ABCs of SLEEPING: A review of the evidence behind pediatric sleep practice recommendations

Headache in Children and Adolescents

PURPOSE OF REVIEW

This article reviews the approach to a child or adolescent with headache, the criteria for common diagnoses, and the evidence base for treatments.

RECENT FINDINGS

The guidelines for acute and preventive treatment of migraine were updated in 2019. These guidelines summarize the available evidence and outline the questions that should be addressed in future research. The US Food and Drug Administration (FDA) approval of several new classes of drugs and devices to treat adult migraine in the past few years has resulted in ongoing or planned pediatric trials.

SUMMARY

Headache is a common symptom in children, and it is important to take a detailed history and perform a thorough physical examination to make the diagnosis. Nearly 1 in 10 children experience recurrent headaches due to migraine, which cause significant impairment in school performance and quality of life. The acute and preventive treatments that are currently available will help at least two-thirds of children with migraine, and several trials of new therapies offer hope for the future.

Sleep Characteristics in the Italian Pediatric Population: A Systematic Review

OBJECTIVE

During childhood sleep duration, quality and patterns evolve and change greatly and relate strongly to healthy development. This systematic review aims to summarize the literature on sleep characteristics in the Italian pediatric population, adopting a cultural perspective.

METHOD

Pubmed, PsycINFO and Medline databases were systematically searched. Eligible studies had to: include Italian children and adolescents; report data for one or more sleep-related variables; be published in English or Italian.

RESULTS

Twenty-nine studies were selected including 18551 Italian children or adolescents. Studies were categorized by age group: infancy and toddlerhood (0-3 years); preschool and school age (3-12 years); adolescence (12-18 years) and mixed age groups. Overall, studies showed that the Italian pediatric population present shorter sleep duration and longer sleep onset latency compared to international recommendations. Furthermore, data indicate high prevalence of dysfunctional sleep habits, such as late bed-time (all age groups), involvement of parents during bed-time (infancy and toddlerhood), and high variability between sleep times on week-days vs. weekends (adolescence). Nevertheless, most studies lacked comprehensive data on sleep patterns, focusing instead on isolated variables.

CONCLUSION

These results suggest a strong trend among Italian children and adolescents towards unhealthy sleep patterns. Comprehensive data are still lacking and large studies evaluating a broad range of sleep characteristics in Italian pediatric populations are needed. Data strongly suggest that Italian Pediatric Primary Care should place higher focus on sleep problems and implement clinical protocols directed towards improving sleep patterns in children and adolescents.

Cumulative socio-demographic risk factors and sleep outcomes in early childhood

STUDY OBJECTIVES

To examine associations between cumulative socio-demographic risk factors, sleep health habits, and sleep disorder symptoms in young children.

METHODS

Two hundred five caregiver-child dyads (child mean age ± SD: 3.3 ± 1.1 years; 53.7% girls; 62.9% black, 22.4% non-Hispanic/Latinx white, 4.4% Hispanic/Latinx; 85.4% maternal caregiver reporter) completed caregiver-rated sleep measures (Brief Child Sleep Questionnaire [BCSQ]; Pediatric Sleep Questionnaire [PSQ] snoring subscale), which were used to generate indexes of poor sleep health habits, pediatric insomnia symptoms, and obstructive sleep apnea (OSA) symptoms. A cumulative risk index was created reflecting caregiver, family, and neighborhood risks.

RESULTS

Overall, 84.5% of children had ≥ 1 poor sleep health habit, 62.9% had ≥ 1 insomnia symptom, and 40.0% had ≥ 1 OSA symptom. Poisson regression indicated that each increase in the number of cumulative risk factors was associated with a 10% increase in poor sleep health habits, a 9% increase in insomnia symptoms, and an 18% increase in OSA symptoms. Specific caregiver risks (depressive symptoms, lower educational attainment) and family risks (single caregiver, crowded home) were most predictive of poor sleep outcomes.

CONCLUSIONS

Poor sleep health habits and sleep disorder symptoms are highly prevalent in early childhood, particularly among families experiencing cumulative socio-demographic risks. Findings underscore the need for targeted screening and prevention for modifiable sleep behaviors and efforts to tailor such strategies for at-risk children and families, especially those living in crowded conditions, or with caregivers who are single or have a lower educational attainment or depressive symptoms.

Grandparental care and sleep disturbances in preschool children: a population-based prospective cohort study

OBJECTIVES

Sleep disturbances are common in preschoolers, and profoundly affected by parenting. Grandparents are increasingly involved in childcare and have attracted worldwide attention for their potential impacts on child well-being. However, no studies have explored child sleep health within the context of grandparental care. We aimed to explore the association between grandparents as primary caregivers and children's sleep disturbances.

METHODS

Participants included 20,324 preschoolers from the Shanghai Children's Health, Education and Lifestyle Evaluation-Preschool (SCHEDULE-P) in Shanghai, China. They were initially assessed in November 2016 and were reassessed in April 2018 and April 2019. Children's primary caregivers were collected at each survey. Sleep disturbances were assessed by the Children's Sleep Habits Questionnaire (CSHQ).

RESULTS

At baseline, 84.4% of children had global sleep disturbances (CSHQ total score >41). Compared with parents, random-effects model indicated that grandparents as primary caregivers increased the adjusted odds ratio (OR) for children's global sleep disturbances by 30% (OR [95%CI]: 1.30 [1.21, 1.40]). To the specific domains of CSHQ, two-way repeated-measures ANOVA showed significant "caregiver transition" group × wave interaction in the behavioral sleep disturbances, such as "Bedtime Resistance" (p < 0.001). At each survey, children with grandparents as primary caregivers demonstrated significant higher behavioral sleep disturbances than their counterparts with parental care.

CONCLUSIONS

Grandparental care is associated with increased sleep disturbances, particularly behavioral sleep disturbances, in preschoolers. Future studies should explore the underlying mechanisms and whether sleep programs targeting grandparents can decrease children's sleep disturbances.

Sleep Problems, Cumulative Risks, and Psychological Functioning in Early Childhood

BACKGROUND

Sleep problems and cumulative risk factors (e.g., caregiver depression, socioeconomic disadvantage) have independently been linked to adverse child development, but few studies have examined the interplay of these factors. We examined whether cumulative risk exposure moderated the link between sleep problems, including insomnia and poor sleep health, and child psychological outcomes.

METHODS

205 caregiver-child dyads (child Mage = 3.3 years; 53.7% girls; 62.9% Black, 22.4% non-Latinx White, and 4.4% Latinx; 85.4% maternal caregiver reporter) completed child sleep, family sociodemographic, and child psychological functioning (internalizing, externalizing, and executive functioning) questionnaires. Indexes of cumulative risk exposure, insomnia symptoms, and poor sleep health were created.

RESULTS

Ninety percent of children had ≥1 cumulative risks, 62.9% had ≥1 insomnia symptom, and 84.5% had ≥1 poor sleep health behavior. Increased insomnia symptoms were significantly associated with increased child internalizing, externalizing, and global executive functioning impairments controlling for child age, race/ethnicity, and sex. Poor sleep health behaviors were associated with internalizing concerns. Cumulative risk exposure was not associated with outcomes but moderated the association between insomnia symptoms and all psychological outcomes, such that children with higher cumulative risk exposure and insomnia symptoms had the greatest impairments. Children with the poorest sleep health behaviors and highest cumulative risks had the greatest internalizing concerns.

CONCLUSIONS

Insomnia symptoms in particular are associated with poor child outcomes, which are exacerbated when accompanied by greater cumulative risk exposure. Clinicians should assess sleep when treating early psychological concerns, especially within the context of increased cumulative risks.

