Anders Kreuger

Self‐esteem, depression and anxiety among Swedish children and adolescents on and off cancer treatment

Self‐esteem, depression and anxiety were investigated in 51 Swedish children and adolescents, 8‐18y, on (n=16) and off (n= 35) cancer treatment. The self‐report measures “I Think I Am” (ITIA), the Childrens Depression Inventory (CDI) and the Revised Childrens Manifest Anxiety Scale (RCMAS) were used. Data were compared with data previously obtained by others for healthy Swedish children. Children and adolescents on treatment showed levels of self‐esteem, depression and anxiety comparable to those of healthy children. However, children and adolescents off treatment reported higher depression and anxiety levels and lower psychological well‐being and physical self‐esteem than have been reported for healthy Swedish children. Seven children (14%) reported a high level of depression, six of whom were off treatment. The findings suggest that the period after treatment termination is characterized by a higher risk of psychosocial problems than is the actual treatment period.

Pain in paediatric oncology: interviews with children, adolescents and their parents

Ljungman G, Gordh T, Sörensen S, Kreuger A. Pain in paediatric oncology: interviews with children, adolescents and their parents. Acta Pædiatr 1999; 88: 623‐30. Stockholm. ISSN 0803‐5253

Midazolam Nasal Spray Reduces Procedural Anxiety in Children

Objective. Anxiety and pain even in minor procedures are still great problems in pediatrics, not least in pediatric oncology. Conscious sedation is indicated when other means to overcome a childs fear fail. The aim of this study was to investigate whether intranasal administration of midazolam given before insertion of a needle in a subcutaneously implanted central venous port could reduce anxiety, discomfort, pain, and procedure problems. Method. Forty-three children with cancer participated in this randomized, double-blind, placebo-controlled, crossover study in which nasal administration of midazolam spray, .2 mg/kg body weight, was compared with placebo. Children, parents, and nurses completed a visual analog scale questionnaire to evaluate efficacy. Results. Parents and nurses reported reduced anxiety, discomfort, and procedure problems for children in the midazolam group and would prefer the same medication at next procedure. They also reported pain reduction. Children reported reduced anxiety and procedure problems but reduction of pain and discomfort was not significant. No serious or unexpected side effects occurred. Nasal discomfort was the most common side effect (17/38≈45%) and the primary reason for dropouts (8/43≈19%). Anxiety varied with age but not with gender. When anxiety increased, the differences between midazolam and placebo increased. Conclusion. Nasal midazolam spray offers relief to children anxious about procedures, such as insertion of a needle in a subcutaneously implanted intravenous port, venous blood sampling, venous cannulation, etc. Its use, however, may be limited by nasal discomfort in some patients for whom rectal and oral routes might be alternatives.

Pain variations during cancer treatment in children: a descriptive survey.

Structured interviews were conducted with 66 children and their families to investigate how the experience of pain varied during cancer treatment. At diagnosis, 49% experienced cancer-related pain. Intense pain was more common at the beginning of treatment when it was often believed that pain treatment could be better. Procedure- and treatment-related pain were the major problems initially. Procedural pain gradually decreased, but treatment-related pain was constant and dominating. For some procedures pain was rated highest initially, lower during the second period, and higher again during the final part of treatment. Pain intensity measurement was seldom performed, and parents increasingly considered themselves better judges of their childs pain than professionals. Increased knowledge about pain and pain treatment in children with cancer, where most pain is iatrogenic, will help us to meet the needs and demands of children and parents, and to reduce pain to a minimum.

Treatment of pain in pediatric oncology: a Swedish nationwide survey

&NA; Pain treatment is a crucial aspect in the care of children with cancer and there are many studies demonstrating inefficient pain treatment. In this study, questionnaires dealing with pain treatment of children with malignant diseases were sent to all (47) pediatric departments in Sweden. The aims of this nationwide survey were to evaluate the extent and causes of pain, the use of methods for pain evaluation (e.g. analysis of type of pain and monitoring of pain intensity), principles of pain management, side effects of pain treatment and the educational needs of physicians and nurses regarding these issues. The response rate was 100%. Answers from physicians and nurses reveal that pain is a common symptom during different periods of cancer treatment. Pain due to treatment and procedures is a greater problem than pain due to the malignant disease itself. Instruments for the measurement of pain intensity and analysis of the type of pain are still rarely used. Most physicians (63%) follow the analgesic ‘ladder’ principle recommended by World Health Organization (WHO). According to a majority of physicians and nurses (72%), pain could be treated more effectively than it is presently, and 64% state that they need more time for the management of pain. Both physicians and nurses state that they need additional education in different areas of pain evaluation and pain treatment. Swedish treatment practices for the management of pediatric cancer pain roughly follow the published guidelines, but many improvements are still necessary.

Pain in Pediatric Oncology: Do the Experiences of Children and Parents Differ from Those of Nurses and Physicians?

