non-pharmacological
assessment of pain control associated with seven types of medical comfort measures for pain management.
procedures: LP, BMA, bone marrow biopsy, PICC insertion,
venipuncture, intramuscular injection and subcutaneous injection. The survey was initially formulated in English and was translated

Table 1
Objectives Questions Options
• No pain assessment conducted
• Parents/caregivers are asked to proxy-rate the
child’s level of pain
• Physician or Nurse routinely observes for signs
To evaluate practitioners’
of pain
method of pain assess- Briefly describe how pain assessment in children is conducted in your practice.
• Child is asked:
ment in children [1,2,3]
Regarding the absence or presence of pain
To indicate their pain on a scale
To provide a pain score
• Others:
• The WHO Two-step Analgesic Ladder Guidelines
• Other international guidelines
Select the best option that describes your current practice of pain management • Local hospital guidelines
in children. • Adopt senior colleagues’ practices
• Clinical judgment
• Others
To evaluate practitioners’
general management of • Paracetamol
pain in children with • NSAID
cancer [1,2,3] • Morphine
Indicate the analgesics that you most commonly prescribe, or you most • Fentanyl
commonly observe in your practice, to manage moderate to severe pain in • Hydromorphone
children.* • Oxycodone
• Tramadol
• Propofol
• Others
Indicate your level of agreement with the following statements concerning the
use of opioids in children
Practitioner-related misconceptions/ concerns:
Opioids should be avoided in children.
Increasing analgesic requirements is a sign that the child is becoming addicted.
Early use of the opioids reduces its future efficacy. • Strongly agree
To identify practi-
Opioids should only be reserved in terminal stages of cancer. • Agree
tioner-related, institu-
I feel inadequate in dosing opioids in children. • Neural
tional and parent-related
I feel inadequate in managing the side effects of opioids in children. • Disagree
barriers to the use of
Parent-related concerns: • Strongly disagree
opioids in children [1]
Parents are concerned about opioid addiction. • Not sure
Parents are concerned about the adverse effects of opioids.
Parents are concerned about the stigma associated with opioid use.
Institutional barriers:
The regulation of opioids in my institution is too restrictive.
I am concerned about regulatory scrutiny.

J Pediatr Neonatal, 2020 Volume 2 | Issue 1 | 3 of 13

 • Lumbar puncture
• Bone marrow aspirate
To evaluate practitioners’ Using a scale of 0 (no pain) to 10 (worse pain), indicate your perceived
• Bone marrow biopsy
perceived effectiveness degree of pain on children:
• PICC catheter insertion
of current pain control When the procedures are conducted without pharmacological intervention
• Venipuncture
measures [1,2,3] When the procedures are conducted under your routine pain control practices
• Intramuscular injection
• Subcutaneous injection
Indicate with the level of sedation you subject the child to during: • No procedural sedation used
Lumbar puncture • Minimal sedation
Bone marrow aspirate • Moderate sedation
Bone marrow biopsy • Deep sedation
PICC insertion • General anesthesia

To evaluate practitioners’ • No procedural sedation used

procedural sedation • Anxiolytic agents (diazepam, lorazepam)
practices in children with Indicate drug(s) that you most commonly prescribe for procedural seda- • Opioids (morphine, fentanyl, hydromorphone)
cancer [1]* tion during: • Short-acting benzodiazepines for sedation (mid-
Lumbar puncture azolam)
Bone marrow aspirate • α-2 agonist (clonidine, dexmedetomidine)
Bone marrow biopsy • Anesthetic (ketamine, esketamine)
Insertion of peripherally inserted central catheter • Propofol
• Diphenhydramine
• Others
Regardless of whether you practice procedural sedation, indicate with
the relevance of the following challenges you face concerning the use of
procedural sedation for painful procedures in your institution:

Institutional barriers:
Lack of space (hospital beds, recovery areas)
Lack of equipment and logistics (airway management equipment, intravenous
equipment, emergency medications)
Lack of dedicated staff for managing sedation-analgesia
Sedative drugs are not available in the hospital formulary
Sedative drugs are available in the formulary but restrictions are applied for
To identify practi- their use in painful procedures by non-anesthetists doctors
tioner-related, institu-
• Very relevant
tional and parent-related Practitioner-related misconceptions/ concerns:
• Somewhat relevant
barriers to the use of Inadequate training in administering the sedation procedure (eg. Unsure of the
• Not relevant
procedural sedation in appropriate dose and monitoring parameters)
children [1] Lack of adequate training in managing the adverse effects associated with se-
dation (eg. cardio-pulmonary resuscitation course for cardiovascular collapse)
Healthcare providers are generally unsure of the current guidelines in pain
management
Healthcare providers are concerned about the safety and long-term adverse
effects of sedation
Healthcare providers do not perceive the need for sedation-analgesia
Healthcare providers are fearful of potential litigation or liability issues

