Sleep and fatigue in pediatric oncology: A review of the literature

The Effects of Biofeedback Intervention on Negative Emotions and Sleep Quality in Children With Leukemia Receiving Invasive Procedures and Their Caregivers: A Randomized Controlled Trial

OBJECTIVE

Children with leukemia and their caregivers have negative experiences such as pain, fear, and sleep disturbances when receiving invasive procedures. The purpose of this study was to evaluate the effects of a biofeedback intervention on negative emotions and sleep quality for children with leukemia receiving invasive procedures and their caregivers.

METHODS

A randomized controlled study involving 80 child-caregiver dyads was conducted, and dyads were randomly assigned to intervention (n = 40) and control (n = 40) groups. Both groups received health education, while the intervention group additionally received a 4-unit biofeedback intervention. Outcome measures compared at baseline (T0), post-intervention (T1), and 4-week follow-up (T2), included validated measures of pain, fear, worry, sleep quality in children, and anxiety, depression, and sleep quality in caregivers.

RESULTS

At T1 and T2, the scores of children's pain and fear in the intervention group were significantly lower than those in the control group (all p < 0.05). The significant group effects on children's pain (F = 6.064, p = 0.015) and fear (F = 15.532, p < 0.001) indicated that the intervention group had significantly lower scores in pain and fear compared to the control group. At T1 and T2, caregivers in the intervention group had significantly lower anxiety scores and significantly higher sleep quality than those in the control group (all p < 0.05). The significant group effects on anxiety (F = 10.124, p = 0.002) and sleep quality (F = 5.983, p = 0.015) suggested that the intervention group had significantly lower scores in anxiety and higher sleep quality in comparison to the control group.

CONCLUSIONS

The biofeedback intervention demonstrated significant efficacy in alleviating the pain, and fear experienced by children with leukemia during invasive procedures, concurrently relieving their caregivers' anxiety and improving sleep quality. This research furnishes compelling evidence substantiating the effectiveness of biofeedback interventions in alleviating negative emotions in children with leukemia undergoing invasive treatments, as well as in their caregivers.

TRIAL REGISTRATION

ChiCTR2300075306.

Exploring the Landscape of Integrative Medicine in Pediatric Oncology: Characterization of an Outpatient Consultative Service

Background/Objectives: Symptoms from cancer and treatments often cause pediatric patients and their families to seek complementary and integrative medicine (IM) for relief. The aim of this study was to better describe the characteristics of pediatric patients at a tertiary cancer center who utilize an IM consultative service in the outpatient setting and the associated discussions with a pediatric-focused IM physician. Methods: A retrospective study was conducted on initial IM visits for patients aged less than 19 years old at the time of the visit from January 2019 through April 2022 at a tertiary cancer center. Patient demographics, clinical characteristics, and visit information were abstracted from electronic medical records, and discussions with the provider (presenting symptoms and recommendations) were described. Results: In total, 207 patients and their associated visit discussions met the criteria. About half (47%, n = 97) of the patients were female with a mean patient age of 10 years old (median age 11 years, range 0 to 18 years). The overall most common presenting symptoms were nausea (35%, n = 72), pain (30%, n = 62), and poor appetite (26%, n = 53) with variations between age groups. The most discussed topics were supplements (94%), diet (91%), stress management (82%), IM therapies (60%), and medical cannabis (54%). Conclusions: Priority symptoms reported by patients and referred to the IM outpatient consultative service included nausea, pain, and poor appetite. Concerns were addressed during tailored discussions with patients and their families. Having an outpatient consultative IM service may benefit providers, patients, and families to facilitate receiving evidence-informed recommendations in a dedicated, consolidated setting.

Post-traumatic stress, sleep, and neurocognitive problems in children newly diagnosed with a pediatric brain tumor

BACKGROUND

Children diagnosed with brain tumors are at risk to develop neurocognitive problems. Post-traumatic stress and sleep have been associated with poorer neurocognitive outcomes in the general population, and could be potential targets for intervention in brain tumor patients. Therefore, this study examined neurocognitive functioning in children newly diagnosed with a brain tumor and the associations between posttraumatic stress and sleep with neurocognitive outcomes.

METHODS

Children 6-16 years old who were newly diagnosed with a brain tumor completed questionnaires on post-traumatic stress and sleep, actigraphy for sleep, and tests for neurocognitive outcomes. One-sample t-tests and chi-square tests were used to compare neurocognitive scores with age norms. Multivariable regression examined associations between post-traumatic stress, sleep, demographics, and medical factors associated with neurocognitive functioning.

RESULTS

Of all eligible children, 60 patients with newly diagnosed brain tumors were included, at an average of 51 days after diagnosis (67% male, mean = 11.5 years at diagnosis). Compared to age norms, patients with brain tumors scored lower on measures of attention, inhibition, and verbal memory (meanZ = -0.40 to -0.98, p < .05). History of obstructive hydrocephalus was associated with poorer attention (p < .05) and processing speed (p < .05), posterior fossa tumor location was associated with poorer working memory (p < .01), and starting chemotherapy or radiotherapy treatment before the assessment was associated with poorer verbal memory (p < .05). Post-traumatic stress and sleep were not associated with neurocognitive outcomes at this phase (p > .20).

CONCLUSION

A subgroup of children with newly diagnosed brain tumors shows deficits in neurocognitive functioning, which highlights the importance of early monitoring to identify children at-risk for problems. Hydrocephalus, posterior fossa tumor location, and starting treatment, but not post-traumatic stress and sleep, are associated with poorer neurocognitive performance at this phase. Longitudinal research will be important for identifying biopsychosocial factors that may be associated with cognition over time.

Prevalence and Factors Associated With Cancer-Related Fatigue Among Children and Adolescents Undergoing Cancer Treatment: A Systematic Review and Meta-Analysis

BACKGROUND

The literature on fatigue in children and adolescents undergoing cancer treatment is highly variable, creating uncertainties about its prevalence and identifying those at higher risk.

OBJECTIVES

The primary purpose was to describe the prevalence of fatigue among patients (< 21 years) undergoing cancer treatment across cancer types. Secondary outcomes included the prevalence of severe fatigue and factors associated with fatigue.

METHODS

Systematic searches of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO were conducted from inception to May 22, 2023. Two reviewers independently identified relevant citations and extracted data. Pooled prevalence estimates were derived using an inverse variance, random-effects model. We used Joanna Briggs's critical appraisal checklist to assess study quality. (PROSPERO: CRD42020179307).

RESULTS

We included 47 studies: 26 for prevalence and 29 for factors associated with fatigue. The pooled prevalence of fatigue was 73% (95% [Confidence Interval, CI: 66%-79%; I2 96%; 26 studies; 2699 patients], and severe fatigue was 30% [95% CI 14%-46%, I2 98%; 8 studies; 1027 patients]). Subgroup analyses based on cancer type, study design, fatigue scale, fatigue reporting personnel, sample frame, and response rate did not reveal significant differences in fatigue prevalence. Fatigue prevalence significantly differed by treatment setting (inpatient [83%] vs. outpatient [55%] vs. inpatient and outpatient [69%]; p: 0.02). Due to considerable heterogeneity among studies, data on fatigue-associated factors are presented descriptively.

CONCLUSIONS

The prevalence of fatigue among children and adolescents undergoing cancer treatment is variable but notably high. Systematic evaluation of factors associated with fatigue is essential to understanding which children are at high risk of developing fatigue.

TRIAL REGISTRATION

PROSPERO: CRD42020179307.

The Effect of Virtual Reality Distraction and Fatigue Training on Anxiety and Fatigue Levels in Children with Cancer: A Randomized Controlled Study

OBJECTIVES

This randomized controlled trial evaluated the effect of virtual reality (VR) distraction and fatigue training on anxiety and fatigue in children with cancer.

METHODS

The sample of this parallel design randomized controlled trial consisted of 41 children aged 7 to 16 who were receiving chemotherapy treatment in the pediatric hematology and oncology wards of a university hospital. Data was collected with the Child Anxiety Scale-State, Child Fatigue Scale-24-Hours, and Visual Fatigue Scale in both groups before and during the first three days of chemotherapy treatment. All children admitted to the clinic during chemotherapy received fatigue education. On the first, second, and third days of chemotherapy treatment, children in the study group underwent a 15-minute VR distraction intervention following stratified randomization. Repeated measures analysis of variance was used to compare scale scores by group, time, and group-time interaction.

RESULTS

Of the patients, 63.4% were male, and 39% had neuroblastoma. There was no difference between the groups in terms of diagnosis, age, duration of diagnosis, chemotherapy, or hemoglobin levels. A statistically significant difference was found between the mean scores of the anxiety and fatigue scores in the intervention and control groups in terms of group, time, and group-time interaction.

CONCLUSION

Applying VR distraction on the first, second, and third days of chemotherapy treatment was found to be useful in lowering anxiety and fatigue levels in addition to fatigue training.

IMPLICATIONS FOR NURSING PRACTICE

Virtual reality distraction is an effective method for reducing anxiety and fatigue in this population.

