Exploring sleep-wake experiences of mothers during maintenance therapy for their child's acute lymphoblastic leukemia

Sleep and psychological characteristics of children with cancers and type 1 diabetes and their caregivers

OBJECTIVES

Children with chronic illnesses and their parents are more at risk to develop sleep problems, which are linked to worse psychological and physical well-being. This study aimed to assess sleep patterns and their connections with psychological outcomes in children with type 1 diabetes (T1D) and cancer and their caregivers, compared to a control sample. In addition, we explored the associations between caregiver and child's sleep quality across the three groups.

METHODS

We enrolled 56 children with T1D, 33 children with cancer, and 61 healthy children between 7 and 15, and their respective caregivers. Caregivers filled out an ad-hoc survey assessing their sleep disturbances, parenting stress, general well-being, anxiety, and their children's sleep patterns and psychological adjustments.

RESULTS

Children with cancer showed lower sleep quality than the other groups. Moreover, worse psychological adjustment was associated with greater sleep disturbances in both clinical groups. As for caregivers, the cancer group reported the worst sleep quality and greater anxiety compared to the other samples. Greater anxiety was also linked to worse sleep quality. Furthermore, greater sleep problems in children were associated with poorer caregivers' sleep quality in the whole sample and the T1D group.

CONCLUSIONS

A better understanding of sleep patterns and problems for chronically ill children and their parents is fundamental to provide adequate care for these vulnerable populations. Furthermore, an illness-specific approach may better inform and guide the practitioners in clinical practice.

Parental sleep when their child is sick: A phased principle-based concept analysis

Sleep is a common challenge for parents with sick children and can impact parents' health, wellbeing, and caregiving responsibilities. Despite the vast research around parental sleep when their child is sick, the concept is not clearly defined. A phased principle-based concept analysis that includes triangulation of methods and quality criteria assessment was used to explore how the concept is described, used, and measured in the current literature. The aim was to analyse and clarify the conceptual, operational, and theoretical basis of parental sleep when their child is sick to produce an evidence-based definition and to identify knowledge gaps. A systematic literature search including databases CINAHL, Embase, MEDLINE, PsychARTICLES, PsychINFO, Pubmed, Scopus and Web of Science, identified 546 articles. The final dataset comprised 74 articles published between 2005 and 2021 and was assessed using a criteria tool for principle-based concept analysis. Data were managed using NVivo, and thematic analysis was undertaken. A precise definition is not present in the literature. Various tools have been used to measure parents' sleep, as well as exploration via interviews, open-ended questions, and sleep diaries. The terminology used varied. Parental sleep when their child is sick is interrelated with other concepts (e.g., stress). A recommended definition is offered. A conceptual understanding of parental sleep when their child is sick will help to guide translational research and to conduct studies critical to clinical practice and research. Future research includes developing a measurement tool for parental sleep when their child is sick to be used in study design and future interventions.

The Physical Health of Caregivers of Children With Life-Limiting Conditions: A Systematic Review

CONTEXT

Parental caregiving for a child with a life-limiting condition (LLC) is complex physical and mental work. The impact of this caregiving on parents' physical health is unknown.

OBJECTIVES

(1) To review existing evidence on the physical health of parents caring for a child with a LLC and (2) to determine how physical health of parents is measured.

DATA SOURCES

Medline, Embase, PsycINFO, and Cumulative Index of Nursing and Allied Health Literature were searched.

STUDY SELECTION

Peer-reviewed articles were included if they reported primary data on the physical health of a caregiver of a child with a LLC. Studies were excluded if they described only the caregiver's mental health or if the caregivers were bereaved at the time of data collection.

DATA EXTRACTION

Of 69 335 unique citations, 81 studies were included in the review.

RESULTS

Caregiver health was negatively impacted in 84% of studies. Pain and sleep disturbance were the most common problems. Ways of measuring the physical health of caregiver varied widely. We found an absence of in-depth explorations of the social and economic contexts, which could potentially mitigate the impact of caregiving. Furthermore, we find health interventions tailored to this group remain largely unexplored.

LIMITATIONS

Studies were heterogenous in methodology, making comparisons of results across studies difficult.

