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Prevalence of Insomnia among Paediatric Cancer Patients: A Hospital-based Observational Study
Correspondence Address :
Dr. Pooja Bharti,
SMGS Hospital, Shalamar-180001, Jammu and Kashmir, India.
E-mail: drbhartipooja@gmail.com
Introduction: Insomnia and other sleep disturbances are the common occurrences in paediatric patients suffering from cancer. These may be attributed to the disease itself or its treatment and accompanying psychosocial stress. Sleep disorders including insomnia are known to have a detrimental effect on the quality of life in these patients.
Aim: To estimate the prevalence of insomnia among cancer patients aged 1-15 years admitted in the paediatric oncology ward.
Materials and Methods: A prospective observational, hospital-based study was conducted in the Paediatric Oncology ward, Shri Maharaja Gulab Singh (SMGS) Hospital, Government. Medical College (tertiary care institute), Jammu, India, from June 2022 to August 2022. A total of 50 patients, in the age group of 1-15 years, diagnosed with malignancies like leukaemia, lymphoma, aplastic anaemia, hepatoblastoma, etc., were enrolled after taking informed consent from their parents. Insomnia Severity Index (ISI) was administered to parents of children below 10 years age and to patients themselves who were between 10-15 years to screen for symptoms of insomnia with the help of their parents/investigators as and when required. Continuous variables were expressed as mean±Standard Deviation (SD) and categorical variables were summarised as frequencies and percentages.
Results: The study subjects were distributed according to their age into three groups, as 1-5 years (n=26), 6-10 years (n=16), and 11-15 years (n=8). There were 24 (48%) males and 26 (52%) females. In this study, 32 (64%) study subjects did not have insomnia, 5 (10%) had subthreshold insomnia, 13 (26%) had moderate insomnia and none had severe insomnia.
Conclusion: The prevalence of insomnia found in the study was 26%. Insomnia is common in paediatric cancer patients necessitating its recognition and management for improved quality of life.
Children, Malignancy, Oncology, Sleep
Sleep disturbances like insomnia, increased daytime sleepiness, increased time to sleep onset, decreased sleep duration, poor sleep quality, etc., are the common consequences of cancer and its treatment in paediatric patients (1). Advances in the treatment of paediatric cancer have led to significant increases in long-term survival, highlighting the need to address not only survival but treatment associated morbidity and improved quality of life as well (1),(2),(3). In paediatric patients, cancer and its treatment can result in impaired cognitive function, functional impairment, activity limitations and impaired mental health issues like pain and anxiety (1). One of the most chronic and disturbing side-effects reported by paediatric cancer patients and survivors is problems with sleep, suggesting that this is a major quality of life concern. Surgery, chemotherapy and radiotherapy, in addition to the effect of the cancer, can all cause short-and long-term sleep disturbance (4),(5),(6),(7),(8),(9). Sleep represents a complex, multi-staged process required for survival, daily functioning, neurocognitive and physical development (10),(11). Poor sleep in the children is associated with deleterious effects on mood and neurocognition; a higher risk of clinical depression and anxiety; increased behavioural difficulties, including increased rates of hyperactivity; and less success in school. Sleep disorders are linked with pain, fatigue, and hospitalisation in paediatric cancer patients (12),(13),(14),(15). Thus, it is important to identify and address insomnia and other sleep disturbances in paediatric patients with cancer for their holistic management and improvement in quality of life. This study was conducted to estimate the prevalence of insomnia among cancer patients aged 1-15 years admitted in the Paediatric Oncology ward.
This prospective observational, hospital-based study was conducted in the Paediatric Oncology ward, Shri Maharaja Gulab Singh (SMGS) Hospital, Government Medical College, Jammu, India, from June 2022 to August 2022. Ethical clearance was obtained from the Institutional Ethics Committee (no IEC/GMCJ/2022/1069) before conducting the study.