Diagnosis and treatment of pain are central components in the care of children withcancer. The aim of the present study was to compare the viewpoints of children andparents with those of professionals, on different aspects of pain in children with cancer.Information was collected through questionnaires and interviews. In particular, wefocused on the extent and causes of pain, strategies to reduce procedural pain, painevaluation, and attitudes to pain treatment.We found that both families and professionals shared the opinion that pain was acommon symptom during different phases of cancer treatment but, surprisingly, profes-sionals regarded it as more frequent than families. The groups agreed that treatmentrelated pain is the most critical problem, followed by procedure and cancer relatedpain. Concerning strategies to decrease procedural pain, there was a high concordancein views between groups. Nurses and physicians more often claimed that failing paintreatment was associated with psychological factors such as high levels of anxiety inparents and children, loneliness, and lack of preparation. The self-report, according toboth parents and professionals, is a feasible procedure even in young children from 4years of age. Both groups asserted that parents were better in ascertaining the extent oftheir childs pain. In conclusion, although the families and professionals in this study have many com-parable views concerning pain in children with cancer, divergences also exist. Toacquire a more accurate picture of the situation we must focus on the views of the chil-dren first, and then those of parents and professionals. Atendency to overestimate theproblems was observed in professionals. Hopefully this reflects a keen awareness ofthe current situation.

Medical follow-up visits in adults 5-25 years after treatment for childhood acute leukaemia, lymphoma or Wilms' tumour

Aim: One aspect of organizing medical follow‐up for adult survivors of childhood cancer is to determine to what extent the former patient experiences a need for health services. In the present paper, we studied how the healthcare needs, both subjectively and objectively, were fulfilled for our former patients. Methods: 335 survivors over 18 y of age, with a follow‐up time of more than 5 y after completion of therapy, were sent a questionnaire probing their present use of health services. Results: The response rate was 73%. A majority (60%) of the survivors had no regular follow‐up visits, and 42% of these reported that they missed not having one. More than one third were thus far dissatisfied with the follow‐up programme. Only 3% of those who had regular follow‐ups found them “unnecessary”. Complaints subjectively related to their diseases or treatments were reported by 47%. Out of all responders, 34% did not miss having regular follow‐up visits. Neither perceived disease‐related complaints nor radiation therapy was a predictor for having a scheduled follow‐up visit.

Transient erythroblastopenia of childhood: prospective study of 10 patients with special reference to viral infections.

Purpose It has been proposed that human parvovirus B19 or human herpesvirus 6 (HHV-6) causes transient erythroblastopenia of childhood (TEC). This study was performed prospectively and accurately in a sufficiently large population to confirm or reject these suggestions, or possibly to find another causative agent for TEC. Patients and Methods The authors studied prospectively the causative aspects of 10 consecutive children with TEC presenting at five Swedish pediatric clinics from 1994 to 1998 using serologic assays and polymerase chain reaction assays for B19, HHV-6, cytomegalovirus, and Epstein–Barr virus (EBV). The authors also performed isolation investigations of virus from bone marrow, stools, and aspirate from the nasopharynx. Results The authors found acute EBV infection in one child. There were no other instances of IgM positivity for any viruses at presentation, but a few children did show IgG positivity to HHV-6 (n = 2), EBV (n = 1), and cytomegalovirus (n = 1). No children were positive with respect to IgG for B19. However, it could not be determined when these children had been infected, and thus, a connection to TEC cannot be proved or excluded. No child showed B19 or HHV-6 DNA in serum or bone marrow collected at presentation. Isolation of virus from bone marrow, stools, and aspirate from nasopharynx culture was negative in all children but one, who had rotavirus in stool. Conclusions HHV-6, B19, EBV, and cytomegalovirus are not common causative agents of TEC. The authors found no proof of any single agent causing TEC.

Oral Mercaptopurine in Childhood Leukemia: Influence of Food Intake on Bioavailability

Plasma concentrations of 6-mercaptopurine (6-MP) were determined by gas chromatography-mass spectrometry. Ten children (nine with acute lymphatic leukemia) were studied on 2 consecutive days after oral intake of 6-MP. On one day the drug was administered in the fasting state and on the other (in random order) together with breakfast. The peak plasma concentrations of 6-MP after the dose intake with breakfast in percent of that in the fasting state (meal in % of fasting for each individual) varied between 33 and 181% (mean 111), and the area under the plasma concentration-time curve varied between 47 and 186% (mean 103). Thus, there were considerable variations among patients, but, for the group as a whole, there were no statistically significant differences between the two experimental conditions. This study cannot therefore form the basis for a recommendation as to whether 6-MP should be administered on an empty stomach or together with food.

Prognosis after Relapse in Acute Lymphoblastic Leukemia in Childhood

This is a survey of all the 265 relapses occurring in 515 children with ALL diagnosed in Sweden in the years 1973-1980. Two hundred and nineteen relapses occurred on therapy, and 46 after discontinuation of therapy. Bone marrow was involved in the relapse in 71% and 67% of the two groups, respectively. Only 38/265 (14%) children with relapse were still alive at follow-up in January 1985. Of these, 16/219 (7%) had relapsed during therapy (median survival time after relapse 9 months) compared to 22/46 children (48%) with a relapse after cessation of therapy (median 43 months). The prognosis was better if relapse occurred after cessation of therapy and in children with isolated testicular relapse. Thirteen children were bone marrow transplanted, and 6 of these were alive at follow-up. It is concluded that children with ALL relapse have very bad prognosis with cytostatic regimens used today, especially if the bone marrow is involved.