CONCLUSIONS

These findings support the need for improving access to interventions aimed at improving physical health in this population. The rate of health-seeking behaviors, preventive health care access and screening for health conditions is understudied and represent important directions for further research.

Challenges Faced by Mothers Caring for Children with Leukaemia During COVID-19 Pandemic: A Qualitative Study

PURPOSE

This study aimed to investigate the experiences of parents who care for children diagnosed with leukaemia. This paper is focused solely on reporting the interview findings from participating mothers regarding the challenges of caring for children with leukaemia in the context of the COVID-19.

DESIGN AND METHODS

The study took place in a Jordanian hospital where a descriptive qualitative design approach was applied on one oncology floor and an oncology clinic. Semi-structured interviews were conducted with mothers of children aged 1-12 with acute lymphoblastic leukaemia (ALL). Inductive thematic analysis approach was undertaken. Written consent was obtained from all participants.

RESULTS

Fifteen interviews were conducted with fifteen mothers. Four major themes reflect the different challenges parents and children face during the COVID-19 pandemic: children refusing to wear masks, social isolation, family relationship and financial concerns.

CONCLUSIONS

The findings of the current study present important data for health care professionals to help them understand the challenges faced by parents and children with leukaemia, especially during the COVID-19 pandemic.

PRACTICAL IMPLICATIONS

This study suggests activating emotional support teams in hospitals. These teams can actively help mothers express their concerns and worries which might otherwise foster self-blame, guilt and isolation.

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.

Parental functioning during maintenance treatment for childhood acute lymphoblastic leukemia: Effects of treatment intensity and dexamethasone pulses

BACKGROUND

During maintenance treatment, Dutch pediatric patients with medium-risk (MR) acute lymphoblastic leukemia (ALL) receive intravenous chemotherapy and cyclic dexamethasone. Dexamethasone affects child's sleep and behavior. Standard-risk (SR) patients only receive oral chemotherapy, without dexamethasone. Effects of stratified therapy on parents are not well known. This study compares parental sleep, distress and quality of life (QoL) with the general population, between MR and SR groups, and on- and off-dexamethasone (MR group).

PROCEDURE

One year after diagnosis, parents of MR patients completed the Medical Outcomes Study (MOS) sleep, distress thermometer for parents and Short Form-12 (SF-12) twice; once on-dexamethasone and once off-dexamethasone. SR parents completed one measurement. Sleep problems, distress and QoL scores (off-dexamethasone) were compared to reference values and between MR and SR. Score differences on- and off-dexamethasone were assessed by multilevel regression analysis.

RESULTS

Parents (80% mothers) of 121 patients (57% males; 75% MR, 25% SR) completed 191 measurements. Compared to reference values, parents reported more sleep disturbances, higher distress, and lower mental QoL. Additionally, MR parents reported clinical distress (score ≥ 4), whereas SR parents (on average) did not (mean 4.8 ± 2.4 vs 3.5 ± 2.4, P = .02). Within the MR group, outcomes did not significantly differ on- and off-dexamethasone.

CONCLUSIONS

Parents of ALL patients report sleep problems, high distress, and QoL impairment. Within the MR group, parental functioning did not differ on- and off-dexamethasone. However, MR parents reported clinical distress more often than SR parents, possibly reflecting differences in prognostic estimates and treatment burden. This perhaps includes the overall strain of cyclic dexamethasone. This study highlights the need for psychosocial support throughout treatment, regardless of risk stratification.

Pediatric psycho-oncology in Russia: Caregiver mental health and sleep outcomes on the oncology wards

OBJECTIVES

Caregivers are at risk of poor sleep and elevated distress during their child's cancer treatment. Russia is currently underrepresented in the international psycho-oncology field, with no identified psychosocial standards of care, and limited or inconsistent psychological service provision, particularly for caregivers. This study aimed to determine the prevalence of Russian caregivers' psychological distress and identify factors associated with caregiver sleep duration when staying on the pediatric oncology ward.

METHODS

We recruited 74 caregivers of children with cancer and 74 comparison caregivers in Rostov-on-Don, Russia. Participants completed a survey assessing clinical outcomes, sleep (St Mary's Hospital Sleep Questionnaire), and psychological distress (Depression Anxiety Stress Scales-21 [DASS-21]).

