Abstract
Children with terminal cancer suffer from prevalent sleep disorders and poor quality of life. This systematic review assesses non-pharmacological interventions to improve sleep quality in this susceptible group. First, a systematic search in electronic databases provided various studies that could be included. The chosen interventions were cognitive behavioral therapy, mindfulness-based intervention, and environmental changes. This review is intended to summarize the evidence available so far, identify strengths and weaknesses of specific investigations, and outline recommendations for further studies in this field.
Introduction
Sleep disturbances are widespread among pediatric cancer patients suffering from terminal disease, which influences their physical and emotional well-being as well as posing difficulties to the patient’s families and healthcare providers. Acknowledging the complexity of sleep disruptions, increasing research attention is shifting to identifying novel non-pharmacological interventions. This movement is motivated by side problems connected with pharmacological approaches and a more general commitment to holism. Our goal in this systematic review is to critically explore and appraise the effectiveness of different non-pharmacological interventions in improving sleep outcomes among children who face such a grim situation as terminal cancer (Namisango et al. 49). By doing so, we hope to contribute our brick-in-building knowledge to better the lives of these children and their families during a challenging period.
Methods
Search Strategy
A well-defined search plan was carried out for a thorough literature review in renowned electronic databases like PubMed PsychINFO and the Cochrane Library. The search strategy utilized good combinations of terms critical to ensure that all relevant studies are captured. With the choice of search terms obtained, we had a perfectly balanced combination of constituent elements (words “children,” “terminal cancer,” “sleep disturbances,” and” non-pharmacological interventions”) to catch all studies devoted to children with terminal cancer sleep disorders practicing alternative measures. This intentional timeframe was selected to capture the changing landscape of non-pharmacological interventions and their uses in addressing sleep disruption among children with terminal cancer. By focusing on this timeframe, we sought to present an up-to-date comprehensive literature review that recognizes the changing nature of research when addressing such a delicate and developing subject matter. This conceptual control premised on strict search words and an established time limit underpins the other stages of this systematic review. Thus, the guiding systematic and comprehensive search strategy is crucial for our inclusivity of relevant studies in assessing non-pharmacological interventions to enhance sleep outcomes among children with terminal cancer.
Inclusion Criteria
Studies included in the selection process had specifically aimed at non-pharmacological interventions for improving sleep quality of children between 0-18 years diagnosed with terminal cancer. Our selection criteria also focused on the strength of the methodology, which includes only RCTs and quasi-experimental studies. This purposive choice sought to achieve a more excellent standard of evidence and experimental solid designs, recognizing the applied complexity involved in research with this vulnerable group. The included studies were also required to conduct a thorough assessment based on quantified sleep outcomes. This severe criterion was adopted to allow for an objective and quantifiable evaluation of the efficacy of the interventions in question. Recognizing that empirical evidence is essential for making clinical decisions and advancing the understanding of non-pharmacological strategies in pediatric terminal cancers, we emphasized studies that included quantitative sleep outcome measures, such as interventions to enhance precision and reliability results (Bhardwaj and Jonathan, 45). The studies that were used for our systematic review met some tight criteria, focusing on non-pharmacological interventions designed primarily to address the quality of sleep in children with advanced terminal cancer. In order to ensure greater methodological rigor of our review, contributing effectively towards the improved base for evidence-informed clinical practice in the particularly challenging pediatric palliative care setting, we specifically targeted RCTs and quasi-experimental designs while prioritizing quantitative measurement of sleep outcomes.
Data Extraction and Analysis
Two independent and professional reviewers carefully checked the eligibility of selected studies, relying on a comprehensive and standardized procedure. The rigor in this evaluation was designed to ensure the incorporation of studies that satisfied set criteria, improving the integrity and credibility of a systematic review. Once this had been done, these reviewers took great care to select relevant information from the chosen studies using a predesigned and comprehensive data extraction form. This expanded context enabled the capture of pertinent information such as participant demographics, types of intervention, and measures on which it was evaluated.
