Variations in Pain, Sleep, and Activity During Hospitalization in Children With Cancer

Sleep disturbances in hospitalized children: a wake-up call

Although sleep is essential for (recovery of) health, it is adversely affected by hospitalization, due to disease discomfort, environmental noise, and care routines, causing reduced sleep and increased disturbances. This study evaluates factors affecting sleep quality and quantity in hospitalized children and compares inpatient sleep with sleep at home. Using an observational, prospective study design, we assessed sleep in hospitalized children aged 1-12 years, admitted to a tertiary center, and compared this with home 6-8 weeks after discharge. We measured total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency, awakenings, and subjective sleep quality, using actigraphy, sleep diaries, and PROMIS questionnaires. We explored an array of sleep-disturbing factors. Regression analyses identified key determinants affecting sleep patterns, while mixed linear models compared sleep in hospital to sleep at home. Out of 621 eligible patients, 467 were invited, and 272 (58%) consented to participate. Key determinants of sleep included pain, number of previous admissions, (underlying) chronic illness, and environment-, staff-, and disease-related factors. Parents reported lower perceived sleep quality in the hospital compared to at home, 97-min (SE 9) lower TST, 100-min (5) longer WASO, more difficulties with falling asleep, lower sleep satisfaction, and more awakenings. Actigraphy outcomes revealed shorter TST (20 min (6)), but better sleep efficiency and fewer awakenings in the hospital. Conclusion: Sleep in hospital was compromised in comparison to sleep at home, primarily due to disturbances related to treatment, environment, and staff. These findings underscore the necessity and potential of relative simple interventions to improve sleep quality and minimize sleep disturbances in hospitalized children.

Pediatric Intensive Care Unit related Sleep and Circadian Dysregulation: a focused review

The pediatric intensive care unit (PICU) is bright, loud, and disruptive to children. Strategies to improve the sleep of adults in the ICU have improved delirium and mortality rates. Children need more sleep than adults for active growth, healing, and development when well; this is likely true when they are critically ill. This review was performed to describe what we know in this area to date with the intent to identify future directions for research in this field. Since the 1990s, 16 articles on 14 observational trials have been published investigating the sleep on a total of 312 critically ill children and the melatonin levels of an additional 144. Sleep measurements occurred in 9 studies through bedside observation (n = 2), actigraphy (n = 2), electroencephalogram (n = 1) and polysomnography (n = 4), of which polysomnography is the most reliable. Children in the PICU sleep more during the day, have fragmented sleep and disturbed sleep architecture. Melatonin levels may be elevated and peak later in critically ill children. Early data suggest there are at-risk subgroups for sleep and circadian disruption in the PICU including those with sepsis, burns, traumatic brain injury and after cardiothoracic surgery. The available literature describing the sleep of critically ill children is limited to small single-center observational studies with varying measurements of sleep and inconsistent findings. Future studies should use validated measurements and standardized definitions to begin to harmonize this area of medicine to build toward pragmatic interventional trials that may shift the paradigm of care in the pediatric intensive care unit.

Outlooks on using a mobile health intervention for supportive pain management for children and adolescents with cancer: a qualitative study

BACKGROUND

Considerable improvements in the prognosis of pediatric cancer patients have been achieved over recent decades due to advances in treatment. Nevertheless, as the most common and distressing health issue for pediatrics with cancer, cancer-related pain is still a significant hurdle that impedes patients' journey to recovery, compromises their quality of life, and delays the positive outcome and effectiveness of their treatments.

PURPOSE

Taking into consideration that acceptability studies are imperative for the design, evaluation, and implementation of healthcare interventions, this study aims to explore pediatric oncology patients' readiness to use a mobile health application that emphasizes social assistance and peer support in addition to conventional pain management methods.

DESIGN AND METHODS

This study followed the Qualitative description approach. Twelve participants were chosen based on purposive sampling and maximum variation sampling. Interviews were analyzed using the conventional content analysis.

RESULTS

Analysis of the interviews revealed four major categories: (A) The need for connectedness; (B) An innovative way to connect yet fearful; (C) A 3D approach; (D) Fears of the unfamiliar.

CONCLUSIONS

This study is the first in Lebanon and the region to undertake an initiative towards introducing technology for pain assessment and management of children with cancer through a dedicated digital platform. The study results attested to the acceptability and potential utilization of this platform by children with cancer.

PRACTICE IMPLICATIONS

Nurses need to be trained to play an essential role in teaching children with cancer about the significance of social support and assisting them to establish their social support network. Children with cancer are encouraged to voice out their need for help. Our proposed application can create an enabling environment to harness the power of social support and provide children with cancer the opportunity to connect on a deeper level in a supportive and pity-free space.

Sleep in hospitalized pediatric and adult patients – A systematic review and meta-analysis

Background

Sleep is essential for recovery from illness. As a result, researchers have shown a growing interest in the sleep of hospitalized patients. Although many studies have been conducted over the past years, an up to date systematic review of the results is missing.

Objective

The objective of this systematic review was to assess sleep quality and quantity of hospitalized patients and sleep disturbing factors.

Methods

A systematic literature search was conducted within four scientific databases. The search focused on synonyms of 'sleep’ and 'hospitalization’. Papers written in English or Dutch from inception to April 25th,2022 were included for hospitalized patients >1 year of age. Papers exclusively reporting about patients receiving palliative, obstetric or psychiatric care were excluded, as well as patients in rehabilitation and intensive care settings, and long-term hospitalized geriatric patients. This review was performed in accordance with the PRISMA guidelines.

Results

Out of 542 full text studies assessed for eligibility, 203 were included, describing sleep quality and/or quantity of 17,964 patients. The median sample size of the studies was 51 patients (IQR 67, range 6–1472). An exploratory meta-analysis of the Total Sleep Time showed an average of 7.2 h (95%-CI 4.3, 10.2) in hospitalized children, 5.7 h (95%-CI 4.8, 6.7) in adults and 5.8 h (95%-CI 5.3, 6.4) in older patients (>60y). In addition, a meta-analysis of the Wake After Sleep Onset (WASO) showed a combined high average of 1.8 h (95%-CI 0.7, 2.9). Overall sleep quality was poor, also due to nocturnal awakenings. The most frequently cited external factors for poor sleep were noise and number of patients in the room. Among the variety of internal/disease-related factors, pain and anxiety were most frequently mentioned to be associated with poor sleep.

