Fatigue in children who have recently completed treatment for acute lymphoblastic leukemia: a longitudinal study

BACKGROUND

This study examined fatigue in patients treated for childhood acute lymphoblastic leukemia (ALL) over a 2-year period (3- to 27-months post-treatment completion), from the perspective of children and parent caregivers, compared to a healthy comparison group.

METHODS

Eighty-three patients (4-16 years at enrolment) and their parents, reported on the child's fatigue using the Pediatric Quality of Life Inventory- Multidimensional Fatigue Scale (PedsQL-MFS), at 3- 15- and 27-months post-treatment completion, and 53 healthy children and their parents reported on fatigue across the same timepoints.

RESULTS

Parent proxy-reporting showed that parents of ALL patients reported more total fatigue than parents of the comparison group at all time points, with all subscales elevated (general, cognitive, and sleep/rest fatigue). In contrast, patient self-report of fatigue over this period differed from the comparison children for the general fatigue subscale only. Self-reported total fatigue was worse than the comparison group at the 27-month timepoint, with cognitive and sleep/rest fatigue symptoms contributing to this difference. Expected improvements in fatigue over time were not evident in either patient or parent report and no demographic risk factors were identified. Parents and children from both groups reported significantly more fatigue at all time points compared to commonly utilised normative population data.

CONCLUSIONS

Patients treated for childhood ALL are impacted by fatigue symptoms in the post-treatment and early survivorship period. These findings highlight that patients in the 2-years following treatment require increased symptom surveillance and may benefit particularly from interventions that target cognitive and sleep/rest fatigue.

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

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

Sleep health behaviors in pediatric patients with newly diagnosed cancer

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fatigue Following Pediatric Arterial Ischemic Stroke: Prevalence and Associated Factors

BACKGROUND AND PURPOSE

The aims of this study were to assess the prevalence of multidimensional fatigue symptoms 5 years after pediatric arterial ischemic stroke and identify factors associated with fatigue.

METHODS

Thirty-one children (19 males) with pediatric arterial ischemic stroke, participating in a larger prospective, longitudinal study, were recruited to this study at 5 years poststroke. Parent- and self-rated PedsQL Multidimensional Fatigue Scale scores were compared with published normative data. Associations between parent-rated PedsQL Multidimensional Fatigue Scale, demographics, stroke characteristics, and concurrent outcomes were examined.

RESULTS

Parent-rated total, general and cognitive fatigue were significantly poorer than population norms, with more than half of all parents reporting fatigue symptoms in their children. One-third of children also reported experiencing fatigue symptoms, but their ratings did not differ significantly from normative expectations, as such, all further analyses were on parent ratings of fatigue. Older age at stroke and larger lesion size predicted greater general fatigue; older age, female sex, and higher social risk predicted more sleep/rest fatigue. No significant predictors of cognitive fatigue were identified and only older age at stroke predicted total fatigue. Greater fatigue was associated with poorer adaptive functioning, motor skills, participation, quality of life, and behavior problems but not attention.

CONCLUSIONS

Fatigue is a common problem following pediatric arterial ischemic stroke and is associated with the functional difficulties often seen in this population. This study highlights the importance of long-term monitoring following pediatric arterial ischemic stroke and the need for effective interventions to treat fatigue in children.

Interleukin-8 Predicts Fatigue at 12 Months Post-Injury in Children with Traumatic Brain Injury

Despite many children experiencing fatigue after childhood brain injury, little is known about the predictors of this complaint. To date, traditional indices of traumatic brain injury (TBI) severity have not predicted reliably persisting fatigue (up to three years post-injury). This study aimed to establish whether persisting fatigue is predicted by serum biomarker concentrations in child TBI. We examined whether acute serum biomarker expression would improve prediction models of 12-month fatigue based on injury severity. Blood samples were collected from 87 children (1-17 years at injury) sustaining mild to severe TBI (Glasgow Coma Scale [GCS] range 3-15; mean 12.43; classified as mild TBI [n = 50, 57%] vs. moderate/severe TBI [n = 37, 43%]), and presenting to the emergency departments (ED) and pediatric intensive care units (PICU) at one of three tertiary pediatric hospitals (Royal Children's Hospital (RCH); Hospital for Sick Children (HSC), Toronto; St Justine Children's Hospital (SJH), Montreal). Six serum biomarker concentrations were measured within 24 h of injury (interleukin-6, interleukin-8 [IL-8], soluble vascular cell adhesion molecule [SVCAM], S100 calcium binding protein B [S100B], neuron specific enolase [NSE], and soluble neural cell adhesion molecule [sNCAM]). Fatigue at 12 months post-injury was measured using the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (parent report), classified as present/absent using previously derived cut-points. At 12 months post-injury, 22% of participants experienced fatigue. A model including IL-8 was the best serum biomarker for estimating the probability of children experiencing fatigue at 12 months post-injury. The IL-8 also significantly improved predictive models of fatigue based on severity.