Neuropsychological Late Effects and Quality-of-Life Outcomes in Pediatric Brain Tumor Survivors: Role of Pediatric Neurologists in Monitoring and Management

Pediatric brain tumor (PBT) survivors are at significantly increased risk of cognitive, psychosocial, and educational/vocational sequelae that impact health-related quality of life. These complications and health morbidities result in high burden on survivors and their families, particularly those already vulnerable to disparities in health care access and outcomes. Since neurological comorbidities are common in this population, neurologists are uniquely positioned to screen, treat identified symptoms, and connect families with services and resources. A tiered assessment approach can facilitate early identification of concerns and reduce barriers to care. We review common presenting conditions, highlight risk factors, and provide screening tools and recommendations to facilitate comprehensive survivorship care for PBT survivors.

Circadian Rhythm Disruption in Cancer Survivors: From Oncogenesis to Quality of Life

BACKGROUND

Circadian rhythms are approximately 24-hour cycles in physiological and behavioral processes. They are entrained to the external solar day via blue wavelength light. Disruptions in these intrinsic rhythms can lead to circadian dysfunction, which has several negative implications on human health, including cancer development and progression.

AIMS

Here we review the molecular mechanisms of circadian disruption and their impact on tumor development and progression, discuss the interplay between circadian dysfunction and cancer in basic scientific studies and clinical data, and propose the potential clinical implications of these data that may be used to improve patient outcomes and reduce cost of treatment.

MATERIALS & METHODS

Using scientific literature databases, relevant studies were analyzed to draw overarching conclusions of the relationship between circadian rhythm dysruption and cancer.

CONCLUSIONS

Circadian disruption can be mediated by a number of environmental factors such as exposure to light at night, shift work, jetlag, and social jetlag which drive oncogenesis. Tumor growth and progression, as well as treatment, can lead to long-term alterations in circadian rhythms that negatively affect quality of life in cancer survivors.

Effects of the re-mission video game on fatigue and quality of life levels of adolescents diagnosed with cancer: a randomized controlled trial

The aim of this study was to investigate the effects of the Re-Mission video game on the fatigue and quality of life of adolescents diagnosed with cancer. A total of 46 adolescents aged who received inpatient chemotherapy treatment in the pediatric hematology clinic were enrolled in the study. The data were obtained by using the Personal Information Form, Scale for the Assessment of Fatigue in Pediatric Oncology Patients Aged 13-18 and Quality of Life scale. Intergroup comparisons demonstrated that there was a significant difference between the experimental and control groups in terms of their mean scores for the overall Scale for the Assessment of Fatigue and Quality of Life calculated at the baseline of the study and one month and three months. The use of Re-mission video game positively affected levels of fatigue and quality of life of adolescents aged between 13 and 18 diagnosed with cancer.

Eating Behavior, Nutritional Status, and Taste Perception Alteration in Children with Cancer

The aim of this study was to investigate eating behavior, nutritional status, and taste alterations in children with cancer. The population of the study consisted of children 8 to 18 years of age and their parents who were followed up and received chemotherapy in the pediatric hematology and oncology clinic and outpatient clinic of a University Faculty of Medicine Oncology Hospital. Data were collected using the Child Identification Form, the Children's Eating Behavior Questionnaire (CEBQ), the Taste Alteration Scale for Children Receiving Chemotherapy (TAC-TAS), and the Subjective Total Taste Acuity Scale (STTA). Body Mass Index (BMI) Z score was between -2 and +2 (normal) in 92.5% of the children and below ≤-2 (malnutrition) in 7.5%. The mean CEBQ subdimensions scores were food craving 12.48±5.36, emotional overeating 5.28±1.45, enjoyment of food 16.83±5.41, passion for drinking 9.72±5.13, satiety enthusiasm 22.93±6.65, slow eating 9.81±4.95, emotional undereating 16.38±4.41, and food selectivity 10.72±2.86, and the mean total TAC-TAS score was 8.66±10.22. A negative, moderate correlation was determined between food craving and enjoyment of food and taste alteration, with food craving and enjoyment decreasing as food alteration increased. A positive moderate correlation was observed between slow eating and taste alteration, with eating slowing down as taste alteration increased.

Symptoms, Physical Activity, and Biomarkers in Children at the End of Leukemia Maintenance Therapy

Background: Symptoms in children with acute lymphocytic leukemia (ALL) change over the trajectory of treatment but little is known about their symptoms as treatment ends. Physical activity may help decrease symptom distress and is vital for ongoing development. The role of biomarkers in symptom science is emerging. The purpose of the study was to explore relationships between self-report of symptoms and physical activity, actigraphy measures, and cerebrospinal fluid (CSF) biomarkers. Methods: Participants were children who were ages 3 to 18 years at the time of ALL diagnosis and were now in the last 12-week cycle of ALL maintenance. Self-reports of fatigue, sleep disturbance, depressive symptoms, and physical activity were completed by participants and parents of younger children. Participants wore a wrist actigraph continuously for the 7 days before other measurements. F2-isoprostanes and interleukin-8 were evaluated in CSF samples. Results: Among the 15 participants, self-report of symptoms and physical activity indicated levels similar to healthy peers. F2-isoprostane had a strong positive correlation with fatigue levels and with depressive symptoms. Fatigue, sleep disturbance, and depressive symptoms positively correlated with each other. Actigraph measures showed children met the CDC guidelines for 60 min of daily moderate to vigorous activity; sleep time was slightly less than healthy norms. Discussion: During maintenance therapy, most children return to healthy norms in symptom burden and physical activity. F2-isoprostane in the CSF is a biomarker for fatigue and depressive symptoms. Children who had persistent symptoms experienced them as a cluster, which confirms previous symptom cluster research.

Longitudinal development of fatigue after treatment for childhood cancer: a national cohort study

BACKGROUND

Fatigue is a distressing and prevalent long-term sequela of treatment for childhood cancer, and there is a need for longitudinal studies to investigate the development of fatigue over time. The objective of this study was to calculate growth-curves for the longitudinal development of fatigue after treatment for childhood cancer, and to investigate the effects of biopsychosocial predictors.

MATERIALS AND METHODS

Participants were recruited from a patient monitoring program and data extracted from medical records. Parent-proxy and self-report versions of PedsQLTM Multidimensional Fatigue Scale were used to repeatedly assess fatigue up to 5 years after the end of treatment for childhood cancer. Fatigue was assessed 2440 times for 761 participants (median:3) with proxy-reports (age 2-8 years) and 2657 times for 990 participants with self-reports (above 8 years) (median:2). Mixed models were used to establish growth-curves and to analyze the effect of predictors separately for participants with solid tumors (ST), hemato-oncological malignancies and central nervous system-tumors (CNS).

RESULTS

CNS-tumors were associated with more cognitive fatigue than ST at the end of treatment, for both proxy-reports (-11.30, p<.001) and self-reports (-6.78, p=.002), and for proxy-reports of general fatigue (-6.78, p=.002). The only significant difference in change over time was for self-reports of sleep-rest fatigue. The raw scores for the CNS-group decreased with -0.87 per year (95% CI -1.64; -0.81, p=.031) compared to the ST-group. Parental distress was overall the variable most associated with increased fatigue, while immunotherapy was the most frequent medical predictor. National centralization of childhood cancer care decreased fatigue for the CNS-group, but not for other diagnoses.

DISCUSSION

Children and adolescents treated for CNS-tumors reported more fatigue than other participants after the end of treatment, and this difference remained over time. Results from this study may help to facilitate the early recognition of children with insufficient recovery of fatigue symptoms.

Fatigue mediates the relationship between emotional and cognitive functioning in children post-cancer treatment

BACKGROUND/OBJECTIVES

Children treated for cancer are at risk to develop cognitive problems. Insight in underlying associations with emotional functioning and fatigue can be used to optimize interventions. We therefore aim to study emotional functioning, fatigue, and cognitive functioning in children postcancer treatment and investigate whether fatigue mediates the relationship between emotional and cognitive functioning.

DESIGN/METHODS

Emotional functioning, fatigue, and cognitive functioning were assessed in children post-cancer treatment using subscales of the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales, Multidimensional Fatigue Scale and Cognitive Functioning Scale. A one sample t-test was used to compare outcomes with general population peers and mediation analysis was used to address the effect of fatigue on the relationship between emotional and cognitive functioning.

RESULTS

A total of 137 children (mean age: 13.6, SD ± 3.3 years; mean time since end of treatment: 7.1 months, SD ± 5.9) participated. Lower scores on emotional functioning (Cohen's d [D]: 0.4), fatigue (D: 0.8) and cognitive functioning (D: 0.6) were found (p < .001) in children post-cancer treatment than in peers. A medium association was found between emotional and cognitive functioning (standardized regression coefficient [β]: 0.27, p < .001), which was mediated by fatigue (β = 0.16).

CONCLUSIONS

Outcomes on emotional and cognitive functioning are decreased and fatigue is increased in children postcancer treatment. Fatigue mediates the relationship between emotional and cognitive functioning. Our results show the importance to focus on fatigue amongst stress as a target for intervention to improve cognitive functioning.

Sleep health behaviors in pediatric patients with newly diagnosed cancer

OBJECTIVE

Disrupted sleep and fatigue are common symptoms in children with cancer, but little is known about this population's sleep health behaviors and how they may impact nighttime sleep. We aimed to describe the sleep health behaviors of children with newly diagnosed cancer and to determine if they changed over the next 8 weeks.

METHODS

Our sample included 169 children with cancer (86 males) who were aged 2-18 years (mean [SD] = 8.14 [4.4] y), with parent proxy report for 140 children (71 male) aged 2-12 years (mean [SD] = 6.67 [3.2] y) and self-report for 78 children (39 male) aged 8-18 years (mean [SD] = 12.0 [2.9] y). Parents and patients completed sleep hygiene questionnaires within 30 days of oncology diagnosis (T1); follow-up questionnaires were collected 8 weeks later (T2). Descriptive analyses characterized the sample by sociodemographic characteristics, cancer diagnosis, treatments received, and prescribed medications.