Fifty patients, in the age group of 1-15 years, diagnosed with malignancy {leukaemia (n=30, 60%), lymphoma (n=7, 14%), aplastic anaemia (n=4, 8%), hepatoblastoma (n=3, 6%), germ cell tumour (n=2, 4%) and others (n=4, 8%)}, were enrolled after taking informed consent from their parents.
A total of 68 patients were admitted in Paediatric Oncology ward during the study period out of which 12 patients were excluded because of critical illness while parents of six patients refused to give consent to participate in the study. Remaining 50 patients were included in the study after obtaining informed consent from their parents.
Inclusion criteria: Patients in the age group of 1-15 years diagnosed with cancer, either on chemotherapy or admitted in the hospital for any other complications (n=50) were included in the study.
Exclusion criteria: Critically, ill patients admitted in Intensive Care Unit (ICU), children of parents who refused to give consent to participate in the study (n=18) were excluded from the study.
Study Procedure
A prestructured questionnaire as per the Hindi version of Insomnia Severity Index (ISI) was administered and the severity of insomnia symptoms in the study participants was assessed. The Hindi version of ISI has been found to be a valid and reliable tool for the assessment of severity of insomnia (16). The questionnaire was administered to the parents of children below 10 years and to patients themselves who were between 10-15 years with the help of their parents/investigators as and when required. The questionnaire included seven items, which were rated on a 5-point Likert scale assessing insomnia symptoms in the last seven days. The scores ranged from 0 to 28 and clinical cut-off points were determined as:
• Score 0-7: No clinically significant insomnia;
• Score 8-14: Subthreshold insomnia;
• Score 15-21: Clinical insomnia-moderate severity; and
• Score 22-28: Clinical insomnia-severe.
All participants with a score of eight or more were classified as having insomnia symptoms. The psychometric properties of the ISI are well-established and have also been investigated in young adult cancer survivors and adolescents (17). The socio-demographic data pertaining to the patient’s age, sex, residence and final diagnosis were also recorded.
Statistical Analysis
The recorded data was compiled and entered in a Microsoft Excel spreadsheet and then exported to data editor of Statistical Package for the Social Sciences (SPSS) software version 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as mean±Standard Deviation (SD) and categorical variables were summarised as frequencies and percentages.
In the study population, the subjects were distributed according to their age into three groups, 1-5 years (n=26), 6-10 years (n=16), and 11-15 years (n=8). There were 24 (48%) males and 26 (52%) females in the study population. Majority of the patients had leukaemia 30 (60%), followed by lymphoma seven (14%), aplastic anaemia four (8%), hepatoblastoma three (6%), germ cell tumour two (4%), others four (8%).
In this study, 32 (64%) study subjects did not have any symptoms of insomnia, while five (10%) had symptoms of sub-threshold insomnia. Thirteen (26%) subjects were observed to have moderate insomnia. Severe insomnia was not observed in any subject. Thus, the prevalence of insomnia found in this study was 26%.
In this study, in the age group of 1-5 years, only 2 (7.7%) subjects had insomnia, in 6-10 years, five (31.3%) subjects had insomnia and six (75%) subjects in the age group of 11-15 years were found to have insomnia. The prevalence of insomnia among female paediatric cancer patients was observed to be 30.8% (n=8) while it was 20.8% (n=5) in males. The prevalence of insomnia in different subgroups and gender wise distribution of insomnia in the study population is shown in (Table/Fig 1).
Sleep disturbances especially insomnia is a common problem encountered among paediatric cancer patients. In both paediatric 18cancer patients and survivors, sleep disturbances are usually severe and need treatment as they affect the quality of life in such population (18). The onset and persistence of such sleep problems in children with cancer have been explained with many proposed models like Sleep Disturbances in Paediatric Cancer Model (SDPCM) (19). The SDPCM proposes that psychosocial, environmental, and biological factors get affected by factors related to cancer like diagnosis and treatment (e.g., medication, radiation therapy, chemotherapy, surgery) which, in turn, lead to disrupted sleep.