Self-Reported Fatigue in Chinese Children and Adolescents During Cancer Treatment

Background: Fatigue is a prevalent and distressing symptom in children and adolescents with cancer. Objectives: This study aimed to (1) investigate the current fatigue status reported by Chinese children and adolescents with cancer during active cancer treatment and (2) examine whether sociodemographic information, disease and treatment information, co-occurring symptoms, function and related clinical data are significantly associated with fatigue according to the biopsychosocial model. Methods: Participants were children aged 8-17 years, who had undergone treatment for cancer at four hospitals in China. Children completed the Chinese version of the Pediatric Patient-Reported Outcomes Measurement Information System short forms. Results: In total, 187 children (33.16% female, mean age 10.28 years) participated. The mean T-score for child-reported fatigue was 48.52 (34-72). Multiple linear regression analysis showed that fatigue in pediatric active cancer treatment could be significantly predicted by greater child-reported pain interference (β = 0.391, p < .001), greater depressive symptoms (β = 0.443, p < .001), and reduced mobility (β = -0.226, p = .004) (adjusted R² = 0.613, F = 16.476, p < .001). Conclusions: Children and adolescents with cancer experience multiple, intersecting troubling symptoms during their treatment. There is a need to attend to the biopsychosocial aspects of care for children and adolescents during active cancer treatment. To reduce pediatric oncology patients' fatigue level, clinicians could develop culturally sensitive interventions to alleviate children's pain interference, treat depressive symptoms, and maximize their physical mobility.

Italian nurses knowledge and attitudes towards fatigue in pediatric onco-hematology: A cross-sectional nationwide survey

Background and Objective

Fatigue is one of the most debilitating and prevalent symptoms in pediatric cancer patients and it is important to know if nurses are able to recognize and manage it. The aim of this study was to investigate the knowledge and attitudes towards fatigue of nurses working in Italian pediatric onco-hematology centers.

Methods

Cross-sectional online survey. An existing questionnaire was adapted to the Italian context, extended with a section on attitudes, and psychometrically tested. The questionnaire was sent to all nurses working in Italian pediatric onco-hematology centers.

Results

Respondents (n = 189), who were working in 37/53 (∼70%) centers, reported 42% of children and 68% of adolescents experiencing fatigue, with intensity increasing with age. Contributing factors were treatments and co-morbidities; frequent symptoms were mood changes and lack of energy. Among respondents who did not assess fatigue, 36.2% did not know an appropriate tool. Nurses recognized fatigue as an important problem and their knowledge and attitudes towards fatigue seemed satisfactory.

Conclusion

This study provides nurses with an instrument to investigate their knowledge and attitudes about fatigue. Nurses' awareness of the significance of fatigue is a fundamental step towards improving its management and offering strategies that can help both the child and their family.

Concordance between paediatric self-reports and parent proxy reports on fatigue: A multicentre prospective longitudinal study

PURPOSE

To investigate the degree of concordance on fatigue assessment between children and adolescents with cancer and their parents, and its changes over time.

METHOD

Multicentre longitudinal study.

RESULTS

Data from 134 dyads were analysed. The mean age of patients was 11.7 years; caregivers had a mean age of 44.1 years. Almost 90% of patients already reported mild or moderate fatigue at the time of diagnosis, decreasing to 69.7% after one year. Concordance on the total fatigue improved over time for the total sample, moving from moderate at the time of diagnosis to good concordance after one year.

CONCLUSIONS

This was the first study with a longitudinal design investigating concordance between paediatric self-reports and parent proxy reports on fatigue. It showed how concordance between proxies and patients changed over time reaching a good level after one year from the cancer diagnosis.

Symptoms in Children Receiving Treatment for Cancer-Part I: Fatigue, Sleep Disturbance, and Nausea/Vomiting