RESULTS

Age-related differences were found in sleep health behaviors, with adolescents reporting better overall sleep health behaviors than younger children at both time points. No differences in sleep health behaviors were found at T1 related to diagnosis, treatment, or medications. Some differences in sleep health behaviors were found at T2 related to gender, diagnosis, treatment, and medications. Sleep health behaviors and sleep problems remained relatively stable over 8 weeks. Fatigue was significantly associated with more pre-bedtime worries, insomnia, and lower rates of daytime sleepiness.

CONCLUSIONS

These findings offer novel descriptive characteristics of sleep health behaviors in a pediatric oncology sample and show relatively stable yet somewhat poor sleep health behaviors across 8 weeks. Better understanding of sleep health behaviors as modifiable factors will help inform targeted interventions.

A Longitudinal Study of Sleep Habits and Leukemia Incidence Among Postmenopausal Women

We sought to assess the relationship between sleep duration, sleep disturbance, and leukemia incidence among postmenopausal women. This study included 130,343 postmenopausal women aged 50-79 years who were enrolled in the Women's Health Initiative (WHI) during 1993-1998. Information on self-reported typical sleep duration and sleep disturbance was obtained by questionnaire at baseline, and sleep disturbance level was defined according to the Women's Health Initiative Insomnia Rating Scale (WHIIRS). WHIIRS scores of 0-4, 5-8, and 9-20 comprised 37.0%, 32.6%, and 30.4% of all women, respectively. After an average of 16.4 years (2,135,109 cumulative person-years) of follow-up, 930 of the participants were identified as having incident leukemia. Compared with women with the lowest level of sleep disturbance (WHIIRS score 0-4), women with higher sleep disturbance levels (WHIIRS scores of 5-8 and 9-20) had 22% (95% confidence interval (CI): 1.04, 1.43) and 18% (95% CI: 1.00, 1.40) excess risks of leukemia, respectively, after multivariable adjustment. A significant dose-response trend was found for the association between sleep disturbance and leukemia risk (P for trend = 0.048). In addition, women with the highest level of sleep disturbance had a higher risk of myeloid leukemia (for WHIIRS score 9-20 vs. WHIIRS score 0-4, hazard ratio = 1.39, CI: 1.05, 1.83). Higher sleep disturbance level was associated with increased risk of leukemia, especially for myeloid leukemia among postmenopausal women.

The Predictive Power of Pain Characteristics and Sleep Quality on Fatigue in Adolescents With Cancer

This study was conducted as descriptive, methodological, and cross-sectional research to determine the predictive power of pain characteristics and sleep quality on fatigue in adolescents with cancer. The study was conducted between November 2020 and April 2021 with 139 adolescents with cancer who reported pain. The study data were collected via an AdolescentInformation Form, the Adolescent Pediatric Pain Tool, the Scale For The Assessment Of Fatigue in Pediatric Oncology Patients Aged 13-18, and the Sleep Assessment Scale for Children with Cancer-Adolescent Form. Mean values, percentage calculations, Pearson correlation analysis, and linear regression analysis were used in the analysis of the data. There was a high level and negative correlation between pain characteristics (pain location, severity, and quality) of the adolescents participating in the study and their mean scores from the overall fatigue scale and its subdimensions and a high level and positive correlation with their mean scores from the overall sleep quality scale. Pain characteristics and sleep quality of adolescents with cancer explained 74% of fatigue. Pain, sleep quality, and fatigue are symptoms that should be closely addressed in adolescents with cancer.

Contribution of Fatigue to Cognitive Dysfunction in Childhood Acute Lymphoblastic Leukemia Survivors

Late effects such as neurocognitive issues and fatigue have been reported in childhood acute lymphoblastic leukemia (cALL) survivors. Yet, their association is often poorly understood. In this study, we wished to (1) describe neurocognitive difficulties and fatigue in a well-characterized cohort of long-term cALL survivors and (2) explore the risk of having neurocognitive deficits as a function of fatigue. Childhood ALL survivors (N = 285) from three Canadian treatment centers completed the DIVERGT battery of cognitive tests and the PedsQL Multidimensional Fatigue Scale. We performed logistic regressions to assess the risk of a survivor to show cognitive deficits (<2.0 SD) depending on their fatigue levels. At least one cognitive deficit on the DIVERGT was present in 31% of participants. Domains primarily affected were working memory, fine motor skills, and verbal fluency. Sleep/rest fatigue in youths was higher than norms (d = 0.35). The risk for cognitive deficits increased independently with levels of fatigue in the domains of cognitive speed and flexibility, working memory, and verbal fluency. For every 10-point increase on general or sleep/rest fatigue on the 0-100 scale, there was a median +23-35% risk of showing a deficit among the 7 tasks significantly associated with fatigue. Fatigue may constitute a complementary target when searching to mitigate cognitive issues in this population.

Bedtime digital media use, sleep and fatigue among survivors of childhood cancer, their siblings and healthy control sibling pairs

Bedtime digital media use (BDM) is linked to poor sleep and fatigue in many populations. Pediatric cancer patients have been observed to engage in BDM in clinical settings, but it is unknown whether BDM rates are higher in this population or how this impacts their sleep and fatigue during treatment and into survivorship. The goal of this study was to evaluate patterns of BDM and its relationship with sleep and fatigue in a sample of pediatric cancer survivors and to compare these patterns with children from their own family (i.e. siblings) and children from unaffected families (i.e. healthy matched controls and siblings of controls). Ninety-nine children (4 groups: 24 acute lymphoblastic leukemia survivors, 13 survivor siblings, 33 controls, 29 control siblings) ages 8-18 were recruited from a long-term survivor clinic at a large children's hospital and via community advertisements. Survivors were 2-7 years post-treatment (M = 4.80 years). Children's BDM was parent-reported. Children completed 7 consecutive days of sleep actigraphy and the PedsQL Multidimensional Fatigue Scale. Most survivors (66.67%) engaged in BDM; smartphones were the most common medium. BDM patterns were equivalent across survivors, their siblings, controls, and control siblings. Statistical trends suggested that BDM was associated with fewer minutes of sleep and greater fatigue for all children; these relationships were equivalent across groups. BDM was common among survivors, but usage was not different from their own siblings or compared to healthy control children and sibling pairs. This study underscores the importance of assessing bedtime digital media use in childhood cancer survivors, although other factors impacting sleep should be explored. Clinicians should emphasize established recommendations for healthy media use and sleep habits in pediatric oncology settings.

Unraveling Dexamethasone-Induced Neurobehavioral and Sleep Problems in Children With ALL: Which Determinants Are Important?

PURPOSE

Dexamethasone, the preferred corticosteroid in most treatment protocols for pediatric acute lymphoblastic leukemia (ALL), can induce undesirable side effects. Neurobehavioral and sleep problems are frequently reported, but the interpatient variability is high. We therefore aimed to identify determinants for parent-reported dexamethasone-induced neurobehavioral and sleep problems in pediatric ALL.

METHODS

Our prospective study included patients with medium-risk ALL and their parents during maintenance treatment. Patients were assessed before and after one 5-day dexamethasone course. Primary end points were parent-reported dexamethasone-induced neurobehavioral and sleep problems, measured with the Strengths and Difficulties Questionnaire and Sleep Disturbance Scale for Children, respectively. Analyzed determinants included patient and parent demographics, disease and treatment characteristics, parenting stress (Parenting Stress Index and Distress Thermometer for Parents), dexamethasone pharmacokinetics, and genetic variation (candidate single-nucleotide polymorphisms rs41423247 and rs4918). Statistically significant determinants identified in univariable logistic regression analyses were incorporated in a multivariable model.

RESULTS

We included 105 patients: median age was 5.4 years (range, 3.0-18.8) and 61% were boys. Clinically relevant dexamethasone-induced neurobehavioral and sleep problems were reported by parents in 70 (67%) and 61 (59%) patients, respectively. In our multivariable regression models, we identified parenting stress as a significant determinant for parent-reported neurobehavioral (odds ratio [OR], 1.16; 95% CI, 1.07 to 1.26) and sleep problems (OR, 1.06; 95% CI, 1.02 to 1.10). Furthermore, parents who experienced more stress before start of a dexamethasone course reported more sleep problems in their child (OR, 1.16; 95% CI, 1.02 to 1.32).

CONCLUSION

We identified parenting stress, and not dexamethasone pharmacokinetics, genetic variation, patient/parent demographics, or disease/treatment characteristics, as a significant determinant for parent-reported dexamethasone-induced neurobehavioral and sleep problems. Parenting stress may be a modifiable target to reduce these problems.