Conclusion

Of all studies, 76% reported poor sleep quality and insufficient sleep duration in hospitalized patients. Children sleep on average 0.7–3.8 h less in the hospital than recommended. Hospitalized adults sleep 1.3–3.2 h less than recommended for healthy people. This underscores the need for interventions to improve sleep during hospitalization to support recovery.

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An overview of the magnitude of sleep deprivation in hospitalized patients.

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A meta-analysis of studies reporting on some of the main sleep outcomes.

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An overview of internal and external factors affecting sleep in hospitalized patients.

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Guidance for potential interventions to improve sleep during clinical admission.

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Uncovers a knowledge gap regarding the sleep quality of hospitalized children and daytime sleep of hospitalized adults.

A systematic review and proposed conceptual model of sleep disturbances during pediatric hospitalizations

STUDY OBJECTIVES

The current review aims to examine factors that influence pediatric inpatient sleep and determine the effectiveness of sleep promotion interventions among hospitalized children.

METHODS

A systematic literature search was conducted across PubMed, PsycINFO, CINAHL, Cochrane Central, Web of Science, Embase, and Scopus databases. Studies included children with a mean age between 1 and 18 years old that either described factors affecting the sleep of children who are hospitalized on a non-intensive care unit or reported on sleep-related intervention outcomes. We conducted separate narrative reviews for each of the two aims and then synthesized findings from quantitative and qualitative studies across both aims.

RESULTS

Forty-five articles were included for review. Despite most sleep disturbances being attributed to environmental disruptions (e.g. noise, staff interruptions), most interventions targeted the child level using relaxation techniques. Although the majority of interventions were small pilot studies, preliminary findings appear to positively impact sleep duration. The Pediatric Inpatient Sleep Model was proposed to illustrate connections between sleep disturbances, factors influencing sleep, and existing intervention components.

CONCLUSIONS

Replication studies are needed, including larger-scale sleep promotion interventions among hospitalized children. Given the identification of environmental factors as the main cause of night wakings, environmental modifications are crucial. Additional research examining contributors to intraindividual variability in disrupted sleep patterns during hospitalizations as well as the consequences of these disturbances is warranted.

Psychometric properties of Pediatric Quality of Life multidimensional fatigue scale in Italian paediatric cancer patients: A multicentre cross-sectional study

OBJECTIVE

The original Pediatric Quality of Life-Multidimensional Fatigue Scale (PedsQL-MFS) developed in 2002 in the English language is a frequently used tool in paediatric oncology. It has been translated into several languages, and the aim of this study was to test the psychometric properties of the Italian version of this scale in paediatric patients with cancer.

METHODS

This was a cross-sectional validation multicentre study.

RESULTS

Acceptability was 100% for patients and 99.2% for parents. Confirmatory factor analysis of the three-factor model of the original scale yielded poor fit indices. A three-factor solution was found through exploratory structural equation modelling, with good fit indices. The internal consistency, evaluated through the Cronbach's alpha coefficient, ranged 0.71-0.92 for the total sample, both in the self-report and in the proxy-report questionnaire.

CONCLUSION

The Italian version of the PedsQL-MFS for children and adolescents with cancer shows adequate psychometric characteristics of both the self- and proxy-report. Further research with larger samples is needed ensuring all age groups are appropriately represented.

MUSIC INTERVENTIONS IN PEDIATRIC ONCOLOGY: Systematic review and meta-analysis

BACKGROUND

Pain is a disagreeable and distressing feeling that affects human beings in multi-dimensional ways. A number of non-pharmacological interventions have had varying degrees of success in treating cancer-related pain, such as breathing and relaxation techniques, and music therapy, which have been identified as beneficial therapies for alleviating pain and anxiety.

OBJECTIVE

Identify the therapeutic effects of music interventions in psychological and physiological terms and on the quality of life of children undergoing cancer treatment.

METHOD

Systematic review of effectiveness based on the methodology of the Joanna Briggs Institute.

RESULTS

Eleven articles were included with a total of 429 children, whose ages ranged from 0 to 18 years. The mean duration of the music intervention was 30.6 (±SD 9.8) min. In a combined estimate of five studies for pain and anxiety outcomes, there were benefits to using music when compared with the control group (SMD -1.05; CI 95 % -1.70 - 0.40 N = 453 I² = 90 %). A combined analysis of five studies to assess quality of life showed that the use of music was favorable when compared with the control (SMD -0.80; CI 95 % -1.17-0.43 N = 457= I² = 71 %).

CONCLUSION

After completing this review, it was determined that there is evidence to support the use of music to reduce pain and anxiety and improve the quality of life of children undergoing cancer treatment.

Sleep in hospitalized children and adolescents: A scoping review

Hospitalized children and adolescents are at risk of short sleep and subsequent adverse health effects, but little is known about actual sleep duration, the factors that cause sleep disturbances in an inpatient pediatric setting, and what has been done to promote sleep in this population. The aim of this review was to systematically identify, categorize, and synthesize the literature on sleep in children and adolescents in an inpatient setting. We searched five electronic databases (PubMed, CENTRAL, CINAHL, PsycINFO, and Scopus) and of the 3770 references identified, 28 were eligible for inclusion. From studies reporting age-specific sleep durations, we found that four out of nineteen fell within the National Sleep Foundations recommendations for age-specific sleep durations. Reported causes of sleep disturbances were primarily related to modifiable, external factors, e.g., nursing care activities and noise from equipment and other patients. Sleep-promoting interventions seemed acceptable to patients, parents, and healthcare professionals. However, the literature in this area is heterogeneous regarding methodology, reporting, and population characteristics. Our findings underline the importance of prioritizing and optimizing sleep in hospitalized pediatric patients and highlight the need for standardization in the planning and reporting of studies within this field.

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.

Pain at home during childhood cancer treatment: Severity, prevalence, analgesic use, and interference with daily life

BACKGROUND

Pain is a common symptom in childhood cancer. Since children spend more time at home, families are increasingly responsible for pain management. This study aimed at assessing pain at home.