Sleep practices in pediatric cancer patients: Indirect effects on sleep disturbances and symptom burden

OBJECTIVE

Sleep hygiene recommendations are commonly given to address patient-reported concerns about sleep, yet few studies have examined the relationship between sleep hygiene and sleep disturbances in the context of pediatric oncology. Because poor sleep may affect the patient's experience of cancer-related symptoms, understanding whether sleep hygiene practices influence sleep disturbances and symptoms may be important to improving symptom burden.

METHODS

One hundred and two caregivers of children ages 5-17 and 59 patients ages 8-17 receiving treatment for cancer completed parallel measures of child sleep, sleep hygiene, pain, fatigue, and nausea. Sleep hygiene practices were described, correlates between measures were examined, and the indirect relationship of sleep hygiene on symptom burden through sleep disturbances was tested using PROCESS.

RESULTS

Patients received adequate sleep for age but sleep timing was later than recommended for more than half of the sample and consistency in sleep times was poor. Sleep disturbances were moderately related to all symptoms, with the exception of patient-reported fatigue. Consistent sleep habits were indirectly related to fewer cancer-related symptoms of pain, fatigue, and nausea through sleep disturbances by caregiver report but not patient report.

CONCLUSION

Sleep disturbances are closely related to pain, fatigue, and nausea in pediatric cancer. Consistency in sleep/wake routines and schedules may be important to experiencing fewer sleep disturbances and lower symptom burden. Providing recommendations supporting consistent sleep habits broadly across pediatric oncology may be more effective than only presenting sleep hygiene recommendations to patients experiencing poor sleep.

Behavioral insomnia in infants and young children

In infants and young children, bedtime problems and night waking are common and the main presentations of insomnia. Poor sleep may critically impact the daytime functioning and mood of the child and their caregivers. A comprehensive sleep history, a sleep diary/log, and the BEARS (Bedtime problems, Excessive daytime sleepiness, Awakenings during the night, Regularity and duration of sleep, and Sleep-disordered breathing) sleep screen are useful for diagnosing sleep problems in young children. Behavioral therapies for this type of insomnia include extinction, bedtime fading with positive routines, and scheduled awakening. Previous studies of behavioral interventions for young children showed significant improvements in sleep-onset latency, night waking frequency, and night waking duration. Parent education about their child's sleep, bedtime routines, and sleep hygiene is essential for treatment.

Defining and measuring bedtime routines in families with young children-A DELPHI process for reaching wider consensus

INTRODUCTION

Bedtime routines are one of the most common family activities. They affect children' wellbeing, development and health. Despite their importance, there is limited evidence and agreement on what constitutes an optimal bedtime routine. This study aims to reach expert consensus on a definition of optimal bedtime routines and to propose a measurement for bedtime routines.

METHOD

Four-step DELPHI process completed between February and March 2020 with 59 experts from different scientific, health and social care backgrounds. The DELPHI process started with an expert discussion group and then continued with 3 formal DELPHI rounds during which different elements of the definition and measurement of bedtime routines were iteratively refined. The proposed measurement of bedtime routines was then validated against existing data following the end of the DELPHI process.

RESULTS

At the end of the four round DELPHI process and with a consistent 70% agreement level, a holistic definition of bedtime routines for families with young children between the ages of 2 and 8 years was achieved. Additionally, two approaches for measuring bedtime routines, one static (one-off) and one dynamic (over a 7-night period) are proposed following the end of the DELPHI process. A Bland-Altman difference plot was also calculated and visually examined showing agreement between the measurements that could allow them to be used interchangeably.

DISCUSSION

Both the definition and the proposed measurements of bedtime routines are an important, initial step towards capturing a behavioural determinant of important health and developmental outcomes in children.

Early Childhood Sleep Intervention in Urban Primary Care: Caregiver and Clinician Perspectives

BACKGROUND

Despite significant income-related disparities in pediatric sleep, few early childhood sleep interventions have been tailored for or tested with families of lower socio-economic status (SES). This qualitative study assessed caregiver and clinician perspectives to inform adaptation and implementation of evidence-based behavioral sleep interventions in urban primary care with families who are predominantly of lower SES.

METHODS

Semi-structured interviews were conducted with (a) 23 caregivers (96% mothers; 83% Black; 65% ≤125% U.S. poverty level) of toddlers and preschoolers with insomnia or insufficient sleep and (b) 22 urban primary care clinicians (physicians, nurse practitioners, social workers, and psychologists; 87% female; 73% White). Guided by the Consolidated Framework for Implementation Research, the interview guide assessed multilevel factors across five domains related to intervention implementation. Qualitative data were analyzed using an integrated approach to identify thematic patterns across participants and domains.

RESULTS

Patterns of convergence and divergence in stakeholder perspectives emerged across themes. Participants agreed upon the importance of child sleep and intervention barriers (family work schedules; household and neighborhood factors). Perspectives aligned on intervention (flexibility; collaborative and empowering care) and implementation (caregiver-to-caregiver support and use of technology) facilitators. Clinicians identified many family barriers to treatment engagement, but caregivers perceived few barriers. Clinicians also raised healthcare setting factors that could support (integrated care) or hinder (space and resources) implementation.

CONCLUSIONS

Findings point to adaptations to evidence-based early childhood sleep intervention that may be necessary for effective implementation in urban primary care. Such adaptations could potentially reduce significant pediatric sleep-related health disparities.

The Relationship Between Parental Accommodation and Sleep-Related Problems in Children with Anxiety

OBJECTIVE

Sleep-related problems, defined as sleep patterns atypical for the child's developmental stage, are common in children with elevated anxiety symptoms and linked to significant mental and physical health consequences. Despite the consequences of sleep-related problems, it remains unclear how these problems are initiated and maintained in children with elevated anxiety symptoms. The current study examines the relationship between sleep-related problems and parental accommodation (e.g., co-sleeping) to determine whether higher levels of accommodation are associated with more frequent sleep-related problems in a sample of children with elevated anxiety symptoms.

METHODS

Participants were 122 children aged 8 to 17 years old (M = 11.97, SD = 2.68; 57% female) and their parents who presented to a university-based anxiety specialty clinic for assessment and treatment. Children completed the Multidimensional Anxiety Scale for Children, and their parents completed the Children's Sleep Habits Questionnaire and Family Accommodation Checklist and Interference Scale. Multiple regression analyses were performed to examine variance in sleep-related problems explained by parental accommodation.

RESULTS

Parental accommodation accounted for a significant amount of variance in sleep-related problems over and above child anxiety and age for both mother report (19%) and father report (15%). When individual accommodation items were examined, parental sleep accommodations (e.g., slept in my child's bed) and nonsleep accommodations (e.g., came home early) were significant predictors for mother-reported sleep-related problems, but only sleep accommodations (e.g., let my child sleep with the lights on) were significant for father-reported sleep-related problems.

CONCLUSION

Parents of children with elevated anxiety symptoms and sleep-related problems engage in accommodation related to their child's sleep (e.g., co-sleeping). Future research elucidating the potential bidirectional and causal links between parental accommodation and sleep-related problems is a necessary step in adapting sleep treatments for this population.

