Risk factors for chemotherapy-induced nausea in pediatric patients receiving highly emetogenic chemotherapy.

BACKGROUND: Little is known regarding risk factors for chemotherapy-induced nausea (CIN) in pediatric patients. PROCEDURE: A secondary analysis was conducted of a previously published multicenter, prospective, randomized, single-blind, sham-controlled trial assessing the efficacy of acupressure in preventing CIN in pediatric patients receiving highly emetogenic chemotherapy. The primary outcome was nausea severity, self-reported using the Pediatric Nausea Assessment Tool. The relationships between acute and delayed nausea severity and patient- (sex, race, age, and cancer diagnosis) and treatment-related (chemotherapy, antiemetic prophylaxis, CIN, and vomiting control) factors were analyzed by a proportional odds generalized estimating equation approach. The acute phase started with administration of the first and continued for 24 hours after the last chemotherapy dose. The delayed phase started at the end of the acute phase and continued until the next chemotherapy block (maximum seven days). RESULTS: In the acute and delayed phases, 165 and 144 patients provided data for analysis, respectively. Nonwhite race was significantly associated with higher acute phase nausea severity (OR, 1.7; 95% CI, 1.1-2.6). Poor CIN control in the acute phase (OR, 16; 95% CI, 4.0-64.6), diagnosis of a cancer other than a central nervous system (CNS) tumor (OR, 2.5; 95% CI, 1.2-5.3), and cisplatin administration (OR, 3.7; 95% CI, 2.1-6.0) were significantly associated with higher delayed phase nausea severity. CONCLUSION: Acute phase CIN was associated with nonwhite race. Delayed phase CIN was associated with poor acute phase CIN control, diagnosis of non-CNS cancer, and receipt of cisplatin. These findings will inform future antiemetic trial design.

Outpatient High-dose Methotrexate for Osteosarcoma: It's Safe and Feasible, If You Want It.

BACKGROUND: High-dose methotrexate (HD MTX) is usually administered as an inpatient to those with osteosarcoma. We prospectively tested the safety and feasibility of administering HD MTX in the ambulatory setting. MATERIALS AND METHODS: In this single arm prospective observational study, eligible patients had previously completed 2 courses of HD MTX as an inpatient. On study, patients received MTX in hospital, discharged home and returned for daily assessment. Criteria to determine safety and feasibility included: (1) parent compliance with home instructions, (2) pump functioning/failure, and/or (3) admission for toxicity/noncompliance. Outpatient therapy was deemed feasible if <25% courses resulted in study event. Patient satisfaction was assessed. RESULTS: Six patients (median age, 13.5 y) with extremity osteosarcoma completed 35 courses of MTX. There were no study events-no hospitalizations or pump failures and all parents were compliant. The Data and Safety Committee concluded that with zero events in 35 courses, it was unlikely for outpatient MTX to be infeasible; study was thus terminated early. Participants reported value to stay out of hospital, permitted life to feel "more normal"; however, burden of daily commute to hospital was cited. CONCLUSIONS: The delivery of HD MTX is safe and feasible in patients with osteosarcoma.

Acupressure bands do not improve chemotherapy-induced nausea control in pediatric patients receiving highly emetogenic chemotherapy: A single-blinded, randomized controlled trial.

BACKGROUND: Chemotherapy-induced nausea and vomiting remain common, distressing side effects of chemotherapy. It has been reported that acupressure prevents chemotherapy-induced nausea in adults, but it has not been well studied in children. METHODS: In this multicenter, prospective, randomized, single-blind, sham-controlled trial, the authors compared acute-phase nausea severity in patients ages 4 to 18 years who were receiving highly emetic chemotherapy using standard antiemetic agents combined with acupressure wrist bands, the most common type of acupressure, versus sham bands. Patients wore acupressure or sham bands continuously on each day of chemotherapy and for up to 7 days afterward. Chemotherapy-induced nausea severity in the delayed phase and chemotherapy-induced vomiting control in the acute and delayed phases also were compared. RESULTS: Of the 187 patients randomized, 165 contributed nausea severity assessments during the acute phase. Acupressure bands did not reduce the severity of chemotherapy-induced nausea in the acute phase (odds ratio [OR], 1.33; 95% confidence limits, 0.89-2.00, in which an OR <1.00 favored acupressure) or in the delayed phase (OR, 1.23; 95% CL, 0.75-2.01). Furthermore, acupressure bands did not improve daily vomiting control during the acute phase (OR, 1.57; 95% CL, 0.95-2.59) or the delayed phase (OR, 0.84; 95% CL, 0.45-1.58). No serious adverse events were reported. CONCLUSIONS: Acupressure bands were safe but did not improve chemotherapy-induced nausea or vomiting in pediatric patients who were receiving highly emetic chemotherapy. Cancer 2018;124:1188-96. © 2017 American Cancer Society.