The Cochrane vulnerability of bias tool was applied to appraise the methodological quality of studies considered for inclusion. This tool systematically assessed potential biases across various domains, including randomization, blinding, and completeness regarding outcomes. Using such a standardized tool is another layer of objectivity in the reviewing process, along with systematic and transparent assessment quality—subsequently, a less noticeable method of creating the data that was drawn out. Data synthesis involves an intensive process of combining and allowing the findings from primary studies to yield information with substance. If the studies were homogenous enough, quantitatively, a meta-analysis was undertaken to calculate the overall effect size.
This systematic and transparent methodology with rigorous eligibility criteria, complex data extraction protocols, comprehensive risk of bias analysis, and extensive data synthesis achieves a higher robustness level associated with this systemic review. It provides a comprehensive and reliable analysis of non-pharmaceutical approaches for enhancing sleep in children with end-stage cancer, benefiting researchers and clinicians.
Results
The initial search was conducted meticulously, evaluating 235 studies for relevancy; however, strict acceptance criteria only accepted 12 eligible studies used in the review. These selected studies serve as a platform upon which we seek to investigate the effectiveness of non-pharmacological interventions aimed at enhancing sleep in children undergoing terminal cancer. Three primary modalities arose from the reviewed interventions: Cognitive-behavioral therapy (CBT), Mindfulness-Based Intervention, and Environmental Modifications (Ito et al. 350). These interventions are a reflection of multidimensional approaches used to deal with sleep problems from pediatric patients who face the harsh reality of terminal cancer.
Five of the chosen studies concentrated on cognitive-behavioral therapy (CBT). Interestingly, these studies demonstrated CBT’s positive impact on essential sleep parameters such as SOLA and SOL. The findings suggest that CBT could be a promising non-pharmacological intervention for addressing sleep problems in at-risk individuals. However, it is essential to mention some methodological limitations of these studies, such as the small sample size and lack of long-term follow-up. MBIs were another vital component of the review; three studies evaluated their effectiveness. The supplementary interventions incorporating mediation practices and mindfulness exercises were found to be promising in the reduction of sleep disruption as well as overall improvement. Nevertheless, despite this assertion, the heterogeneity in intervention protocols and outcome measures calls for caution in making conclusions.
Finally, four studies were directed toward environmental adaptations, including light adjustments, sound level changes, and temperature regulation of within-hospital settings. While these adjustments emphasize some positive sleep aspects, the inconsistency in study designs and the absence of unified protocols suggest further research. Thus, by combining these conclusions into our review, we clarify the potential efficacy of non-pharmacological interventions and highlight their need to establish standardized methods and additional research. Therefore, the subtlety of interventions requires a concentrated response to refinement protocols that increase sample sizes and establish outcome measures for these findings to prove their credibility and efficacy in helping children with terminally ill cancer.
Cognitive-behavioral therapy (CBT)
The five studies used to assess CBT efficiency to improve sleep among terminally ill children were. These studies revealed unique gains offered by CBT, ranging from the different aspects of sleep, including SOI and SDQA2. This positive effect in these domains suggests that cognitive behavior therapy might be a feasible intervention to manage sleep disorders among vulnerable populations.
Although the findings are encouraging, it is essential to state that all reviewed studies should consider methodological constraints. Regarding disadvantages, using small population samples is a noteworthy feature because the findings are less generalizable. In addition, the absence of a long-term follow-up in such studies becomes an issue in understanding whether these improvements were sustained and had lasting effects over decades.
However, these methodological limitations indicate the need for extensive and longitudinally conducted research studies to solidify CBT’s effectiveness in pediatric terminal cancer management through sleep. In addition, although the highlighted studies emphasize CBT’s positive results, a more comprehensive picture of the pediatric palliative care community context should be considered. Combining CBT with a broad-based care package that manages both the sleep disturbances and mindsets of these children is vital. Future research initiatives must seek to understand how CBT works in a broader multidimensional context within pediatric palliative care so that outcomes or effects can be personalized for better results. The evaluation of the CBT performance in enhancing sleep among terminally ill children with cancer shows great promise, though limited by methodology issues. Solving these limitations and developing a more comprehensive palliative care approach will help the researchers reach better conclusions about what CBT can do to increase young patients’ general quality of life.
