118 Chapter 4 ABSTRACT Purpose Dexamethasone, the preferred corticosteroid in most treatment protocols for pediatric acute lymphoblastic leukemia (ALL), can induce undesirable side effects. Neurobehavioral and sleep problems are frequently reported, but the inter-patient variability is high. We therefore aimed to identify determinants for parent-reported dexamethasone-induced neurobehavioral and sleep problems in pediatric ALL. Patients and methods Our prospective study included medium risk ALL patients and their parents during maintenance treatment. Patients were assessed before and after one five-day dexamethasone course. Primary endpoints were parent-reported dexamethasone-induced neurobehavioral and sleep problems, measured with the Strengths and Difficulties Questionnaire (SDQ) and Sleep Disturbance Scale for Children (SDSC), respectively. Analyzed determinants included patient and parent demographics, disease and treatment characteristics, parenting stress (Parenting Stress Index and Distress Thermometer for parents), dexamethasone pharmacokinetics and genetic variation (candidate single nucleotide polymorphisms rs41423247 and rs4918). Statistically significant determinants identified in univariable logistic regression analyses were incorporated in a multivariable model. Results We included 105 patients: median age was 5.4 years (range 3.0-18.8) and 61% were boys. Clinically relevant dexamethasone-induced neurobehavioral and sleep problems were reported by parents in 70 (67%) and 61 (59%) patients respectively. In our multivariable regression models, we identified parenting stress as significant determinant for parentreported neurobehavioral (odds ratio (OR) 1.16, 95%-confidence interval (95%-CI) 1.07-1.26) and sleep problems (OR 1.06, 95%-CI 1.02-1.10). Furthermore, parents who experienced more stress before start of a dexamethasone course reported more sleep problems in their child (OR 1.16, 95%-CI 1.02-1.32). Conclusion We identified parenting stress, and not dexamethasone pharmacokinetics, genetic variation, patient/parent demographics, or disease/treatment characteristics, as a significant determinant for parent-reported dexamethasone-induced neurobehavioral and sleep problems. Parenting stress may be a modifiable target to reduce these problems.
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