Physical Activity as a Treatment for Cancer-Related Fatigue in Children, Adolescents and Young Adults: A Systematic Review

Background: Cancer-related fatigue (CRF) is one of the most common and distressing symptoms in paediatric oncology. Based on previous studies, physical activity interventions are considered to be effective in reducing CRF in adult cancer patients. Aim: The aim of this systematic review is to investigate whether physical activity interventions can reduce CRF in paediatric patients undergoing cancer treatment. Methodology: A systematic literature search was conducted in PubMed and Sport-Discus in October 2021 to identify intervention studies examining the effects of physical activity on CRF in cancer patients ≤ 21 years of age. Their methodological quality was assessed using the JBI Critical Appraisal Tool. Results: A total of 20 studies (seven randomized-controlled, six quasi-experimental and seven single-arm intervention trials) were included in the review. Nine studies reported significant positive effects of physical activity interventions on CRF in group comparison or within groups. Eleven trials reported no significant changes in CRF. Conclusion: Physical activity as a therapeutic intervention in paediatric oncology may have the potential to reduce CRF in childhood cancer patients undergoing cancer treatment. Further high-quality studies with large samples are needed to verify these results and to assess the interdependence of dose and response of physical activity interventions.

Associations between cancer-related distress and fatigue in childhood cancer survivors: A longitudinal study

BACKGROUND AND AIMS

A chronic feeling of fatigue occurs in up to 85% of childhood cancer survivors (CCS). This phenomenon has a detrimental effect on quality of life, reintegration in daily life activities and psychosocial functioning of the patient. Therefore, it is important to elucidate potential individual risk and protective factors.

METHODS

CCS who were treated in the University Hospital of Leuven, completed two annual questionnaires on cancer-related distress (fear of cancer recurrence and post-traumatic stress, resilience and fatigue). Associations between distress and fatigue levels were examined by performing cross-lagged panel analyses. Resilience was included as a potential moderator. These models included all within-time associations, stability paths, and cross-lagged paths. Gender and time since diagnosis were included as covariates.

RESULTS

In total, 110 CCS participated in this study, aged 14-25 years (average time since diagnosis 12.2 years; 41.8% boys; diagnosed with leukemia/lymphoma [49%], solid tumor [15%], brain tumor [16%] or other [20%]). Fear of cancer recurrence and post-traumatic stress at baseline positively predicted fatigue 1 year later. Cross-lagged panel analyses showed that resilience did not buffer the effect of fear of cancer recurrence on fatigue, in contrary to our expectations. Stability coefficients were high for all study variables.

CONCLUSION

This study indicates associations between cancer-related distress (fear of cancer recurrence and post-traumatic stress), resilience and cancer-related fatigue over time in CCS. Interventions to improve fatigue levels could be focusing on both tackling cancer-related distress, while improving resilience levels as well.

An exploratory study of sleep habits in school-aged survivors of retinoblastoma

OBJECTIVE/BACKGROUND

Retinoblastoma is an ocular cancer diagnosed in early childhood. Previous research has indicated the impact of cancer treatment on sleep, but little is known about how sleep is impacted among survivors of retinoblastoma. The current study aimed to describe sleep habits of school-age survivors of retinoblastoma, to examine associations between sleep and quality of life, and to examine concordance between parent and child reports of sleep habits.

PATIENTS/METHODS

Sixty-nine survivors of retinoblastoma (Mage = 10.89, SD = 1.07, 50.7% female; 56.5% unilateral disease) and their caregivers participated, providing information on both self- and parent-reported sleep habits, quality of life, and demographic data.

RESULTS

Greater sleep concerns than national norms were reported by parents (bedtime resistance (t(58) = 2.69, p = .009), greater sleep onset delay (t(66) = 2.46, p = .017), shorter sleep duration (t(57) = 2.12, p = .038), increased daytime sleepiness (t(53) = 6.45, p= <.001)) and children (sleep location (t(61) = 2.39, p = .02), restless legs syndrome (t(62) = -2.21, p = .03), parasomnias (t(64) = 19.19, p=<.001)) . Both children and parents of children who received enucleation endorsed greater sleep concerns across several domains (e.g., electronic use before bed, sleep-disordered breathing). Child- and parent-reported sleep concerns were generally associated with decreased quality of life. Finally, child- and parent-report of sleep habits appeared generally consistent.

CONCLUSIONS

Survivors of retinoblastoma experience sleep difficulties. As such, assessment and targeted intervention is important to mitigate any effects on quality of life. Future research should examine sleep habits of survivors of retinoblastoma across cultures and developmental periods.

Longitudinal use of patient reported outcomes in pediatric leukemia and lymphoma reveals clinically relevant symptomatic adverse events

BACKGROUND

Leukemia and lymphoma (LL) are the most common cancer diagnoses of childhood with high survival rates, but not without impact on the child's functioning and quality of life. This study aimed to use patient-reported data to describe the symptomatic adverse event (AE) experiences among children with LL diagnoses.

METHODS

Two hundred and fifty seven children and adolescents aged 7-18 years with a first LL diagnosis completed the Pediatric Patient-Reported version of the Common Terminology Criteria for Adverse Events (Ped-PRO-CTCAE) and Patient-Reported Outcome Measurement Information System (PROMIS) Pediatric measures before starting a treatment course (T1) and after the treatment (T2).

RESULTS

Fatigue was the most severe AE (68.1% at T1; 67% at T2) and caused the most interference over time. Gastrointestinal AEs were also quite common (e.g., nausea 46.3% at T1 and 48.9% at T2; abdominal pain 42.4% at T1; 46.5% at T2). In general, symptoms were present both at T1 and T2 and did not change significantly in severity or interference. The prevalence of AEs varied by LL disease group (e.g., nausea was most common in acute lymphoblastic leukemia (ALL), fatigue was most severe in ALL and Hodgkin Lymphoma (HL), acute myeloid leukemia had the fewest AEs).

CONCLUSION

Despite current supportive care regimens, many children with LL continue to report fatigue, pain, insomnia, and gastrointestinal symptoms as the most frequent or severe symptoms during therapy.

Evaluating a serious game to improve childhood cancer patients' treatment adherence

Objective

Childhood cancer patients need to have good treatment adherence. Unfortunately, treatment non-adherence often occurs due to high side-effect burdens of treatment and the lack of knowledge of one's illness and treatment. Therefore, a serious game intervention based on the Protection Motivation Theory (PMT) was designed and developed to motivate childhood cancer patients to undergo treatment and to motivate them to undergo treatment, perform daily self-care and educate them about their illness.

Methods

Childhood cancer patients (6–17 years old) and their caregivers were recruited in a multi-centre, single-arm intervention in Malaysia. A total of 24 child-caregiver dyads have completed the study. This study used PMT-based surveys to collect quantitative data regarding children's motivation to adhere to treatment and perform daily self-care. Additionally, a 20-question multiple-choice quiz was used to determine children's knowledge levels. These surveys were conducted pre-test and post-test. Children's and caregivers' feedback were also gathered post-test as qualitative data.

Results

The results showed that overall, the children's intention to undergo cancer treatment had increased significantly. A significant increase in the intention to perform daily self-care was found among younger children, while older children showed significant improvement in their cancer knowledge levels. The post-test feedback suggested that the game was liked by both children and caregivers and it provided various benefits to children with cancer.

Conclusions

Findings suggest that the intervention has the potential to improve childhood cancer patients’ motivation for treatment adherence and daily self-care, in addition to educating them about cancer and treatment.

Secondary Narcolepsy as Worsening Sign in a Pediatric Case of Optic Pathway Glioma

Narcolepsy, a neurologic disorder that leads to excessive daytime sleepiness, may represent a rare consequence of neoplastic lesions involving the sellar/parasellar and hypothalamic regions, the anatomical areas responsible for wakefulness. Optic pathway gliomas represent the most common neoplasm of these regions and present an excellent overall survival, while long-term neurologic impairments, such as visual loss, endocrinopathies, or sleep disorders, are the principal causes of morbidity. In this case report, we describe a non-NF1 patient suffering from a very extensive optical pathway glioma, who several years after the diagnosis in a radiological condition of stable disease, presented with severe narcolepsy, a rare complication, that led to the death of the patient.

Interactive Education on Sleep Hygiene with a Social Robot at a Pediatric Oncology Outpatient Clinic: Feasibility, Experiences, and Preliminary Effectiveness

Objectives: Children with cancer often experience sleep problems, which are associated with many negative physical and psychological health outcomes, as well as with a lower quality of life. Therefore, interventions are strongly required to improve sleep in this population. We evaluated interactive education with respect to sleep hygiene with a social robot at a pediatric oncology outpatient clinic regarding the feasibility, experiences, and preliminary effectiveness. Methods: Researchers approached children (8 to 12 years old) who were receiving anticancer treatment and who were visiting the outpatient clinic with their parents during the two-week study period. The researchers completed observation forms regarding feasibility, and parents completed the Children’s Sleep Hygiene Scale before and two weeks after the educational regimen. The experiences of children and parents were evaluated in semi-structured interviews. We analyzed open answers by labeling each answer with a topic reflecting the content and collapsed these topics into categories. We used descriptive statistics to describe the feasibility and experiences, and a dependent-samples t-test to evaluate the preliminary effectiveness. Results: Twenty-eight families participated (58% response rate) and all interactions with the robot were completed. The children and parents reported that they learned something new (75% and 50%, respectively), that they wanted to learn from the robot more often (83% and 75%, respectively), and that they applied the sleeping tips from the robot afterwards at home (54%). Regarding the preliminary effectiveness, children showed a statistically significant improvement in their sleep hygiene (p = 0.047, d = 0.39). Conclusions: Providing an educational regimen on sleep hygiene in a novel, interactive way by using a social robot at the outpatient clinic seemed feasible, and the children and parents mostly exhibited positive reactions. We found preliminary evidence that the sleep hygiene of children with cancer improved.