Development and Validation of the Pediatric Sleep Practices Questionnaire: A Self-Report Measure for Youth Ages 8-17 Years

Objective: To develop and evaluate the validity of a self-report measure of sleep practices for youth 8-17 years. Methods: Following recommended guidelines for the development of patient reported outcomes (PROs), sleep practice concepts were identified through expert (n = 8) and child (n = 28) concept elicitation interviews and a systematic literature review. Items were developed based on these concepts and tested in cognitive interviews with children (n = 32). Psychometric analyses were applied to item response data collected from a diverse sample of youth 8-17 years (n = 307). Construct validity was evaluated through tests of associations between sleep practices and sleep disturbance and sleep-related impairment. Finally, clinical validity of the tool was assessed by comparing scores of youth with and without a parent-identified sleep problem. Results: The final Pediatric Sleep Practices Questionnaire (PSPQ) included 15 items that were used to identify 5 sleep practices: sleep timing, sleep routines and consistency, technology use before bedtime, sleep environment, and the need for parental presence to fall asleep. A confirmatory factor analysis supported the hypothesized structure (all factor loadings ≥ 0.72) and PSPQ indices were significantly associated with self-reported sleep disturbances and sleep-related impairment. Finally, children with parent-reported sleep problems had shorter sleep opportunity, later bedtimes, greater need for parental presence, poorer bedtime routines, and more technology use than children without parent-reported sleep problems. Conclusions: The PSPQ was developed using best-practice PRO development methodology. The PSPQ can be used in clinical settings and for research assessment to capture modifiable sleep practices that may promote or interfere with healthy sleep.

The intersection of COVID-19, school, and headaches: Problems and solutions

OBJECTIVE

To equip clinicians with recommendations specific to concerns related to the novel coronavirus disease 2019 (COVID-19), which impact the physical, emotional, and social health of youth with headache disorders.

BACKGROUND

COVID-19 has affected societies on a global scale including children and youth with chronic headache disorders. Many concerns are predicted to arise in the 2020-2021 school year, whether classes are conducted in-person or virtually.

METHODS

Clinical impressions were combined with a review of the literature, although limited due to the recent nature of this issue.

RESULTS

We describe recommendations to support caregivers and youth as they face changes expected with the return to school in the fall of 2020.

CONCLUSION

Although there are significant concerns for caregivers and youth with migraine given the context of changes related to the pandemic, there are many recommendations that can help minimize exacerbations of the physical, emotional, and social health of youth with chronic migraine.

The Associations Between Media Use, Midpoint of Sleep, and Sleep Quality in German Preschoolers: A Mediation Analysis Based on the Ulm SPATZ Health Study

INTRODUCTION

The relation of electronic media use with sleep quality among preschoolers is a matter of ongoing debate. Longitudinal data are scarce and do not account for sleeping schedules.

METHODS

We used the German Children's Sleep Habits Questionnaire to measure parent-reported child's sleep quality; its score is computed by the sum of 34 items defined by a 1-3 level Likert scale (score ranging 34-102), with higher values representing lower sleep quality. A causal mediation analysis of these relations using data from the Ulm SPATZ Health Study in Germany was conducted. Repeated data on electronic media use, book reading, sleep quality, sleep duration, and midpoint of sleep were prospectively collected yearly from ages 4 to 6 years (n=563) during parent's working days and free days.

RESULTS

We observed negative correlations of sleep quality with sleep duration and midpoint of sleep at ages 4-5 (R=-0.21 to -0.10), which attenuated with age 6 years. Sleep duration and midpoint of sleep were strongly positively correlated at all ages (R=0.55-0.95). We observed significant negative associations between total electronic media use and TV/DVD watching, while book reading did neither affect the sleep quality score nor sleep duration or midpoint of sleep. We found little evidence for an indirect negative effect of media use on sleep quality via sleep duration or midpoint of sleep, indicating that media use acts independently on sleep duration, midpoint of sleep, and sleep quality. Non-statistically significant associations of sleep duration and midpoint of sleep on sleep quality indicate that these are independent aspects of sleep adequacy. Evidence for this was stronger during free days.

CONCLUSION

Media use acted on sleep quality through a direct effect in a prospective fashion. Thus, we conclude that electronic media use increases the risk for sleep impairments in German preschoolers, while book reading seems to be a safe and healthy alternative.

The Prevalence of Insufficient Sleep and Bedtime Delay Among Kindergarten Children Aged 3 to 6 Years in a Rural Area of Shanghai: A Cross-Sectional Study

Introduction: Sleep deprivation in children is a global public health problem that affects the physical and mental development of children. Bedtime delay induced by longer screen time and heavy study load is a common cause of sleep deprivation in children. However, the prevalence of insufficient sleep and bedtime delay and related influencing factors among kindergarten children is limited in Shanghai, China. Methods: In 2018, we selected 8,586 children aged 3 to 6 years and their parents in Songjiang District, Shanghai. Data was collected among parents by face-to-face questionnaire interview with signed informed consent. We defined insufficient sleep as those who slept for < 10 h in children aged 3-5 years or 9 h in children aged 6 years within 24 h, and we define bedtime delay as children with bedtime after 21:00. SAS 9.1.3 software was used to calculate the prevalence of bedtime delay and insufficient sleep, and logistic regression was used to explore potential influencing factors. Results: The prevalence of insufficient sleep and bedtime delay among children aged 3 to 6 years was 11.67 and 56.85%, respectively. The prevalence of insufficient sleep among boys was slightly higher than among girls [odds ratio (OR) = 1.18, 95% confidence interval (CI): 1.04-1.35]. With the increase of the age of children, the prevalence of insufficient sleep increased gradually (P < 0.05). The prevalence of insufficient sleep was higher among the only child in the family (OR = 1.18, 95% CI: 1.02-1.36) and those with longer hours of TV watching (OR = 109, 95% CI: 1.02-1.16). Meanwhile, the prevalence of bedtime delay was also higher among the only child in the family (OR = 1.17, 95% CI: 1.06-1.79), among those with parents accompanying for sleep (OR = 1.21, 95% CI: 1.10-1.34), and those with longer TV watching time (OR = 1.13, 95% CI: 1.07-1.18). Conclusions: Insufficient sleep and bedtime delay were prevalent in Chinese children aged 3 to 6 years, especially in boys and older children. TV watching as well as parents accompanying for sleep were associated with insufficient sleep and bedtime delay. We recommend that parents should limit the screen time of children, advocate earlier bedtime and later morning wake-up among children, as well as make their children sleep in separate beds or rooms in younger age.

Tratamento multicomponente para insônia infantil e seus efeitos nos padrões, hábitos e rotinas de sono

Problemas de sono são frequentes na infância e estão associados a problemas de comportamento. O estabelecimento de rotinas pré-sono é recomendado para pais de crianças. Nenhum estudo brasileiro investigou os hábitos e rotinas de crianças que apresentam problemas de sono. Os objetivos deste estudo foram investigar os hábitos e rotinas de crianças com problemas de sono e verificar se a educação parental sobre o sono da criança levou a mudanças nos padrões de sono e de rotina. Participaram 57 crianças com problemas comportamentais relacionados ao sono e suas mães. As mães receberam orientações sobre o sono das crianças e estabelecimento de rotinas pré-sono. Os dados foram avaliados através de medidas parentais. Nossos resultados apontaram que crianças com problemas de sono apresentam em sua maioria, hábitos e rotinas inadequadas antes de dormir e que a modificação destes levam a melhora do sono. Espera-se que este trabalho possa estimular a produção de pesquisas nacionais sobre o tema, servindo como incentivo para o desenvolvimento de medidas preventivas e interventivas para os problemas de sono na infância.

An Interactive Smartphone App, Nenne Navi, for Improving Children's Sleep: Pilot Usability Study

BACKGROUND

Healthy sleep is important not only for physical health but also for brain development in children. Several reports have revealed that Japanese adults and children have later bedtimes and shorter sleep durations compared with those in other countries, possibly because of Japanese culture and lifestyles. Therefore, an intervention tool that is suitable to the Japanese sociocultural environment is urgently needed to improve children's sleep problems in their early years.

OBJECTIVE

To provide appropriate sleep health literacy to caregivers and change their parenting behavior, we developed a smartphone app that allows reciprocal interaction between caregivers and pediatric sleep experts. This paper describes a preliminary study to examine the app's basic design and functions and to establish its acceptability and usability in a small sample.