Children and adolescents with cancer often undergo intensive chemotherapy treatment to obtain remission and long-term survival. The pursuit of successful treatment outcomes may lead to high levels of symptom distress related to treatment side effects and toxicities. The Children's Oncology Group Nursing Discipline held a State of the Science Symposium "Symptom Assessment During Childhood Cancer Treatment" in 2018 that included reviews of evidence regarding key symptoms. The purpose of this review is to summarize and synthesize the evidence presented about the prevalence, relationships, trajectories, and associated biomarkers of selected symptoms experienced by children and adolescents during cancer treatment. Five symptoms were selected, with the focus on fatigue, sleep disturbance, and nausea/vomiting and included in Part I of the review. Using Ovid-Medline, studies published between 2008 and 2018 that focused on these specific symptoms during active chemotherapy treatment were selected. Fatigue interferes with normal developmental activities and is associated with sleep disturbances, and its pattern changes within a cycle of chemotherapy as well as across the treatment trajectory. Sleep is disrupted by the hospital environment, treatment medications, and changes in normal childhood and schedules. Disturbances of sleep persist during treatment, preventing recovery from poor quality sleep. Although pharmacologic interventions have advanced for treatment of nausea and vomiting, children and adolescents continue to struggle with this symptom. Its trajectory changes with the intensity of treatment, and over half of the patients report that they experience nausea and/or vomiting. Future research is needed to advance identification of biologic risk factors for symptoms and test effectiveness of symptom-related interventions.

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

Background

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

Methods

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

Results

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

Conclusions

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

Childhood Cancer-Related Fatigue and Day-to-Day Quality of Life

Childhood cancer-related fatigue is often viewed as an inevitable symptom of cancer and cancer treatment leading to underassessment by health care providers and self-management by families in the home and hospital environment. Parents' perspectives of the influence of childhood cancer-related fatigue on their child's day-to-day life is needed to understand how parents may or may not prioritize, report, and/or manage the fatigue symptom. This qualitative study used conventional content analysis to describe parents' observations and perspectives on the influence of fatigue in their child's day-to-day quality of life (QOL). Eleven interviews were gathered from parents. The concept childhood cancer-related fatigue and domains of QOL in pediatric oncology patients were used to guide the study, construct interview questions, and conduct conventional content analysis. A synthesis of three categories and seven codes led to three major findings: (a) parents perceive their child's symptoms as co-occurring not as a discrete entity of fatigue, (b) parents accept the child's behavior as a "new normal," and (c) parents recognize fatigue as a warning sign. The study findings reveal differences in how parents observe childhood cancer-related fatigue and how they perceive the symptom influences day-to-day QOL. Findings of this study support current guidelines underscoring the importance of multidimensional fatigue care. Additionally, the findings suggest a standardized multiple symptom instrument may be helpful in assessing symptom experience.

Perspectives of children, family caregivers, and health professionals about pediatric oncology symptoms: a systematic review

OBJECTIVES

To evaluate the existing body of evidence to determine the current state of knowledge regarding the perspectives of the following groups: (1) children with cancer, (2) family caregivers, and (3) healthcare professionals, about symptoms, as well as factors that may influence the symptom reports.

METHODS

A systematic search was performed for all types of studies that included the perspectives of at least two groups of participants' symptom reports. Children included anyone younger than 19 years of age who was diagnosed with any type of cancer. Electronic searches were conducted in five English databases and four Chinese databases. The appraisal of methodological quality was conducted using the GRADE criteria. Data were extracted into matrix tables.

RESULTS

Thirty-three studies were included. The pediatric oncology symptoms reported by children, family caregivers, and healthcare professionals were synthesized. Findings suggested that family caregivers' symptom reports were more closely aligned with children's reports than with the healthcare professionals' reports. Influencing factors on the different symptom reports included the children's diagnosis, symptom characteristics, social-demographic factors, and family caregivers' psychosocial status.

CONCLUSIONS

Children with cancer should be the primary reporters for their symptoms. When there are reporters other than the children, the potential discrepancy between the different perspectives needs to be carefully considered.

Adapted Delivery of Cognitive-Behavioral Treatment for Insomnia in Adolescent and Young Adult Cancer Survivors: A Pilot Study

Adolescent and young adult cancer survivors (AYACS) are at risk for the development of insomnia, though it remains vastly undertreated. Limited research has evaluated cognitive-behavioral treatment for insomnia (CBT-I) in AYACS. The present study piloted adapted CBT-I designed to improve treatment accessibility by delivering a three-session intervention in person and via videoconference. AYACS with insomnia (N = 12) enrolled in the study. Ten AYACS completed the intervention, with six in person and four via videoconference. Sleep variables improved immediately postintervention and were sustained at two-month follow-up. Within sample effect sizes of the adapted intervention for sleep, variables were large, and there were no noted differences on sleep outcomes between the in-person and videoconference participants. These pilot findings indicate that an adapted CBT-I intervention is feasible and promising in AYACS populations.