PROCEDURE

In this longitudinal observational study (April 2016-January 2017), pain severity and prevalence, analgesic use, and pain interference with daily life (Brief Pain Inventory Short Form) were assessed for 4 consecutive days around the time of multiple chemotherapy appointments. Descriptive statistics (frequencies and percentages) were used to report pain severity (with clinically significant pain defined as: score ≥ 4 on "worst pain" or "average pain in the last 24 h"), pain prevalence, and analgesic use. Mixed models were estimated to assess whether patient characteristics were associated with pain severity, and whether pain severity was associated with interference with daily life.

RESULTS

Seventy-three children (50.7% male) participated (1-18 years). A majority (N = 57, 78%) experienced clinically significant pain at least once, and 30% reported clinically significant pain at least half the time. In 33.6% of scores ≥ 4, no medication was used. We found an association between pain severity and interference with daily life: the higher the pain, the bigger the interference (estimated regression coefficient = 1.01 [95% CI 0.98-1.13]).

CONCLUSIONS

The majority of children experienced clinically significant pain at home, and families frequently indicated no medication use. A stronger focus on education and coaching of families seems essential, as well as routine screening for pain in the home setting.

Clinical validity of the PROMIS pediatric sleep short forms in children receiving treatment for cancer

BACKGROUND

Rates of sleep disturbances vary widely across pediatric cancer studies, partly due to differences in measurement tools. Patient-reported outcomes measurement information system (PROMIS) offers a rigorously developed, well-validated pair of pediatric sleep health instruments needed to advance sleep research and clinical practice in pediatric cancer. The current study evaluated the clinical validity of PROMIS pediatric sleep scales (sleep disturbances [SD] and sleep-related impairment [SRI]) among children in active cancer treatment.

PROCEDURE

Caregiver-patient dyads were enrolled during cancer treatment in 2-12 months after diagnosis: 45 children (ages 8-17 years) and 102 caregivers of children (ages 5-17 years) completed PROMIS SD and SRI 8-item short form self-report or caregiver-proxy scales, and caregivers reported the prior week's cancer treatments and blood counts.

RESULTS

Both scales demonstrated strong internal consistency reliability across reporters. SD and SRI were higher than the PROMIS general population calibration sample for caregivers and patients. Oncology caregivers reported lower SD and SRI than sleep clinic caregivers, but oncology patients were similar to sleep clinic patients. Convergent validity was evidenced through moderate correlations between scales by reporter and both scales being significantly higher in patients taking medications for sleep. There were no significant differences in SD or SRI by diagnostic group, receiving radiation, or having low blood counts.

CONCLUSION

The PROMIS SD and SRI short forms are promising measures for pediatric oncology, demonstrating strong internal consistency reliability and multiple indications of clinical validity. Although groups did not differ based on treatment variables, results suggest the need for universal screening for sleep problems during pediatric cancer treatment.

Symptoms in Children Receiving Treatment for Cancer-Part II: Pain, Sadness, and Symptom Clusters

Children and adolescents receiving treatment for cancer experience multiple symptoms as a consequence of their disease and its treatment that interfere with the child's quality of life. Understanding of symptom assessment in children with cancer is foundational to the work of the Children's Oncology Group Nursing Discipline, whose research aims are to address knowledge gaps including understanding illness-related distress. This article is the second of a two-part summary of current evidence addressing the assessment of symptoms frequently reported by children and adolescents receiving treatment for cancer. Studies reporting assessment of pain, sadness, and symptom clusters published between January 2008 and May 2018 were included. Forty-three publications addressed pain. Pain was highly prevalent and distressing, varied in its trajectory across a cycle of chemotherapy and across multiple cycles of treatment, and correlated with biomarkers associated with the pain response. Consequences of pain were poorer functional status and emotional health. Twenty publications addressed sadness. Sadness was the most prevalent psychosocial symptom. Its prevalence decreased over the course of treatment and over a cycle of chemotherapy. Persistent sadness was of greater severity and distress. Eight publications addressed symptom clusters. These studies identified both groups of co-occurring symptoms and groups of patients with common symptom profiles. This two-article series provides evidence for the distressing nature of symptoms among children receiving cancer treatment. Efforts to support clinicians in routine symptom assessment are needed. Additional research directed at alleviating symptoms and building resilience among the child experiencing symptoms is needed.

Parental Behaviors, Emotions at Bedtime, and Sleep Disturbances in Children with Cancer

Background

Poor sleep is common for children during cancer treatment, but there is limited understanding of the nature of children’s sleep throughout the treatment trajectory. The current exploratory study used an explanatory sequential mixed method approach to examine quantitative associations among sleep problems in children with cancer, parental behavior, and children’s sleep hygiene, with follow-up qualitative characterizations of children’s sleep across cancer treatment stages.

Procedure

Eighty parents of children with cancer (aged 2–10 years; in active treatment, maintenance treatment, or off treatment) completed an online survey querying the child’s sleep quality (Sleep Disturbance Scale for Children—Disorders of Initiating and Maintaining Sleep subscale) and behaviors (Child Sleep Hygiene Scale) and sleep-related parenting behaviors (Parental Sleep Strategies). A subsample (n = 17 parents) participated in qualitative interviews to better characterize the processes of children’s sleep and parents’ sleep-related behaviors.

Results

Children’s sleep quality, sleep hygiene, or parental sleep strategies were not significantly different by cancer treatment groups. Greater sleep disturbance in children was associated with their parents’ tendency to accommodate the child’s bedtime requests. Qualitatively, cancer treatment-related anxiety in both children and parents influence the onset of these disruptive sleep behaviors.

Conclusion

Parents’ sleep-related behaviors affect children’s sleep during cancer treatment. Parents’ accommodation may start during active treatment to alleviate cancer-related challenges, and these behaviors may continue into maintenance therapy and off treatment to reinforce sleep disturbance. Behavioral interventions targeting unhelpful parental behaviors may improve sleep in children with cancer during and after cancer treatment.

