Growth effects of methylphenidate among childhood cancer survivors: a 12-month case-matched open-label study

Height, weight, and cardiovascular effects of stimulants on children with brain tumors

INTRODUCTION

Children with brain tumors may develop inattention, slow processing, and hypersomnia. Stimulant medications improve these problems, but their effect on growth, heart rate, and blood pressure (BP) are inadequately explored.

PROCEDURE

We retrospectively studied children with brain tumors treated at our institution that had data available for 1 year pre and 2 years on stimulant treatment. Tumor location, gender, radiation treatment (RT), age at RT, drug type, and hormone therapy were variables of interest.

RESULTS

We identified 65 children (35 males) that fulfilled eligibility criteria. Focal RT was utilized in 58; 11 additionally had whole brain RT; and seven received no RT. Thirty were treated for hypersomnia and inattention, eight for hypersomnia alone, and rest for inattention. Modafinil was the first drug in 18 (27.7%), and methylphenidate in the others. Forty-seven (72.3%), 45 (69.2%), and 49 (75.4%) were on thyroxine, cortisone, and growth hormones, respectively. There was no difference in pre- and post-stimulant body mass index (BMI), heart rate, and BP. There was also no difference between modafinil and methylphenidate groups. Rate of height acquisition slowed on stimulants (P = .0096). Thyroxine treatment correlated with increase in BMI after stimulants (P = .04). Younger age (P = .0003) and higher prestimulant BMI (P = .0063) correlated with increased heart rate on stimulants, while higher age at RT (P =.016) correlated with elevated systolic BP on stimulants. No associations were found with height acquisition and diastolic BP.

CONCLUSION

Stimulants are well tolerated by children with brain tumors that are appropriately managed for endocrine deficiencies, but may reduce the trajectory of height attainment.

The Effects of Methylphenidate Treatment on Child Growth in Thai Children and Adolescents with Attention-Deficit/Hyperactivity Disorder

Objectives: To determine the effects of methylphenidate treatment on child growth in Thai pediatric patients with attention-deficit/hyperactivity disorder (ADHD). Methods: The medical records of children and adolescents with ADHD, between 5 and 18 years of age, who received pharmacological treatment with methylphenidate as a sole psychiatric medication for ≥1 year between 2001 and 2018 at the Rajanagarindra Institute of Child Development, Thailand, were retrospectively reviewed. Data on anthropometric parameters and methylphenidate use were extracted. Height and weight were converted to age- and gender-corrected standard scores (z-scores) using norms from the Thai pediatric population. Changes in height and weight z-scores were assessed using a paired t-test or one-way repeated measures ANOVA with the Bonferroni correction. Results: In this retrospective observational study, 911 children and adolescents were eligible, with the mean age of 95.0 ± 19.5 months at baseline, the cumulative duration of methylphenidate treatment of 39.4 ± 23.5 months, and the average daily dosage of 14.1 ± 6.2 mg/day. Comparative analysis found no statistically significant change in height z-scores between baseline and last recorded measurement (mean difference = 0.0017, confidence interval [95% CI] = -0.0004 to 0.0038, p = 0.107), while a slight, but significant increase in weight z-scores was observed (mean difference = 0.0271, 95% CI = 0.0179-0.0362, p < 0.001). Longitudinal analysis observed that weight z-scores were significantly decreased during the first year of therapy, but regained in the second year and continued to increase in subsequent years of therapy. Conclusion: Treatment with methylphenidate in our cohort of Thai pediatric patients with ADHD was not associated with growth deficits, except for a slightly significant decrease in weight during the first year of therapy.

Interventions for managing weight change following paediatric acquired brain injury: a systematic review

OBJECTIVE

To systematically review literature reporting interventions for weight change following paediatric acquired brain injury (ABI).

METHOD

A systematic search of the literature was conducted using advanced search techniques. The retrieval identified 1562 papers, of which 30 were relevant. The total number of paediatric participants was 759.

RESULTS

There is a paucity of higher quality evidence to support the use of weight change interventions following paediatric ABI. Substantial variation in screening, outcome measures, intervention, and reporting were demonstrated. Some support was found for the use of hypothalamic-sparing surgery as a method to prevent obesity following craniopharyngioma resection.