Teenage and Young Adult Cancer-Related Fatigue Is Prevalent, Distressing, and Neglected: It Is Time to Intervene. A Systematic Literature Review and Narrative Synthesis

PURPOSE

Cancer-related fatigue in adults has been the subject of considerable recent research, confirming its importance as a common and debilitating symptom, and establishing a number of evidence-based interventions. There has, however, been limited focus on the fatigue suffered by teenagers and young adults with cancer, a group recognized as having unique experiences and developmental needs. We have undertaken a systematic review of the literature to provide a comprehensive overview of studies evaluating fatigue in this younger patient group in order to guide clinical practice and future research.

METHOD

We searched MEDLINE, EMBASE, PsycINFO, and CINAHL databases for literature containing data relating to any aspect of fatigue in patients aged 13-24 at cancer diagnosis or treatment.

RESULTS

Sixty articles were identified, of which five described interventional clinical trials. Cancer-related fatigue was consistently one of the most prevalent, severe, and distressing symptoms, and it persisted long-term in survivors. It was associated with a number of factors, including poor sleep, depression, and chemotherapy. There was little evidence for the effectiveness of any intervention, although exercise appears to be the most promising. Importantly, fatigue was itself a significant barrier to physical and social activities.

CONCLUSION

Cancer-related fatigue is a major and disabling problem in young cancer patients. Effective management strategies are needed to avoid compounding the dependence and social isolation of this vulnerable patient group. Future research should focus on providing evidence for the effectiveness of interventions, of which activity promotion and management of concurrent symptoms are the most promising.

Evaluating the cancer related fatigue by children, mothers, and nurses in Turkish pediatric oncology patients

PURPOSE

The aims of this study were to evaluate cancer related fatigue by children', mothers', and nurses' perspectives in recently diagnosed pediatric oncology patients, to evaluate levels of agreement between the fatigue scales, and to evaluate the relationships between fatigue and sample characteristics.

METHOD

The sample of this cohort, descriptive, correlational study consisted of 26 recently cancer diagnosed children between the ages of 7 and 12, receiving inpatient treatment in pediatric oncology/hematology units, their mothers and their nurses. The data about children's fatigue were collected using the Child Fatigue Scale-24 h, Parent Fatigue Scale-24 h and Staff Fatigue Scale-24 h, for two consecutive days in the second and third weeks of the patient's first chemotherapy treatment cycle.

RESULTS

The mean scores of the Child Fatigue Scale-24 h showed the children's fatigue to be at a moderate level, a statistically significant difference was found between the CFS-24 h and PFS-24 h mean scores in the first and second measurement (p < 0.05). The Intraclass correlation showed a good agreement between scales and repeated measurements for these scales.

CONCLUSION

Fatigue in recently diagnosed cancer patients is an important symptom which is of particular concern to the children, their parents and nurses. The study showed that these three scales can be used alone an also used simultaneously, and also proved that these scales are reliable for repeated measurements.

Pilot Study of Massage to Improve Sleep and Fatigue in Hospitalized Adolescents With Cancer

BACKGROUND

Adolescents with cancer experience many troubling symptoms, including sleep disruptions that can affect mood and quality of life. Massage is a safe and popular intervention that has demonstrated efficacy in pediatric and adult patients with cancer. This study aimed to assess the feasibility of conducting a massage intervention to help with sleep in hospitalized adolescent oncology patients.

PROCEDURE

Adolescents ages 12-21 with cancer who were expected to be hospitalized for at least four consecutive nights were recruited from the inpatient unit at Children's National Health System and randomized to either massage intervention or a waitlist control. Patients in the intervention group received one massage per night, for two or three nights. Sleep was measured with actigraphy and patient and proxy reported instruments were used to measure fatigue, mood, and anxiety.

RESULTS

The majority (78%) of patients approached for the study consented, and almost all patients in the intervention group (94%) received at least one massage, 69% received two, and rates of completion of instruments among adolescents were high demonstrating feasibility. There were trends toward increased night time and overall sleep in the intervention group compared with standard of care, but no differences between groups in the patient reported outcome measures. Participant and parent feedback on the intervention was positive and was the impetus for starting a clinical massage service at the hospital.

CONCLUSIONS

Massage for hospitalized adolescents with cancer is feasible, well received, and can potentially improve patients' sleep. A randomized multicenter efficacy study is warranted.

The impact of cancer and its treatment on physical activity levels and behavior in Hong Kong Chinese childhood cancer survivors

BACKGROUND

Research indicates that regular physical activity is associated with numerous physiological and psychological health benefits for childhood cancer survivors. A review of the literature reveals that no study has so far examined the physical activity levels and behavior of Hong Kong Chinese childhood cancer survivors, and how the cancer and its treatment affect the physical activity and other behavior of these children remains unclear.

OBJECTIVE

The aims of this study were to assess the physical activity levels of Hong Kong Chinese childhood cancer survivors and to explore the factors that affect their adherence to and maintenance of regular physical activity.

