Background: The 2012 WHO guidelines recently recommended the 2step strategy in managing pediatric cancer pain. There is little experimental evidence to support this practice. Objectives: To describe characteristics & causes of pain in department of pediatric oncology in South Egypt Cancer Institute, to ascertain the effectiveness of WHO analgesic ladder in these pediatric cancer patients & to address side-effects occurred under treatment with opioid therapy in accordance with step 2 & 3 of the ladder. Methods: During 30 months duration from (1 Jan 2011 till 30 June 2013), A prospective study was conducted on pediatric cancer patients who complained of pain & fulfilled all the inclusion criteria for enrollment in this study. Data collected were: patients' demographics, pain characteristics & pain intensity scores. The 1 st 24h average intensity pain scores after change of pain therapy & reduction of > 30 % from their initial levels were used to calculate the adequacy of pain control. All patients who had persisting pain after treatment with step-1 (paracetamol) divided into 2 groups: "group 1" received step-2 (tramadol) & "group 2" moved directly to step-3 of WHO analgesic ladder (Low dose of morphine). Results: The study included 133 pain cycles comprising a total of 1028 treatment days. Step-1 analgesia was effective in 50.6% of all documented treatment days, while Step-2 analgesia was effective in 17.02% of all documented treatment days and Step-3 analgesia was required in 23.6% of all documented treatment days. After failure to obtain adequate pain control on non-opioid analgesics, it was found that median average intensity pain scores in the 1 st 24h after administration of low dose morphine as a two-step strategy (step-3) was 1.33, which was lower compared to those obtained after tramadol therapy (step-2), which was 3.33 and the difference was statistically significant (p value = 0.002). Adverse effects which included somnolence, constipation, nausea &/ or vomiting and pruritis were found to be less frequent in weak opioid drugs compared to strong opioid drugs and these differences were statistically significant (p value < 0.05). Conclusions: Efficacy of WHO analgesic ladder was ascertained in managing pain in children with cancer in our department. Disease-related pain was the most frequent cause of pain cycles and somatic type of pain was the most frequently occurring type. Use of low dose morphine in a two-step strategy was associated with lower pain scores, fewer drug changes for pain therapy when treatment was initiated & shorter duration of pain, but associated with more frequent side-effects than the conventional three-step WHO ladder.

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