Parent-related concerns:
Parents have concerns about cost
Parents have concerns about safety
• Pre-procedural pain counselling to child
• Pre-procedural pain counselling to parent
To identify practitioners’ • Distraction (play, videos)
practice and perceived ef- Indicate if your institution adopts non-pharmacological comfort measures for • Relaxation techniques (massage)
fectiveness of non-phar- pain management (yes or no), and your perceived effectiveness (effective, • Hypnosis
macological interven- neutral, or not effective) of these methods in controlling pain. • Breathing exercises
tions for procedural pain • Music
• Heat and /or cold compresses
• Applying pressure or vibration
1
Differences in responses were evaluated between respondents from different geographical regions: South China versus North China/China/another region.
2
Differences in responses were evaluated between respondents of different professional roles: physicians versus allied healthcare provider (non-physicians).
3
Differences in responses were evaluated between respondents with different length of clinical experience: Less than 10 years of clinical experience versus respon-
dents with more than 10 years of experience.
*
Analyses for these questions were only performed among respondents who identified themselves as “physicians” as physicians typically make key prescribing
decisions in most clinical settings within China.

J Pediatr Neonatal, 2020 Volume 2 | Issue 1 | 4 of 13

 Table 2
Responds to repeated or Spontaneous Cardiovascular Common drugs/ combination
Patient conscious Airway
painful stimuli ventilation function of drugs
Minimal Conscious Yes Unaffected Unaffected Unaffected • Benzodiazepine
Yes, respond to verbal • Benzodiazepine +/- opioid
Moderate Depressed consciousness Unaffected Unaffected Unaffected
tactile stimuli (eg: Fentanyl)
• Short-acting sedative agents
Depressed consciousness
Yes, respond to repeated May require May be Usually (eg: Propofol, etomidate, or
Deep and cannot be easily
or painful stimuli intervention inadequate maintained a benzodiazepine)
aroused
• Propofol +/- ketamine
General Often require Usually • Barbiturates
Loses consciousness No Impaired
anesthesia intervention inadequate • Opioid
American Academy of Pediatrics, American Academy of Pediatric Dentistry, 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. Pediatrics 2006;118:2587.
Godwin SA, Burton JH, Gerardo CJ, Hatten BW, Mace SE, Silvers SM et al. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Annals
of Emergency Medicine 2014;63:258.e18.
Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural
Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society
of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology 2018;128:437-79.
Sheta SA. Procedural sedation analgesia. Saudi Journal of Anaesthesia. 2010;4(1):11-16.

into Simplified Chinese by two independent bilingual investigators. Frequency n (%)