METHODS

A cross-sectional study was used. A total of 128 childhood cancer survivors (9-16-year-olds) who underwent medical follow-up in the outpatient clinic were invited to participate in the study.

RESULTS

There was a significant decline in physical activity levels among childhood cancer survivors. Most of them did not take physical exercise regularly. Concern about academic performance, fatigue, and a decrease in physical strength and endurance after remission prevented them from engaging in regular physical activity.

CONCLUSIONS

This study indicates that many childhood cancer survivors did not engage in regular physical activity and that they overlooked or underestimated its importance.

IMPLICATIONS FOR PRACTICE

It is essential for nurses to correct misconceptions about physical activity among childhood cancer survivors and their parents and, most importantly, to advocate the principle of regular physical activity for these children, with the aim of enhancing their physical and psychological well-being.

Fatigue in child chronic health conditions: a systematic review of assessment instruments

BACKGROUND AND OBJECTIVE

Fatigue is common in chronic health conditions in childhood, associated with decreased quality of life and functioning, yet there are limited data to compare assessment instruments across conditions and childhood development. Our objective was to describe fatigue assessment instruments used in children with chronic health conditions and critically appraise the evidence for the measurement properties of identified instruments.

METHODS

Data sources included Medline, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO (using the EBSCOhost platform). Study selection included quantitative assessment of fatigue in children with health conditions. Data extraction was as follows: (1) study design, participant and fatigue instruments, (2) measurement properties of fatigue instruments, (3) methodological quality of included studies, and (4) synthesis of the quality of evidence across studies for the measurement properties of fatigue instruments.

RESULTS

Twenty fatigue assessment instruments were identified (12 child reports, 7 parent reports, 1 staff report), used in 89 studies. Fatigue was assessed in over 14 health conditions, most commonly in children with cancer and chronic fatigue syndrome. Evidence for the measurement properties of instruments varied, and overall quality was low. Two fatigue instruments demonstrated strong measurement properties for use in children with diverse health conditions and children with cancer.

CONCLUSIONS

The review is limited to children younger than 18 years and results are specific to health conditions described, limiting generalizability of findings to other populations. Evidence for the measurement properties of fatigue instruments varied according to the population in which instruments were used and informant. Further evidence is required for assessment of fatigue in younger children, and children with particular health conditions.

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

A qualitative study was designed to explore sleep-wake experience of mothers of children in maintenance treatment for Acute Lymphoblastic Leukemia. Interviews were conducted with 20 participants using open-ended, semi-structured questions and were transcribed verbatim. Two main themes emerged: "It's a whole new cancer world" and "I don't remember what it's like to have sleep." Mothers experience difficulty sleeping during their children's treatment, and expressed several serious issues. Although the mothers were able to employ various mechanisms to address sleep deprivation and disruption, interventions such as social support, journaling, spiritual guidance, and/or self-talk may be most beneficial.

Fatigue in adolescents with cancer compared to healthy adolescents

BACKGROUND

Cancer-related fatigue is one of the most pervasive and debilitating side-effects of cancer treatment and adolescents consistently rate cancer-related fatigue as one of the most distressing aspects of treatment. Because fatigue is also high in adolescents without cancer, the current study aims to describe fatigue in adolescents with cancer relative to a control group and to identify associates of such fatigue. Knowing this is important for understanding the extent of the problem in adolescents with cancer relative to healthy adolescents and for understanding who is most at risk for fatigue and related distress.

PROCEDURE

Adolescents with cancer and their caregivers (n = 102) and adolescents without a history of chronic health conditions and their caregivers (n = 97) completed the Multidimensional Fatigue Scale and measures of depression, quality of life (QoL), affect, coping, and family functioning.

RESULTS

Adolescents with cancer and their caregivers reported significantly more adolescent fatigue across all domains (with the exception of adolescent reports of cognitive fatigue) relative to adolescents without chronic health conditions. Higher fatigue was significantly related to adolescent report of more symptoms of depression, poorer QoL, higher negative affect, less positive affect, and behavioral disengagement coping style. Fatigue was not related to active coping or family functioning.

CONCLUSIONS

Adolescents with cancer experience significantly more fatigue than peers without chronic health conditions. Reports of fatigue are closely related to multiple indicators of psychosocial well-being, suggesting that fatigue may be an important cancer-related symptom to assess and manage to improve adolescent QoL.

