Online Exclusive Article

Nausea, Pain, Fatigue, and Multiple Symptoms in Hospitalized Children With Cancer

Elizabeth Miller

Eufemia Jacob

Marilyn J. Hockenberry

children, nausea, nausea/vomiting, cancer pain, pain, cancer-related fatigue, fatigue
ONF 2011, 38(5), E382-E393. DOI: 10.1188/11.ONF.E382-E393

Purpose/Objectives: To describe the prevalence, frequency, severity, and distress of multiple symptoms in hospitalized children with cancer and to examine the overall symptom scores and global distress in patients reporting nausea, pain, and fatigue.

Design: Descriptive design with repeated measures.

Setting: Inpatient pediatric hematology-oncology unit.

Sample: 39 inpatients (ages 10-17) diagnosed with cancer.

Methods: Five-day data collection using the Memorial Symptom Assessment Scale (MSAS) Pediatric 10-18.

Main Research Variables: Thirty-one symptoms included in the MSAS Pediatric 10-18.

Findings: The most common symptoms (prevalence greater than 34%) were nausea, fatigue, decreased appetite, pain, and feeling drowsy. Differences in symptom experiences occurred in the presence of nausea, pain, and fatigue compared to days when they were not reported (p < 0.001). Prevalence of pain and fatigue symptoms decreased over the five days (p < 0.05), but not nausea (p > 0.05).

Conclusions: Nausea, pain, and fatigue were among the most prevalent symptoms in hospitalized children with cancer; however, the most prevalent symptoms were not always the most severe or distressing. The presence of these symptoms significantly impacted symptom experience, including total burden of symptoms experienced by the child (i.e., global distress).

Implications for Nursing: Additional examination of symptom management is needed. Nausea and its related symptoms have received little attention and more effective interventions are warranted. Multidimensional scales and the use of handheld electronic devices to track symptoms may be used to provide a more comprehensive assessment and treatment of symptoms.