RESULTS

Caregivers of children with cancer reported significantly higher scores for all DASS-21 subscales and higher depression (48.6% vs. 24.6%), anxiety (47.3% vs. 12.3%), and stress (45.9% vs. 0%) scores from "moderate" to "extremely severe." Caregivers of children with cancer reported significantly shorter sleep duration (5.82 vs. 7.49 h, t[143] = -6.22, p = 0.002), more night-time awakenings (3.20 vs. 1.25, t[135] = 6.94, p < 0.001) and worse sleep quality (46.5% vs. 9.6%; x² [1] = 24.4, p < 0.001) than comparison caregivers. Caregivers with a higher total DASS-21 score (B = -1.32, p = 0.032) and those who were closer to diagnosis (B = -1.53, p = 0.012) reported shorter sleep duration.

CONCLUSIONS

Russian caregivers of children with cancer experience high rates of psychological distress and poor sleep on the oncology ward. These findings provide an important target for future research and culturally relevant clinical interventions to improve caregivers' mental health and capacity for care.

Maternal Caregiving for Children Newly Diagnosed with Acute Lymphoblastic Leukemia: Traditional Chinese Mothering as the Double-Edged Sword

AIMS AND OBJECTIVES

To explore the meaning of maternal caregiving in the Chinese culture for children newly diagnosed with acute lymphocytic leukemia (ALL).

BACKGROUND

Recurrence of and death associated with ALL remain the main concerns for mothers. Mothers experience guilt and anxiety towards their child's cancer.

DESIGN

Descriptive phenomenological study.

METHODS

Twelve mothers were recruited from a medical centre in Central Taiwan. The mothers were primary caregivers for their child diagnosed as having ALL in the past 3 months to 1 year. Data were collected through semi-structured interviews and analysed using Colaizzi's method.

RESULTS

Four main themes emerged: feeling this world crashing by knowing the diagnosis, feeling the double-edged sword of mothering, worrying about potential risks for their vulnerable child, and passing through difficulties with power of support.

CONCLUSIONS

Most mothers felt this world crashing due to potential loss of their child and seeing their child's suffering. The mother was blamed for her child's cancer but was also required to shoulder all caregiving for their child. The mothers needed to compromise their lives to protect their child from potential infection. Perceived power of support helped the mothers overcome difficulties.

RELEVANCE TO CLINICAL PRACTICE

Findings support that nurses encouraging mothers to tell their stories, regardless of culture, will facilitate healing. Establishing trust and providing support from nurses, physicians, psychologists and social workers will lead mothers' readiness to deal with care of their sick child. Increasing visiting time for parental support for children hospitalized in the PICU is suggested as well.

Concurrence of sleep problems and distress: prevalence and determinants in parents of children with cancer

Background: Parents of children with cancer are at risk for sleep problems. If these problems persist, an important perpetuating factor might be ongoing parental distress. Objective: The aim of this study is to assess the prevalence of sleep problems and the concurrence with distress in parents of children treated for cancer, and to identify predictors of this symptom clustering. Method: Parents completed the Medical Outcomes Study (MOS) Sleep Scale and Distress Thermometer for Parents (DT-P). Clinically relevant sleep problems were defined as a score >1SD above the norm and clinical distress as a thermometer score above the established cut-off of 4. Four parent categories were constructed: neither sleep problems nor distress; no distress but sleep problems; no sleep problems but distress; both sleep problems and distress. Predictive determinants (sociodemographic, medical, psychosocial) for each category were assessed with multilevel multinomial logistic regression. Results: Parents (202 mothers and 150 fathers) of 231 children with different cancers participated. Mean time since diagnosis was 3.3 ± 1.4 years (90% off-treatment). The prevalence of sleep problems was 37%. Fifty percent of parents reported neither sleep problems nor distress, 9% had only sleep problems, 13% only distress, and 28% reported both. Compared to parents without sleep problems or distress, parents who reported both were more likely to report parenting problems (OR 4.4, [2.2-9.1]), chronic illness (OR 2.8, [1.2-6.5]), insufficient social support (OR 3.7, [1.5-9.1]), pre-existent sleep problems (OR 6.2, [2.0-18.6]) and be female (OR 1.8, [1.1-4.2]). Conclusions: Sleep problems are common in parents of children treated for cancer, and occur mostly in the presence of clinical distress. Future research must show which interventions are most effective in this group: mainly targeted at sleep improvement or with prominent roles for stress management or trauma processing.