Recommendations for high-priority research on cancer-related fatigue in children and adults

Over the past decades, some scientific progress has been made in understanding and treating cancer-related fatigue (CRF). However, three major problems have limited further progress: lack of agreement about measurement, inadequate understanding of the underlying biology, and problems in the conduct of clinical trials for CRF. This commentary reports the recommendations of a National Cancer Institute Clinical Trials Planning Meeting and an ongoing National Cancer Institute working group to address these problems so that high-priority research and clinical trials can be conducted to advance the science of CRF and its treatment. Recommendations to address measurement issues included revising the current case definition to reflect more rigorous criteria, adopting the Patient Reported Outcomes Measurement Information System fatigue scales as standard measures of CRF, and linking legacy measures to the scales. With regard to the biology of CRF, the group identified the need for longitudinal research to examine biobehavioral mechanisms underlying CRF and testing mechanistic hypotheses within the context of intervention research. To address clinical trial issues, recommendations included using only placebo-controlled trial designs. setting eligibility to minimize sample heterogeneity or enable subgroup analysis, establishing a CRF severity threshold for participation in clinical trials, conducting dissemination trials of efficacious interventions (such as exercise), and combining nonpharmacologic and pharmacologic interventions to exploit the potential synergy between these approaches. Accomplishing these goals has the potential to advance the science of CRF and improve the clinical management of this troubling symptom.

Predictors of stress of parents of a child with cancer: a Jordanian perspective

BACKGROUND

Most paediatric oncology studies agree that being parents of a child with cancer is an emotionally stressful event. Although an increasing number of studies have investigated psychological stress of parents of a child with cancer, few of these studies have included both parents or investigated the predictors of high stress levels for the mothers and the fathers. Moreover, studies published over the last few decades were limited to Western countries and have shown inconsistent findings about parental perceived stress whose children have cancer. This study explored differences in predictors of perceived stress between Jordanian mothers and fathers of children with cancer.

METHODS

This study involved a survey of 300 couples parenting a child with cancer. Participants answered the Arabic version of the Perceived Stress Scale 10-items, demographic and characteristics check list questionnaires. The main aims were to measure perceived stress levels for mothers and fathers, explore the predictors associated with high perceived stress levels and make a comparison between them.

FINDINGS

Mothers reported significantly higher stress levels than fathers (p<0.001), with a large effect size (0.30). Some of the factors associated with mothers and fathers high stress levels affected both parents whereas employment status affected only fathers' stress levels.

CONCLUSIONS

These findings indicate the need to work with the mothers and the fathers with a child with cancer in Jordan to recognise their psychological needs at the time of diagnosis and followed by on-going psychological support for both parents.

Psychometric properties of instruments used to measure fatigue in children and adolescents with cancer: a systematic review

CONTEXT

Despite the recognized distressing symptom of fatigue in children with cancer, little information is available to assist in the selection of an instrument to be used to measure fatigue.

OBJECTIVES

The objectives of this study were to 1) describe the instruments that have been used to measure cancer-related fatigue in children and adolescents and 2) summarize the psychometric properties of the most commonly used instruments used to measure fatigue in children and adolescents with cancer.

METHODS

Five major electronic databases were systematically searched for studies using a fatigue measurement scale in a population of children or adolescents with cancer. Fatigue scales used in those studies were included in the review.

RESULTS

From a total of 1753 articles, 25 were included. We identified two main fatigue measurement instruments used in a pediatric oncology population: 1) the Fatigue Scale-Child/Fatigue Scale-Adolescent and the proxy report versions for parents and staff and 2) the PedsQL™ Multidimensional Fatigue Scale. These two scales show similar attributes with reasonably good internal consistency and responsiveness.

CONCLUSION

Either the Fatigue Scale or PedsQL Multidimensional Fatigue Scale can be incorporated into clinical research. Future research should focus on identifying specific fatigue measures more suited to different purposes such as comparative trials or identification of high-risk groups.

The Fifth Vital Sign

Adolescent oncology patients with chronic pain require holistic management using interdisciplinary care, multimodal therapies, and family-centered treatment. Adolescents are at a crucial stage of development and require unique assessment that incorporates seeking their input, valuing their opinion, and establishing a developmentally appropriate treatment plan to give them a sense of control. This article discusses the essential elements of assessment that pediatric nurse practitioners should use when evaluating chronic pain in this unique patient population. A comprehensive assessment should determine the biological, psychosocial, and developmental functioning of the patient through objective and subjective measurements. The purpose of this literature review is to outline the mainstays of evaluating pain in a vulnerable population. Ascertaining the barriers that lead to underreporting and undertreating this symptom may lead to more effective management. This article assembles concepts established in research conducted on adolescents with nonmalignant chronic pain and studies on pain in the general pediatric oncology population to assist in evaluating adolescent oncology patients with chronic pain.

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.