Pain science education for children living with and beyond cancer: Challenges and research agenda

Pain in children living with and beyond cancer is understudied and undertreated. Pain science education (PSE) is a conceptual change strategy facilitating patients' understanding of the biopsychosocial aspects of pain. Preliminary studies on the adaptation of PSE interventions to adults with and beyond cancer provide a foundation for pediatric research. PSE could help childhood cancer survivors experiencing persistent pain and pain-related worry after active treatment. PSE may also help children receiving cancer treatment, providing them with a foundation of adaptive pain beliefs and cognitions, and preparing them for procedural and treatment-related pain. We direct this paper toward pediatric oncology clinicians, policy makers, and researchers working with children living with and beyond cancer. We aim to (a) identify challenges in adapting PSE for children living with and beyond cancer, (b) offer possible solutions, and (c) propose research questions to guide the implementation of PSE for children living with and beyond cancer.

Insomnia Symptoms and Daytime Fatigue Co-Occurrence in Adolescent and Young Adult Childhood Cancer Patients in Follow-Up after Treatment: Prevalence and Associated Risk Factors

Insomnia symptoms and daytime fatigue commonly occur in pediatric oncology, which significantly impact physical and psychosocial health. This study evaluated the prevalence of insomnia only, daytime fatigue only, the co-occurrence of insomnia−daytime fatigue symptoms, and associated risk factors. Childhood cancer patients (n = 565, 12−26 years old, ≥6 months after treatment) participated in a national, cross-sectional questionnaire study, measuring insomnia symptoms (ISI; Insomnia Severity Index) and daytime fatigue (single item). Prevalence rates of insomnia and/or daytime fatigue subgroups and ISI severity ranges were calculated. Multinomial regression models were applied to assess risk factors. Most patients reported no insomnia symptoms or daytime fatigue (61.8%). In the 38.2% of patients who had symptoms, 48.1% reported insomnia and daytime fatigue, 34.7% insomnia only, and 17.1% daytime fatigue only. Insomnia scores were higher in patients with insomnia−daytime fatigue compared to insomnia only (p < 0.001). Risk factors that emerged were: female sex and co-morbidities (all), shorter time after treatment and bedtime gaming (insomnia only), young adulthood (insomnia−fatigue/fatigue only), needing someone else to fall asleep and inconsistent wake times (both insomnia groups), lower educational level and consistent bedtimes (insomnia−fatigue). Insomnia symptoms and daytime fatigue are common and often co-occur. While current fatigue guidelines do not include insomnia symptoms, healthcare providers should inquire about insomnia as this potentially provides additional options for treatment and prevention.

Sleep Disturbance and Its Association With Sluggish Cognitive Tempo and Attention in Pediatric Brain Tumor Survivors

Background

Pediatric brain tumor (PBT) survivors are at risk for developing sleep disturbances. While in other pediatric populations sleep disturbance has been associated with worse cognitive functioning, it is unclear to what extent this relationship generalizes to PBT survivors. The aim of the current study was to assess the relationship between sleep disturbance and aspects of cognition, including sluggish cognitive tempo (SCT) as well as attention and working memory.

Materials and Methods

Eighty-three PBT survivors 6–18 years of age who were at least 3 months post-treatment were included in the present cross-sectional study. Level of sleep disturbance was measured as a composite score reflecting various sleep problems as rated by caregivers. Cognitive measures included caregiver-ratings of sluggish cognitive tempo and attention problems, as well as performance-based cognitive measures assessing attention and executive functioning. Hierarchical regression analysis was used to assess associations between sleep and cognition.

Results

Of all caregivers, 32.5% reported one or more sleep disturbances as “very/often true” and over 68% of caregivers rated at least one sleep-related item as “somewhat true.” Of all cognitive variables, scores were most frequently impaired for SCT (30%). A higher level of sleep disturbance was associated with worse SCT and parent-rated attention problems. Associations between sleep and performance-based cognitive measures assessing attention and working memory were not statistically significant.

Conclusion

Findings of the current study highlight the importance of further investigation into the relationship between sleep and cognition in PBT survivors, which may assist efforts to maximize cognitive outcome and health-related quality of life in PBT survivors. The current study additionally suggests further investigation of SCT in this population is warranted, as it may be more sensitive to detecting possible associations with sleep disturbance relative to discrete measures that assess cognitive performance under ideal circumstances.

Effect of virtual reality-based exercise intervention on sleep quality in children with acute lymphoblastic leukemia and healthy siblings: A randomized controlled trial

OBJECTIVE

Sleep is one of the important measurements of the quality of life for children especially suffering from a chronic illness such as cancer. Our aim was to determine the changes in sleep quality and to investigate the effect of virtual reality-based exercise (VRBE) approaches on sleep in patients with acute lymphoblastic leukemia (ALL) off treatment.

METHOD

The participants (ALL and healthy siblings) were evaluated for sleep quality with polysomnography and "Children's Sleep Habit Questionnaire" before and after 12 weeks. The study randomized into two groups: an exercise group who received VRBE in two days in a week, 45 min of each session for 12 weeks and an control group who were managed with supportive measures. The VRBE comprised of aerobic exercise in four different games by Nintendo Wii Fit Plus®.

RESULTS

This randomized controlled trial was carried out on 38 participants. Before intervention, ALL patients (n = 24) and healthy siblings (n = 14) had similar sleep quality in terms of polysomnography and Children's Sleep Habit Questionnaire findings. After intervention, total time asleep (p = 0.023), respiratory disturbance index of hypopnea (p = 0.005), apnea/hypopnea index (p = 0.008), and number of apnea (p = 0.028) statistically significant improved.

SIGNIFICANCE OF RESULTS

Patients with ALL off treatment had similar values of sleep quality with healthy siblings. Novel types of exercises like VRBE have positive effects on sleep disorders in children with ALL and also healthy siblings. Future studies are needed comparing the different types of interventions.

Actigraphy-Based Characteristics of Sleep in Paediatric Cancer Patients in Remission and a Comparison with Their Healthy Peers in the Recovery Stay

BACKGROUND

Previous research has demonstrated that paediatric cancer survivors (PCS) have lower sleep quality than their healthy peers. However, the research to date has focused mainly on self-reported data. Therefore, the aim of this cross-sectional study was to characterise selected sleep parameters in PCS using objective monitoring techniques and to compare them with a control group (CG) of their healthy peers during a structured recovery stay. A specific objective was to characterise sleep with respect to gender, age, and cancer type.

METHODS

26 PCS and 38 CG aged 7-15 years participated in the study. Selected sleep indicators (time in bed, total sleep time, sleep efficiency) were objectively assessed with an Actigraph wGT3X-BT accelerometer for 12 days during the recovery stay.

RESULTS

No significant differences were found between the PCS and CG groups in terms of the selected sleep parameters. The total time in bed was 543.1 min/day in the PCS and 537.2 min/day in the CG (p=0.91). The total sleep time was 455.3 min/day in the PCS and 457.5 min/day in the CG (p=0.57). Sleep efficiency was 85.3% in the PCS and 86.3% in the CG (p=0.36). Sleep efficiency >85% was achieved by 62% of the PCS (n=16) and 68% of the CG (n=26). There were no significant differences in sleep parameters in terms of variables such as gender, age, or cancer type.

CONCLUSION

The results of our study suggest that - under the same conditions - the PCS did not differ from their healthy peers in terms of the indicators of time in bed, total sleep time, and sleep efficiency. No significant differences according to age, gender, or cancer type were found.

When Reality and Research Collide: Guidelines Are Essential for Optimal Nutrition Care in Pediatric Oncology

Nutritional problems are common in pediatric oncology due to the side effects of the disease and treatment. Nutrition intervention can be challenging, and little is known about the current clinical practice of registered dietitian nutritionists. An online questionnaire emailed to members of the pediatric, oncology nutrition, and clinical manager practice groups of the Academy of Nutrition and Dietetics, consisted of items related to current nutrition practice. Our questionnaire results suggest that the field of pediatric oncology is employed with relatively new dietitians (62% had <5 y of experience). Many registered dietitian nutritionists (60%) are providing care across the cancer care continuum (standard therapy, transplant, and survivorship) versus specializing in a particular area. Approximately half (52%) felt that their center had inadequate staffing, many reporting little in the outpatient setting. Barriers to providing optimal patient care included inadequate staffing, lack of time for research initiatives, and lack of evidence-based guidelines. Future studies should determine follow-up guidelines and appropriate staffing ratios for nutrition care in pediatric oncology. Approaches should be developed to support less experienced dietitians. Collaboration between dietitians at different facilities will likely be key in developing essential evidence-informed guidelines.

"Emotional Chemobrain": A new concept for chemotherapy adverse drug effect?

"Emotional chemobrain" is a new paradigm that relates the occurrence of alterations in the psychological wellbeing of patients to the adverse drug effects of chemotherapy on the neurobiological level. The concept of "emotional chemobrain" is the analogue concept of the classical concept of "chemobrain" but that concerns emotional disturbances related to chemotherapy. Disgust is a negative emotion that might accompany any stressful life event such as having cancer. Increased disgust may lead to the development of mental disorders such as mood and anxiety disorders. Patients with cancer may develop negative emotions such as self-disgust because of their affected autonomy and life style on the one hand and because of chemotherapy's effect on their brain on the other. Self-disgust might be considered as a factor contributing to psychological distress exacerbation in this category of physically ill individuals. In addition to lifestyle modifications and body changes, self-disgust might be exacerbated by chemotherapy in the same way other negative emotions might be exacerbated by this kind of treatment. It might be speculated that the emotional side effects of chemotherapy concern activation modifications in brain regions relevant to emotional elaboration and regulation such as the insular lobe and the amygdala. "Emotional chemobrain" should be considered whenever neuropsychiatric adverse effects of chemotherapy are manifested in patients with cancer. Future studies might be interested in studying the effect of chemotherapy on brain regions that can affect regulation of emotions such as self-disgust.