The Critical Role of Parents in Pediatric Cancer-Related Pain Management: a Review and Call to Action

PURPOSE OF REVIEW

Even with optimized medical management, pain remains an inevitable part of pediatric cancer care. The most effective interventions for nonpharmacologic pain management within pediatric psychology include parent skills training. This review specifically explored the role of parents in cancer-related pain management with the goal of defining a set of evidence-based skills that could translate to improved pediatric cancer pain management.

RECENT FINDINGS

Pain is now widely understood to be both a sensory and emotional experience. As a result, within pediatric non-cancer pain management there is increasing application of the biopsychosocial model for pain management, inclusive of evidence-based psychological intervention. This review, specifically focusing on the role of parent training in cancer-related pain management, finds few interventions that systematically included parents. There is a need for continued evidence-based innovation and knowledge dissemination in this area of care. This paper highlights a critical gap in translational science within pediatric cancer pain management, namely, that parents who have a child with cancer are not reliably gaining access to well-established, evidence-based psychological skills training that can help to mitigate pain and pain-related stress. Based on the literature, the authors provide recommendations for generating adaptable, evidence-informed interventions that support and empower parents to help their child with pain management through all phases of cancer treatment.

Quality of Life and Pain Experienced by Children and Adolescents With Cancer at Home Following Discharge From the Hospital

An exploratory study was conducted to examine the quality of life and pain experienced by patients with pediatric cancer at home after discharge. Physical, cognitive, social, and emotional aspects of quality of life were measured and how these may be affected by age, sex, diagnosis, and pain status. The authors also characterized intensity, location, and quality of pain experienced. A sample of 33 patients participating in a larger study was selected on the basis of having pain on the day of discharge and having completed the Pediatric Quality of Life Inventory Generic, Cancer Module, Multidimensional Fatigue Scale, and the Adolescent Pediatric Pain Tool at home. Cancer diagnoses were leukemias/lymphomas (42.4%), brain/central nervous system tumors (27.3%), sarcomas (24.2%), or other (6.1%). More than half of patients reported pain (n=17; 51.5%). Patients with pain had more fatigue affecting the quality of life (P=0.01), and lower physical and emotional functioning, leading to lower overall health-related quality of life scores (P=0.011). Female individuals and adolescents reported worse emotional functioning (P=0.02 and P=0.05, respectively). Physical, cognitive, and social functioning were lowest among patients diagnosed with sarcomas (P=0.00, P=0.01, and P=0.04, respectively). It is important to understand the symptom experience of patients at home as a first step in moving towards optimal discharge teaching and treatment.

Translation, Cross-Cultural Adaptation, and Validation of the Adolescent Pediatric Pain Tool (APPT) for Multidimensional Measurement of Pain in Children and Adolescents

BACKGROUND

Pain is subjective and multidimensional in nature. Its assessment is very challenging especially in the pediatric population. Adequate assessment of pain in children is the keystone for effective management. Accurate and comprehensive evaluation of the child's pain experience requires the use of multidimensional pain assessment tools such as the Adolescent Pediatric Pain Tool (APPT) which measures the intensity, location and quality of pain.

AIMS

The aim of this study was to translate and culturally validate the APPT for use in Lebanese children and adolescents with cancer.

METHODS

The instrument was translated and culturally adapted following the WHO four steps; 1) forward translation and back-translation, 2) expert panel, 3) pre-testing and 4) cognitive interviewing. The semantic validation of the pain quality descriptors was performed by healthy children and children with cancer aged 8-17 years, using the Q-sort method.

RESULTS

A final Arabic version with 31 pain descriptors equivalent to the original tool was produced based on the results from the pilot study and the children's interviews. Children were able to differentiate between the different words they use to describe their pain.

CONCLUSION

Our results showed that the Lebanese version of the APPT is a culturally sensitive tool to assess the location, intensity and quality of pain in Lebanese children with cancer. Health professionals are encouraged to use this tool to assess the pain characteristics in Lebanese children with cancer, hence leading to effective pain management.

Frequency, Severity, and Distress Associated With Physical and Psychosocial Symptoms at Home in Children and Adolescents With Cancer

Malignancy- and cancer-related treatments lead to multiple symptoms. Although treatments focus on cure, few research studies have examined the symptoms that accompany these aggressive and complicated treatments. The purpose of the study was to evaluate the symptoms experienced by children at home. Children (n = 25) and adolescents (n = 33) diagnosed with cancer completed the Memorial Symptoms Assessment Scale during the 5 days at home after discharge from the hospital. The most frequent physical symptoms were fatigue (52.1%), nausea (50.7%), lack of appetite (43.7%), and pain (42.3%). The most frequent psychological symptoms were difficulty sleeping (21.1%), worrying (18.3%), feeling sad (18.3%), and feeling nervous (16.9%). Significant differences were found in the overall physical and psychosocial symptoms and Global Distress Index in patients with and without pain, fatigue, and nausea. Results indicated that physical and psychosocial symptoms and Global Distress Index increased as severity of pain, nausea, and fatigue increased. Children and adolescents were experiencing many symptoms at home but were often not reporting them.

The Investigation of Unplanned Hospital Visits and Admissions in the Children Receiving Chemotherapy

This study aimed to determine incidence, risk factors of unplanned hospital visits children receiving chemotherapy. The study was conducted with 65 children. Data were collected using form consisting of questions regarding causes of their unplanned hospital visits. Chi-square test were used analysis of data. Three quarters of children receiving chemotherapy were determined to have unplanned hospital visits, majority of them were found to be admitted. Knowing high-risk factors for unplanned hospital visits and admissions of children receiving chemotherapy and applying appropriate interventions for discharge education and home care regarding these factors may contribute to reduce unplanned hospital visits.

Perspectives on Cancer Pain Assessment and Management in Children

OBJECTIVE

To report evidence regarding pain assessment and management for children and adolescents receiving treatment for cancer.

DATA SOURCES

Published research and clinical guidelines.

CONCLUSION

Children and adolescents experience multiple sources of pain across the cancer continuum. They require developmentally relevant approaches when assessing and managing pain. This review suggests that consideration of the developmental stage and age of the child are essential in both pain assessment and pain management.

IMPLICATIONS FOR NURSING PRACTICE

Pediatric oncology nurses play a key role in developmentally appropriate pain assessment, identification of potential strategies to manage pain, and delivery of pharmacologic and nonpharmacologic therapies.