Fatigue in survivors of childhood acute lymphoblastic and myeloid leukemia in Japan

BACKGROUND

Fatigue in cancer survivors is a serious problem in pediatric oncology, but reports on this issue are limited, especially in Asian countries.

METHODS

Sixty-three patients with acute lymphoblastic leukemia and 18 patients with acute myeloid leukemia who attended a follow-up outpatient clinic were enrolled. Participants were required to be >8 years of age, in remission, and without any cancer treatment for at least the previous 1 year. A control group consisted of 243 subjects whose age and gender were matched with the patient group. A questionnaire consisting of 12 items was devised for fatigue measurement.

RESULTS

Principal factor analysis identified three dimensions, defined as physical fatigue, decreased function, and altered mood. The mean total and the three fatigue dimension scores tended to be higher in the control group, but significant differences between the scores were seen only in the total and physical fatigue scores. Multiple regression analysis indicated an association of present older age or shorter duration after completion of treatment with total and physical fatigue, and an association of presence of total body irradiation with decreased function.

CONCLUSION

Pediatric leukemia survivors in Japan experience equal or less fatigue compared with that of controls in different fatigue dimensions. Elucidation of underlying mechanisms of cancer-related fatigue including the differences of cultural background among different countries is necessary for future study of this issue.

Fatigue in young survivors of extracranial childhood cancer: a Finnish nationwide survey

PURPOSE/OBJECTIVES

To evaluate self-reports of fatigue by young cancer survivors (aged 11-18 years), to compare young survivors' fatigue scores with the scores of a healthy control group and of the parent proxy evaluation, and to analyze whether demographic or disease-related factors are associated with young survivors' fatigue.

DESIGN

Cross-sectional quantitative study.

SETTING

An urban hospital in southwestern Finland.

SAMPLE

384 survivors diagnosed with an extracranial malignancy at age 16 or younger, who have survived four or more years postdiagnosis, and who are free of cancer. General matched population controls were randomly selected from the Finnish Population Registry.

METHODS

Demographic data and a self-report written fatigue questionnaire.

MAIN RESEARCH VARIABLES

Total fatigue (TF), general fatigue (GF), sleep or rest fatigue (SF), and cognitive fatigue.

FINDINGS

The control populations reported significantly more issues with TF, GF, and SF than did the survivor population. In survivors, older age, the need for remedial education at school, and a sarcoma diagnosis were associated with increasing fatigue, whereas female gender, better school grades, and greater health-related quality-of-life (HRQOL) scores were associated with lower fatigue. The study variables explained 49%-65% of the variation in fatigue scores.

CONCLUSIONS

Although survivors and their matched controls seem to have similar fatigue, subgroups of survivors do experience excessive fatigue, which may have an impact on their HRQOL.

IMPLICATIONS FOR NURSING

This study increases the knowledge about fatigue levels of young survivors of extracranial malignancies and identifies the need for instruments specifically designed to assess fatigue in this population. The healthcare team should pay attention to the fatigue level of young survivors, particularly SF.

Exercise Recommendations for Cancer-Related Fatigue, Cognitive Impairment, Sleep problems, Depression, Pain, Anxiety, and Physical Dysfunction: A Review

Cancer and its treatments produce a myriad of burdensome side effects and significantly impair quality of life (QOL). Exercise reduces side effects and improves QOL for cancer patients during treatment and recovery. Exercise prior to, during, and after completion of cancer treatments provides numerous beneficial outcomes. Exercise represents an effective therapeutic intervention for preparing patients to successfully complete treatments, for reducing acute, chronic and late side effects, and for improving QOL during and after treatments. This overview of exercise oncology and side-effect management summarizes existing evidence-based exercise guidelines for cancer patients and survivors.

Effectiveness and feasibility of using the computerized interactive virtual space in reducing depressive symptoms of Hong Kong Chinese children hospitalized with cancer

PURPOSE. To examine the effectiveness and feasibility of using the computerized interactive virtual space in reducing depressive symptoms of children hospitalized with cancer. DESIGN AND METHODS. A nonequivalent control group design was employed. Children (8-16 years of age; n= 122) admitted to a pediatric oncology ward during a 14-month period were recruited. RESULTS. The results support the effectiveness and feasibility of using the computerized interactive virtual space in reducing depressive symptoms of children hospitalized with cancer. PRACTICE IMPLICATIONS. The results heighten the awareness in nurses of the importance of integrating play activities as an essential component of holistic and quality nursing care.