Differences in the official language used in different regions of 20 – 29 81 (26.6)
China led practitioners from Hong Kong to complete the English
30 – 39 118 (38.8)
version on paper, while practitioners in mainland China adopted
Age (years) 40 – 49 66 (21.7)
an electronic version disseminated through “WeChat”, the most
widely and frequently used social media platform among Chinese 50 – 59 34 (11.2)
people. WeChat was also listed among the most common platforms Above 60 5 (1.6)
used by Chinese physicians to acquire medical knowledge in a Male 238 (78.3)
Sex
mobile environment [15]. Self-administration of this questionnaire Female 66 (21.7)
required approximately 15–20 minutes. Physician 149 (49.0)
Junior level 21 (14.1)
Statistical analysis
Mid-level 43 (28.9)
Descriptive statistics were used to evaluate the oncology Profession
practitioners’ responses to each question. The analyses of Senior 85 (57.1)
procedural sedation practice and the choices of sedatives and strong Nurse 129 (42.4)
analgesics included only physicians, as these professionals often Pharmacist 26 (8.6)
make key prescribing decisions in most Chinese clinical settings. Pediatric oncology 225 (74.0)
Allied healthcare providers typically play a supportive role in Pediatric hematology 199 (65.5)
Primary area(s) of
pain assessment and management. The chi-square test was used practice* Pediatric surgery 17 (5.6)
for secondary analyses in which the categorical responses were
General pediatrics 45 (14.8)
compared between the following predefined groups: (1) physicians
(pediatric oncologists and hematologists) and allied healthcare Less than 1 year 23 (7.6)
providers (nurses, pharmacists etc.), (2) practitioners with more or Years of clinical
1–4 68 (22.4)
fewer than 10 years of clinical experience in pediatric oncology/ experience in 5–9 65 (21.4)
hematology and (3) groups defined by the geographical locations pediatric oncology 10 – 14 41 (13.5)
of their healthcare practices. All analyses were conducted using or/and hematology
15 years and more 103 (33.9)
SAS (SAS 9.4, SAS Institute, Cary NC).
Missing 4 (1.3)
South China region 189 (62.2)
Results Region of
practice# North China and other regions 115 (37.8)
Sample characteristics
A total of 304 respondents, including physicians (49%), nurses (42%) Community/ government/ municipal /
142 (46.7)
‎provincial hospital
and pharmacists (9%), completed the questionnaire (Table 3). The Primary practice
majority of respondents practiced in the South China region (62%) setting Academic/ university/ research centers 155 (51.0)
and at either public hospitals (47%) or academic medical institutions Private practice 7 (2.3)
(51%). Approximately half of the practitioners (47%) possessed Table 3: Demographic Information and Clinical Experience of
more than 10 years of healthcare experience, and the most frequent Respondents (n=304).
specialties were pediatric oncology (74%) and hematology (66%). *Numbers do not add up as practitioners may have multiple areas of
primary practice.
J Pediatr Neonatal, 2020 Volume 2 | Issue 1 | 5 of 13
# South China region (“Hua-nan”) refers to the Hong Kong Special and PICC insertion (69%) as procedures that inherently induce
Administrative Region, and cities in the Guangdong, Guangxi and Hainan moderate (pain score of 5–7) or severe pain (pain score of 8–10)
provinces. They are grouped together as these provinces have similar in children (Figure 1). Even after applying currently available
socioeconomic indices, cultural background and healthcare practices. pain control measures, 32–37% of respondents still perceived that
their pediatric patients experienced moderate to severe pain during
Pain assessment and overall pain management practices these painful procedures, indicating the inadequate effectiveness
Overall, the majority of respondents had adopted either international of these measures (Figure 1).
(46%) or local hospital (26%) recommendations to guide their
clinical decision-making (Table 4). Differences in practices were
observed between regions. A higher proportion of respondents
from South China had adopted the recommendations of local
institutional guidelines and in-house pain teams, compared with
those from North China or other regions (33% vs 16%; P=0.0005).
Respondents with fewer than 10 years of practice were more likely
to rely on the clinical experiences and supervision of their senior
colleagues, compared to more experienced respondents (17.3% vs
7.6%; P=0.0009).

The most common pain assessment approaches involved

behavioral observation by a healthcare provider during the
procedure (72%) and the child’s report of the presence of pain
(71%) (Table 4). Compared with physicians, allied healthcare Figure 1: Perceived Pain and Effectiveness of Pain Control Associated
providers were more likely to use validated pain scales (44% vs with Common Medical Procedures in Children with Cancer (n=304).
69%; P<0.0001) and pain scores (47% vs 72%; P<0.0001) in their Grey bars: Proportion who perceived moderate (pain score 5 to 7) to
practices. Respondents from the South China region were also severe pain (pain score 8 to 10) associated with each procedure without
more likely than respondents from other regions to conduct formal any pain control measures.
pain assessments using validated pain scales (P=0.0018). In the White bars: Proportion who perceived moderate (pain score 5 to 7) to
absence of pain control interventions, the majority of respondents severe pain (pain score 8 to 10) associated with each procedure, after
perceived LP (70%), BM aspiration (78%), BM biopsy (91%) current pain control measures are applied.