Evaluation of a joint adult and pediatric clinic for cancer survivorship care.

OBJECTIVES: The best model of care for long-term follow-up of survivors of childhood cancer is uncertain. We describe the care experience provided by the joint adult/pediatric AfterCare Clinic at the McMaster Children's Hospital. Secondary outcomes include an evaluation of cancer worry, self-management skills, and loss to follow-up rates. METHODS: AfterCare Clinic patients aged 19-29 years were approached for study participation between January and March 2016. Data were collected from a cross-sectional survey, consisting of the Cancer Care Experience Questionnaire (CCEQ), Cancer Worry Scale (CWS), and Self-Management Skills Scale (SMSS). Responses were analyzed using descriptive statistics. RESULTS: Seventy-three (40%) patients participated in the survey, 17 (23%) anonymously. Demographic characteristics of the nonanonymous participants were representative of the total clinic cohort. Most respondents were satisfied with the quality of care and anticipatory guidance provided, demonstrated by the CCEQ responses. Respondents had a high degree of cancer worries (mean score 50.6 [±18.4]), but good self-management skills (72.0 [±10.9]). Our 5-year loss to follow-up rate was 3.8%. Sensitivity analyses showed no difference in responses between the total cohort and the nonanonymous participants. CONCLUSIONS: This sample of young adult survivors of childhood cancer had a higher degree of cancer worries and higher self-management skills scores than a younger cohort of survivors of childhood cancer in the literature. Given this, along with the positive care experience reported, and the low loss to follow-up rate, the joint adult/pediatric model of survivorship care appears to be meeting the needs of this population.

Smoking, Binge Drinking, and Drug Use Among Childhood Cancer Survivors: A Meta-Analysis.

INTRODUCTION: Childhood cancer survivors are at risk for late effects of therapy, some of which may be exacerbated by smoking, alcohol, or drug use. We undertook a meta-analysis of the literature to determine whether survivors engage in risk-taking behaviors at rates different from their peers/siblings. METHODS: Studies comparing current engagement in risk-taking behaviors between cancer survivors and siblings or matched peers were identified in MEDLINE (1946-), EMBASE (1947-), PsychINFO (1806-), and the Cochrane Controlled Trials Register. Two reviewers assessed publications for inclusion and extracted data independently. Studies were combined using inverse variance weighting to determine odds ratios (OR) and prevalence rates of risk-taking behaviors in survivors compared to controls. RESULTS: Fourteen of 1,713 studies satisfied inclusion criteria. Twelve assessed smoking, six binge drinking, and seven drug use. Among survivors, 22% (95% confidence interval 0.19, 0.26) smoked, 20% (0.08, 0.51) were binge drinkers, and 15% (0.10, 0.23) used drugs. Survivors were less likely than siblings to smoke (OR 0.68 [0.49, 0.96]) or binge drink (OR 0.77 [0.68, 0.88]), but similarly likely to use drugs (OR 0.33 [0.03, 3.28]). Survivors were less likely than matched peers to smoke (OR 0.54 [0.42, 0.70]) or use drugs (OR 0.57 [0.40, 0.82]), but equally likely to binge drink (OR 0.97 [0.38, 2.49]). CONCLUSIONS: Childhood cancer survivors engage in similar or lower rates of risk taking than their siblings/peers. Future studies should identify survivors most likely to benefit from focused interventions, and determine the impact of risk-taking behaviors on the risk for late effects of cancer therapy.

Advanced practice nurses: Improving access to fertility preservation for oncology patients.

Cancer therapies such as chemotherapy, radiation therapy and surgery may place the future fertility of both children and young adults at risk. Oncofertility is a rapidly evolving area that involves increasing access to fertility preservation (FP) information and services. This manuscript aims to: a) highlight the fertility risks associated with cancer therapy and its psychosocial impact, b) describe FP options, c) discuss the unique challenges of FP in distinct cancer populations, and d) illustrate the pivotal role of APNs in oncofertility counselling and education.