Health Professionals’ Estimation of Cancer-Related Fatigue in Children

Many studies show that cancer-related fatigue is one of the most common symptoms experienced by children as a side effect of cancer therapy. This problem has grown considerably in recent years; the exact mechanisms underlying fatigue remain unclear. Therefore, assessing and managing this symptom can be problematic. This article describes the findings from a survey evaluating how health professionals (n = 56) at the Pediatric Oncology Centers in Izmir currently define and assess cancer-related fatigue. The results demonstrate that while the problems associated with fatigue are acknowledged, assessment tools are not widely used, and the majority of health professionals report that they would benefit from further education on the subject to assist in the care of patients.

Fatigue in children with cancer at the end of life

CONTEXT

Fatigue is a prevalent source of suffering in children with advanced cancer; yet, little is known about it.

OBJECTIVES

This study aimed to describe fatigue experienced by children with advanced cancer and to identify the factors associated with suffering from fatigue and its treatment.

METHODS

A retrospective cross-sectional study of 141 parents of children who died of cancer (response rate: 64%) was conducted in two tertiary-level U.S. pediatric hospitals.

RESULTS

By parent report, 96% of children experienced fatigue in the last month of life. Nearly 50% experienced significant suffering from fatigue; this was associated with suffering from pain, dyspnea, anorexia, nausea/vomiting, diarrhea, anxiety, sadness, or fear (P<0.05), and with side effects from pain or dyspnea treatment (P<0.05). In multivariate analysis of symptom-related factors, suffering from nausea/vomiting (odds ratio [OR]=3.93, 95% confidence interval [CI]=1.23-12.61, P=0.02); anorexia (OR=7.52, 95% CI=1.87-30.25, P=0.005); and fear (OR=5.13, 95% CI=2.03-12.96, P ≤ 0.001) remained independently associated with fatigue. Children suffering from fatigue had primary oncologists with fewer years' experience than children who did not suffer from fatigue (mean=7.7 years, standard deviation [SD]=4.9 vs. mean of 9.9 years, SD=6.0, P=0.02). Among children with fatigue, 17 of 129 (13%) received fatigue-directed treatment, which was successful in 3 of 12 (25%). Children experiencing side effects from dyspnea or pain treatment were more likely to be treated for fatigue (relative risk=1.25, 95% CI=1.06-1.47, P=0.009).

CONCLUSION

Fatigue is a common source of suffering in children with cancer at the end of life. Palliation of this symptom is rarely successful. Increased attention to factors associated with fatigue and effective interventions to ameliorate fatigue are needed.

Changes in children's reports of symptom occurrence and severity during a course of myelosuppressive chemotherapy

The purposes of this study in children who underwent a cycle of myelosuppressive chemotherapy were to describe changes in symptom occurrence and severity during the chemotherapy cycle. Patients (N = 66) 10 to 18 years of age completed the Memorial Symptom Assessment Scale for 10- to 18-year-olds (MSAS 10-18) at the start of a chemotherapy cycle (T1) and weekly for the next 2 weeks (T2 and T3). More than 30% of children reported 10 or more symptoms at all 3 time points. Symptom occurrence trajectories were tested with multilevel logistic regression. In all, 6 symptoms (ie, fatigue, sadness, irritability, worrying, weight loss, sweating) showed a decreasing linear trend. Significant quadratic patterns of change were found for feeling drowsy, nausea, and vomiting. Changes in symptom severity over time were evaluated with multilevel negative binomial regression. No significant differences over time were found in any of the symptom severity scores on the MSAS. Children experienced a high number of symptoms at the initiation of a chemotherapy cycle that persisted over the subsequent 2 weeks.

Differences in symptom occurrence, frequency, intensity, and distress in adolescents prior to and one week after the administration of chemotherapy

PURPOSE/OBJECTIVES

The purpose of this study was to describe differences in occurrence, frequency, intensity, and distress of symptoms prior to (T1) and one week following (T2) the administration of intravenous chemotherapy.

DESIGN

Longitudinal, descriptive.

SETTINGS

Two regional children's cancer centers in the Pacific Northwest.

SAMPLE

A total of 51 adolescents 10 to 19 years old receiving cancer chemotherapy.

METHODS

Memorial Symptom Assessment Scale (MSAS 7-12).

FINDINGS

No significant differences were found in symptom occurrence rates between T1 and T2. Fatigue was the only symptom with significantly greater frequency and intensity, and nausea was the only symptom with significantly greater distress at T2 compared with T1.

CONCLUSIONS

Adolescents receiving chemotherapy experience multiple symptoms that persist over time.

IMPLICATIONS FOR NURSING

In monitoring for symptoms, nurses need to be aware of the extent to which symptoms are present throughout treatment, as evidenced by these findings that symptom occurrence was significant even prior to receiving a subsequent course of chemotherapy.