Exploring the Potential of a Pretend Play Intervention in Young Patients With Leukemia

PURPOSE

The aims of the study are 1) to gain knowledge of parents' and professionals' perceptions about cancer stricken children's resources, burdens, and ability to pretend play, and 2) to prepare the initiation of a pretend play intervention based on children's needs and included parents' and professionals' feedback.

DESIGN AND METHODS

Qualitative design using semi-structured interviews with 13 parents of children diagnosed with leukemia and 15 professionals in the field of pediatric oncology. Themes were derived with content analysis via deductive and inductive coding.

RESULTS

Analysis resulted in five topics. (1) Ability to play in the context of leukemia (2) ways of coping with leukemia (3) difficulty in transition to normality (4) parental quality of life and parents' needs (5) perceptions of the potential of pretend play.

CONCLUSION

Study results indicate the potential of pretend play interventions for young cancer patients and the need for additional professional support of parents.

PRACTICE IMPLICATIONS

Pretend play is a tool children carry with them regardless of their circumstances. If we can enhance their ability to play, doing so should give them an advantage in creative problem solving and creative expression as they deal with a life threatening disease.

The relationship between child and caregiver sleep in acute lymphoblastic leukemia maintenance

PURPOSE

The purposes of this study are to describe sleep quality and sleep disturbance among caregivers of children in the maintenance phase of acute lymphoblastic leukemia (ALL) and to examine the relationship between sleep quality, child sleep disturbance, and caregiver guilt and worry.

METHODS

Caregivers of 68 children with ALL, ages 3 to 12 years old, completed measures of caregiver guilt and worry, caregiver sleep quality, and child's developmental history and sleep habits. Demographic and treatment correlates of poor caregiver sleep were examined, and caregiver guilt and worry was tested as a moderator between child and caregiver sleep.

RESULTS

More than half of caregivers (55.9%) reported clinically significant poor sleep and less than 40% were obtaining adequate sleep durations. Caregiver sleep was significantly related to child age at diagnosis, child sleep, and caregiver guilt and worry. Caregiver guilt and worry did not moderate the relationship between child sleep and caregiver sleep.

CONCLUSIONS

Poor sleep is common in caregivers of children with cancer. Further research on the timing of sleep interventions and the most effective intervention targets are needed to maximize caregiver functioning during a child's cancer treatment. Targeted interventions seeking to improve caregiver sleep should be directed towards caregivers of children diagnosed in early childhood, caregivers of children with poor sleep, and caregivers with high guilt and worry.

Short- and long-term health consequences of sleep disruption

Sleep plays a vital role in brain function and systemic physiology across many body systems. Problems with sleep are widely prevalent and include deficits in quantity and quality of sleep; sleep problems that impact the continuity of sleep are collectively referred to as sleep disruptions. Numerous factors contribute to sleep disruption, ranging from lifestyle and environmental factors to sleep disorders and other medical conditions. Sleep disruptions have substantial adverse short- and long-term health consequences. A literature search was conducted to provide a nonsystematic review of these health consequences (this review was designed to be nonsystematic to better focus on the topics of interest due to the myriad parameters affected by sleep). Sleep disruption is associated with increased activity of the sympathetic nervous system and hypothalamic-pituitary-adrenal axis, metabolic effects, changes in circadian rhythms, and proinflammatory responses. In otherwise healthy adults, short-term consequences of sleep disruption include increased stress responsivity, somatic pain, reduced quality of life, emotional distress and mood disorders, and cognitive, memory, and performance deficits. For adolescents, psychosocial health, school performance, and risk-taking behaviors are impacted by sleep disruption. Behavioral problems and cognitive functioning are associated with sleep disruption in children. Long-term consequences of sleep disruption in otherwise healthy individuals include hypertension, dyslipidemia, cardiovascular disease, weight-related issues, metabolic syndrome, type 2 diabetes mellitus, and colorectal cancer. All-cause mortality is also increased in men with sleep disturbances. For those with underlying medical conditions, sleep disruption may diminish the health-related quality of life of children and adolescents and may worsen the severity of common gastrointestinal disorders. As a result of the potential consequences of sleep disruption, health care professionals should be cognizant of how managing underlying medical conditions may help to optimize sleep continuity and consider prescribing interventions that minimize sleep disruption.