Analysis Stratified by Clinical

All Analysis Stratified by Profession Analysis Stratified by Region
Experience
Allied North
South
Physicians healthcare China/ < 10 years ≥ 10 years
(n=304) China
(n=149) providers others (n=156) (n=144)
(n=189)
(n=155) (n=115)
Best description of pain management
n (%) n (%) n (%) p n (%) n (%) p n (%) n (%) P
practices#
WHO Two-step Analgesic Ladder
Guidelines and other international 139 (45.7) 71 (47.7) 68 (43.9) 86 (45.5) 53 (46.1) 72 (46.2) 66 (45.8)
guidelines
Local guidelines from hospital or/and pain <0.0001 0.0009
80 (26.3) 18 (12.1) 62 (40.0) 62 (32.8) 18 (15.7) 44 (28.2) 34 (23.6)
team
Adopting senior colleagues’ practices 47 (15.5) 23 (15.4) 15 (9.7) 22 (11.6) 16 (13.9) 27 (17.3) 11 (7.6)
Solely based on clinical judgement 38 (12.5) 37 (24.8) 10 (6.4) 19 (10.1) 28 (24.3) 13 (8.3) 33 (22.9)
Pain assessment method* n% n% n% p n% n% p n% n% P
No pain assessment conducted 12 (4.0) 5 (3.4) 7 (4.5) 0.60 8 (4.2) 4 (3.5) 0.74 4 (2.6) 5 (3.5) 0.64
Observation by physician or nurses 219 (72.0) 107 (71.8) 112 (72.3) 0.93 145 (76.2) 74 (64.3) 0.020 108 (69.2) 108 (75.0) 0.26
Regarding the presence of pain 217 (71.4) 105 (70.5) 112 (72.3) 138 (73.0) 79 (68.7) 0.42 115 (73.7) 100 (69.4) 0.41
To indicate their pain on a scale
Child
(Visual analogue scale, Faces Pain 172 (56.6) 65 (43.6) 107 (69.0) 0.73 120 (63.5) 52 (45.2) 0.0018 92 (59.0) 78 (54.2) 0.40
is
scale)
asked:
To provide a pain score (eg. pain
182 (59.9) 70 (47.0) 112 (72.3) <0.0001 126 (66.7) 56 (48.7) 0.0019 99 (63.5) 81 56.3) 0.20
score)
Table 4: Pain Management Practices in Children with Cancer (n=304).
# Respondents were asked to select only one response that best describes his/her practice. Comparison was conducted among predefined groups (pro-
fession, region and years of clinical practice) for the overall adopted practice.
*Respondents could select more than one response. Comparison was conducted among predefined groups (profession, region and years of clinical
practice) for each pain assessment method.
J Pediatr Neonatal, 2020 Volume 2 | Issue 1 | 6 of 13
 Lumbar puncture Bone marrow aspiration Bone marrow biopsy PICC Insertion
South China North China and South China North China and South China North China and South China North China and
Level of Sedation
(n=60) others (n=89) (n=60) others (n=89) (n=60) others (n=89) (n=60) others (n=89)
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)
No Sedation 10 (16.7) 44 (49.4) 15 (25.0) 46 (51.7) 11 (18.3) 34 (38.2) 17 (28.3) 36 (40.5)
Any sedation 47 (78.3) 43 (48.3) 43 (71.7) 41 (46.0) 46 (76.6) 49 (55.0) 42 (70.0) 49 (55.0)
Minimal/moderate
35 (58.3) 35 (39.3) 30 (50.0) 35 (39.3) 32 (53.3) 40 (44.9) 30 (50.0) 35 (39.3)
sedation
Deep 12 (20.0) 8 (9.0) 13 (21.7) 6 (6.7) 14 (23.3) 9 (10.1) 12 (20.0) 14 (15.7)
General anesthesia 3 (5.0) 2 (2.3) 2 (3.3) 2 (2.3) 3 (5.0) 6 (6.7) 1 (1.7) 4 (4.5)
P <0.0001 0.0012 0.0096 0.13
Table 8: Physicians’ Practices for Painful Procedures in Children with Cancer (n=149).
PICC: Peripherally inserted central catheter.
Analysis was only performed among respondents who identified themselves as “physicians” as physicians typically make key prescribing decisions
in most clinical settings within China.
Comparison was conducted between proportion of physicians who adopted sedation and those who did not adopt sedation at all, across the 2 pre-de-
fined geographical regions for each specific procedure.

Figure 2: Barriers to the Use of Opioids in Children with Cancer (n=304).

Figure 3: Barriers to the Use of Procedural Sedation in Children with
Cancer (n=304).