INTERPRETATION

There is a need for further study in this area to inform clinical and research practice; recommendations are given.

Computerized Cognitive Training for Amelioration of Cognitive Late Effects Among Childhood Cancer Survivors: A Randomized Controlled Trial

PURPOSE

Children receiving CNS-directed therapy for cancer are at risk for cognitive problems, with few available empirically supported interventions. Cognitive problems indicate neurodevelopmental disruption that may be modifiable with intervention. This study evaluated short-term efficacy of a computerized cognitive training program and neural correlates of cognitive change.

PATIENT AND METHODS

A total of 68 survivors of childhood acute lymphoblastic leukemia (ALL) or brain tumor (BT) with identified cognitive deficits were randomly assigned to computerized cognitive intervention (male, n = 18; female, n = 16; ALL, n = 23; BT, n = 11; mean age ± standard deviation, 12.21 ± 2.47 years) or waitlist (male, n = 18; female, n = 16; ALL, n = 24; BT, n = 10; median age ± standard deviation, 11.82 ± 2.42 years). Intervention participants were asked to complete 25 training sessions at home with weekly, telephone-based coaching. Cognitive assessments and functional magnetic resonance imaging scans (intervention group) were completed pre- and postintervention, with immediate change in spatial span backward as the primary outcome.

RESULTS

Survivors completing the intervention (n = 30; 88%) demonstrated greater improvement than controls on measures of working memory (mean ± SEM; eg, Wechsler Intelligence Scale for Children [fourth edition; WISC-IV] spatial span backward, 3.13 ± 0.58 v 0.75 ± 0.43; P = .002; effect size [ES], 0.84), attention (eg, WISC-IV spatial span forward, 3.30 ± 0.71 v 1.25 ± 0.39; P = .01; ES, 0.65), and processing speed (eg, Conners' Continuous Performance Test hit reaction time, -2.10 ± 1.47 v 2.54 ± 1.25; P = .02; ES, .61) and showed greater reductions in reported executive dysfunction (eg, Conners' Parent Rating Scale III, -6.73 ± 1.51 v 0.41 ± 1.53; P = .002; ES, 0.84). Functional magnetic resonance imaging revealed significant pre- to post-training reduction in activation of left lateral prefrontal and bilateral medial frontal areas.

CONCLUSION

Study findings show computerized cognitive training is feasible and efficacious for childhood cancer survivors, with evidence for training-related neuroplasticity.

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

Cancer in children has detrimental effects on sleep patterns and sleep quality, which in turn impacts on the perception of, and the ability to cope with, the emotional and physical challenges associated with both the disease and its treatment. This places an added burden on their quality of life that can last many years beyond diagnosis and treatment. In addition to the effect of the cancer itself, surgery, chemotherapy and radiotherapy can all contribute both short and long term to sleep disruption. Sleep disorders have also been associated with pain, fatigue, medication and hospitalisation in children suffering from cancer. This review will explore the relationship between childhood cancer and associated sleep disorders, in the acute stage of diagnosis, during treatment and in the years following. We will discuss the possible causes and the current treatment modalities used to treat sleep disorders in children with cancer, and in childhood cancer survivors. It has been estimated that the recent advances in treatment have improved the overall five year survival rate for all childhood cancers to over 80%, with some cancers achieving a near 100% cure rate such as early stage Wilms' tumour. Thus, recognition and appropriate treatment of associated sleep disorders is essential to optimise long term quality of life.

Developing interventions for cancer-related cognitive dysfunction in childhood cancer survivors

Survivors of childhood cancer frequently experience cancer-related cognitive dysfunction, commonly months to years after treatment for pediatric brain tumors, acute lymphoblastic leukemia (ALL), or tumors involving the head and neck. Risk factors for cancer-related cognitive dysfunction include young age at diagnosis, treatment with cranial irradiation, use of parenteral or intrathecal methotrexate, female sex, and pre-existing comorbidities. Limiting use and reducing doses and volume of cranial irradiation while intensifying chemotherapy have improved survival and reduced the severity of cognitive dysfunction, especially in leukemia. Nonetheless, problems in core functional domains of attention, processing speed, working memory and visual-motor integration continue to compromise quality of life and performance. We review the epidemiology, pathophysiology and assessment of cancer-related cognitive dysfunction, the impact of treatment changes for prevention, and the broad strategies for educational and pharmacological interventions to remediate established cognitive dysfunction following childhood cancer. The increased years of life saved after childhood cancer warrants continued study toward the prevention and remediation of cancer-related cognitive dysfunction, using uniform assessments anchored in functional outcomes.