Radiological Assessment and Outcome of Local Disease Progression after Neoadjuvant Chemotherapy in Children and Adolescents with Localized Osteosarcoma.

OBJECTIVE: We examined the interobserver reliability of local progressive disease (L-PD) determination using two major radiological response evaluation criteria systems (Response evaluation Criteria in Solid Tumors (RECIST) and the European and American Osteosarcoma Study (EURAMOS)) in patients diagnosed with localized osteosarcoma (OS). Additionally, we describe the outcomes of patients determined to experience L-PD. MATERIALS AND METHODS: Forty-seven patients diagnosed with localized OS between 2000 and 2012 at our institution were identified. Paired magnetic resonance imaging of the primary tumor from diagnosis and post-neoadjuvant chemotherapy were blindly assessed by two experienced radiologists and determined L-PD as per RECIST and EURAMOS radiological criteria. Interobserver reliability was measured using the kappa statistic (κ). The Kaplan Meier method and log-rank test was used to assess differences between groups. RESULTS: Of 47 patients (median age at diagnosis 12.9 years), 16 (34%) had L-PD (by RECIST or EURAMOS radiological definition). There was less agreement between the radiologists using EURAMOS radiological criteria for L-PD (80.9%, κ = 0.48) than with RECIST criteria (97.9%, κ = 0.87). Patients with radiologically defined L-PD had a 5-year progression-free survival (PFS) of 55.6%, compared to a 5 year-PFS of 82.7% in the group of patients without L-PD (n = 31) (Log rank p = 0.0185). CONCLUSIONS: The interobserver reliability of L-PD determination is higher using RECIST than EURAMOS. RECIST can be considered for response assessment in OS clinical trials. The presence of L-PD was associated with worse outcomes.

Postoperative fevers in pediatric solid tumor patients: how should they be managed?

UNLABELLED: It is unclear how aggressively postoperative fevers should be managed in immunosuppressed pediatric oncology patients after major surgery. Little data exists on this subject. Therefore, a retrospective study of patients treated at our center was undertaken to examine this. PURPOSES: (1) to describe the prevalence of fever and infection in postoperative pediatric solid tumor patients undergoing primary tumor resection, (2) to examine the risk factors that contribute to the development of postoperative infections, and (3) to describe the variation in practice in managing fevers. METHODS: Chart reviews were performed on patients diagnosed with a spectrum of tumor types from January 2000 to October 2005 who received preoperative chemotherapy, followed by tumor resection. RESULTS: Ninety-eight children met inclusion criteria and 73 (74%) developed fevers postoperatively; 14% of these had documented infections and 1 patient died from sepsis. Factors associated with increased risk of infection were a diagnosis of neuroblastoma (P=0.015), and surgery longer than 8 hours (P=0.059). The investigation and management of postoperative fevers varied in these patients. CONCLUSIONS: Postoperative fevers may be indicative of severe infection. We suggest that a standardized approach to the management of these patients, including prompt physical assessment, clinical investigations, and empiric antibiotic consideration is vital to minimize complications.

Understandability, content validity, and overall acceptability of the Children's International Mucositis Evaluation Scale (ChIMES): child and parent reporting.

Mucositis assessment in children has primarily relied on assessment tools that have been developed for an adult population. A mucositis assessment scale for use in children has previously been developed from expert opinion, namely Children's International Mucositis Evaluation Scale (ChIMES). After the development of ChIMES, we aimed to evaluate the user perspective of the scale by testing the understandability, content validity, and overall acceptability of ChIMES working with parents, children, and teenagers as content experts. Overall acceptability of the scale was satisfactory; however, comments provided by the participants questioned several aspects of the initial version of ChIMES. After discussion of the results, a refined version of ChIMES was produced that accounts for the views of the target population.

Designing an oral mucositis assessment instrument for use in children: generating items using a nominal group technique.

