		Assistant Professor, Duquesne University School of Nursing

	Over the past decade, evidence has mounted recognizing sleep disturbances and fatigue as common occurrences in children with cancer during treatment, after treatment, and in long-term survivors.

	An investigation of nighttime sleep disruptions in hospitalized children with cancer found that school-aged children experienced limited sleep cycles due to a variety of environmental conditions, such as sound and light, as well as clinical care interruptions (ie, medication dosing).

 An earlier study of this population noted that parents or staff entered or exited a patient’s room 3-22 times per night (11:00pm - 7:00am), resulting in a disturbance of the child’s sleep 1-14 times during each night shift.

	Medication side effects and schedules have been implicated in sleep disturbances and fatigue in children with acute lymphoblastic leukemia (ALL) during chemotherapy.

 In this study, problematic and disturbed sleep scores were associated with greater fatigue in the majority of children and some of their parents. Another multisite study identified sleep and fatigue as behavioral responses to maintenance dexamethasone treatments, with the authors concluding that their “findings indicate that pediatric patients receiving dexamethasone for ALL have fewer actual sleep minutes, stay in bed longer, but have poorer sleep quality than well children, children, with chronic illnesses, or pediatric patients hospitalized for illnesses other than cancer.

	Research has also documented the psychological and social impact sleep disturbances and fatigue may have on the child and the family, suggesting that sleep disturbance during cancer treatment may impair a child’s quality of life.

 Researchers also have identified a correlation between fatigue and depressive symptoms in children receiving chemotherapy,

 and family functioning may also be altered alongside that of the child who is experiencing sleep disruption.

	There is scant research on specific, appropriate, and effective interventions to improve sleep in children with cancer; however, educating hospital staff, educating clinicians in outpatient clinics, and providing anticipatory guidance to parents on the myriad factors that can place children at risk for sleep problems can be the first step in prevention. Knowing the expected norm for the type and amount of sleep within a certain age group can help both parents and clinicians establish realistic expectations and goals. For example, preschool children average 9-10 hours of sleep during the night, and eventually transition from one nap to no naps. Preschool children typically have 90-minute sleep cycles with high levels of slow-wave sleep, the period during which it is most difficult to awaken.

Commonly Practiced Sleep Hygiene Techniques

			A consistent sleep schedule to maintain and regulate the internal clock

			Use of “zeitgebars” or environmental cues to help entrain the internal clock by lowering the lights in evening and providing early-morning light exposure

			Eliminating screen time several hours before bed to allow natural effects of melatonin, a hormone that rises in response to decreased light and helps to induce sleepiness

			The bedroom should be cool, dark, quiet, and comfortable

			A dim nightlight and a security object can be helpful to decrease anxiety

			Regulating daytime activities with consistent mealtimes, snacks, exercise, and therapies earlier in the day followed by quiet evening activities

			Being aware of and eliminating caffeinated drinks and energy foods

	Parents should be provided knowledge and given specific help regarding chemotherapeutic agents that result in sleep disruption (ie, dexamethasone) or sedation (ie, beta interferon); malignancies involving the central nervous system and subsequent radiation that can predispose a child to be at high risk for sleep-wake schedule disruption (eg, central apnea); particular side effects of treatment that may result in pain, nausea, or sedation and appropriate options that can minimize these secondary conditions (eg, hypnotherapy); and the need for counseling and mental health support should the insomnia be a symptom of anxiety or depression.

	Finally, staff and parents should view themselves as advocates for promoting overall quality of life within the hospital by limiting the number of patient room entrances and exits, lowering the lights early in the evening, and advocating for optimal timing of medication for best clinical results as well as sleep enhancement.

	Many children with cancer experience disturbed sleep, and this can negatively affect the healing process and quality of life—not only for the child but also for caregivers. Although causal pathways vary, understanding the root cause or causes can help direct an individualized intervention to promote sleep and minimize fatigue.

				Linder LA, Christian BJ. Nighttime sleep disruptions, the hospital care environment and symptoms in elementary school-age children with cancer. 

				Hinds PS, Hockenberry M, Rai SN, et al. Nocturnal awakenings, sleep environment interruptions, and fatigue in hospitalized children with cancer. 

				Zupanec S, Jones H, Stremler R. Sleep habits and fatigue of children receiving maintenance chemotherapy for ALL and their parents. 

				Hinds PS, Hockenberry MJ, Gattuso JS, et al. Dexamethasone alters sleep and fatigue in pediatric patients with acute lymphoblastic leukemia. 

				van Litsenburg RL, Huisman J, Hoogerbrugge PM, Egeler RM, Kaspers GJ, Gemke RJ. Impaired sleep affects quality of life in children during maintenance treatment for acute lymphoblastic leukemia: an exploratory study. 

				Hockenberry MJ, Hooke MC, Gregurich M, McCarthy K, Sambuco G, Krull K. Symptom clusters in children and adolescents receiving cisplatin, doxorubicin, or ifosfamide. 

				Gedaly-Duff V, Lee KA, Nail LM, Nicholson HS, Johnson KP. Pain, sleep disturbance, and fatigue in children with leukemia and their parents: a pilot study. 

				McGrath P, Rawson-Huff N. Corticosteroids during continuation therapy for acute lymphoblastic leukemia: the psycho-social impact.

Articles

Rebecca Kronk, PhD, CRNP, MSN, writes about evidence recognizing sleep disturbances and fatigue as common occurrences in children with cancer during treatment, after treatment, and in long-term survivors.

By Rebecca Kronk, PhD, CRNP, MSN

Articles

Promoting Sleep in Children With Cancer