Working memory training in survivors of pediatric cancer: a randomized pilot study

OBJECTIVES

Survivors of pediatric brain tumors and acute lymphoblastic leukemia (ALL) are at increased risk for neurocognitive deficits, but few empirically supported treatment options exist. We examined the feasibility and preliminary efficacy of a home-based, computerized working memory training program, CogmedRM, with survivors of childhood cancer.

METHODS

Survivors of brain tumors or ALL (n = 20) with identified deficits in attention and/or working memory were randomized to either the success-adapted computer intervention or a non-adaptive, active control condition. Specifically, children in the adaptive condition completed exercises that became more challenging with each correct trial, whereas those in the non-adaptive version trained with exercises that never increased in difficulty. All participants were asked to complete 25 training sessions at home, with weekly, phone-based coaching support. Brief assessments were completed pre-intervention and post-intervention; outcome measures included both performance-based and parent-report measures of working memory and attention.

RESULTS

Eighty-five percent of survivors were compliant with the intervention, with no adverse events reported. After controlling for baseline intellectual functioning, survivors who completed the intervention program evidenced significant post-training improvements in their visual working memory and in parent-rated learning problems compared with those in the active control group. No differences in verbal working memory functioning were evident between groups, however.

CONCLUSIONS

Home-based, computerized cognitive training demonstrates good feasibility and acceptability in our sample. Children with higher intellectual functioning at baseline appeared to benefit more from the training, although further study is needed to clarify the strength, scope, and particularly the generalizability of potential treatment effects.

Growth dysregulation and ADHD: an epidemiologic study of children in France

OBJECTIVE

A small literature suggests that ADHD may be associated with dysregulated growth, but this prior work primarily used clinically referred samples, so it faces difficulties of interpretation. The objective of this study is to sample the general French population for ADHD and evaluate if ADHD is associated with dysregulated growth.

METHODS

Starting with 18 million telephone numbers, 7,912 were randomly called. Among 4,186 eligible families, 1,012 were recruited. The goal was for the final distribution of the sample to match the demographic background of the French population. A telephone interview was administered to all families to diagnose ADHD and assess other psychopathology and functioning variables.

RESULTS

Medication-naïve ADHD was associated with being taller, t(515) = 26.3, p < .001, and heavier, t(518) = 1.8, p = .03, for young children. In contrast, for older children, medication-naïve ADHD participants were shorter and lighter. These results were stronger for weight than height.

CONCLUSION

Although these data do not cast doubt on the well-documented association of stimulant treatment with delays in growth, they provide some support for the idea that, in the absence of medication exposure, ADHD is associated with dysregulated growth.

Toxicity and efficacy of the acetylcholinesterase (AChe) inhibitor donepezil in childhood brain tumor survivors: a pilot study

BACKGROUND

Neurocognitive deficits are a recognized late effect of curative brain tumor therapy. We evaluated the feasibility, tolerance, and impact of a pilot pharmacologic intervention with the acetylcholinesterase (AChe) inhibitor, donepezil, in pediatric brain tumor (BT) survivors at risk for neurocognitive dysfunction.

PROCEDURE

A single institution open-label pilot study was conducted in childhood BT survivors: ≥1 year from cancer treatment; and who received >23.5 Gy cranial radiation therapy (RT). Toxicity, adherence and neurocognitive outcomes were evaluated at baseline and serially during 24 weeks of donepezil, and following a 12-week washout period off drug.

RESULTS

From a pool of subjects, 13 were successfully contacted and screened, and 11 met all eligibility criteria to initiate donepezil at a median of 4.7 (1.9-11.9) years from RT. Seventy-two percent of patients completed the 24-week drug study visit. Despite transient gastrointestinal toxicity (vomiting and diarrhea) in 30% of patients there was no weight loss on donepezil. Significant improvement in performance was noted at 24 weeks on the Dellis-Kaplan Executive Function (D-KEF) Tower test (P < 0.001), the Wide Range Assessment of Memory and Learning, 2nd Edition (WRAML-2) Visual memory (P = 0.007), and the Number/Letter task (P = 0.018).