Psychosocial risk, symptom burden, and concerns in families affected by childhood cancer

PURPOSE

The revised Psychosocial Assessment Tool (PATrev) is a common family-level risk-based screening tool for pediatric oncology that has gained support for its ability to predict, at diagnosis, the degree of psychosocial support a family may require throughout the treatment trajectory. However, ongoing screening for symptoms and concerns (e.g., feeling alone, understanding treatment) remains underutilized. Resource limitations necessitate triaging and intervention based on need and risk. Given the widespread use of the PATrev, we sought to explore the association between family psychosocial risk, symptom burden (as measured by the revised Edmonton Symptom Assessment System (ESAS-r)), and concerns (as measured by the Canadian Problem Checklist (CPC)).

METHODS

Families (n = 87) with children ≤ 18 years of age (M = 11.72, male: 62.1%) on or off treatment for cancer were recruited from the Alberta Children's Hospital. One parent from each family completed the PATrev and the CPC. Participants 8-18 years of age completed the ESAS-r.

RESULTS

Risk category (universal/low risk = 67.8%, targeted/intermediate risk = 26.4%, clinical/high risk = 5.7%) predicted symptom burden (F_{[2, 63.07]} = 4.57, p = .014) and concerns (F_{[2, 82.06]} = 16.79, p < .001), such that universal risk was associated with significantly lower symptom burden and fewer concerns.

CONCLUSION

Family psychosocial risk is associated with cross-sectionally identified concerns and symptom burden, suggesting that resources might be prioritized for families with the greatest predicted need. Future research should evaluate the predictive validity of the PATrev to identify longitudinal concerns and symptom burden throughout the cancer trajectory.

Cognitive Fatigue and Processing Speed in Children Treated for Brain Tumours

OBJECTIVE

The relationship between fatigue and cognition has not been fully elucidated in children and adolescent survivors of brain tumours. The aim of the present study was to investigate the potential relationship between fatigue and cognitive impairments in these survivors, as this group is at risk for both types of deficits.

METHODS

Survivors of paediatric brain tumours (n = 45) underwent a neuropsychological testing on average 4 years after diagnosis. Mean age at follow-up was 13.41 years. Cognition was assessed with neuropsychological tests, and fatigue with the Pediatric Quality of Life (PedsQL™) Multidimensional Fatigue Scale. Regression analysis, adjusted for cranial radiotherapy and age at diagnosis, was used to investigate the associations between cognitive variables and fatigue subscales. Cognitive variables associated with fatigue were subsequently exploratively assessed.

RESULTS

Significant associations were found for cognitive fatigue and measures of cognitive processing speed; Coding: p = .003, r = .583, 95% CI [9.61; 22.83] and Symbol Search: p = .001, r = .585, 95% CI [10.54; 24.87]. Slower processing speed was associated with poorer results for cognitive fatigue. Survivors with the largest decrease in processing speed from baseline to follow-up also experienced the most cognitive fatigue. Survivors expressed more cognitive fatigue compared to other types of fatigue.

CONCLUSIONS

The association between cognitive fatigue and cognitive processing speed in children and adolescents treated for brain tumours is in concordance with the results previously reported in adults. Some survivors experience fatigue without impairment in processing speed, indicating the need for comprehensive assessments. Moreover, the study supports that fatigue is a multidimensional concept which should be measured accordingly.

Effect of Progressive Muscle Relaxation on Sleep Quality and Side Effects of Chemotherapy in Children with Cancer: Randomized Clinical Trial

BACKGROUND: Sleep disturbance affects quality of life in children receiving chemotherapy. AIM: The aim of this study was to identify the effect of progressive muscle relaxation on the sleep quality and side effects of chemotherapy in children with cancer. METHODS: This study used randomized clinical trial with single blind method, where 30 children were allocated randomly to the control group and intervention group. The intervention group received progressive muscle relaxation twice a day, in the morning and evening, 15 minutes each session for 7 days. Control group received routine nursing care. RESULTS: The study concluded there was no significant difference in the two groups on fatigue and pain. However, progressive muscle relaxation had significant relation to decreased sleep quality score. CONCLUSION: Relaxation therapy, particularly progressive muscle relaxation, may be one of the nursing cares to improve sleep quality and reduce the side effects of chemotherapy in children with cancer.

Non-pharmacological sleep interventions for pediatric cancer patients and survivors: a systematic review protocol

BACKGROUND

Sleep disturbances constitute a common complication in pediatric cancer patients and survivors and are frequently severe enough to warrant treatment. Suboptimal sleep has been associated with decreased emotional well-being and cognitive functioning and increased behavioral problems. Standardized guidelines for non-pharmacological sleep interventions for adults with cancer exist, but no standard of care intervention or standard guidelines are available to guide such intervention in pediatric cancer patients and survivors. Therefore, effective behavioral interventions for improving sleep quality need to be identified. The objective of the review is to evaluate the effect of non-pharmacological sleep interventions on sleep quality in pediatric cancer patients and survivors.

METHODS

The review will consider studies that include children and adolescents between 0 and 18 years diagnosed with cancer or who have a history of cancer who have non-respiratory sleep disturbance. We will include experimental and quasi-experimental studies evaluating non-pharmacological interventions such as psychological interventions, technical/device interventions, interventions targeting physical activity, and complementary and alternative medicine interventions (e.g., yoga, massage, music). Interventions involving medications, ingestible supplements, products purported to work through absorption, and medical devices will be excluded. Primary outcome will be sleep quality as measured by methods including retrospective ratings, daily sleep diary, and validated questionnaires. Secondary outcomes will include total sleep time, sleep onset latency, wake after sleep onset, daytime sleepiness, and daytime sleep duration (naps) as measured by retrospective ratings, daily sleep diary, validated questionnaires, and/or actigraphy. Databases will include MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, CINAHL (Ebsco), and PsycINFO (Ovid) and will be queried from database inception to present. Two reviewers will independently screen all citations, full-text articles, and extract data. The study methodological quality will be assessed using Joanna Briggs Institute (JBI) critical appraisal tools. Data will be extracted and findings pooled and synthesized using a meta-aggregation approach via the JBI System for the Unified Management, Assessment, and Review of Information (SUMARI). If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., methodological quality, study design, outcome measures).

DISCUSSION

This systematic review will synthesize and consolidate evidence on existing non-pharmacological interventions to improve sleep in pediatric cancer patients and survivors. Findings may help inform practitioners working with pediatric cancer patients and survivors experiencing sleep disturbances and is intended to identify gaps and opportunities to improve methodical quality of further non-pharmacological sleep intervention research in this population toward developing an eventual standard of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020200397 .

The effect of playing games with toys made with medical materials in children with cancer on pain during intravenous treatment

OBJECTIVE

This research aims to examine the effect of playing games with toys made of medical materials in children with cancer on pain that occurs during intravenous (IV) treatment.

METHODS

The randomized controlled clinical trial was conducted between May 2016 and February 2018. The study sample comprised 110 children (experimental group 55; control group 55), determined using power analysis from the study population. The data were collected by the researcher, using face-to-face interview techniques, the Information Form, and Wong-Baker FACES Pain Rating Scale (WBS).

RESULTS

The pre- and post-test pain mean scores of patients in the experimental group were 2.27 ± 0.91 and 0.43 ± 0.66, respectively (p = 0.0001). The pre- and post-test pain mean scores of patients in the control group were 1.72 ± 0.82 and 3.34 ± 0.77, respectively (p = 0.0001).

SIGNIFICANCE OF RESULTS

The experience of playing with toys made from materials used for invasive procedures relieves pain the during IV treatment.

Sleep Quality Among Teenagers and Young Adults With Cancer

BACKGROUND

Teenagers and young adults (TYAs) with cancer are known to suffer poor sleep quality and sleep disturbances; understanding the level of burden is essential to improving patient outcomes via supportive care interventions.

OBJECTIVES

To compare sleep quality and the prevalence of sleep disturbances among TYA cancer patients, TYA survivors, and general population TYAs with no history of cancer.

METHODS

Teenager and young adult patients receiving active cancer treatment (n = 70), TYA cancer survivors (n = 151), and general population TYAs (n = 324) aged between 13 and 24 years completed the Pittsburgh Sleep Quality Index. Analyses of covariance were used to investigate potential group differences. Age at survey diagnosis, gender, ethnicity, and health status were included as covariates.

RESULTS

84.29% of TYA patients, 62.91% of TYA cancer survivors, and 65.12% of general population TYAs reported Pittsburgh Sleep Quality Index scores greater than 5, suggesting clinically significant sleep disorders. Teenager and young adult patients reported significantly poorer global sleep quality compared with TYA survivors (mean difference, 0.99; 95% confidence interval, 0.03-1.96; P = .044) and general population TYAs (mean difference, 1.34; 95% confidence interval, 0.26-2.41; P = .009). Teenager and young adult patients and survivors reported significantly poorer sleep latency (P = .003 for TYA patients, P = .035 for TYA survivors off treatment) and habitual sleep efficiency (P < .001 for TYA patients, P = .014 for TYA survivors) than general population controls.