METHODS

A total of 10 caregivers and 10 infants (aged 18-28 months; 4/10, 40% boys) living in Japan participated in the study. At the start of the trial, the e-learning content regarding sleep health literacy was delivered via a smartphone. Thereafter, caregivers manually inputted recorded data about their own and their infant's sleep habits for 8 consecutive days per month for 2 months. After pediatric sleep experts retrieved this information from the Osaka University server, they specified the problems and provided multiple sleep habit improvement suggestions to caregivers. Caregivers then selected one of the feasible pieces of advice to practice and reported their child's sleep-related behaviors via the app. Actigraphy was used to monitor children's sleep behaviors objectively. The concordance between the information provided by caregivers and the actigraphy data was assessed. The acceptability and usability of the app were evaluated using self-report questionnaires completed by caregivers; qualitative feedback was obtained via semistructured interviews after the intervention.

RESULTS

There was no significant difference between the information provided by the caregivers and the actigraphy data for bedtimes and wake-up times (P=.13 to P=.97). However, there was a difference between the actigraphy data and the caregivers' reports of nighttime sleep duration and nighttime awakenings (P<.001 each), similar to prior findings. User feedback showed that 6 and 5 of the 10 caregivers rated the app easy to understand and easy to continue to use, respectively. Additionally, 6 of the 10 caregivers rated the app's operativity as satisfactory. Although this was a short-term trial, children's sleep habits, caregivers' sleep health consciousness, and parenting behaviors improved to some extent.

CONCLUSIONS

The present findings suggest that the app can easily be used and is acceptable by Japanese caregivers. Given the user feedback, the app has the potential to improve children's sleep habits by sending individualized advice that fits families' backgrounds and home lives. Further studies are needed to confirm the efficacy of the app and facilitate social implementation.

Sleep timing and sleep problems of preschoolers in Aotearoa/New Zealand: relationships with ethnicity and socioeconomic position

OBJECTIVES

To provide descriptive sleep data and explore sleep inequities, we investigated maternal reports of when and how well Māori (Indigenous) and non-Māori preschoolers sleep, and examined relationships between ethnicity (child and maternal), socioeconomic position (SEP) and sleep timing and problems of 3-4 year old children in Aotearoa/New Zealand (NZ).

METHODS

This study involved cross-sectional analysis of data from the Moe Kura: Mother and Child, Sleep and Wellbeing in Aotearoa/New Zealand longitudinal study. Log-binomial regression models were used to investigate associations between child and maternal demographic variables and preschooler bedtimes, social jetlag and maternally-reported sleep problems. Child models included child ethnicity, child gender, area- and individual-level deprivation. Maternal models included maternal ethnicity, maternal age, area- and individual-level deprivation.

RESULTS

340 Māori and 570 non-Māori preschoolers and their mothers participated. Māori preschoolers had later average bedtimes and wake times than non-Māori preschoolers. Ethnicity and area-level deprivation were independently associated with later bedtimes. Ethnicity was associated with social jetlag and sleep problems, independent of SEP. Individual-level deprivation was associated with problems falling asleep. Preschoolers of Māori mothers in least deprived areas were more likely to have problems falling asleep than preschoolers of non-Māori mothers in least deprived areas.

CONCLUSIONS

Research is needed to understand what sleep timing differences mean for preschoolers' wellbeing in NZ. Fundamental causes of social and economic disadvantage experienced by Indigenous children and mothers and by families who hold low SEP must be addressed, in order to eliminate sleep health inequities in early childhood.

Perceived Determinants of Children's Inadequate Sleep Health. A Concept Mapping Study among Professionals

An increasing number of children experience inadequate sleep, which negatively effects their health. To promote healthy sleep among children, it is essential to understand the underlying determinants. This online concept mapping study therefore explores potential determinants of children’s inadequate sleep as perceived by professionals with expertise in the sleep health of children aged 4–12 years. Participants (n = 27) were divided in three groups: (1) doctors (n = 9); (2) nurses (n = 11); (3) sleep experts (n = 7). Participants generated potential determinants (i.e., ideas) of children’s inadequate sleep. Subsequently, they sorted all ideas by relatedness and rated their importance. These data were analysed using multidimensional scaling and hierarchical cluster analysis. The results of all three groups were combined and validated by an additional group of professionals (n = 16). A large variety of perceived determinants were identified. The most important determinants perceived by all groups belonged to the categories psychosocial determinants (i.e., worrying, a change in daily life), daytime and evening activities (i.e., screen use before bedtime, stimulating game play before bedtime, inadequate amount of daytime physical activity), and pedagogical determinants (i.e., inconsistent sleep schedule, lack of a bedtime routine). These perspectives are valuable for future longitudinal studies on the determinants of children’s sleep and the development of future healthy sleep interventions.

Bedtime, body mass index and obesity risk in preschool-aged children

BACKGROUND

Although sleep duration is a risk factor for obesity in young children, less is known about other aspects of sleep health, including bedtime, on obesity risk.

OBJECTIVE

To determine whether bedtime is associated with body mass index (BMI) z-score or obesity risk in children ages 2 to 5 years, and to determine if associations are independent of sleep duration.

METHODS

Cohort analyses were undertaken using three early life obesity prevention trials (POI, INSIGHT, Healthy Beginnings) and a longitudinal cohort study (HOME). Bedtime was assessed by questionnaire and BMI through clinical measurement between 2 and 5 years in 1642 children. Adjusted regression models examined whether BMI z-score and obesity (BMI z-score ≥ 2) were associated with bedtime, nocturnal sleep time and 24-hour sleep time. A discrete mixture model categorized children into bedtime trajectory groups across time points.

RESULTS

Bedtime was inconsistently associated with BMI z-score. Although each hour later of bedtime was associated with greater odds of obesity at ages 3 (OR; 95% CI: 1.05; 1.003, 1.10) and 5 (1.35; 1.08, 1.69) years, odds were attenuated after adjustment for nocturnal or 24-hour sleep time. Longer nocturnal sleep duration at 2 years was associated with lower odds of obesity (OR 0.90; 0.86, 0.94), as was longer 24-hour sleep duration at 3 years in girls (0.70; 0.62, 0.78). BMI z-score and odds of obesity were not significantly different between 'early to bed' and 'late to bed' trajectory groups.

CONCLUSIONS

Timing of bedtime appears inconsistently related to obesity in young children, possibly via influencing overall sleep duration.

Perspectives on Sleep from Multiethnic Community Parents, Pediatric Providers, and Childcare Providers

OBJECTIVE

To describe the perceptions of (1) parents, childcare, and health care providers regarding sleep health among multiethnic infants and toddlers living with socioeconomic adversity, (2) factors that contribute to sleep health and its consequences, and (3) best ways to promote sleep health in these children.

METHODS

Nested within a larger community-engaged mixed methods study, we used a descriptive qualitative design to describe the experience of multiethnic young parents who were raising 6- to 36-month-old children, pediatric health care providers, and childcare providers living and working in an urban under-resourced community. Semistructured interviews with 25 parents and 16 providers were conducted, transcribed, coded, and analyzed using thematic analysis by a 6-member research team. Interviews continued until themes were saturated.

RESULTS

Parent responses and provider responses resulted in overlapping and divergent findings. Common themes among all respondents were the importance of sleep, interest and desire for more sleep health information, and common environmental/social impediments to healthy family sleep. Divergent themes included the importance of bedtime routines and timing, views on the family bed, importance of naps, and healthy sleep aids. Childcare centers were suggested as good sites for sleep health promotion programs.