CONCLUSIONS

Donepezil was well tolerated among childhood BT survivors who had received substantial prior therapy. Based on improved executive function and memory performance in this pilot trial, a randomized placebo controlled trial of this pharmacologic agent is warranted to fully evaluate its efficacy in remediating neurocognitive dysfunction.

Computerized cognitive training in survivors of childhood cancer: a pilot study

The objective of the current study was to pilot a computerized cognitive training program, Captain's Log, in a small sample of survivors of childhood cancer. A total of 9 survivors of acute lymphoblastic leukemia and brain tumors with attention and working memory deficits were enrolled in a home-based 12-week cognitive training program. Survivors returned for follow-up assessments postintervention and 3 months later. The intervention was associated with good feasibility and acceptability. Participants exhibited significant increases in working memory and decreases in parent-rated attention problems following the intervention. Findings indicate that home-based, computerized cognitive intervention is a promising intervention for survivors with cognitive late effects; however, further study is warranted with a larger sample.

Parent and teacher ratings of attention during a year-long methylphenidate trial in children treated for cancer

OBJECTIVE

Longitudinally examine attention performance in childhood cancer survivors prescribed methylphenidate (MPH) to ameliorate cognitive late effects, comparing measures for inter-rater and inter-method discrepancies.

METHODS

Survivors of acute lymphoblastic leukemia (n = 33) or brain tumor (n = 35), mean age 11.11 ± 0.37 years, completed a 12-month, open-label trial of MPH. Conners' Parent and Teacher Rating Scales were completed at baseline, 1, 3, 6, and 12 months. The Conners' Continuous Performance Test (CPT) was completed at baseline and 12 months.

RESULTS

Improved attention was reported after 1 month of MPH (p < .05), with relative stability throughout the trial. Inter-rater agreement was low-to-moderate (ICC = -.06 to .46). Observer ratings correlated with select CPT indices at baseline (p < .05), but not at 12 months.

CONCLUSIONS

Childhood cancer survivors' attention improved after 1 month on MPH. Modest agreement between parents and teachers, and low-to-moderate correlations between behavior ratings and performance-based attention measures highlight a need for multimodal assessment.

Long-term efficacy of methylphenidate in enhancing attention regulation, social skills, and academic abilities of childhood cancer survivors

PURPOSE

Methylphenidate (MPH) ameliorates attention problems experienced by some cancer survivors in the short term, but its long-term efficacy is unproven.

PATIENTS AND METHODS

This study investigates the long-term effectiveness of maintenance doses of MPH in survivors of childhood brain tumors (n = 35) and acute lymphoblastic leukemia (n = 33) participating in a 12-month MPH trial. Measures of attention (Conners' Continuous Performance Test [CPT], Conners' Rating Scales [CRS]), academic abilities (Wechsler Individual Achievement Test [WIAT]), social skills (Social Skills Rating System [SSRS]), and behavioral problems (Child Behavior Checklist [CBCL]) were administered at premedication baseline and at the end of the MPH trial while on medication. A cancer control group composed of patients who were not administered MPH (brain tumor = 31 and acute lymphoblastic leukemia = 23) was assessed on the same measures 12 [corrected] months apart.

RESULTS

For the MPH group, repeated measures analysis of variance revealed significant improvement in performance on a measure of sustained attention (CPT indices, P < .05); parent, teacher, and self-report ratings of attention (CRS indices, P < .05), and parent ratings of social skills or behavioral problems (SSRS and CBCL indices; P < .05). In contrast, the cancer control group only showed improvement on parent ratings of attention (Conners' Parent Rating Scale indices; P < .05) and social skills (SSRS and CBCL indices; P < .05). There was no significant improvement on the academic measure (WIAT) in either group.

CONCLUSION

Attention and behavioral benefits of MPH for childhood cancer survivors are maintained across settings over the course of a year. Although academic gains were not identified, MPH may offer benefits in academic areas not assessed.