Pediatric cancer pain varies from acute pain exacerbations (breakthrough), procedure-related pain to chronic pain. the goals for its management are to ensure the function, and overall quality of life. the main differences between adult and pediatric patients are the role of parents. Fear of addiction to narcotics is the common concern among families. Therefore the parents’ opinion or preferences are the major determinant in management.

Each child experiences pain differently Therefore it is important to tailor the treatment plan based on each child’s needs.

Four principals of pharmacological pain management are:

1. By the route: medicines should be administered by the simplest, most effective, and least painful route.

2. By the clock: medication should be scheduled around the clock at regular intervals and as needed medications for breakthrough pain.

3. By the ladder: in children two–step leader therapy is recommended. This approach includes non–opioids for mild pain and strong opioids for moderate to severe pain. Morphine is the medicine of choice for the second step, although other strong opioids should be considered as an alternative to morphine in case of side effects. Adjuvant agents can be initiated during therapy as needed. There is not enough evidence about the safety and efficacy of invasive pain management procedures in children.

4. By the child: adapting treatment to the child’s circumstance, needs, and response.

Despite these therapeutic approaches, worsening pain may be caused by disease progression, development of tolerance and psychological distress. Switching opioids and/or route of administration is recommended in the presence of inadequate analgesia and/or intolerable side effects. And, most of all, family involvement in assessment, evaluation, and treatment plans is essential for success.