Sleep Disruption in Pediatric Cancer Survivors: Conceptual Framework and Opportunities for Clinical Assessment and Behavioral Treatment

Sleep disruption is a commonly reported consequence of cancer and its treatment in pediatric patients and survivors. This review summarizes common sleep concerns in this population and introduces a multidimensional framework of risk factors specific to childhood cancer that may interact to develop and maintain disrupted sleep. Based on the extant literature, parameters of the cancer and its treatment, physical and social environmental conditions both during and after treatment, changes to family behavior and norms, psychological factors and traumatic stress, and reduced physical activity are hypothesized to be the most pertinent risk factors for disrupted sleep in this population. Potential clinical assessment strategies and behavioral interventions relevant to these considerations are discussed, with reference to the behavioral model of insomnia. The review concludes by offering directions for research and clinical practice, including developing and testing comprehensive assessment tools, intervention effectiveness studies in both oncology and primary care clinics, and efforts to increase patient-provider communication about sleep in pediatric oncology.

Are parenting behaviors associated with child sleep problems during treatment for acute lymphoblastic leukemia?

Sleep disturbance is a recognized common side effect in children treated for acute lymphoblastic leukemia (ALL). Although associated with treatment factors such as hospitalization and corticosteroids, sleep problems may also be influenced by modifiable environmental factors such as parenting behaviors. The purpose of this study was to examine sleep problems in children undergoing treatment for ALL compared to healthy children and whether parenting practices are associated with sleep difficulties. Parents of 73 children aged 2–6 years who were (1) in the maintenance phase of ALL treatment (ALL group, n = 43) or (2) had no major medical illness (healthy control group, n = 30) participated in the study. Parents completed questionnaires measuring their child's sleep behavior and their own parenting practices. Parents of children undergoing ALL treatment reported significantly more child sleep problems; 48% of children with ALL compared to 23% of healthy children had clinical levels of sleep disturbance. Parents of the ALL group also reported significantly more lax parenting practices and strategies associated with their child's sleep including co‐sleeping, comforting activities, and offering food and drink in the bedroom. Results of multivariate regression analysis indicated that, after controlling for illness status, parent–child co‐sleeping was significantly associated with child sleep difficulties. Strategies employed by parents during ALL treatment may be a potential modifiable intervention target that could result in improved child sleep behaviors. Future research aimed at developing and testing parenting interventions aimed to improve child sleep in the context of oncology treatment is warranted.

Sleep in mother and child dyads during treatment for pediatric acute lymphoblastic leukemia

PURPOSE/OBJECTIVES

To compare the sleep of children with acute lymphoblastic leukemia (ALL) during maintenance treatment with controls and to measure the effect on maternal sleep.

DESIGN

Comparative, descriptive.

SETTING

Pediatric oncology clinic and communities in Colorado.

SAMPLE

26 dyads of mothers and children with ALL and matched controls.

METHODS

Mothers completed insomnia severity, mood, and stress questionnaires and wore a wrist actigraph, and mothers and children completed a seven-day sleep diary.

MAIN RESEARCH VARIABLES

Mother and child sleep parameters (e.g., total sleep time, sleep latency, sleep efficiency, awakenings); maternal insomnia severity, mood, and stress; child sleep habits.

FINDINGS

Mothers of children with ALL reported greater insomnia compared to controls, which was correlated with anxiety, depressive symptoms, and stress. Maternal groups did not differ on diary- and actigraph-measured sleep outcomes; both groups experienced sleep fragmentation. Children with ALL took longer to fall asleep and had more variable sleep patterns.

CONCLUSIONS

Actigraph and sleep diary data indicated adequate maternal sleep duration and sleep latency. Self-reported insomnia severity in mothers of children with ALL suggested sleep fragmentation that may be undetected by these measures.

IMPLICATIONS FOR NURSING

Oncology nurses are in a unique position to identify sleep problems in mothers and children with ALL, which may lead to recommendations for improved sleep and referrals for treatment.