CONCLUSION

Sleep is a topic of interest and importance for young families. There are unique family challenges to be considered in any sleep health promotion program tailored to the needs of the community. The voices of parents and community providers are valuable assets informing the development of novel family-friendly approaches for decreasing sleep disparities and improving the health of young children and families.

Time for bed! Earlier sleep onset is associated with longer nighttime sleep duration during infancy

OBJECTIVE/BACKGROUND

Clinical recommendations include putting infants to bed using a consistent bedtime routine at an appropriate hour to promote longer nighttime sleep. Actigraphy was used in this exploratory study to examine how bedtime routines and nighttime sleep onset were associated with nighttime total sleep time (TST) and efficiency from 6 to 24 weeks of age.

PATIENTS/METHODS

Infants (n = 24) wore sleep actigraphs for three, one-week periods at 6, 15, and 24 weeks of age. Nighttime TST, sleep efficiency, sleep onset and offset were quantified. Mothers reported on infant bedtime routines using the Brief Infant Sleep Questionnaire at each age. Multilevel models examined between- and within-person associations.

RESULTS

As infants aged, sleep onset was earlier, and bedtime routines became shorter (p's < 0.05). Infants fell asleep between 7 and 8:00PM on 24% of the nights. Most mothers (70%) reported that they often fed infants to sleep for the night. For every 1 h earlier in infants' usual sleep onset, nighttime TST was 34.4 min longer that night (p < 0.01). Infants with earlier than usual sleep onset had slightly earlier sleep offset the next morning (8.4 min for every 1 h earlier in onset; p = 0.02). Between-person analyses showed similar patterns. Infants with a more consistent bedtime routine and who were not typically fed to sleep at bedtime had longer nighttime TST at 6 weeks, with a trend or no association at later ages.

CONCLUSION

Infants who fell asleep earlier also slept longer at night. Keeping infants up later in hopes of them sleeping in longer may be counterproductive.

Music on Prescription to Aid Sleep Quality: A Literature Review

Research on the efficacy of music for improving sleep quality has produced mixed results. We investigated whether the number of music dosages could be a reason for the lack of clarity. Six longitudinal music sleep studies using the Pittsburgh Sleep Quality Index (PSQI) over 3 weeks were identified. Music when compared to active (audiobooks or medication) or passive controls significantly improved (improvement is reflected by a lower score) PSQI within the first or second week of prescription. The improvement was an average mean difference of −1.15 (SD = 0.53) for each week. Music dosages continued to be associated with improved PSQI over a study that had a 3-month music intervention. One study with a low initial PSQI score resulted in poor sleepers (PSQI > 5) achieving healthy sleep (PSQI < 5) within 3 weeks of regular music intervention. For future studies, “prescribing” music beyond 3 weeks may lead to more instances of healthy sleep, particularly for those who have mild sleep problems. To explain the findings, we proposed that the relationship between weeks of music listening and improved PSQI are attributed to the truncation of poor bedtime habits linked to ruminative tendencies and consequent hyperarousal prior to the music intervention. Music listening at bedtime replaces those bad habits, we argue, by forming a new psychological link between bedtime and sleep through evaluative conditioning. The findings of the present study provide disarming evidence of the potential for prescription of music for treating mild sleep disorder.

Sleeping without Prescription: Management of Sleep Disorders in Children with Autism with Non-Pharmacological Interventions and Over-the-Counter Treatments

Autism Spectrum Disorders (ASD) are lifelong neurodevelopmental conditions characterized by abnormal social interaction, communication, and behavior. Sleep disturbances represent a common comorbidity in children and adolescents with ASD, with prevalence ranging from 50 to 80%. It has been proved that sleep disruption worsens the symptoms of autism and results in challenging behaviors. Improving sleep should therefore be a primary therapeutic goal. Treatment options range from lifestyle modifications to pharmacological therapy. Several reviews have been written on pharmacological treatments, but very few on the beneficial effects of non-pharmacological interventions, over-the-counter drugs, and nutritional supplements. This study consists of a narrative review of the literature, presenting the available evidence on the following treatments: sleep education, behavioral interventions, complementary and alternative medicine (special mattresses and blankets, massage, aromatherapy, yoga, physical activity), and commonly used over-the-counter medications and supplements (antihistamines, melatonin, tryptophan, carnosine, iron, vitamins, and herbal remedies). For some treatments—such as melatonin and behavioral interventions—effectiveness in ASD is well established in the literature, while other interventions appear of benefit in clinical practice, even if specific studies in children and adolescents with ASD are lacking. Conversely, other treatments only seem to show anecdotal evidence supporting their use.

Development of a consensus statement on the role of the family in the physical activity, sedentary, and sleep behaviours of children and youth

BACKGROUND

Children and youth who meet the physical activity, sedentary, and sleep behaviour recommendations in the Canadian 24-Hour Movement Guidelines are more likely to have desirable physical and psychosocial health outcomes. Yet, few children and youth actually meet the recommendations. The family is a key source of influence that can affect lifestyle behaviours. The purpose of this paper is to describe the process used to develop the Consensus Statement on the Role of the Family in the Physical Activity, Sedentary, and Sleep Behaviours of Children and Youth (0-17 years) and present, explain, substantiate, and discuss the final Consensus Statement.

METHODS

The development of the Consensus Statement included the establishment of a multidisciplinary Expert Panel, completion of six reviews (three literature, two scoping, one systematic review of reviews), custom data analyses of Statistics Canada's Canadian Health Measures Survey, integration of related research identified by Expert Panel members, a stakeholder consultation, establishment of consensus, and the development of a media, public relations, communications and launch plan.

RESULTS

Evidence from the literature reviews provided substantial support for the importance of family on children's movement behaviours and highlighted the importance of inclusion of the entire family system as a source of influence and promotion of healthy child and youth movement behaviours. The Expert Panel incorporated the collective evidence from all reviews, the custom analyses, other related research identified, and stakeholder survey feedback, to develop a conceptual model and arrive at the Consensus Statement: Families can support children and youth in achieving healthy physical activity, sedentary and sleep behaviours by encouraging, facilitating, modelling, setting expectations and engaging in healthy movement behaviours with them. Other sources of influence are important (e.g., child care, school, health care, community, governments) and can support families in this pursuit.

CONCLUSION

Family is important for the support and promotion of healthy movement behaviours of children and youth. This Consensus Statement serves as a comprehensive, credible, and current synopsis of related evidence, recommendations, and resources for multiple stakeholders.

Sleep health in young children living with socioeconomic adversity

Racially and ethnically diverse young children who live with socioeconomic adversity are at high risk for sleep deficiency, but few behavioral sleep interventions (BSIs) are tailored to their needs. To support the future development of a feasible, acceptable, and culturally relevant sleep intervention, we conducted a community-engaged, mixed-methods study with 40 low-income, racially, and ethnically diverse parents to describe sleep characteristics, sleep habits, and parental sleep knowledge of their 6-36-month-old children and to examine the associations between children's sleep characteristics and sleep habits. This report presents quantitative data from this mixed-methods study. We measured objective (actigraphy) and parent-reported sleep (Brief Infant Sleep Questionnaire) characteristics, sleep habits at bedtime, sleep onset, and during night awakenings, parental sleep knowledge, psychological function (Brief Symptom Inventory), and parenting stress (Parenting Stress Index). Children had low sleep duration (537.2 ± 54.7 nighttime and 111.2 ± 29.8 nap minutes), late bedtimes (22:36 ± 1.5 hr), and high bedtime variability (mean squared successive difference = 3.68 ± 4.31 hr) based on actigraphy. Parental knowledge about sleep recommendations was limited. Sleep habits before bedtime, at sleep onset, and during night awakenings were varied. Sixty-five percent of parents reported co-sleeping. Feeding near bedtime or during the night was associated with later bedtimes, more fragmented sleep, and increased bedtime variability. These findings suggest the need for BSIs to support earlier bedtimes and improve sleep duration and continuity by addressing modifiable behaviors. Tailored BSIs that consider socioecological influences on the development of sleep habits are needed.