J Pediatr Neonatal, 2020 Volume 2 | Issue 1 | 7 of 13

No statistically significant differences in the perceived effectiveness cancer by physicians in the South China region, compared to those
of current practices were observed between respondents from in North China and other regions (P<0.05 for all). Up to half of
different regions or with different levels of clinical experience the physicians from North China performed LP (49%) and BM
(Table 5). However, allied healthcare providers were more likely aspiration (52%) without procedural sedation, compared with 17%
to report inadequate pain management during LP, compared to and 25% in South China, respectively.
physicians (21% vs 11%; P=0.028). Similar trends were also
observed for other procedures, although those differences were not In the overall cohort, the respondents commonly cited a lack of
statistically significant (Table 5). confidence in administration (72%), lack of awareness of current
guidelines (73%) and fear of potential litigation or liability issues
Physicians (n=149, Table 6) who participated in the study were (70%) as practitioner-related barriers (Figure 3) to conducting
asked to identify the analgesics that they would prescribe to procedural sedation. Respondents also identified institutional
children experiencing moderate to severe pain. Overall, non- barriers such as inadequate space (69%) and facilities (56%), a
steroidal inflammatory drugs (NSAID) (79%), tramadol (69%) and lack of dedicated staff (77%) and a restrictive sedative formulary
fentanyl (61%) were the most commonly prescribed analgesics for non-anesthetists (70%). Compared with respondents from
(Supplement 5). Differences in the physicians’ prescribing patterns South China, a larger proportion of respondents from North China
were observed between geographical regions. Physicians who and other regions identified inadequate training, inexperience with
practiced in the South China region were more likely than those guidelines and parental concerns regarding costs as major barriers
in North China and other regions to report the use of opioids, such (Figure 5).
as morphine (70% vs 49%; P=0.013), fentanyl (75% vs 52%;
P=0.00042) and tramadol (78% vs 63%; P=0.05) (Table 7). Use of non-pharmacological pain control measures
Distraction methods (59%) and the provision of pre-procedural
Use of opioids for moderate to severe pain pain counselling to the parent (51%) and child (49%) were the
Half of the respondents identified inadequate training in the most frequently practiced non-pharmacological pain control
dosing, monitoring and management of side effects as a barrier to measures (Table 9). Other measures reported less frequently
the use of opioids in children with cancer (Figure 2). Interestingly, included relaxation techniques, breathing exercises and music.
14-18% of the respondents harbored misconceptions, including
the avoidance of opioids in children (15%) and reservation of
Method Used in clinical practice
opioids only for patients in the terminal stages of cancer (14%),
as well as the misinterpretation of signs of opioid tolerance as n (%)
opioid addiction (18%). Respondents also reported the restrictive Pre-procedural pain counselling to parent 154 (50.7)
nature of the opioid formulary in their institutions (26%), as well Pre-procedural pain counselling to child 149 (49.0)
as concerns about regulatory scrutiny (35%). Three quarters of Distraction (play, videos) 178 (58.6)
the respondents also identified parents’ concerns about addiction,
Relaxation techniques (massage) 111 (36.5)
adverse effects and stigma as major barriers to the use of opioids in
their pediatric patients. Respondents from North China and other Hypnosis 42 (13.8)
regions were more likely to report inadequate opioid administration Breathing exercises 87 (28.6)
and management than respondents from the South China region Music 101 (33.2)
(Figure 4).
Heat and /or cold compresses 60 (19.7)
Use of procedural sedation Applying pressure or vibration 25 (8.2)
Stark differences in procedural sedation practices were observed Others* 9 (3.0)
between regions (Table 8). Procedural sedation was more Table 9: Use of Non-pharmacological Interventions in Children with
commonly administered for painful procedures in children with Cancer (n=304).
Table 5
Bone marrow aspira-
Lumbar puncture# Bone marrow Biopsy# PICC Insertion#
tion#
n % n % n % n %
South China (n=189) 29 (15.8) 29 (15.8) 34 (18.5) 31 (17.1)
Regions North China/ Others (n=115) 18 (16.4) 21 (19.3) 22 (20.2) 20 (18.2)
P-value 0.89 0.44 0.72 0.82
Physicians (n=149) 16 (11.2) 20 (14.0) 23 (16.1) 20 (14.2)
Professionals Allied healthcare provider (n=155) 31 (20.5) 30 (20.0) 33 (22.0) 31 (20.7)
P-value 0.028 0.17 0.19 0.14
< 10 years (n=156) 21 (13.6) 21 (13.6) 23 (14.9) 22 (14.3)
Years of clinical
≥ 10 years (n=144) 25 (18.4) 28 (20.7) 32 (23.7) 29 (21.8)
experience
P-value 0.26 0.10 0.05 0.09
Table 5: Difference Perceived Effectiveness of Pain Control Associated with Common Medical Procedures in Children with Cancer.
#Proportion who indicated severe pain (pain score 7 to 10) after pain control measures are applied.
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 Physicians (n=149) Non-physicians (n=155)
Demographics
n % n %
20 – 29 15 (10.1) 66 (42.6)
30 – 39 59 (39.6) 59 (38.1)
Age (years) 40 – 49 41 (27.5) 25 (16.1)
50 – 59 29 (19.5) 5 (3.2)
Above 60 5 (3.4) 0 (0)
Male 60 (40.3) 6 (3.9)
Sex
Female 89 (59.7) 149 (96.1)
Physician - - - -
Junior level 21 (14.1) - -
Profession Mid-level 43 (28.8) - -
Senior 85 (57.1) - -
Nurse - - 129 (83.2)
Pediatric oncology 112 (75.2) 113 (72.9)
Pediatric hematology 119 (79.9) 80 (51.6)
Primary area(s) of practice*
Pediatric surgery 4 (2.7) 13 (8.4)
General pediatrics/ other pediatric specialties 6 (4.0) 39 (25.2)
Less than 1 year 10 (6.8) 13 (8.4)
1–4 20 (13.4) 48 (31.0)