Pain, sleep patterns and health-related quality of life in paediatric patients with cancer

PURPOSE

To compare sleep and health-related quality of life (HRQOL) in children and adolescents with cancer who had pain, with those who had no pain during hospitalisation.

METHOD

A prospective comparative study was used to collect data from paediatric oncology units in three countries (Portugal, Brazil, USA). Participants (n = 118; 8-18 years) completed the Quality of Life Inventory (PedsQL) Cancer module, which includes a pain subscale, and wore a wrist actigraph for at least 72 hr.

RESULTS

Almost half of the participants (48.3%) reported having pain. Sleep patterns were not affected by pain. Girls, adolescents and patients diagnosed with leukaemia/lymphoma who reported pain, had significantly lower HRQOL scores. Low sleep duration and HRQOL were found, irrespectively of pain status.

CONCLUSIONS

The low sleep duration and HRQOL score in children and adolescents with cancer highlight the importance of physical and psychosocial nursing interventions during hospitalisation. The mediating effect of gender, age and diagnoses on the relation between pain and HRQOL needs to be further understood.

Cultural adaptation of the Adolescent Pediatric Pain Tool in Turkish children with cancer

PURPOSE

Pain is very common among pediatric cancers. This study aimed to assess the reliability and validity of the Turkish version of the Adolescent Pediatric Pain Tool (APPT).

METHODS

In this methodological study, language validity and content validity of the words in the third section of the scale, which was administered to children with cancer, were tested using the Q-sort method. The APPT was used to measure test-retest reliability once for each of the 1st, 2nd and 3rd weeks of the chemotherapy protocols for 30 children. A reliability test was conducted using the APPT for 96 children with cancer.

RESULTS

The number of words included in the third section of the APPT was reduced to 56 following the completion of the language and content validity using the Q-sort method. In the test-retest method, results from the three measures taken showed that the intra-class correlation coefficient was good. The internal consistency of the scale was also good (α = .78) in terms of the total number of body areas marked on body outline diagram, pain severity, pain intensity ratings, total number of word descriptors, and total number of sensory, affective, evaluative and temporal word descriptors. Correlations were found between the total number of body areas marked on the body outline diagram and the total number of word descriptors (r = .53), the pain severity and pain intensity ratings (r = .95), and the total number of word descriptors (r = .38).

CONCLUSIONS

The Turkish version of the APPT was determined to be valid, reliable and easy to use for pediatric cancer patients.

Pain and its Impact on the Functional Ability in Children Treated at the Children's Cancer Center of Lebanon

PURPOSE

The purpose of this study was to describe the characteristics of pain in children under treatment at the Children Cancer Centre of Lebanon at the American University of Beirut Medical Centre. Design and Methods A cross-sectional correlational survey was used. The Adolescent Pediatric Pain Tool and the Functional Disability Inventory were used to examine the characteristics of pain experienced in a consecutive sample of children treated at the CCCL and its impact on their functional abilities.

RESULTS

The mean age of the 62 participants was 12.3 (SD 2.9). The overall mean pain intensity rating for the sample was 5.06 (SD 1.87) on a 10 cm Word Graphic Rating Scale. More than one-half of the children in the sample (57.4%) reported having pain "sometimes" with a median duration of two hours per pain episode. The most frequently reported locations of pain were the forehead, the abdomen, and the lower back. For the most part, the children used sensory words to describe their pain experience. The children reported moderate levels of functional disability (mean FDI score 25.04, SD 13.81). Multivariable linear regression analysis identified frequency, duration, location, use of affective descriptors, and treatments as statistically significant predictors of pain intensity.

CONCLUSION

Regrettably, the findings reported attest once again to unrelieved pain in a pediatric oncology population.

PRACTICE IMPLICATIONS

Policy makers can contribute to pain control by introducing legislation and national policies to ensure adequate pain management for children with cancer in Lebanon.

Fatigue and health related quality of life in children and adolescents with cancer

PURPOSE

The study examined the different dimensions of fatigue (general, sleep/rest, cognitive), health related quality of life (HRQL) (physical, emotional, cognitive, social), and the relationships between fatigue and HRQL in hospitalized children and adolescents with cancer in Brazil.

METHOD

Participants were recruited from a pediatric oncology inpatient unit in a comprehensive cancer care hospital in southeast Brazil. They completed the PedsQL Multidimensional Fatigue Scale and the PedsQL Inventory of Quality of Life (Generic and Cancer module) once during hospitalization.

RESULTS

The majority (66.7%) of the participants (n = 38; mean age 12.1 ± 2.9 years) had total fatigue scores < 75 on 0 to 100 scale; with the mean total fatigue score of 63.8 ± 18.5. The majority (72.2% generic; 83.3% cancer modules) had total PedsQL scores < 75 on 0 to 100 scale. The mean PedsQL score on generic module (61.1 ± 17.0) was similar to the mean PedsQL score cancer module (59.1 ± 16.7). Significant correlations were found between total fatigue and quality of life generic (r = 0.63, p = 0.000) and cancer module (r = 0.74, p = 0.000).

CONCLUSIONS

The study is the first to report fatigue and health related quality of life in hospitalized children and adolescents with cancer in Brazil. Similar to experiences of other children in the world, our findings indicate that children and adolescents with cancer had problems with fatigue that were associated with low HRQL. Future studies are recommended to examine interventions (exercise, leisurely activities) that may alleviate fatigue and improve HRQL in pediatric patients with cancer.

Development of a mHealth Real-Time Pain Self-Management App for Adolescents With Cancer: An Iterative Usability Testing Study [Formula: see text]

PURPOSE

A user-centered design approach was used to refine the mHealth Pain Squad+ real-time pain self-management app for adolescents with cancer for its usability (defined as being easy to use, easy to understand, efficient to complete, and acceptable).

METHOD

Three iterative usability testing cycles involving adolescent observation and interview were used to achieve this objective. During each cycle, adolescents used the app while "thinking aloud" about issues encountered. Observed difficulties and errors were recorded and a semistructured interview about the experience was conducted. Using a qualitative conventional content analysis approach, themes related to app usability were identified.