CONCLUSIONS

The significant differences observed suggest young people with cancer, particularly those on treatment, may benefit from specialized sleep interventions.

IMPLICATIONS FOR PRACTICE

Efforts to ensure health professionals have the knowledge and skills to provide advice about sleep to young people with cancer are needed.

Does the guided online cognitive behavioral therapy for insomnia "i-Sleep youth" improve sleep of adolescents and young adults with insomnia after childhood cancer? (MICADO-study): study protocol of a randomized controlled trial

BACKGROUND

Adolescents and young adults who had childhood cancer are at increased risk for insomnia, due to being critically ill during an important phase of their life for the development of good sleep habits. Insomnia is disabling and prevalent after childhood cancer (26-29%) and negatively impacts quality of life, fatigue, pain, and general functioning and is often associated with other (mental) health problems. Insomnia and a history of childhood cancer both increase the risk of adverse health outcomes, posing a double burden for adolescents who had childhood cancer. The first-line treatment for insomnia is cognitive behavioral therapy for insomnia (CBT-I). However, access to this type of care is often limited. The guided online CBT-I treatment "i-Sleep" has been developed to facilitate access via online care. i-Sleep is shown effective in adult (breast cancer) patients, but it is unknown if iCBT-I is effective in pediatric oncology.

METHODS/DESIGN

We developed a youth version of i-Sleep. Our aim is to evaluate its effectiveness in a national randomized-controlled clinical trial comparing iCBT-I to a waiting-list control condition at 3 and 6 months (n = 70). The intervention group will be also assessed at 12 months to see whether the post-test effects are maintained. Adolescents and young adults aged 12-30 years with insomnia, diagnosed with (childhood) cancer, currently at least 6 months since their last cancer treatment will be eligible. Outcomes include sleep efficiency (actigraphic), insomnia severity (self-report), sleep and circadian activity rhythm parameters, fatigue, health-related quality of life, perceived cognitive functioning, chronic distress, depressive and anxiety symptoms, and intervention acceptability.

DISCUSSION

Insomnia is prevalent in the pediatric oncology population posing a double health burden for adolescents and young adults who had childhood cancer. If guided iCBT-I is effective, guidelines for insomnia can be installed to treat insomnia and potentially improve quality of life and the health of adolescents and young adults who had childhood cancer.

TRIAL REGISTRATION

NL7220 (NTR7419; Netherlands Trial register). Registered on 2 August 2018.

Effect of Two Interventions on Sleep Quality for Adolescent and Young Adult Cancer Survivors: A Pilot Randomized Controlled Trial

BACKGROUND

Sleep disturbance is common among adolescent and young adult (AYA) cancer survivors. Physical activity (PA) and behavioral activation (BA) therapy have been reported as enhancing sleep quality, but few studies exist on the effects of such interventions combined with technology to promote sleep quality in AYA cancer patients.

OBJECTIVE

The aim of this study was to investigate the feasibility and effects of intelligent wearable device-based PA therapy and internet-based modified BA therapy to improve sleep quality among AYA cancer patients.

METHODS

A randomized controlled trial with 143 AYA cancer patients was conducted. Participants were randomly assigned to a control group (n = 48), which performed routine care, a PA group (n = 47), which received 8-week PA therapy based on intelligent wearable devices, and a BA group (n = 48), which participated in internet-based modified BA therapy for 8 weeks.

RESULTS

At 1 week and 3 months after the intervention for sleep quality, there were statistically significant differences between the PA group and the control group (P = .020), but no statistically significant difference between the BA group and the control group.

CONCLUSIONS

The intelligent wearable device-based PA therapy has more advantages than internet-based modified BA therapy in improving the overall state of AYA cancer patients, and the intervention effect was sustained for at least 3 months.

IMPLICATIONS FOR PRACTICE

Developing and implementing PA plans for AYA cancer survivors can improve their sleep quality. Social media, intelligent wearable devices, and mobile health applications have unique advantages in promoting sleep quality for AYA cancer survivors.

Executive Function and Psychosocial Adjustment in Adolescent Survivors of Pediatric Brain Tumor

Adolescent survivors of pediatric brain tumor (PBT) are a sparsely studied subset of childhood cancer survivors. Sustaining a PBT may complicate the development of executive functions (EFs), which play a vital role in long-term psychosocial adjustment. In this study, 48 adolescent survivors and their parents completed questionnaires assessing EF, psychological symptoms, fatigue, and adaptive functioning, and 26 survivors underwent neuropsychological assessment. Survivors reported significantly more problems with adaptive functioning than a healthy control group, and this was most strongly associated to executive dysfunction, compared to psychological symptoms and fatigue. The findings have important implications for long-term follow-ups.

Sleep practices in pediatric cancer patients: Indirect effects on sleep disturbances and symptom burden

OBJECTIVE

Sleep hygiene recommendations are commonly given to address patient-reported concerns about sleep, yet few studies have examined the relationship between sleep hygiene and sleep disturbances in the context of pediatric oncology. Because poor sleep may affect the patient's experience of cancer-related symptoms, understanding whether sleep hygiene practices influence sleep disturbances and symptoms may be important to improving symptom burden.

METHODS

One hundred and two caregivers of children ages 5-17 and 59 patients ages 8-17 receiving treatment for cancer completed parallel measures of child sleep, sleep hygiene, pain, fatigue, and nausea. Sleep hygiene practices were described, correlates between measures were examined, and the indirect relationship of sleep hygiene on symptom burden through sleep disturbances was tested using PROCESS.

RESULTS

Patients received adequate sleep for age but sleep timing was later than recommended for more than half of the sample and consistency in sleep times was poor. Sleep disturbances were moderately related to all symptoms, with the exception of patient-reported fatigue. Consistent sleep habits were indirectly related to fewer cancer-related symptoms of pain, fatigue, and nausea through sleep disturbances by caregiver report but not patient report.

CONCLUSION

Sleep disturbances are closely related to pain, fatigue, and nausea in pediatric cancer. Consistency in sleep/wake routines and schedules may be important to experiencing fewer sleep disturbances and lower symptom burden. Providing recommendations supporting consistent sleep habits broadly across pediatric oncology may be more effective than only presenting sleep hygiene recommendations to patients experiencing poor sleep.

Correlation Between Symptom Clusters and Quality of Life in Children With Acute Leukemia During Chemotherapy

BACKGROUND

Children with acute leukemia experience various distressing symptoms due to the disease and its treatment during chemotherapy. These symptoms cluster together and have negative impacts on patient outcomes.

OBJECTIVE

The aim of this study was to examine symptom clusters that children with acute leukemia undergoing chemotherapy are experiencing and the impact of these symptom clusters on their quality of life.

METHODS

A cross-sectional study design was used, and 184 Chinese children with acute leukemia who were undergoing chemotherapy were invited to participate in the study. Memorial Symptom Assessment Scale 10-18 and Pediatric Quality of Life Inventory General Core Module version 4.0 were applied. Exploratory factor analysis and multiple regression were used to identify symptom clusters and their influence on the quality of life.

RESULTS

Six symptom clusters were identified as gastrointestinal, emotional, neurological, skin mucosal, self-image disorder, and somatic cluster. The severity of each symptom cluster was negatively correlated with quality of life. Among them, gastrointestinal, emotional, and somatic clusters were significant predictors of quality of life.

CONCLUSIONS

There are multiple symptom clusters in children with acute leukemia, which seriously affect children's quality of life. To relieve symptom burden and improve quality of life, nursing and medical staff should pay attention to the symptom management and control in a symptom cluster perspective.

IMPLICATIONS FOR PRACTICE

The results of this study will provide suggestions for the healthcare provider to plan for these symptoms and manage any concurrent symptoms for the successful promotion of children's quality of life.

Fatigue among children with a chronic disease: a cross-sectional study

OBJECTIVE

To determine: (1) which biological/lifestyle, psychological and/or social factors are associated with fatigue among children with a chronic disease and (2) how much each of these factors contributes to explaining variance in fatigue.

DESIGN AND SETTING

This was a cross-sectional study across two children's hospitals.

PATIENTS

We included children aged 8-18 years who visited the outpatient clinic with cystic fibrosis, an autoimmune disease or postcancer treatment.

MAIN OUTCOME MEASURES

Fatigue was assessed using the PedsQL Multidimensional Fatigue Scale. Generic biological/lifestyle, psychological and social factors were assessed using clinical assessment tools and questionnaires. Multiple linear regression analyses were used to test the associations between these factors and fatigue. Finally, a multivariable regression model was used to determine which factor(s) have the strongest effect on fatigue.

RESULTS

A total of 434 out of 902 children were included (48% participation rate), with a median age of 14.5 years; 42% were male. Among these 434 children, 21.8% were severely fatigued. Together, all biopsychosocial factors explained 74.6% of the variance in fatigue. More fatigue was uniquely associated with poorer physical functioning, more depressive symptoms, more pressure at school, poorer social functioning and older age.

CONCLUSIONS

Fatigue among children with a chronic disease is multidimensional. Multiple generic biological/lifestyle, psychological and social factors were strongly associated with fatigue, explaining 58.4%; 65.8% and 50.0% of the variance in fatigue, respectively. Altogether, almost three-quarters of the variance in fatigue was explained by this biopsychosocial model. Thus, when assessing and treating fatigue, a transdiagnostic approach is preferred, taking into account biological, psychological and social factors.