Years of clinical experience in pedi- 5–9 30 (20.1) 35 (22.6)

atric oncology or/and hematology 10 – 14 21 (14.1) 20 (12.9)
15 years and more 68 (45.6) 35 (22.6)
Missing 0 (0) 4 (2.6)
South China region 60 (40.3) 129 (83.2)
Region of practice#
North China and other regions 89 (59.7) 26 (16.8)
Community/ government/ municipal‎/ provincial hospital 50 (33.6) 92 (59.4)
Primary practice setting Academic/ university/ research centers 95 (63.8) 60 (38.7)
Private practice 4 (2.7) 3 (1.9)
Table 6: Demographic Information and Clinical Experience of Respondents Stratified by Profession.
*Numbers do not add up as practitioners may have multiple areas of primary practice.
# South China region (“Huanan Qu”) refers to the Hong Kong Special Administrative Region, and cities in the Guangdong, Guangxi and Hainan prov-
inces. They are grouped together as these cities have similar socioeconomic indices and cultural background.

Pharmacological interventions All Physicians (n=149) South China Region (n=60) North China and others (n=89) P
n % n % n %
NSAID 117 (78.5) 43 (71.7) 74 (83.1) 0.09
Tramadol 103 (69.1) 47 (78.3) 56 (62.9) 0.046
Fentanyl 91 (61.1) 45 (75.0) 46 (51.7) 0.0042
Strong analgesics Morphine 86 (57.7) 42 (70.0) 44 (49.4) 0.013
Paracetamol 62 (41.6) 35 (58.3) 27 (30.3) 0.0007
Oxycodone 27 (18.1) 20 (33.3) 7 (7.9) <0.0001
Hydromorphone 17 (11.6) 10 (16.7) 7 (7.9) 0.082
Short-acting benzodiazepines 58 (38.9) 28 (46.7) 30 (33.7) 0.11
Anxiolytic agents 48 (32.2) 21 (35.0) 27 (30.3) 0.55
Anesthetic 29 (19.5) 19 (31.7) 10 (11.2) 0.0020
Sedatives
α-2 agonist 17 (11.4) 1 (1.7) 16 (18.0) 0.0021
Propofol 18 (12.1) 9 (15.0) 9 (10.1) 0.37
Opioids 16 (10.7) 10 (16.7) 6 (6.74) 0.055
Table 7: Physicians’ Top Strong Analgesics and Sedative Agents across Regions (n=149).
Analysis was only performed among respondents who identified themselves as “physicians” as physicians typically make key prescribing decisions
in most clinical settings within China.
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Figure 4: Differences between South China (Blue) and North China/others Figure 5: Differences between South China (Blue) and North China/others
(Brown) in Barriers towards the Use of Strong Analgesics (n=304). (Brown) in Barriers towards the Use of Procedural Sedation (n=304).

Discussion as up to 37% of our respondents perceived the inadequacy of

To the best of our knowledge, this was one of the largest studies current pain control measures applied to children undergoing
to evaluate the practices and perspectives of Chinese pediatric painful procedures. In particular, our study identified poor pain
oncology practitioners regarding the administration of painful management education as a major concern, as reflected by the fair
procedures to children. Additionally, this was the first study proportion of respondents who indicated concerns regarding the
to compare practices among different geographical regions use of opioids and the answers to questions requiring knowledge
within China and identify areas requiring improvements in pain about pain assessment and drug use. Our results were consistent
management. The oncology practitioners reported varied practices with those of a qualitative study by Wang et al., which revealed that
and levels of consensus regarding procedural sedation and the Chinese pediatricians had insufficient knowledge about analgesia
choice of first-line analgesics for children with moderate to severe and sedation usage due to a lack of formal pain management
pain. Regardless of region, however, oncology practitioners education for healthcare providers [13]. This issue is exacerbated
recounted that Chinese parents expressed fear and stigma regarding by the lack of specific Chinese reference standards regarding
the use of strong analgesics, as well as safety concerns about pediatric procedural pain management. These results support the
sedatives. The practitioners also highlighted an inadequate level development of continual professional education programs to
of knowledge and skill regarding the administration of procedural improve the knowledge and skills of all oncology practitioners
sedation and dosing of opioids, as well as institutional barriers that regarding the provision of pain control. The proper administration
restricted their access to sedatives. of procedural sedation includes a pre-sedation assessment of the
suitability of the patient for sedation, selection of an appropriate
Although mainland China has experienced progressive advances agent based on knowledge about the pharmacology of sedatives,
in cancer support and palliative care [16], the topic of pain continuous monitoring of patients and an emergency resuscitation
management in pediatric oncology remained as an under- protocol to address potential airway or circulatory complications
researched and under-addressed area. Improvements are needed, [5,10,11]. Such formalized programs should target the education of
J Pediatr Neonatal, 2020 Volume 2 | Issue 1 | 10 of 13
both senior and junior practitioners regarding the characterization is also needed to correct the misconceptions held by patients and
and psychological burden of pain, pain assessment skills and the parents, overcome their aversions to strong opioids and empower
practical and theoretical knowledge about pain management and them with essential information about the safe dosing, storage and
the pharmacology of analgesics and sedatives. disposal of opioids.