Association of Maternal Depression and Anxiety Symptoms with Sleep Duration in Children at Preschool Age

OBJECTIVES

To evaluate the effect of maternal depression and anxiety symptoms on daily sleep duration in 4-5-year-old children.

METHODS

Data were obtained from the PREDI Study, a larger cohort study conducted in Brazil. The current study is a cross-sectional study carried out in the homes of the participants between July 2016 and August 2017. The participants were submitted to anthropometric assessment and demographic, socioeconomic and psychological data were obtained. Total sleep time was self-reported by the women and classified as ≥ 10 or < 10 h of sleep/day. Maternal depression and anxiety symptoms were assessed using the Beck Depression Inventory and Beck Anxiety Inventory, respectively.

RESULTS

Of the 216 children included in the study, 77.3% and 22.7% had ≥ 10 and < 10 h of sleep/day, respectively. Regarding the women, 20.0% and 19.5% had moderate/severe depression and anxiety symptoms, respectively. Moderate/severe symptoms of maternal depression were associated with < 10 h of sleep/day (p = 0.034). Unadjusted analysis showed that children whose mothers had moderate/severe depression symptoms were significantly more likely to sleep < 10 h/day at 4-5 years of age than those whose mothers had minimal/mild depression symptoms (OR 2.38, p = 0.037). This association continued to be significant and increased to an OR of 3.99 (p = 0.006) after adjusting for potential confounders.

CONCLUSIONS FOR PRACTICE

Our study showed that sleeping less than 10 h/day at preschool age was associated with moderate/severe maternal depression symptoms. These results are important from a public health perspective since strategies designed to treat depression in women with school-age children may help improve their child's sleep quality and, consequently, his cognitive performance and related behavioral and emotional problems in the future.

Sleep and Adiposity in Children From 2 to 6 Years of Age

OBJECTIVES

To compare sleep in young children at different obesity risks, which were based on parental weight, as well as to explore the longitudinal associations of sleep characteristics with adiposity.

METHODS

In total, 107 children from an obesity prevention project were included, of which 43 had normal-weight parents (low obesity risk) and 64 had overweight and/or obese parents (high obesity risk). Sleep was measured yearly from ages 2 to 6 years by using actigraphy. Five sleep characteristics, that of late sleep, long sleep latency, short sleep duration, low sleep efficiency, and irregular sleep onset, were defined and scored across ages, with a higher score indicating more frequent exposure. The outcome variables, also measured yearly, were BMI z score and waist circumference.

RESULTS

There was no difference in sleep patterns among children at different risks. Higher short sleep duration score was associated with a greater increase in BMI z score (0.12; 95% confidence interval [CI] 0.01 to 0.25) across ages. Independently of sleep duration, higher late sleep score was associated with greater increases in BMI z score (0.16; 95% CI 0.05 to 0.27) and waist circumference (0.60 cm; 95% CI 0.23 to 0.98). Moreover, compared with children at low risk and without habitual late sleep, children at high risk and with habitual late sleep had greater increases in BMI z score (0.93; 95% CI 0.40 to 1.45) and waist circumference (3.45 cm; 95% CI 1.78 to 5.12).

CONCLUSIONS

More frequent exposures to late sleep were associated with greater increases in adiposity measures from ages 2 to 6 years, particularly in children with obese parents.

Child and Parent Perceived Determinants of Children's Inadequate Sleep Health. A Concept Mapping Study

Many children do not meet the recommendations for healthy sleep, which is concerning given the potential negative effects on children’s health. To promote healthy sleep, it is crucial to understand its determinants. This concept mapping study therefore explores perspectives of children and parents on potential determinants of children’s inadequate sleep. The focus lies on 9–12 year old children (n = 45), and their parents (n = 33), from low socioeconomic neighbourhoods, as these children run a higher risk of living in a sleep-disturbing environment (e.g., worries, noise). All participants generated potential reasons (i.e., ideas) for children’s inadequate sleep. Next, participants sorted all ideas by relatedness and rated their importance. Subsequently, multidimensional scaling and hierarchical cluster analyses were performed to create clusters of ideas for children and parents separately. Children and parents both identified psychological (i.e., fear, affective state, stressful situation), social environmental (i.e., sleep schedule, family sleep habits), behavioural (i.e., screen behaviour, physical activity, diet), physical environmental (i.e., sleep environment such as temperature, noise, light), and physiological (i.e., physical well-being) determinants. These insights may be valuable for the development of future healthy sleep interventions.

A Review of Pediatric Nonpharmacological Sleep Interventions: Effects on Sleep, Secondary Outcomes, and Populations With Co-occurring Mental Health Conditions

Sleep problems are common in school-age children and linked to numerous negative outcomes. Sleep disturbances are particularly common in children with mental health disorders, such as attention-deficit/hyperactivity disorder, depression, and anxiety. Despite frequent use of nonpharmacological pediatric sleep interventions to treat common sleep problems, there is a paucity of research on whether these interventions are effective. Further, it is unclear whether by targeting sleep, these interventions lead to broader improvements in the domains of functioning that are commonly affected by poor sleep. The present review includes 20 studies that evaluated nonpharmacological sleep treatments for school-aged youth, including 5 studies specifically focused on youth with externalizing or internalizing problems. Multimodal approaches consisting of psychoeducation and sleep hygiene in combination with other components were effective at treating insomnia and general sleep problems in typically developing samples. The addition of behavioral parent training to sleep interventions was effective for youth with externalizing problems, whereas incorporating cognitive strategies into sleep interventions for youth with internalizing problems was found to be ineffective. A variety of secondary outcomes were examined, with the strongest support emerging for improvement in anxiety and behavioral problems. Implications for clinical practice and future research directions are discussed.

Music Therapy and Story Telling: Nursing Interventions to Improve Sleep in Hospitalized Children

Music therapy and story telling are examples of nursing interventions that facilitate the management of sleep disturbance in children. However, only a few studies have addressed the effectiveness of music therapy and storytelling on hospitalized children. This study aimed to examine the effect of music therapy and storytelling on sleep disturbance in hospitalized children for various medical conditions. This recent study was a preliminary study that included two intervention groups without a control group. This study involved 31 children with ages ranging from infancy to school age who were assigned to a 3-day music therapy or storytelling intervention group. Group 1 received music therapy (n = 16) and group 2 was provided with story telling (n = 15). Data collection was conducted from February through April 2018 in an infectious diseases ward of a hospital in Jakarta. Data related to sleep disturbance in children was collected using GATIA scale, an instrument measuring a sleep disturbance scale. Study results showed a significant change in the average of sleep disturbance scale score in both group 1 and group 2 (p < α; α = .05) which demonstrate that both music therapy and story telling improved scores on a sleep disturbance scale in hospitalized children. Music therapy and story telling were equally effective in managing sleep disturbance in children. Music therapy and story telling are safe, cheap, and convenient interventions that can improve the quality of sleep in children during hospitalization.

Childhood sleep disturbances and white matter microstructure in preadolescence

BACKGROUND

Sleep problems occur in up to 30% of children and have been associated with adverse developmental outcomes. However, due to a lack of longitudinal neuroimaging studies, the neurobiological changes that may underlie some of these associations have remained unclear. This study explored the association between sleep problems during childhood and white matter (WM) microstructure in preadolescence.