GOALS OF WORK: There was a need to develop a mucositis instrument that would be specific for use with children. This paper describes the step of generating items in the process of developing a new instrument for the assessment of oral mucositis in children. MATERIALS AND METHODS: Nine health care professionals with expertise in pediatric cancer, mucositis assessment, and oral assessment in children were invited to participate in a nominal group technique to generate items that should be included in an instrument. RESULTS: Thirty items were generated initially. Voting processes established that six of these items were thought to be necessary for inclusion: (1) presence of ulcers, (2) pain assessment, (3) amount of pain medication received, (4) effect on eating, (5) drooling-pooling of saliva, and (6) effect on drinking. Using these six items, an initial draft of an instrument was developed that could be used to assess oral mucositis in children, namely, the Children's International Mucositis Evaluation Scale. CONCLUSION: The six items generated by this process provided the basis for a simple, feasible, and reliable instrument. With increased clinical research investigating interventions to reduce and prevent oral mucositis, such an instrument will be critical to the effective conduct of this research in children. Further testing of this instrument is necessary.

The Impact of Physical Activity on the Health of Young Adult Survivors of Childhood Cancer: An Exploratory Analysis.

Purpose: Physical activity (PA) habits of young adult survivors of childhood cancer (SCC) have not been well-characterized, and it is unclear whether PA has a relationship with the health status of young adult SCC. The objective of this study was to determine PA participation of young adult SCC and examine associations between PA participation and late adverse effects of treatment. Methods: A retrospective chart review, including SCC enrolled in the McMaster AfterCare program, was performed. Patient characteristics, health outcomes, and PA information were abstracted. Multivariable logistic regression models were used to examine associations in this exploratory analysis. Results: We identified 253 young adult SCC, 240 of whom had sufficient information on PA participation to determine a Leisure Score Index (LSI). Of these, 45% reported adequate PA (LSI ≥24) and 26% reported no PA (LSI = 0). Significant associations between PA and bone mineral density (p = 0.03), blood pressure (p = 0.04), triglycerides (p = 0.05), and high-density lipoprotein cholesterol (p < 0.01) were demonstrated. Conclusions: The majority of young adult SCC in this cohort reported inadequate PA, despite ongoing healthy active living counseling. We identified associations between PA and bone mineral density as well as lipid profile in this group, which suggest that PA may mitigate risk of sequelae of cancer treatment. Strategies to improve young adult SCC engagement in PA are required.

Challenges of mucositis assessment in children: expert opinion.

Mucositis is a challenging treatment-related complication in children receiving therapy for cancer. The conduct of clinical trials that investigate mucositis prevention and treatment requires adequate evaluation of the oral cavity. However, few instruments to measure mucositis in children have been appropriately developed or evaluated. A focus group of nine health care professionals with expertise in mucositis assessment, oral assessment in children and paediatric cancer aimed to determine the challenges and possible solutions to mucositis assessment in children. The results led to the identification of several areas of concern that included: (1) challenges in oral assessment in children related to age and cooperation, (2) the need for proxy responses while recognizing the challenges of reporting pain and function attributed to oral mucositis, (3) the need for an instrument that is simple, quick to complete, and easy to use in almost all children and (4) educational considerations. The results provide a basis from which guidelines for the oral assessment of mucositis in children can begin. This information could be used to aid in the development of a new scale for the assessment of oral mucositis in children.

Group-Wide, Prospective Study of Ototoxicity Assessment in Children Receiving Cisplatin Chemotherapy (ACCL05C1): A Report From the Children's Oncology Group.

Purpose Optimal assessment methods and criteria for reporting hearing outcomes in children who receive treatment with cisplatin are uncertain. The objectives of our study were to compare different ototoxicity classification systems, to evaluate the feasibility of including otoacoustic emissions and extended high frequency audiometry, and to evaluate a central review mechanism for audiologic results for cisplatin-treated children in the cooperative group setting. Patients and Methods Eligible participants were 1 to 30 years, with planned cisplatin-containing treatment. Hearing evaluations were conducted at baseline, before each cisplatin cycle, and at the end of therapy. Audiologic results were assessed and graded by the testing audiologist and by two central review audiologists using the American Speech-Language-Hearing Association Ototoxicity Criteria (ASHA), Common Terminology Criteria for Adverse Events, version 3.0 (CTCAE), and Brock Ototoxicity Grades (Brock). One central reviewer also used the International Society of Pediatric Oncology Ototoxicity Scale (SIOP). Results At the end of treatment, the prevalence of any degree of ototoxicity ranged from 40% to 56%, and severe ototoxicity ranged from 7% to 22%. Compared with CTCAE, SIOP detected significantly more ototoxicity ( P = .004), whereas Brock criteria detected significantly fewer patients with any or severe ototoxicity ( P < .001 for both). SIOP detected ototoxicity earlier than did the other scales. Agreement between the central reviewers and the institutional audiologist was almost perfect for ASHA and Brock, whereas the poorest agreement occurred with CTCAE. Conclusion The SIOP scale may be superior to ASHA, Brock, and CTCAE scales for classifying ototoxicity in pediatric patients who were treated with cisplatin. Future studies should evaluate inter-rater reliability of the SIOP scale.