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    American Cancer Society. (2011). Cancer facts and figures 2011. Retrieved from
    Baggott, C., Dodd, M., Kennedy, C., Marina, N., & Miaskowski, C. (2009). Multiple symptoms in pediatric oncology patients: A systemic review. Journal of Pediatric Oncology Nursing, 26, 325-339.
    Baggott, C. R., Dodd, M., Kennedy, C., Marina, N., Matthay, K. K., Cooper, B., & Miaskowski, C. (2010). An evaluation of the factors that affect the health-related quality of life of children following myelosuppressive chemotherapy. Supportive Care in Cancer. Advanced online publication.
    Bland, J. M., & Altman, D. G. (1996). Transforming data. BMJ, 312, 770.
    Bryant, R. (2003). Cancer treatment side effects. Journal of Pediatric Nursing, 18, 113-125.
    Chang, V. T., Hwang, S. S., Feuerman, M., Kasimis, B. S., & Thaler, H. T. (2000). The Memorial Symptom Assessment Scale Short Form (MSAS-SF) reliability and validity. Cancer, 89, 1162-1171.
    Chen, M., & Tseng, H. (2006). Symptom clusters in cancer patients. Supportive Care in Cancer, 14, 825-830.
    Collins, J. J., Byrnes, M. E., Dunkel, I. J., Lapin, J., Nadel, T., Thaler, H. T., … Portenoy, R. K. (2000). The measurement of symptoms in children with cancer. Journal of Pain and Symptom Management, 19, 363-377.
    Dodd, M., Janson, S., Facione, N., Froelicher, E. S., Humphreys, J., Lee, K., … Taylor, D. (2001). Advancing the science of symptom management. Journal of Advanced Nursing, 33, 668-675.
    Dolgin, M. J., Katz, E. R., Zeltzer, L. K., & Landsverk, J. (1989). Behavioral distress in pediatric patients with cancer receiving chemotherapy. Pediatrics, 84, 103-110.
    Enskar, K., Ljusegren, G., Berglund, G., Eaton, N., Harding, R., Mokoena, J., … Moleki, M. (2007). Attitudes to and knowledge about pain and pain management, of nurses working with children with cancer: A comparative study between UK, South Africa, and Sweden. Journal of Nursing Research, 12, 501-515.
    Enskar, K., & von Essen, L. (2008). Physical problems and psychosocial function in children with cancer. Paediatric Nursing, 20, 37-41.
    Gibson, F., Aldiss, S., Horstman, M., Kumpunen, S., & Richardson, A. (2010). Children and young people's experience of cancer care: A qualitative research study using participatory methods. International Journal of Nursing Studies. Advanced online publication.
    Gibson, F., Aldiss, S., Taylor, R. M., Maguire, R., & Kearney, N. (2009). Involving health professionals in the development of an advanced symptom management system for young people. European Journal of Oncology Nursing, 13, 187-192.
    Gibson, F., Mulhall, A. B., Edwards, J. L., Ream, E., & Sepion, B. J. (2005). A phenomenologic study of fatigue in adolescents receiving treatment for cancer. Oncology Nursing Forum, 32, 651-660.
    Hedstrom, M., Haglund, K., Skolin, I., & von Essen, L. (2003). Distressing events for children and adolescents with cancer: Child, parent, and nurse perceptions. Journal of Pediatric Oncology Nursing, 20, 120-132.
    Hinds, P. S., Hockenberry, M., Rai, S. N., Zhang, L., Razzouk, B. I., McCarthy, K., … Rodriguez-Galindo, C. (2007). Nocturnal awakenings, sleep environment interruptions, and fatigue in hospitalized children with cancer. Oncology Nursing Forum, 34, 393-402.
    Hockenberry, M. (2004). Symptom management research in children with cancer. Journal of Pediatric Oncology Nursing, 21, 132-136.
    Hockenberry, M., & Hooke, M. C. (2007). Symptom clusters in children with cancer. Seminars in Oncology Nursing, 23, 152-157.
    Hockenberry, M. J., Hooke, M. C., Gregurich, M., McCarthy, K., Sambuco, G., & Krull, K. (2010). Symptom clusters in children and adolescents receiving cisplatin, doxorubicin, or ifosfamide [Online exclusive]. Oncology Nursing Forum, 37, E16-E27.
    Holdsworth, M. T., Raisch, D. W., & Frost, J. (2006). Acute and delayed nausea and emesis control in pediatric oncology patients. Cancer, 106, 931-940.
    Jacob, E., Hesselgrave, J., Sambuco, G., & Hockenberry, M. (2007). Variations in pain, sleep, and activity during hospitalization in children with cancer. Journal of Pediatric Oncology Nursing, 24, 208-219.
    Jacob, E., Jacob, A., Secola, R., Townsend, P., Loera, K., Adlard, K., … Pelty, M. (2010, May). Self-monitoring of pain and symptoms at home using PDAs in children and adolescents with cancer. Poster session presented at the UCLA School of Nursing Research Day, Los Angeles, CA.