METHODS

Children from the population-based birth cohort, the Generation R Study, who had repeatedly assessed sleep problems between 1.5 and 10 years of age and a MRI scan at age 10 (N = 2,449), were included. Mothers reported on their child's sleep problems using the Child Behavior Checklist (CBCL 1.5-5) when children were 1.5, 3, and 6 years of age. At age 2, mothers completed very similar questions. At age 10, both children and their mothers reported on sleep problems. We used whole-brain and tract-specific fractional anisotropy (FA) and mean diffusivity (MD) values obtained through diffusion tensor imaging as measures of WM microstructure.

RESULTS

Childhood sleep problems at 1.5, 2, and 6 years of age were associated with less WM microstructural integrity (approximately 0.05 SD lower global FA score per 1-SD sleep problems). In repeated-measures analyses, children with more sleep problems (per 1-SD) at baseline had lower FA values at age 10 in particular in the corticospinal tract (-0.12 SD, 95% CI:-0.20;-0.05), the uncinate fasciculus (-0.12 SD, 95% CI:-0.19;-0.05), and the forceps major (-0.11 SD, 95% CI:-0.18;-0.03), although effect estimates across the tracts did not differ substantially.

CONCLUSIONS

Childhood sleep disturbances are associated with less WM microstructural integrity in preadolescence. Our results show that early neurodevelopment may be a period of particular vulnerability to sleep problems. This study cannot demonstrate causality but suggests that preventive interventions addressing sleep problems should be further explored to test whether they impact adverse neurodevelopment.

How Lifestyle Factors Affect Cognitive and Executive Function and the Ability to Learn in Children

In today's research environment, children's diet, physical activity, and other lifestyle factors are commonly studied in the context of health, independent of their effect on cognition and learning. Moreover, there is little overlap between the two literatures, although it is reasonable to expect that the lifestyle factors explored in the health-focused research are intertwined with cognition and learning processes. This thematic review provides an overview of knowledge connecting the selected lifestyle factors of diet, physical activity, and sleep hygiene to children's cognition and learning. Research from studies of diet and nutrition, physical activity and fitness, sleep, and broader influences of cultural and socioeconomic factors related to health and learning, were summarized to offer examples of research that integrate lifestyle factors and cognition with learning. The literature review demonstrates that the associations and causal relationships between these factors are vastly understudied. As a result, current knowledge on predictors of optimal cognition and learning is incomplete, and likely lacks understanding of many critical facts and relationships, their interactions, and the nature of their relationships, such as there being mediating or confounding factors that could provide important knowledge to increase the efficacy of learning-focused interventions. This review provides information focused on studies in children. Although basic research in cells or animal studies are available and indicate a number of possible physiological pathways, inclusion of those data would distract from the fact that there is a significant gap in knowledge on lifestyle factors and optimal learning in children. In a climate where childcare and school feeding policies are continuously discussed, this thematic review aims to provide an impulse for discussion and a call for more holistic approaches to support child development.

What does sleep hygiene have to offer children's sleep problems?

Sleep hygiene practices have been described extensively in the literature. There is considerably less clarity about relationships between particular elements of sleep hygiene and particular sleep outcomes, and which intervention approaches using sleep hygiene principles are effective. In this review, we describe themes extracted from a systematic review of the sleep hygiene literature. We systematically searched Psycinfo, CINAHL, Cochrane, Ovid Medline, Embase, and Web of Science Search Engines up to August, 2017. We included all studies that associated sleep hygiene (behaviors adjacent to bedtime and during the night) with sleep duration and/or sleep onset latency and/or night waking or that used sleep-hygiene based interventions to improve sleep duration and/or sleep onset latency and/or night waking (n = 44). We organized our findings into themes by age group, sleep hygiene factors, and interventions. We provide evidence-based recommendations about areas of sleep hygiene that have significant empirical support and those that require urgent attention.

"We're doing the best job we can": maternal experiences of facilitators and barriers to preschoolers sleeping well in Aotearoa/New Zealand

OBJECTIVES

This study considered sleep from a social determinants of health and socioecological perspective. It aimed to explore facilitators and barriers to 4-year-old children sleeping well, as experienced by Māori and non-Māori mothers, with low and high socioeconomic position (SEP), in Aotearoa/New Zealand.

DESIGN

Experiential qualitative research involving face-to-face, semistructured individual interviews.

PARTICIPANTS

Fifteen Māori (low SEP = 7; high SEP = 8) and 16 non-Māori (low SEP = 7; high SEP = 9) mothers of preschoolers.

MEASUREMENTS

Interviews were guided by questions about how preschoolers slept and what mothers thought made a difference to their child's sleep. Data were analyzed inductively using thematic analysis.

RESULTS

Four themes were identified: "health, activity, and diet"; "sleep-promoting physical environments"; "consistency"; and "doing it our way." Children being healthy and active, sleep-conducive bedroom spaces, consistent routines, and supportive social environments assisted preschoolers to sleep well. However, broader contextual factors beyond mothers' control influenced the degree of autonomy they had over implementing sleep-supporting strategies that worked for their families. External influences included access to financial resources; parental work patterns; early childhood education service practices; access to quality housing; and affordable, culturally responsive, and respectful professional sleep advice.

CONCLUSION

Efforts aimed at facilitating healthy sleep among preschoolers and effective preschooler sleep interventions must go beyond simply recommending individual-focused sleep-promoting tips to include actions on the social determinants of sleep and the sociopolitical drivers that influence these.

Toddler Bedtime Routines and Associations With Nighttime Sleep Duration and Maternal and Household Factors

STUDY OBJECTIVES

The aims of this study were to examine (1) relationships among implementing a bedtime routine, nighttime awakenings, and nighttime sleep duration in toddlers from low-income, minority families and (2) differences in maternal and household characteristics between mothers who did versus those who did not implement a nightly bedtime routine for their toddler.

METHODS

Data were collected from mothers of toddlers on maternal and household characteristics and toddler sleep, measured using the Children's HealthWatch Survey and the Extended Brief Infant Sleep Questionnaire (BISQ). A path analysis model was tested to investigate whether nighttime awakenings mediated the relation between implementing a bedtime routine and toddlers' nighttime sleep duration. Chi-square tests were conducted to examine differences in maternal and household characteristics (ie, maternal depressive symptoms, food, housing and energy insecurity) between mothers who did versus those who did not implement nightly bedtime routines over the past 2 weeks.

RESULTS

Implementing a bedtime routine was associated with longer toddler sleep duration through a decrease in nighttime awakenings (β = 5.04, 95% confidence interval = 0.61 to 11.35). More consistent sleep routine implementation was associated with fewer nighttime awakenings and longer sleep duration. Maternal depressive symptoms, housing insecurity, and food insecurity were associated with decreased likelihood of implementing a nightly bedtime routine.

CONCLUSIONS

Maternal depressive symptoms, food insecurity, and household insecurity (factors associated with low socioeconomic status) may be associated with a negative sleep environment and poor toddler sleep quality, potentially because of decreased implementation of bedtime routines.

COMMENTARY

A commentary on this article appears in this issue on page 821.

A pilot randomized controlled trial examining the impact of a sleep intervention targeting home routines on young children's (3-6 years) physical activity

BACKGROUND

Given evidence suggesting that sleep impacts on metabolic processes, interventions targeting sleep may improve child physical activity (PA).

OBJECTIVES

To describe the potential effect of an intervention to increase sleep on young children's (3-6 years) moderate to vigorous PA (MVPA) and total PA. To determine adherence to the intervention, impact on sleep duration as well as feasibility, uptake and acceptability was also assessed.

METHODS

Pilot randomized controlled trial with 76 parent-child dyads randomly allocated to an intervention (n = 38) or control group (n = 38). Parents in the intervention group received a 3-month theory-informed intervention consisting of an online video, a telephone call and two text messages. Child PA was assessed using accelerometers at baseline and approximately 3 months. Parents also completed a sleep log and a telephone interview.