Physicians and allied health professionals gave slightly different Currently, procedural sedation is recommended for children
responses concerning the perceived effectiveness of current pain during painful procedures [5,9,12]. Although the majority of
control measures for medical procedures in children with cancer. respondents indicated that they provided some degree of sedation
Compared to physicians, a higher proportion of allied healthcare to their pediatric patients, the clinical approaches differed across
providers reported the inadequate management of current pain geographical areas. To the best of our knowledge, few current
control measures during LP procedures. Specifically, a higher regional guidelines in mainland China dictate the methodology of
proportion of allied healthcare providers reported the use of pain procedural sedation and indicate the most effective interventions.
scores and pain scales to assess procedural pain in children, whereas The reasons underlying the observed discrepancies are likely
physicians seemed to rely more on clinical observations. Similar multifactorial and may include differences in the culture,
differences in the pain assessments of healthcare professionals education or training backgrounds of healthcare professionals
have been reported in the literature [7,8]. One study reported that and the available resources. In the absence of a dedicated team,
physicians tend to underestimate pediatric pain, as reflected by a institutional limitations, including space (e.g., hospital beds,
low concordance between the child’s and physician’s perceptions recovery areas) and equipment support (e.g., airway management
of pain [8]. This discrepancy may be partly attributable to an equipment, intravenous equipment, emergency medications),
unawareness or underestimation of anxiety and traumatic stress, may pose challenges to the administration of procedural
which could exacerbate the child’s perception of pain. These sedation. Pediatric cancer centers in Hong Kong generally allow
collective findings highlight the importance of a multimodal pediatricians to administer procedural sedation. In contrast,
strategy involving the observation of pain-related behavioral pediatricians at some institutions in mainland China may prefer
and psychological changes in the child and the application of a to perform these procedures under general anesthesia provided
formal pain assessment using well-established pain rating scales. by a trained anesthesiologist [13,22]. However, hospitals in
Such intentional approaches are necessary. In particular, the mainland China are often burdened by high patient volume with
Chinese population is known to be culturally less expressive when each anesthesiologist delivering sedation care for up to 50 patients
verbalizing pain and parental perceptions, as well as being less per day in some rural hospitals [22], while sedation training
aware of the psychological effects of uncontrolled pain in children provided to non-anesthesiologists is often inadequate. Such hectic
and harboring misconception that procedural pain is inevitable and environment and demanding workload create a significant barrier
necessary for effective treatment [13,17]. for pediatric oncology teams to adopt procedural sedation. In our
study, oncology practitioners from certain regions of South and
The World Health Organization recommends a 2-step approach North China also indicated a restricted access to and/or availability
to general pain management [18]. A 2-step analgesic ladder of opioids and sedatives due to regulatory obstacles and a lack
includes relatively cost-effective medicines, such as NSAIDs and of health policies advocating such pain services. Therefore,
morphine, in a stepwise approach. Paracetamol and ibuprofen are hospital administrators and policymakers must support and direct
recognized as first-line options for mild pain, whereas opioids are sustainable changes in each unique institutional setting.
recommended as the second step for the treatment of moderate to
severe pain. Specifically, many international guidelines recommend Older children and adolescents may choose to undergo certain
morphine as a first-line strong opioid for the treatment of persistent procedures without sedation, given the deleterious adverse effects
moderate to severe pain in children with medical illnesses [18]. associated with sedatives and strong analgesics. In such cases,
However, only 57% of all physicians in our study reported the healthcare providers should adopt alternatives to reduce the
use of morphine in their patients. Therefore, the physicians in our child’s anxiety in the absence of sedation. Emerging evidence now
sample might have been reluctant to treat pain with opioids due to supports the use of non-pharmacological comfort measures for both
inadequate knowledge about the dosing regimen and parents’ fears adult and pediatric patients [1,23,24]. Our results demonstrated
about addiction and adverse effects. Practitioners in the South that comfort measures, such as distraction, music and pre-
China region seemed less likely to prescribe NSAIDs as a first- procedural counselling, are commonly used in clinical settings,
line option for moderate to severe pain, compared to practitioners despite limitations on robust efficacy or guidelines regarding
from other regions in China. This discrepancy may be attributed implementation in the pediatric cancer population. These measures
to pain guidelines issued in Hong Kong and the southern cities of may be popular because of the ease of use and relatively low cost.