RESULTS

Participants required an average of 4.3 minutes to complete the pain assessment component of Pain Squad+. Overall, the app was acceptable. Problematic issues related to software malfunction, interface design flaws, and confusing text. Software revisions were made to address each issue.

CONCLUSION

The multifaceted usability approach used provided insight into how a real-time app can be made acceptable to adolescents with cancer and succeeded in developing a Pain Squad+ app that is fit for future effectiveness testing.

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.

Sleep and Pain in Pediatric Illness: A Conceptual Review

BACKGROUND

Sleep disruption is a common comorbidity of pediatric pain. Consequences of pain and disrupted sleep, evidence for the pain-sleep relation, and how aspects of illness, treatment, and pharmacological pain management may contribute to or exacerbate these issues are presented.

AIMS

This conceptual review explored the relation between pain and sleep in children diagnosed with chronic medical or developmental conditions. The goal of this review is to expand upon the literature by examining common themes in sleep disturbances associated with painful conditions across multiple pediatric illnesses. Populations reviewed include youth with intellectual and developmental disabilities (IDD), migraines, cystic fibrosis (CF), sickle cell disease (SCD), cancer, juvenile idiopathic arthritis (JIA), juvenile fibromyalgia (JFM), and functional gastrointestinal disorders (FGIDs).

RESULTS

Consistent evidence demonstrates that children with medical or developmental conditions are more vulnerable to experiencing pain and subjective sleep complaints than healthy peers. Objective sleep concerns are common but often under-studied. Evidence of the pain-sleep relationship exists, particularly in pediatric SCD, IDD, and JIA, with a dearth of studies directly examining this relation in pediatric cancer, JFM, CF, and FGIDs. Findings suggest that assessing and treating pain and sleep disruption is important when optimizing functional outcomes.

CONCLUSION

It is essential that research further examine objective sleep, elucidate the pain-sleep relationship, consider physiological and psychosocial mechanisms of this relationship, and investigate nonpharmacological interventions aimed at improving pain and sleep in vulnerable pediatric populations.

Objective assessment of sleep status and its correlates in hospitalized children with cancer: Exploratory study

BACKGROUND

Children with cancer are known to have sleep problems. Although hospitalization and psychosocial factors are considered to be the factors affecting children's sleep, few studies have confirmed these effects. The aims of this study were to describe the sleep status of hospitalized children with cancer and to explore the correlates.

METHODS

The sleep status of 11 hospitalized children (aged 2-12 years) with cancer was measured using actigraph and sleep diary during hospitalization and a short home stay. Possible correlates were assessed using a questionnaire.

RESULTS

The participants had significantly longer sleep onset latency, earlier bedtime, and poorer self-evaluated sleep quality during hospitalization than the short home stay. They had shorter total sleep time, longer wake time after sleep onset, and less sleep efficiency at home, compared with healthy historical controls. Children's age, symptoms, hospitalization period, Cognitive Fatigue, Procedural Anxiety, Treatment Anxiety, Social Anxiety, and Separation Anxiety, as well as caregiver anxiety, Receptive and Focused Attitude, and Regimented Attitude were significantly correlated with sleep variables.

CONCLUSIONS

Hospitalization decreased self-evaluated sleep quality, and difficulty falling asleep. The sleep of the participants at home was disturbed compared with that of healthy children. Hospitalization, patient characteristics, disease-related, and some psychosocial factors were associated with sleep variables. Medical professionals should develop a favorable environment for falling asleep in hospital for individual children. Children with cancer in the early period of hospitalization need increased care to facilitate good sleep.

Through Their Words: Sources of Bother for Hospitalized Children and Adolescents With Cancer

An increased intensity of inpatient treatment, hospital-based routines, and separation from the familiar home environment may collectively increase the burden of the pediatric cancer experience. This study explored children and adolescents' perceived sources of bother related to hospitalization using two questions: (1) What bothered you the most about the hospital or hospital environment? and (2) What do you think could improve the hospital or hospital environment? Fifty children and adolescents (mean age 12.6 years) responded to these questions during each shift of a 3-day/3-night data collection period. Responses were analyzed using content analysis and chi-square analyses. Themes related to sources of bother included (1) "nothing/don't know," (2) "treatment and its consequences," (3) "isolation and loneliness," (4) "imposed bother," (5) "negative environment," and (6) "staff behaviors." Themes related to improving the hospital environment included (1) "nothing/don't know," (2) "normalizing activities," (3) "quality of the hospital environment," (4) "decrease burden of cancer and its treatment," and (5) "patient care issues." Participants' responses to these questions provide a foundation for actionable change to alleviate the burden associated with hospitalization.

Initial Validation of the Sleep Disturbances in Pediatric Cancer Model

OBJECTIVE : The current study evaluates content validity of the Sleep Disturbance in Pediatric Cancer (SDPC) model using qualitative and quantitative stakeholder input.  METHODS : Parents of children (aged: 3-12 years) with acute lymphoblastic leukemia (n = 20) and medical providers (n = 6) participated in semi-structured interviews about child sleep during cancer treatment. They also rated SDPC model component importance on a 0-4 scale and selected the most relevant sleep-related intervention targets.  RESULTS : Qualitatively, parents and providers endorsed that changes in the child's psychosocial, environmental, and biological processes affect sleep. Stakeholders rated most model components (parent: 32 of 40; provider: 39 of 41) as important (>2) to child sleep. Parents were most interested in interventions targeting difficulty falling asleep and providers selected irregular sleep habits/scheduling, though groups did not differ significantly. CONCLUSIONS : Stakeholders supported SDPC content validity. The model will inform subsequent measure and intervention development focusing on biological and behavioral factors most salient to sleep disturbances in pediatric cancer.

Cancer-Related Pain and Pain Management: Sources, Prevalence, and the Experiences of Children and Parents

Advances in treatment mean children are increasingly cared for by their parents at home, leading to a shift in responsibility from health care professionals to parents. Little is known about parents' pain management experiences and the etiology of pain experienced by children with cancer especially when at home. A rapid review of the literature was undertaken investigating children's cancer-related pain, with emphasis on the management of pain outside the health care setting. Electronic databases were searched and a quality assessment was conducted. Forty-two articles were included. Despite advances in pain management techniques, children with cancer regularly cite pain as the most prevalent symptom throughout the cancer trajectory. The source of pain is usually treatment side effects or painful procedures. Parents find dealing with their child's pain distressing and demanding and may hold misconceptions about pain management. Findings indicate a need for more robust research into parental pain management leading to the development of effective pain management resources for parents.

