Chang, C.W., Mu, P.F., Jou, S.T., Wong, T.T., & Chen, Y.C. (2013). Systematic review and meta-analysis of nonpharmacological interventions for fatigue in children and adolescents with cancer. Worldviews on Evidence-Based Nursing/Sigma Theta Tau International, Honor Society of Nursing, 10, 208–217.

DOI Link


STUDY PURPOSE: To review the published evidence on non-pharmacologic interventions for fatigue in children and adolescents with cancer

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy

DATABASES USED: Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews, CINAHL, PsycINFO, Ovid, MEDLINE, ProQuest Dissertations and Theses, the Electronic Theses and Dissertations System, the Index to Taiwan Periodical Literature, Electronic Thesis and Dissertation System (Chinese)

KEYWORDS: experimental study, random study, quasi-experimental study, children, adolescents, pediatric, cancer, oncology, nonpharmacological interventions, massage, exercise, fitness, physical activity, cognitive-behavioral, stress management, energy conservation, sleep therapy, relaxation, distraction, psychoeducation, fatigue, cancer-related fatigue, loss of energy, levels of tiredness, tired, side effect, symptoms

INCLUSION CRITERIA: RCT or quasi-experimental studies; 1–18 years of age, experiencing cancer-related fatigue; maintenance stage or survivor stage; hospitalized or home; acute lymphoblastic leukemia (ALL)/acute myeloid leukemia (AML)/lymphoma/solid tumor; interventions with descriptions of length, frequency setting, and provider, and including activity enhancement, psychosocial interventions, cognitive behavioral therapy, stress management, relaxation, nutrition consultation, massage, or educational interventions; use of validated scales for cancer-related fatigue in outcomes

EXCLUSION CRITERIA: Written in languages other than English or Chinese

Literature Evaluated


EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Retrieved papers reviewed by two independent reviewers with a third for disagreements about methodologic validity

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED =  6, 3 in meta-analysis
  • KEY SAMPLE CHARACTERISTICS: Outpatient and hospitalized children; ALL, solid tumor, AML, and lymphoma; ALL most common; varied disease stage; range from first cycle of chemo to survivor; five studies in the United States, one in Taiwan; home, community, and hospital setting; interventions of exercise-training, physical activity, massage, health education, and exercise training

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care     



Two studies showed no significance in decreasing total fatigue with exercise. Two studies suggested exercise reduced general fatigue (p < .01). No significance was found for sleep/rest fatigue or cognitive fatigue. Study of massage showed no effect on fatigue. Final study used nurse education session on fatigue versus UC with reports that interventions were “effective.”


No study reduced total fatigue in any population. General fatigue was the only fatigue measure with significant improvement in some studies.


The phases of care, tumor type, and age varied. Children may not have had an ability to differentiate fatigue and relaxation, making fatigue perhaps difficult to measure.

Nursing Implications

Exercise may be a safe intervention for improving general fatigue in children and adolescents experiencing cancer-related fatigue.

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