RESULTS

The consent rate was 41% (76/186). Estimated effect size for the intervention relative to control was 10.8 min/day for MVPA, 2.7 min/day for PA and 0.9 h for sleep. Sixteen (44%) parents accessed the video, and 18 (50%) received the telephone call. Over 40% of parents found the video and telephone call useful/very useful.

CONCLUSIONS

This study reports promising effects that an intervention targeting sleep may improve child MVPA and sleep duration. Some modifications to data collection methods and intervention delivery are needed.

Promoting Mental Health and Wellness in Youth Through Physical Activity, Nutrition, and Sleep

The medical benefits to youth conferred by physical activity, balanced nutrition, and quality sleep have been increasingly encouraged by medical and mental health providers. Emerging evidence continues to reveal benefits for youth mental health and well-being, including for youth with psychiatric disorders. This evidence seems multifactorial through both neurobiological and psychosocial systems, with common mechanisms present between physical activity, nutrition, and sleep. This article reviews the benefits of optimizing physical activity, nutrition, and sleep; how to assess these lifestyle domains with patients and their parents; and appropriate interventions to optimize well-being in youth.

Behavioral intervention for sleep problems in childhood: a Brazilian randomized controlled trial

Background

Sleep problems are common in children and can have an effect on behavioral and emotional functioning. Despite the importance of sleep for children’s health, there is a lack of studies on this topic in Brazil. The aim of this study was to evaluate the efficacy of behavioral intervention for sleep problems in young children and to investigate the effects on their daytime behavior.

Methods

Sixty-two children (ages 1–5; M = 2.3, SD = 1.3) with bedtime problems and night waking were randomized to a parent-based intervention or a wait list control group. After the waiting period, the wait list participants were offered treatment. The intervention was composed of five sessions over 2 months, during which the parents were educated on their child’s sleep and received guidance on the establishment of sleeping schedules and routines and on the use of extinction and positive reinforcement techniques. Sleep patterns and behavior problems were assessed with parent-report measures. Sleep patterns were also assessed with actigraphy. Assessments were completed at pre-intervention, post-intervention, 1-month follow-up, and 6-month follow-up.

Results

Children who received intervention showed greater baseline to post-treatment improvements in sleep latency, night waking, behavior such as resisting going to bed, the desire to sleep with their parents, and daytime behavior than the control group. These improvements were maintained at follow-up.

Conclusions

We concluded that behavioral parent-based intervention is effective in improving the quality of sleep and the diurnal behavior of children. This study provides initial support for use of this protocol in psychology clinics/schools. Brazilian clinical trials registration, RBR-4kxxd5. Retrospectively registered on December 13, 2016.

Orientação Parental para Insônia Infantil em Irmãos Gêmeos: Um Relato de Caso

Resumo A intervenção comportamental, por meio da orientação parental, vem alcançando resultados positivos no manejo da insônia em crianças. Contudo, questiona-se a efetividade de tais intervenções em irmãos gêmeos, pelo fato de os pais partilharem os cuidados de duas crianças da mesma idade e nível de desenvolvimento. O objetivo deste estudo é apresentar um relato de caso de intervenção comportamental para insônia infantil em irmãos gêmeos por meio de um programa dirigido aos pais e verificar o efeito da intervenção no sono e comportamentos diurnos das crianças. A mãe dos gêmeos foi orientada quanto as técnicas de extinção e reforço positivo no manejo do problema de sono infantil. Os resultados demonstraram que depois da intervenção houve melhora nos hábitos de sono, na qualidade do sono e nos comportamentos internalizantes e externalizantes das crianças. Os achados apresentados neste estudo mostraram os efeitos positivos que a intervenção baseada na aprendizagem operante teve sobre o sono e o comportamento infantil. Este aspecto ressalta a importância de uma inserção maior da questão do sono na Psicologia, a partir de práticas preventivas e interventivas.

Social Media Content About Children's Pain and Sleep: Content and Network Analysis

BACKGROUND

Social media is often used for health communication and can facilitate fast information exchange. Despite its increasing use, little is known about child health information sharing and engagement over social media.

OBJECTIVE

The primary objectives of this study are to systematically describe the content of social media posts about child pain and sleep and identify the level of research evidence in these posts. The secondary objective is to examine user engagement with information shared over social media.

METHODS

Twitter, Instagram, and Facebook were searched by members of the research team over a 2-week period using a comprehensive search strategy. Codes were used to categorize the content of posts to identify the frequency of content categories shared over social media platforms. Posts were evaluated by content experts to determine the frequency of posts consistent with existing research evidence. User engagement was analyzed using Netlytic, a social network analysis program, to examine visual networks illustrating the level of user engagement.

RESULTS

From the 2-week period, nearly 1500 pain-related and 3800 sleep-related posts were identified and analyzed. Twitter was used most often to share knowledge about child pain (639/1133, 56.40% of posts), and personal experiences for child sleep (2255/3008, 75.00% of posts). For both topics, Instagram posts shared personal experiences (53/68, 78% pain; 413/478, 86.4% sleep), Facebook group posts shared personal experiences (30/49, 61% pain; 230/345, 66.7% sleep) and Facebook pages shared knowledge (68/198, 34.3% pain; 452/1026, 44.05% sleep). Across platforms, research evidence was shared in 21.96% (318/1448) of pain- and 9.16% (445/4857) of sleep-related posts; 5.38% (61/1133) of all pain posts and 2.82% (85/3008) of all sleep posts shared information inconsistent with the evidence, while the rest were absent of evidence. User interactions were indirect, with mostly one-way, rather than reciprocal conversations.

CONCLUSIONS

Social media is commonly used to discuss child health, yet the majority of posts do not contain research evidence, and user engagement is primarily one-way. These findings represent an opportunity to expand engagement through open conversations with credible sources. Research and health care communities can benefit from incorporating specific information about evidence within social media posts to improve communication with the public and empower users to distinguish evidence-based content better. Together, these findings have identified potential gaps in social media communication that may be informative targets to guide future strategies for improving the translation of child health evidence over social media.

Caregiver-perceived sleep outcomes in toddlers sleeping in cribs versus beds

OBJECTIVE

Little is known about whether sleep space impacts toddler sleep outcomes. We examined the prevalence of crib-sleeping and its association with caregiver-reported sleep patterns and problems in a large sample of toddlers from Western countries.

METHODS

Participants were caregivers of 1983 toddlers ages 18.0-35.9 months (51.7% male; mean age 25.3 months) from Australia, Canada, New Zealand, the United Kingdom, and the United States sleeping in a crib or bed in a separate room from caregivers. Caregiver-reported sleep patterns and problems were collected via a free, publicly available child sleep smartphone application.

RESULTS

Across countries/regions, rates of crib-sleeping decreased linearly with age, with 63.4% of toddlers ages 18.0-23.9 months, 34.3% of toddlers ages 24.0-29.9 months, and 12.6% of toddlers ages 30.0-35.9 months sleeping in a crib. Across age groups and countries, crib sleeping was significantly associated with an earlier bedtime, shorter sleep onset latency, fewer night awakenings, longer stretches of time asleep, increased nighttime sleep duration, and decreased bedtime resistance and sleep problems. The duration of night awakenings did not significantly differ by sleep space.

CONCLUSION

Sleeping in a crib instead of a bed is associated with enhanced caregiver-reported sleep quantity and quality for toddlers in Western countries. Consistent with practice recommendations, deferring the crib-to-bed transition until age 3 years may benefit toddlers' sleep in Western contexts. Additional research is needed to identify the impact of sleep space on child sleep in other countries/regions.