A Feasibility Pilot Trial of Individualized Homeopathic Treatment of Fatigue in Children Receiving Chemotherapy.

BACKGROUND: Fatigue is a major problem in children with cancer. The objective was to examine the feasibility of performing a clinical trial of homeopathic treatment for fatigue in children receiving chemotherapy. MATERIALS: This was a single-institution, open-label, pilot study. Children 2 to 18 years old, diagnosed with cancer, and receiving chemotherapy were eligible. Participants were given individualized homeopathic treatment for a maximum of 14 days. In-home or clinic assessments were conducted up to 3 times weekly. Feasibility was defined as the ability to recruit and administer homeopathy to 10 participants within 1 year. Fatigue was measured using the Symptom Distress Scale daily and the PedsQL Multidimensional Fatigue Module weekly. RESULTS: Between April 2012 and April 2014, 155 potential participants were identified. There were 45 eligible and contacted patients; 36 declined participation, 30 because they were not interested; 9 agreed to participate, but 1 participant withdrew prior to treatment initiation. Median length of homeopathic treatment was 10.5 (range = 6 to 14) days. All parents found homeopathic treatment to be easy or very easy to follow. CONCLUSIONS: Trials of individualized homeopathy for fatigue reduction in pediatric cancer are not feasible in this context; lack of interest was a primary reason. Alternative approaches to evaluating homeopathy efficacy are needed.

Inpatient versus outpatient management of low-risk pediatric febrile neutropenia: measuring parents' and healthcare professionals' preferences.

PURPOSE: Our primary objective was to describe and compare parents' and healthcare professionals' strength of preference scores for outpatient oral antibiotic relative to inpatient parenteral antibiotic treatment for low-risk febrile neutropenic children. Our secondary objective was to identify predictors of strength of preference for oral outpatient treatment. METHODS: Respondents were parents of children receiving cancer chemotherapy, and pediatric oncology healthcare professionals. First, the inpatient and outpatient options were described, and the respondent indicated their initially preferred option. The respondent next ranked how important seven factors (including "fear/anxiety" and "comfort") were in making their initial choice. The threshold technique was then used to elicit the respondent's strength of preference score for oral outpatient, relative to parenteral inpatient management. RESULTS: There were 75 parent and 42 healthcare-professional respondents. There was no significant difference (P =.08) in the proportions of parents (40 of 75; 53%) and healthcare professionals (30 of 42; 71%) who initially would choose outpatient management. For parents, stronger preference for oral outpatient therapy was associated with higher anticipated quality of life for the parent and child at home relative to hospital, lower importance rank for "fear/anxiety," and higher importance rank for "comfort." Conversely, for professionals, only lower importance rank for "fear/anxiety" was associated with higher strength of preference scores for outpatient oral antibiotic management. CONCLUSION: Only 53% of parents would choose outpatient oral antibiotic management for low-risk febrile neutropenia. Predictors of strength of preference scores for outpatient oral antibiotic relative to inpatient parenteral antibiotic treatment differed between parent and professional respondents.

Parent reports of quality of life for pediatric patients with cancer with no realistic chance of cure.

PURPOSE: To compare quality of life of children with cancer with no reasonable chance of cure reported by parents 6 months or fewer versus more than 6 months before death. PATIENTS AND METHODS: This cross-sectional study included children between the ages of 2 and 18 years with cancer and no reasonable chance of cure at The Hospital for Sick Children, Toronto, Ontario, Canada. Parents reported quality of life on behalf of their children. Outcomes were the PedsQL 4.0 Generic Core Scales, Acute Cancer Module, and Multidimensional Fatigue Scale. RESULTS: Seventy-three parents of children participated. Compared with children who survived more than 6 months (n = 43), those who died at 6 months or fewer (n = 30) had significantly worse physical health (mean difference, 15.9; 95% CI, 1.8 to 30.0; P = .028), more pain and hurt (mean difference, 15.5; 95% CI, 0.9 to 30.0; P = .037), and worse general fatigue (mean difference, 15.8; 95% CI, 2.4 to 29.1; P = .021) and sleep/rest fatigue (mean difference, 16.0; 95% CI, 3.5 to 28.5; P = .013). Among the entire cohort, those with leukemia/lymphoma had worse physical and psychosocial quality of life compared with those with solid or brain tumors. Recent stem-cell transplantation was associated with worse psychosocial health. CONCLUSION: Parents of children with cancer reported worse physical health, pain, and fatigue proximal to death. Those with leukemia/lymphoma were at higher risk for impaired quality of life. This knowledge can help in the design of targeted interventions to improve quality of life for children dying as a result of cancer.