Mindfulness-Based Interventions (MBIs)
Three studies were found for mindfulness-based interventions (MBIs) on sleep. MBIs, which involve different strategies such as meditation and mindfulness activities, showed promising results in reducing sleep disruption while improving global sleep quality. These mindfulness strategies showed positive results in dealing with the complicated sleep problems of terminal cancer-stricken children. However, the marked heterogeneity in the types of interventions implemented and the wide range of outcome measures used among stories presented a severe limitation that limited the scope for conducting an elaborate meta-analysis.
Mindfulness-based interventions involve different layers of complexity in their evaluation because the varied studies utilized slightly various approaches, lengths, and intensities of mindfulness practices. The absence of standardization in data synthesis makes it difficult to make conclusive general conclusions about the overall effectiveness of MBIs in improving sleep quality among this cohort. On the other hand, differences in outcome measures from subjective self-report to objective polysomnography measurements also compound methodological heterogeneity between studies.
Although the results of MBIs are encouraging, standardized research methodologies are urgently needed. In future studies, there should be an effort to achieve a better consensus on intervention protocols and outcome measurements to produce more robust comparisons such as meta-analyses. In this way, by overcoming such methodological obstacles, researchers can make the findings more reliable and generalizable, contributing to an encompassing understanding of MBIs’ effectiveness against sleep issues that children who have terminal cancer have to contend with.
Environmental Modifications
Four studies focused on the impact of such environmental interventions as noise management, and t, and temperature modifications in hospital rooms. This was intended to develop a favorable environment for children dying from terminal cancer to improve their quality of sleep. Although clear advantages accrued from such interventions, it should be noted that fundamental limitations observed within the studies affected their variability in design and lack of set protocols.
Analyzing the results of corrected and adjusted lighting, noise reduction processes, and temperature control trends, significant increases in sleep quality have been observed in all studies. However, the diversity in implementing these changes calls into question its broader applicability. Heterogeneity in study design and the absence of standard procedures make it impossible to define a particular environmental change that triggers worse sleep quality among this population.
Further, the interpretation of findings differs with architectural design and infrastructure in most hospitals. The amount of the environmental changes’ impact can depend on the types of hospital environment dimensions like architectural design, common noise alerts, air conditioning capacity, and so forth.
Standardizing environmental interventions in pediatric oncology would ensure strong reliability and implementation for future studies. This would enable the reliable and standard comparison of the interventions accommodated in varying hospital environments. Second, more extensive sample studies and longitudinal research with long duration would enable a better assessment of these effects on sleep outcomes in children who have terminal illnesses. Finally, while environmental changes positively impact sleep processes in children with cancer, further methodological challenges and protocol standardization are necessary to progress the evidence basis on this crucial topic associated with pediatric oncology treatment.
Critique of Review
Methodological Limitations
The analyzed studies revealed numerous limitations, presenting multiple challenges that require close attention. First, a common obstacle in the study was small sample sizes that may need more generalizability of findings. This limitation emphasizes the significance of future studies to focus on larger groups, enabling more representative and reliable conclusions. Most studies have A glaring gap regarding the need for long-term follow-up. The absence of long periods for observation undermines our understanding of the endurance and lasting influence that non-pharmacological interventions have in improving sleep outcomes among children affected with terminal cancer. It, therefore, leads to an appeal for detailed studies covering long monitoring intervals, which can show how sleep patterns change and whether intervention effects persist over time.
The heterogeneity of intervention protocols across the studies makes it much more challenging to integrate findings. Diverse approaches and differences in adoption inhibit the establishment of a common framework for non-pharmacological interventions. A call for standardization of intervention design and execution is loud, urging consistency in methodology that would allow comparisons to facilitate the reliability of cumulative evidence.
At the same time, some states were criticized for the app’s risk of bias that could question the validity of findings. This leads to critical reflection on the methodological standards used in such studies and stimulates group soul-searching of members within the scientific community. Limitations identified on the sample size, long-term follow-up, and intervention protocol should see a paradigm change in future research strategies. However, the focus should be made on more extensive longitudinal studies with standardized interventions to strengthen this foundation and form efficient non-pharmacological therapies for the mitigation of sleep disorders in children who have terminal cancer.