Incorporating measures of sleep quality into cancer studies

INTRODUCTION/BACKGROUND

Sleep disturbance may influence the development of cancer and responses to treatment. It is also closely tied to recovery and quality of life in cancer patients, survivors, and caregivers, and recent studies have begun to show beneficial effects of sleep-promoting interventions. Despite the importance of sleep to cancer and its treatment and the availability of numerous tools for measuring sleep quality and quantity, sleep measurements are underutilized in cancer studies.

METHODS

This review, written for cancer researchers interested in incorporating sleep measures into their studies, is designed to raise awareness about the importance of sleep and suggests strategies for including sleep evaluation in cancer studies.

CONCLUSIONS

Inclusion of readily available sleep measures may ultimately improve cancer care by facilitating studies that lead to a greater understanding of how sleep and sleep disturbance influence all aspects of cancer care and the patient experience.

Nursing care for adolescents and young adults with cancer: literature review

Cancer patients belonging to the adolescent and young adult (AYA) age group have unique and very specific needs, which require special attention from the caring staff. The difficulty in maintaining the personal and professional development at this age is both natural and normal. Adding to this, coping with a life-threatening disease turns this stage in life into a period with many dilemmas and challenges of quite a complex nature. AYA patients have to deal with issues above and beyond the disease itself, which create a very complex coping picture. On top of that, prognosis for this age group has not improved in recent years, unlike the situation in other age groups like children and adults. The literature on this subject is extensive and comprehensive. However, most of the papers on this subject are very specific and narrow in their approach, each dealing with a specific topic. In this article, we bring together many different papers which make a wide and comprehensive picture of the subject of AYAs coping with cancer, coupled with recommendations for the caring staff. In this review we focus on the various aspects of the disease and treatments in AYAs, based on the conceptual model of quality of life proposed by Ferrell and colleagues [Cancer Nurs 1992;15:153-160; Cancer Nurs 1992;15:247-253], including physical, social, emotional and spiritual aspects. From the psychological standpoint, most of the papers discuss the negative aspects; however, in this article we try to include some articles from the positive psychology school of thought. From our findings it is apparent that there is an opportunity and need to further explore research in this regard. It is apparent that taking a unique approach to AYA cancer patients is needed in order to deal with the unique needs of this age group. This article aims at putting a framework around this issue, with actionable recommendations for the caring staff.

Pain prevalence in a pediatric hospital: raising awareness during Pain Awareness Week

BACKGROUND

Despite the evidence and availability of numerous validated pain assessment tools and pain management strategies for infants and children, their use remains inconsistent in clinical practice.

OBJECTIVES

To describe the prevalence of pain, pain assessment and pain management practices at a tertiary pediatric hospital in Canada.

METHODS

The cross-sectional study design involved a combination of interviews with children and⁄or caregivers, and chart audits in five inpatient units. Information regarding pain intensity, painful procedures and pain management strategies was obtained from children and⁄or caregivers by interview. Patient charts were reviewed for information regarding pain assessment, pain scores, and pharmacological and nonpharmacological interventions.

RESULTS

Sixty-two children (four days to 17 years of age) participated. Most children or their caregivers (n=51 [84%]) reported that pain was experienced during their hospitalization, with 40 (66%) reporting their worst pain as moderate or severe. Almost one-half reported analgesics were administered before or during their most recent painful procedure. Nineteen (32%) reported sucrose, topical anesthetics or nonpharmacological interventions were used; however, they were documented in only 17% of charts. Pain scores were documented in 34 (55%) charts in the previous 24 h. The majority of the children or their caregiver (n=44&nbsp;[71%]) were satisfied with pain management at the study hospital.

CONCLUSIONS

Most infants and children had experienced moderate or severe pain during their hospitalization. Analgesics were frequently used, and although nonpharmacological strategies were reported to be used, they were rarely documented. Most parents and children were satisfied with their pain management.

Adolescent pediatric pain tool for multidimensional measurement of pain in children and adolescents

Very few multidimensional tools are available for measurement of pain in children and adolescents. We critically reviewed the scientific literature to examine the psychometrics and utility of the Adolescent Pediatric Pain Tool (APPT), a multidimensional self-report tool that evaluates the intensity, location, and quality (including affective, evaluative, sensory, and temporal) dimensions of pain. The APPT is available in English and Spanish for children and adolescents, and was modeled after the McGill Pain Questionnaire in adults. We found good evidence for construct validity, reliability, and sensitivity of the APPT for the measurement of pediatric pain. The APPT was used to measure pain in children with different conditions, such as cancer, sickle cell disease, orthopedic, traumatic injuries, and allergy testing. Although the APPT was designed to assess the multiple dimensions of pain, the majority of the reports included results only for the intensity ratings. Unlike the numerical and pediatric faces rating scales, which are widely used in clinical practice and research, the APPT is not limited to the single dimension of pain intensity. It measures multiple dimensions, and may be able to discriminate between nociceptive and neuropathic pain. The APPT is one of a few multidimensional pain measures that can help to advance the science of pediatric pain and its management. When the APPT is used in practice or research, the multiple dimensions of pain may be characterized and compared in different painful conditions. It may guide the use of multimodal interventions in children and adolescents with a variety of pain conditions.

Nighttime sleep disruptions, the hospital care environment, and symptoms in elementary school-age children with cancer

PURPOSE/OBJECTIVES

To describe nighttime sleep-wake patterns during a 12-hour night shift among school-age children with cancer receiving inpatient chemotherapy and relationships among nighttime sleep, environmental stimuli, medication doses, and symptoms during that shift.

DESIGN

Exploratory, descriptive, multiple-case study.

SETTING

Inpatient pediatric oncology unit at a tertiary pediatric hospital in the western United States.

SAMPLE

15 elementary school-age children with cancer receiving inpatient chemotherapy.