Factors affecting treatment choices in paediatric palliative care: comparing parents and health professionals.

STUDY AIM: When children with cancer are no longer curable, parents often need to decide between further aggressive treatments or symptom relief alone. Objectives were to: (1) Describe and compare factors influencing parent and healthcare professional (HCP) decision-making regarding the choice between chemotherapy versus supportive care alone in paediatric palliative care; and (2) Describe how these factors influence this choice. METHODS: Participants included parents of children with cancer without a reasonable chance of cure and health care professionals in paediatric oncology. Respondents were asked to indicate the preferred option and to report what factors affected their choice. Each factor was then rated on an importance visual analogue scale (VAS) ranging from 0 to 10. The importance scales were compared between parents and HCPs and the influence of importance ratings on preferred option was examined. RESULTS: A total of 77 parents and 128 health care professionals participated. For parents the median importance scores for hope, increased survival time and child quality of life were rated as most important (VAS score=10). Parents rated these factors to be significantly more important than HCPs. Conversely, HCPs rated financial considerations more important than parents. For HCPs, stronger importance ranking for parent opinion was associated with stronger preference for aggressive chemotherapy. CONCLUSION: Hope, increased survival time and child quality of life are all more important factors to parents when decision-making at end-of-life compared to HCPs. Conversely, HCPs place greater emphasis on the families' financial considerations than parents. Understanding these differences may aid in communication and improve end-of-life care for children with cancer.

Concordance between couples reporting their child's quality of life and their decision making in pediatric oncology palliative care.

In children 18 years and younger with cancer and no reasonable chance for cure the authors used a cross-sectional study design to (1) describe concordance between fathers' and mothers' evaluation of quality of life (QoL) and (2) determine parental correlation for how factors such as hope, anticipated QoL, and prolonged survival time influence decisions between supportive care alone versus aggressive chemotherapy. Both parents of 13 children performed PedsQL 4.0 Generic Core Scales, Acute Cancer Module, and Multidimensional Fatigue Scale. Concordance was assessed using intraclass correlation coefficient (ICC). Parents reported preferences of supportive care versus aggressive chemotherapy in a hypothetical scenario and rated factors that influenced decision making. Concordance was variable across QoL domains, better for physical health (ICC = 0.46), nausea (ICC = 0.61), general fatigue (ICC = 0.50), and sleep/rest fatigue (ICC = 0.76). Correlation was variable between parents on the influence of factors on their decision, with particularly poor correlation for importance of hope (r = -0.24). Variable concordance was reported between parental assessment of child QoL and factors influencing their decision making, suggesting parents may have different perspectives in decision making and that understanding both is important in clinical care.

Refinement of the Children's International Mucositis Evaluation Scale (ChIMES): child and parent perspectives on understandability, content validity and acceptability.

PURPOSE: A new paediatric mucositis assessment instrument, the Children's International Mucositis Evaluation Scale (ChIMES), has required several phases of development. A draft of ChIMES was developed that required further refinement. This paper describes two iterations of refinements of ChIMES using child and parent reporting of understandability, content validity and overall acceptability. METHODS: Parents, children and teenagers were asked to rate their opinion of understandability and overall acceptability of ChIMES on a five-point ordinal scale. Content validity was assessed by whether participants considered the instrument "good", "okay" or "bad". Descriptive analysis of the results was conducted. RESULTS: One hundred and twenty-two participants evaluated two iterations. On the initial evaluation, ChIMES was considered easy to understand, acceptable and have content validity. However, minor amendments were required and a further iteration of testing was necessary to achieve a satisfactory instrument. A final version of ChIMES was developed. CONCLUSION: Modification of each draft of ChIMES was performed until comments were minimal and the scores from participants were consistently high. A final instrument appeared to contain the correct content and was easy to understand by parents, older children and teenagers.