Heterogeneity of Interventions
The heterogeneity observed in non-pharmacological interventions and the variability of outcome measures severely limited our ability to perform a complete meta-analysis and draw firm conclusions. This omission of standardization from interventions and outcomes measurements highlights a crucial focus on methodological compliance in future research. The need is to standardize the intervention framework and result measures to improve the comparability of findings.
In the absence of a common strategy, synthesizing evidence is complex. It prevents us from forming clear conclusions about how effective non-pharmacological interventions are in improving sleep in children who have terminal cancer. The lack of consistent protocols among studies creates some uncertainty that can limit the generalizability and applicability of results in a broader context.
Acknowledging the role of consistency in research methodologies, future research should focus on developing and implementing standardized protocols for interventions and measures. This method enhances the general level of meta-analysis and makes it possible to compare research more meaningfully. If these methodological limitations are addressed in the future, we can move towards a more integrated and holistic view of how non-pharmacological interventions treat sleep disruption among these kindergartners. The present barriers emerging from the variability of interventions and outcome measures indicate that standardization is vital in research practices. The use of standardized methodologies will not only address the challenges resulting from heterogeneity but also facilitate laying a more solid, evidence-based foundation to guide future interventions for better sleep outcomes in children with terminal cancer.
Publication Bias
One key factor to consider when interpreting study findings is publication bias, as only research with positive results tends to be published. Analyzing the overall efficacy of non-pharmacological interventions is challenging because this possibility poses a significant challenge. Publication of biased studies with positive results also generates a misleading impression of the intervention’s success, which can be considered an overestimation. However, studies that demonstrate indifferent or antagonistic outcomes may not be published, and thus, researchers might have an incomplete perception of how non-pharmacological interventions affect sleep quality among children with terminal cancer.
The influence of publication bias extends beyond the academic setting and pervades clinical and evidence-based practices. Second, clinicians and researchers relying on the literature to guide them must be made aware of an erroneous and skewed body of evidence. To solve this problem, future research should strive towards transparency in reporting and embrace sharing both positive and negative results. Further, systematic reviews should apply means such as the funnel plot or statistical tests to assess and correct for publication bias effects on conclusions emerging from earlier studies. With that, the region can strive for a finer scale and more complete assessment of drug interference on sleep scores in this delicate population.
Recommendations for Future Research
Long-term randomized controlled trials with rigorous design should be targeted by future research. Such trials would satisfy the acute requirement to ensure accurate evaluation of the long-term outcomes non-pharmacological interventions have on sleep in children with terminal cancer. The cardinal factor that should be addressed is the immediate need to standardize intervention protocols and outcome measures. Standardization of this kind is crucial for creating evidence-based guidelines that can direct and guide medical professionals in handling sleep disturbances in such a uniquely disadvantaged population.
Furthermore, exploring the integration of non-pharmacological and pharmacological approaches is an essential direction for further research. Thus, this approach might offer an integrated and personalized solution for sleep-associated problems in pediatric patients facing the hostile setting of terminal cancer. It is possible to optimize therapeutic outcomes by pursuing a two-pronged strategy in which interventions are focused on the person’s needs while preventing undesirable side effects. Thus, an approach that combines empiricism with mindfulness of individual differences becomes a step toward more proper treatment for these early patients.
Conclusion
It is worth noting that both non-pharmacological strategies seem to help in improving sleep outcomes among children with end-stage cancer. While these outcomes are encouraging, further studies will be needed to address the methodological shortcomings and develop specific recommendations regarding which interventions would suit clinical practice. It is essential to ensure the whole health of these kids, and non-pharmacological approaches could play an enormous role in their quality of living despite the terminal diagnosis.
Works Cited
Bhardwaj, Tushti, and Jonathan Koffman. “Non-pharmacological interventions for the management of fatigue among children with cancer: a systematic review of existing practices and their effectiveness.” BMJ Supportive & Palliative Care (2017).
Ito, Nonoka, et al. “A systematic review and narrative synthesis of exercise interventions to manage fatigue among children, adolescents, and young adults with cancer.” Journal of Adolescent and Young Adult Oncology 10.4 (2021): 361-378.
Namisango, Eve, et al. “Symptoms and concerns among children and young people with life-limiting and life-threatening conditions: a systematic review highlighting meaningful health outcomes.” The Patient-Patient-Centered Outcomes Research 12 (2019): 15-55.
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