METHODS

Wrist actigraphs measured sleep-wake patterns. Data loggers and sound pressure level meters measured bedside light, temperature, and sound levels. Medication doses and occurrences of pain, nausea, and vomiting were identified through chart review.

MAIN RESEARCH VARIABLES

Minutes of sleep.

FINDINGS

Sleep varied based on time of night (F = 56.27, p < 0.01), with sleep onset delayed past 10 pm. A basic mixed linear model identified significant fixed effects for sound (F = 50.87, p < 0.01) and light (F = 7.04, p < 0.01) on minutes of sleep. A backward regression model including sound, light, medication doses, pain, and nausea accounted for about 57% of the variance in sleep minutes (F = 62.85, p < 0.01).

CONCLUSIONS

Sleep was marked by frequent awakenings, limiting children's ability to experience full sleep cycles. Multiple factors-in particular, excessive sound levels-compromise sleep quantity and quality throughout the night.

IMPLICATIONS FOR NURSING

Efforts to develop and test individualized and system-based interventions to modify the hospital care environment to promote nighttime sleep are needed. Oncology nurses have the opportunity to influence the care environment at an individual level and to influence unit-based practices to promote a healthy nighttime sleep environment.

Development and testing of a multidimensional iPhone pain assessment application for adolescents with cancer

Background

Pain is one of the most common and distressing symptoms reported by adolescents with cancer. Despite advancements in pain assessment and management research, pain due to cancer and/or its treatments continues to be poorly managed. Our research group has developed a native iPhone application (app) called Pain Squad to tackle the problem of poorly managed pain in the adolescent with cancer group. The app functions as an electronic pain diary and is unique in its ability to collect data on pain intensity, duration, location, and the impact pain has on an adolescent’s life (ie, relationships, school work, sleep, mood). It also evaluates medications and other physical and psychological pain management strategies used. Users are prompted twice daily at configurable times to complete 20 questions characterizing their pain and the app transmits results to a database for aggregate reporting through a Web interface. Each diary entry represents a pain case filed by an adolescent with cancer and a reward system (ie, moving up through law-enforcement team ranks, built-in videotaped acknowledgements from fictitious officers) encourages consistent use of the diary.

Objective

Our objective was to design, develop, and test the usability, feasibility, compliance, and satisfaction of a game-based smartphone pain assessment tool for adolescents with cancer.

Methods

We used both low- and high-fidelity qualitative usability testing with qualitative semi-structured, audio-taped interviews and iterative cycles to design and refine the iPhone based Pain Squad app. Qualitative thematic analysis of interviews using constant comparative methodology captured emergent themes related to app usability. Content validity was assessed using question importance-rating surveys completed by participants. Compliance and satisfaction data were collected following a 2-week feasibility trial where users were alarmed to record their pain twice daily on the app.

Results

Thematic analysis of usability interviews showed the app to be appealing overall to adolescents. Analyses of both low- and high-fidelity testing resulted in minor revisions to the app to refine the theme and improve its usability. Adolescents resoundingly endorsed the game-based nature of the app and its virtual reward system. The importance of app pain diary questions was established by content validity analysis. Compliance with the app, assessed during feasibility testing, was high (mean 81%, SD 22%) and adolescents from this phase of the study found the app likeable, easy to use, and not bothersome to complete.

Conclusions

A multifaceted usability approach demonstrated how the Pain Squad app could be made more appealing to children and adolescents with cancer. The game-based nature and built-in reward system of the app was appealing to adolescents and may have resulted in the high compliance rates and satisfaction ratings observed during clinical feasibility testing.

Physical symptoms, perceived social support, and affect in adolescents with cancer

Treatment for cancer among adolescents is often more intense and lasts longer than treatment for older or younger patients. It typically causes pain, fatigue, and nausea and affects social and emotional well-being. This study examined the relationships among demographics, physical symptoms, perceived social support from friends and family, and affect (positive and negative) in 102 adolescents (age 13-19) with cancer using correlational analyses. Additionally, perceived social support was explored as a mediator and moderator of the relationship between physical symptoms and affect using regression. Females reported significantly lower friend support and higher negative affect compared to males. Minority participants were more likely to endorse physical symptoms and less negative affect compared to White respondents. Higher report of physical symptoms was significantly related to greater negative affect, whereas higher perceived social support from friends was related to higher positive affect. Adolescents consistently reported high levels of social support from family and friends. Additionally, adolescents tended to report average levels of positive affect and low levels of negative affect compared to healthy populations. No significant mediation or moderation effects were found. This research highlights that females and minorities, and those with greater physical symptoms, may be more vulnerable to poor adjustment to cancer during adolescence. However, overall this study lends support to the notion that adolescents with cancer are an especially resilient population, as these patients endorsed generally high levels of social support and positive affect, with low levels of negative affect.

Review of symptom experiences in children and adolescents with cancer

BACKGROUND

Inadequate symptom relief in children and adolescents with cancer leads to unnecessary suffering. This review assesses research on children and adolescents with cancer that had been published from 2002 to 2010.

OBJECTIVES

The review identifies the symptom experiences of children and adolescents undergoing treatment and describes the progress that has been made since Docherty's 2003 systematic review of nurse researcher published studies from 1990 to 2002, which identified gaps in research on the symptoms of pediatric oncology patients.

METHOD

A computerized search of medical and nursing literature produced 50 published studies and 2 dissertations that addressed the symptom experiences of children and adolescents receiving treatment for cancer.

RESULTS

Pain from cancer-related procedures and fatigue were the most frequently identified symptoms, followed closely by nausea and vomiting. More preschool-aged subjects and nonwhite subjects need to be assessed, distinctions between age groups and gender should be explored, and instrumentation for the prereading group must be developed.

CONCLUSIONS

Research on symptoms experienced by children and adolescents has gained momentum within the last 10 years, and some of the gaps identified by Docherty have been addressed. Multicenter trials would increase sample sizes and decrease enrollment time.

IMPLICATIONS FOR PRACTICE

By synthesizing research completed from 2002 to 2010 on symptoms of children who had cancer, new ideas can be generated and shared with clinical nursing staff to improve patient care. Gaps to further direct research are also identified.