Parental Experiences of Adolescent Cancer-Related Fatigue: A Qualitative Study

Objective

Cancer-related fatigue is common, disabling, and chronic, but professional help is not necessarily sought. Parents can support symptom management and facilitate help-seeking. This study explored parental experiences of their adolescent’s cancer-related fatigue and what they do to help.

Methods

Qualitative semi-structured interviews were conducted with 21 parents of 17 adolescents aged 12–18 who were previously diagnosed with cancer. Reflexive thematic analysis was used to analyze the data.

Results

Three high-order themes were generated. Firstly, “fatigue is inevitable and unpredictable.” This encompassed parental perceptions of fatigue as variable, distinct from normal tiredness, and linked to sleep and mood. Fatigue was seen as arising from cancer, which rendered parents helpless. Secondly, “fatigue is disruptive to normal life” beyond cancer treatment, which is contrary to expectations. Thirdly, parents managed fatigue by trying to balance the adolescent’s desires for normality and their own perception of what is realistic with encouraging activities, and by seeking support from others.

Conclusions

Parents see adolescent cancer-related fatigue as multi-faceted and experience it as unpredictable and attributed to cancer. They struggle to distinguish normal adolescent behavior from problematic fatigue, and to balance supporting and empowering the adolescent to live life to the fullest whilst also being realistic about the limitations imposed by fatigue and the benefits of activity. Parents try to manage fatigue practically but want more information about adolescent cancer-related fatigue to help establish their own and their adolescent’s expectations.

Neurodevelopmental Consequences of Pediatric Cancer and Its Treatment: The Role of Sleep

Cognitive impairment is frequent in pediatric cancer, and behavioral and psychological disturbances often also affect children who have survived cancer problems. Furthermore, pediatric tumors are also often associated with sleep disorders. The interrelationship between sleep disorders, neurodevelopmental disorders and pediatric cancer, however, is still largely unexplored. In this narrative review we approach this important aspect by first considering studies on pediatric cancer as a possible cause of neurodevelopmental disorders and then describing pediatric cancer occurring as a comorbid condition in children with neurodevelopmental disorders. Finally, we discuss the role of sleep disorders in children with cancer and neurodevelopmental disorders. Even if the specific literature approaching directly the topic of the role of sleep in the complex relationship between pediatric cancer and neurodevelopmental disorders was found to be scarce, the available evidence supports the idea that in-depth knowledge and correct management of sleep disorders can definitely improve the health and quality of life of children with cancer and of their families.

Cross-Sectional Associations of Fatigue Subtypes with Pain Interference in Younger, Middle-Aged, and Older Adults with Chronic Orofacial Pain

Objective

Mental, emotional, physical, and general fatigue, as well as vigor, have each been associated with pain interference—defined as pain-related disruption of social, recreational, and work-related activities—in patients with chronic orofacial pain (COFP). The objectives of the current study were to compare levels of these fatigue subtypes across younger, middle-aged, and older patients with COFP and test the associations between fatigue subtypes and pain interference in these age groups.

Design

A cross-sectional cohort design was used.

Setting

Participants self-reported fatigue subtypes (Multidimensional Fatigue Symptom Inventory–Short Form), pain interference (West Haven–Yale Multidimensional Pain Inventory), pain intensity (visual analog scale), pain duration (months), depression (Symptom Checklist 90–Revised), and sleep quality (Pittsburgh Sleep Quality Index) at their initial appointment at a tertiary orofacial pain clinic.

Subjects

Sixty younger (age 18–39), 134 middle-aged (age 40–59), and 51 older (age 60–79) COFP patients provided data for the study.

Methods

Analysis of variance was used to compare levels of fatigue subtypes between the age groups. Regression with dummy-coding was used to test if the relationship between fatigue subtypes and pain interference varied by age.

Results

Older COFP patients reported less general fatigue and more vigor than younger or middle-aged adults. Fatigue subtypes were each associated with greater pain interference, but associations became nonsignificant after controlling for depression, sleep, and pain intensity/duration. Age group–by–fatigue subtype interactions were not observed.

Conclusions

Managing fatigue may be important to reduce pain interference in COFP populations and may be accomplished in part by improving depression and sleep.

Cognitive fatigue in relation to depressive symptoms after treatment for childhood cancer

Background

Cognitive fatigue after childhood cancer is frequently overlooked despite guidelines recommending follow-up, and might be mistaken for depression due to overlapping symptoms. Our objectives were: 1) to examine ratings of fatigue in survivors of paediatric brain tumours (BT) and acute lymphoblastic leukaemia (ALL) compared to healthy controls, 2) to examine the relationship between symptoms of depression and cognitive fatigue, and 3) to evaluate parent-child concordance in ratings of cognitive fatigue.

Methods

Survivors of BT (n = 30), survivors of ALL (n = 30), and healthy controls (n = 60) aged 8–18 years completed the Pediatric Quality of Life Multidimensional Fatigue Scale and the Beck Youth Inventories. Associations between cognitive fatigue, diagnosis and depression were assessed with general linear modelling. Group differences were analysed using the Kruskal–Wallis test. Parent-child concordance was investigated with internal consistency reliability.

Results

Cognitive fatigue was prevalent in 70% of survivors of BT survivors and in 30% of survivors of ALL. Diagnosis was the main predictor of cognitive fatigue (p < .001, η_p² = 0.178), followed by depression (p = .010, η_p² = 0.080). Survivors of BT reported significantly more fatigue than healthy controls on all fatigue subscales. While they also expressed more symptoms of depression, we found no evidence for an interaction effect. Parent-child concordance was moderate to good among survivors, but poor for controls.

Conclusions

Survivors of BT and ALL suffer from cognitive fatigue, with survivors of BT expressing more problems. Cognitive fatigue and depression should be assessed in survivors of childhood cancer using both self-rated and proxy-rated measures, and appropriate interventions offered.

High prevalence of parent-reported sleep problems in pediatric patients with acute lymphoblastic leukemia after induction therapy

OBJECTIVE

To assess sleep problems (prevalence and predictors) in pediatric patients with acute lymphoblastic leukemia (ALL) after the most intensive phase of therapy (induction).

METHODS

Patients (≥2 years) treated according to the Dutch ALL-11 protocol were included. Sleep was measured using parent-reports and self-reports (Children's Sleep Habits Questionnaire; CSHQ) and actigraphy. Parental sleep (Medical Outcome Study Sleep Scale) and distress and parenting problems (Distress Thermometer for Parents) were assessed with questionnaires. Z-scores were calculated for total CSHQ scores using age-appropriate scores of healthy Dutch children. The prevalence of sleep problems (defined as a Z-score > 1) in patients with ALL was compared to healthy children (chi-square tests). Actigraphic sleep estimates were collected in healthy Dutch children (n = 86, 2-18 years) for comparison with patients (linear regression). Determinants of parent-reported child sleep (total CSHQ Z-score) were identified with regression models.

RESULTS

Responses were collected for 124 patients (response rate 67%), comprising 123 parent-reports, 34 self-reports, and 69 actigraphy assessments. Parents reported sleep problems in 38.0% of the patients compared to 15.2% in healthy children (P < .001). Patients reported fewer sleep problems themselves: 12.1% compared to 15.8% in healthy children (P = .33). Total time in bed (B (95% CI): 22.89 (9.55-36.22)) and total sleep time (B (95% CI):16.30 (1.40-31.19)), as derived from actigraphy, were significantly longer in patients. More parent-reported child sleep problems were predicted by parenting problems, more parental sleep problems, bedroom sharing, and child's sleep medication use (explained variance: 27.4%).

CONCLUSIONS

Systematic monitoring of child and parental sleep and implementation of effective interventions may be a gateway to improve quality of survival in pediatric ALL.

The Mediating Role of Exercise on Relationships Between Fatigue, Sleep Quality, and Quality of Life for Adolescents With Cancer

BACKGROUND

Fatigue and poor sleep are two of the most common and most distressing symptoms for adolescents with cancer. These 2 symptoms concurrently heighten distress, further decreasing quality of life (QoL).

OBJECTIVES

The aims of this study were to describe the degree of exercise involvement, fatigue, sleep quality, and QoL among adolescents with cancer and to determine whether exercise mediates the relationships between (a) fatigue and QoL and (b) sleep quality and QoL.

METHODS

A cross-sectional study of 100 participants was conducted. Multiple regression was performed to examine the mediation relationship.

RESULTS

Participants in the off-treatment group had a significantly higher degree of exercise involvement, as well as less fatigue, greater sleep quality, and less QoL distress. Exercise partially mediated the adverse effect of fatigue on QoL for adolescents undergoing cancer treatment, accounting for 49.80% of the total variation; exercise partially mediated the adverse effect of poor sleep on QoL for adolescents both in treatment and in survivorship, accounting for 42.06% and 28.71% of the total variations, respectively.

CONCLUSION

Exercise partially mediated the relationship between fatigue and QoL for adolescents in cancer treatment and partially mediated the relationship between sleep quality and QoL both for those in cancer treatment and for those in survivorship.

IMPLICATIONS FOR PRACTICE

Developing tailored exercise programs based on both treatment status and the degree of fatigue and sleep quality is important. In-service education that enhances nurses' awareness of the importance of exercise in improving adolescents' QoL is recommended.