Kaushik P et al., assessed sleep patterns in 63 children between age group 3-15 years undergoing therapy for cancer using Bedtime problems, Excessive daytime sleepiness, Awakenings during sleep, Regularity and duration of Sleep (BEARS) screening tool and the Children’s Sleep Habits Questionnaire (CSHQ). It was found that the overall prevalence of sleep disturbances in paediatric cancer patients, based on BEARS tool and CSHQ scores was 60.3% and 69.8%, respectively as compared to 34% in normal healthy children (20).
A review by Merz EL and Madsen LT studied common sleep problems in children with cancer and suggested certain risk factors specific to childhood cancer which may contribute to disrupted sleep (10). According to literature, most important risk factors hypothesised for sleep problems in paediatric cancer patients were disease parameters and its treatment, specific environmental conditions both during and after treatment, family factors like changes in family behaviour and norms, psychological factors and decreased physical activity (10).
Such sleep disturbances are more commonly seen in patients of the adolescent age group who usually are in knowledge of the illness and its accompanying complications and prognosis. In this study, eight out of 50 participants belonged to the age group of 11-15 years, out of which six patients (75%) were found to have symptoms of insomnia. The prevalence of insomnia in 6-10 years age group was 31.3%, while it was 7.7% in 1-5 years age group. In this study, insomnia was observed in 26% (13 out of 50) of study participants who were between 1-15 years of age. In a cross-sectional study by Peersmann SHM et al., insomnia was reported by 31.7% of patients, where the study participants belonged to the age group between 12-26 years (17). Also, the sample size studied by Peersmann SHM et al., was 565 as compared to 50 patients enrolled in this study.
In this study, 36.6% (11 out of 30) patients with leukaemia were reported to have insomnia. In a retrospective case series review by Rosen G and Brand SR sleep problems were characterised in 70 children with cancer. Authors found that 39% of children with leukaemia had insomnia and it was the most common sleep problem identified (21).
In a literature review by Sheikh IN et al., sleep changes such as daytime sleepiness, insomnia, increased sleep onset time, and poor sleep quality, were reported to be common in paediatric cancer patients and survivors. About 40% and in some cases, greater than 80%, of children with leukaemia were reported to have some form of sleep disturbance, most prevalent of which was insomnia (1).
In this study, the prevalence of insomnia in female paediatric cancer patients was observed to be 30.8% while, it was 20.8% in male paediatric cancer patients. Peersmann SHM et al., also determined females being as a risk factor for insomnia with an explanation that they are more vulnerable to other mental health complaints, such as anxiety or depression, which often co-occur with insomnia symptoms and daytime fatigue (17).
For the management of sleep issues in the paediatric cancer population, interventions like massage and physical activity have been evaluated by some small pilot studies. However, no large randomised controlled trials have evaluated these potential interventions in paediatric cancer patients with sleep disturbances (1).
Limitation(s)
The sample size in this study was small. The scale used for screening study subjects for symptoms of insomnia was the same for all the age groups. However, sleep requirements have been observed to be different for different age groups necessitating a much more comprehensive evaluation of sleep needs and their problems.
Insomnia and other sleep disturbances are a common occurrence in paediatric cancer patients, gravely affecting the overall quality of their lives. Owing to improved survivorship of such patients and increased concerns for better quality of life, identification and addressal of these sleep disturbances hold crucial importance in current times. More research in this field is needed to determine the burden of sleep problems in paediatric population diagnosed with malignancies. Healthcare providers need to be sensitised to common sleep problems including insomnia so that their diagnosis and management forms a part of the comprehensive care and treatment of paediatric cancer patients.
DOI: 10.7860/JCDR/2023/63042.17827
Date of Submission: Jan 23, 2023
Date of Peer Review: Feb 28, 2023
Date of Acceptance: Apr 05, 2023
Date of Publishing: May 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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