mainland China, which discourage the use of NSAIDs in children Specifically, various advantages of a novel approach involving
with cancer due to concerns about thrombocytopenia. Regionally, virtual reality as an interactive form of distraction include the
a structured educational program that encourages the increased requirement for less-specialized facilities and the provision of
use of strong opioids is needed, and robust evidence demonstrates an immersive environment that distracts the child’s attention
that such programs can improve pain remission rates, especially in from the painful environment [25]. In Hong Kong, an ongoing
patients with moderate to severe pain [19-21]. An education model research study is evaluating the use of immersive virtual reality
J Pediatr Neonatal, 2020 Volume 2 | Issue 1 | 11 of 13
interventions for pain and anxiety in pediatric cancer patients. major pediatric oncology institutions in China. This approach may
The preliminary results suggest positive outcomes, namely the have helped to establish the sampling frame and likely reduced
reduction of psychological distress in children [26]. Future studies the risk of recruiting ineligible or careless respondents. Despite
should aim to evaluate the efficacy profiles and efficacies of the limitations associated with the online survey, this approach
non-pharmacological interventions for reducing the intensity of has been widely accepted as an effective means of collecting
sedation or strong analgesia during painful pediatric procedures. behavioral data from individuals in a large geographical region.
We emphasize that this study should be interpreted as an effort to
We hope that the findings from this study will encourage the understand the perceptions and practices of the medical community
pediatric oncology community in China to establish a nationwide in China and to generate future directions for addressing gaps in
breakthrough pain and procedural pain management program research and knowledge. However, the findings from this study
for children with cancer. In 2011, the Ministry of Health of the should not be considered the primary and sole evidence on any
People’s Republic of China launched the Good Pain Management aspect of this subject matter.
(GPM) program, which aimed to standardize the treatment of
cancer pain, improve the quality of life of patients with cancer Conclusion
and promote quality cancer-related health care services [27]. This study solicited the perspectives of a reasonably large sample
GPM originated from the “Professional Committee of Cancer of pediatric oncology/hematology specialists across China
Rehabilitation and Palliative Care of the Guangdong Anti-cancer regarding the various aspects of pain management practices. Our
Association” in South China [28]; this may explain our findings results suggest the relative inadequacy of procedural control in
that higher proportion of practitioners in South China who certain regions of mainland China. We have identified potential
endorsed systematic pain management protocols in their practices, institutional barriers and gaps in physicians’ knowledge and
as compared to respondents from other regions of China. By early education about the use of procedural sedation and strong
2016, 67 national wards and 769 provincial wards were accredited, analgesics. These findings provide critical information to support
and an increasing number of hospitals in mainland China have service planning, policy making and capacity building activities
implemented and adhered to a common set of guidelines for the intended to overcome these gaps in China. Standardized and
establishment of GPM wards. This group recently published evidence-based pain management models are needed to address
promising short-term outcomes observed after raising the standard the needs of childhood cancer patients and complement the unique
of care for pain management in cancer wards, as reflected by healthcare systems in China.
significant increases in the consumption of strong opioid drugs and
pain-related health literacy in Chinese patients [27]. However, the Acknowledgement
GPM in China mainly targets adult oncology patients. Therefore, The authors would like to acknowledge all respondents who
procedural pain management for pediatric cancer patients is not participated in this survey; Ms. Rita Cheung and Ms. Liwen Peng
adequately addressed. Limited evidence is available to support for their contribution in data entry and cleaning; Ai You Foundation
the treatment of cancer breakthrough pain and procedural pain in in China for their financial support to needy families.
children. Further research-driven practices and clinical consensus
from experts are needed to encourage good pain management, Funding
specifically in children with cancer. Based on the findings of this • Startup funding from the School of Pharmacy, The Chinese
study, systematic and evidence-based pain management facilities University of Hong Kong, awarded to YT. Cheung.
and protocols are needed for children with cancer who experience • Student Campus Work Scheme 2017/18 (ref: 17107) from the
cancer pain and/or are undergoing invasive procedures at accredited Chinese University of Hong Kong, awarded to YT. Cheung.
childhood cancer treatment hospitals throughout China. These • St. Baldrick’s International Scholar Award (ref: 581580) from
efforts will enable the eager promotion and provision of effective the St. Baldrick’s Foundation, awarded to H. Zhang.
pain management for children with cancer throughout China. • Startup funding (ref: 4001004) from Guangzhou Women and
Children’s Medical Center, awarded to H. Zhang.
Limitations
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