    Jacob, E., McCarthy, K. S., Sambuco, G., & Hockenberry, M. (2008). Intensity, location, and quality of pain in Spanish-speaking children with cancer. Pediatric Nursing, 34, 45-52.
    Jindal, V., Ge, A., & Mansky, P. J. (2008). Safety and efficacy of acupuncture in children. Journal of Pediatric Hematology Oncology, 30, 431-442.
    Kearney, N., McCann, L., Norrie, J., Taylor, L., Gray, P., McGee-Lennon, M., … Maguire, R. (2009). Evaluation of a mobile phone-based, advanced symptom management system (ASyMS©) in the management of chemotherapy-related toxicity. Supportive Care in Cancer, 17, 437-444.
    Ladas, E. J., Post-White, J., Hawks, R., & Taromina, K. (2006). Evidence for symptom management in the child with cancer. Journal of Pediatric Hematology Oncology, 28, 601-615.
    Lai, J., Cella, D., Kupst, M., Holm, S., Kelly, M. E., Bode, R. K., & Goldman, S. (2007). Measuring fatigue for children with cancer: Development and validation of the pediatric functional assessment of chronic illness therapy-fatigue (pedsFACIT-F). Journal of Pediatric Hematology Oncology, 29, 471-479.
    Linder, L. (2005). Measuring physical symptoms in children and adolescents with cancer. Cancer Nursing, 28, 16-26.
    Lobchuk, M. (2003). The Memorial Symptom Assessment Scale: Modified for use in understanding family caregivers' perceptions of cancer patients' symptom experiences. Journal of Pain and Symptom Management, 26, 644-654.
    Mooney-Doyle, K. (2006). An examination of fatigue in advanced childhood cancer. Journal of Pediatric Oncology Nursing, 23, 305-310.
    Naeim, A., Dy, S. M., Lorenz, K. A., Sanati, H., Walling, A., & Asch, S. M. (2008). Evidenced-based recommendations for cancer nausea and vomiting. Journal of Clinical Oncology, 26, 3903-3910.
    Oakes, L. L., Anghelescu, D. L., Windsor, K. B., & Barnhill, P. D. (2008). An institutional quality improvement initiative for pain management for pediatric cancer inpatients. Journal of Pain and Symptom Management, 35, 656-669.
    Patterson, K. L. (1992). Pain in the pediatric oncology patient. Journal of Pediatric Oncology Nursing, 9, 119-130.
    Quimby, E. L. (2007). The use of herbal therapies in pediatric oncology patients: Treating symptoms of cancer and side effects of standard therapies. Journal of Pediatric Oncology Nursing, 24, 35-40.
    Ream, E., Gibson, F., Edwards, J., Seption, B., Mulhall, A., & Richardson, A. (2006). Experience of fatigue in adolescents living with cancer. Cancer Nursing, 29, 317-326.
    Rheingans, J. L. (2008). Pediatric oncology nurses' management of patients' symptoms. Journal of Pediatric Oncology Nursing, 25, 303-311.
    Robinson, D. L., & Carr, B. A. (2007). Delayed vomiting in children with cancer after receiving moderately high or highly emetogenic chemotherapy. Journal of Pediatric Oncology Nursing, 24, 70-80.
    Rogovick, A. L., & Goldman, R. D. (2007). Hypnosis for treatment of pain in children. Canadian Family Physician, 53, 823-825.
    Santucci, G., & Mack, J. W. (2007). Common gastrointestinal symptoms in pediatric palliative care: Nausea, vomiting, constipation, anorexia, cachexia. Pediatric Clinics of North America, 54, 673-689.
    Smith, A. R., Repka, T. L., & Weigel, B. J. (2005). Brief report: Aprepitant for the control of chemotherapy induced nausea and vomiting in adolescents. Pediatric Blood and Cancer, 45, 857-860.
    Varni, J. W., Burwinkle, T. M., & Katz, E. R. (2004). The PedsQL™ in pediatric cancer pain: A prospective longitudinal analysis of pain and emotional distress. Developmental and Behavioral Pediatrics, 25, 239-246.
    von Baeyer, C. L., & Hicks, C. L. (2000). Support for a common metric for pediatric pain intensity scales. Pain Research and Management, 5, 157-160.
    Woodgate, R. L., & Degner, L. F. (2003). Expectations and beliefs about children's cancer symptoms: Perspectives of children with cancer and their families. Oncology Nursing Forum, 30, 479-491.
    Yeh, C., Chiang, Y., Chien, L., Lin, L., Yang, C., & Chuang, H. (2008). Symptom clustering in older Taiwanese children with cancer. Oncology Nursing Forum, 35, 273-281.
    Yeh, C., Wang, C., Chiang, Y., Lin, L., & Chien, L. (2009). Assessment of symptoms reported by 10-18-year-old cancer patients in Taiwan. Journal of Pain and Symptom Management, 38, 738-746.