Fatigue in children and adolescents with cancer from the perspective of health professionals 1

ABSTRACT Objective: to investigate health professionals' knowledge about the concept, assessment and intervention in fatigue in children and adolescents with cancer. Method: exploratory study with qualitative approach, with 53 health professionals (10 nurses, 33 assistant nurses, 3 physicians, 3 nutritionists, 2 psychologists and 2 physical therapists). Semi structured interviews were held, which were recorded and analyzed by means of inductive thematic content analysis. Results: the data were organized around three themes: knowledge of health professionals about fatigue; identification of fatigue and interventions to relieve fatigue. Conclusion: the results indicate the health professionals' limited knowledge about fatigue, as well as the lack of investment in their training and continuing education. Most of all, the lack of research on the theme in the Brazilian context remains a barrier to support improvements in care for this symptom in children and adolescents with cancer.

In addition, the lack of CRF management protocols is a problem that affects care (2) .
In Brazil, empirical data obtained from a study at a teaching hospital in the State of São Paulo, based on reports of children and adolescents with cancer, revealed their clear discomfort and desire to rest, mainly during the infusion of chemotherapy and the first days afterwards, showing the CRF as a result of the experience of the disease, the chemotherapy or the hospitalization process (12) .
The importance of knowing the heath professionals' experiences in terms of knowledge, assessment and intervention in CRF in hospitalized children and adolescents with cancer can strongly contribute to specialized care. Besides the clinical and therapeutic assessment, the health professionals need knowledge and sensitivity to perceive the suffering, due to the different reactions that permeate the cancer treatment, mainly focusing on the symptoms (13) . In addition, the multiprofessional health team's control and relief of the CRF are relevant issues that need to be inherent in integrative oncology care (14) . Understanding this phenomenon is a challenge to identify the fatigue as well as to implement measures that can be efficient with a view to achieving a better quality of life for these patients. The objective in this research was to investigate health professionals' knowledge about the concept, assessment and intervention in fatigue in children and adolescents with cancer.

Method
An exploratory study with a qualitative approach was undertaken, based on inductive thematic content analysis (15) . The research process took place at the pediatric outpatient clinic and pediatric onco-hematology clinic of a public hospital located in the State of São Paulo, Brazil. Among other specialties, the institution, which was planned for care, teaching and research, is a referral hospital for the treatment of children and teenagers with onco-hematologic disorders.
At the start of the data collection, the multidisciplinary health team was comprised of 72 health professionals, including seven physicians, 12  The empirical data were analyzed by means of signification/interpretation of the emerging themes (15) .
It is highlighted that the inductive thematic modality permits the extraction of themes from the data, as a data coding process that does not drift on the preexisting theoretical structure.
The second analysis phase was developed manually, when each unit of meaning was marked with distinct colors. Therefore, the empirical material was subject to exhaustive readings, in the attempt to identify words, excerpts and semantic similarities repeated in each interview, followed by their indexation and content analysis. In excerpts from testimonies in which the word fatigue corresponded to its definition, for example, the color green was used; when it referred to interventions and/or practical actions for its management, the color blue was used, and so forth.

Identification of fatigue
In the testimonies, it was observed that the fatigue symptom has been recognized based on the children or  As observed, these are activities related to the daily life of a healthy child that, in the hospital context, are intended to offer close-to-normal conditions.
Children and teenagers under treatment for cancer can experience different psychoneurological symptom clusters, which frequently include fatigue. These symptom groups normally take place simultaneously, and mainly involve pain, nausea, sleep disorders, anguish, suffering and fear. It is believed that this can be one of the aspects that hamper the diagnosis of the fatigue. It is highlighted that the psychoneurological symptom clusters are associated with worse prognoses, low survival, behavioral changes and psychophysiological performance disorders, reduced treatment adherence and lower health-related quality of life (13)(14) .
Difficulties to recognize and manage fatigue include the fact that it is a subjective symptom, which is not life threatening and is considered an unavoidable consequence by the health team. In addition, in most cases, fatigue is underdimensioned and, therefore, the health professionals may not fully perceive the level of suffering and functional loss it causes (4) . In children and adolescents, however, tools have been used to assess and identify fatigue ( Scale (10) .
A cross-sectional study, conducted in 11 European countries, using a paired sample of 1,933 patients and health professionals to investigate the level of agreement between the patients and health professionals' assessments of cancer symptoms, indicated that 71% of the patients assessed the fatigue symptom as moderate and that 54% of the professionals assessed it as severe.
The health professionals underestimated the symptoms in approximately one out of ten patients (11) .
Another study revealed that the patients often The professionals need technical-scientific qualification to identify the symptom, which can be achieved through continuing education programs. This is a route towards the emancipation and autonomy of health professionals, as it is at the crossing between professional education and the job world that learning and teaching are incorporated into the institutions' daily reality (29) .
Managing CRF represents a great challenge for the health professionals, but the interventions in children and teenagers with cancer that are being developed or tested to managed this symptom are still insufficient, mainly due to the methodological quality of the clinical trials conducted, sample size problems and difficulties to recruit participants because of the parents' overprotection (14,27) .
The treatment success depends on an approach mediated by health education, which considers the nature of the fatigue, the therapeutic complementarities and the possible problems. Due to the distinct causes of fatigue, the therapeutic plan should be multidimensional and individual, also recommending the family's engagement for the sake of a better assessment of the symptom and identification of management strategies (4) .
Although fatigue is often mainly described as a physical symptom in the literature, promoting interventions that only consider this dimension and its biological manifestations, this symptom interferes in several areas of the patients' lives, affecting physical, cognitive, affective and behavioral domains and can be experienced at different levels, ranging from mild to severe (4,7,28) . The psychological and social support  (2) .
The increased knowledge on fatigue has not sufficiently encouraged the patients to discuss the symptom with their physicians and nurses. The patients cope with the symptom intuitively, as well as the health team, despite valid and reliable assessment instruments and a range of effective management instruments (1,4) .
The health professionals hardly use these guidelines and the patients do not know which interventions can relieve the fatigue. The oncologists and oncologic nurses who take care of these patients are challenged to implement the available scientific evidence in their practice (4) .
A limitation of the study is the analysis of data