Racial disparities and sleep among preschool aged children: a systematic review

Perceptions of sleep health among African American mothers regarding their preschool-aged children: A qualitative study to decrease sleep health disparities

OBJECTIVES

African American children are documented as having poor sleep health due to shorter sleep duration, sleep timing, and sleep behaviors compared to White peers, contributing to child health disparities. Identifying cultural-environmental, and societal factors impacting a child's sleep among African American families is essential for developing interventions for this population. This study evaluated holistically why African American children may have poorer sleep health by examining sleep duration, timing, and behaviors. This was assessed by examining sleep-related beliefs, barriers, and facilitators to sleep schedules and routines. We also explored parental ideas for a sleep intervention.

METHODS

African American mothers of preschool-aged children (2-5years) were recruited using local partnerships and social media. Individual semistructured interviews were conducted by phone. Interviews were transcribed, coded, and analyzed thematically using grounded-theory.

RESULTS

Eighteen African American mothers completed the study. Five themes related to sleep emerged: The importance of adequate nighttime sleep, the influence of family and friends on parental sleep practices, the relationship between environmental and home dynamics on child sleep duration, the impact of acute and chronic societal-level stressors on family sleep health, and considerations for culturally tailored interventions to improve child sleep health.

CONCLUSIONS

Good sleep health was important among African American mothers. Cultural-environmental and societal factors significantly impact children's sleep health. Clinicians and researchers should be aware of financial resources and home dynamics leading to challenges with adequate sleep health when developing or adapting sleep interventions. Identifying cultural-environmental, and societal factors must be considered for targeted efforts to improve sleep health in African American children.

Diagnosis of sleep disorders in child healthcare settings

OBJECTIVES

Sleep disorders impact at least 10 % of children, pose risks to overall wellbeing, and are key targets of preventive interventions. The objectives of this study were to describe the prevalence of pediatric sleep disorder diagnoses across sociodemographic characteristics and co-occurring conditions, and to explore potential sociodemographic disparities.

METHODS

Cross-sectional analysis of 12,394,902 children (0-17 years; 50.9 % Medicaid-insured) in the 2017 MarketScan database. Prevalence was assessed utilizing ICD-10 codes, with multivariate logistic regressions examining disparities (insurance coverage; race and ethnicity in Medicaid-insured) for diagnoses in ≥0.10 % of children.

RESULTS

The prevalence of sleep disorder diagnoses was 2.36 %. The most common diagnoses were obstructive sleep disordered breathing (oSDB, 1.17 %), unspecified sleep disorders (0.64 %), insomnia (0.52 %), and other SDB (0.10 %), with <0.10 % for all other diagnoses. Insomnia and parasomnias diagnoses were much lower than diagnostic estimates. Sleep diagnoses were more prevalent in Medicaid versus commercially insured youth, 2-5-year-olds, and in children with co-occurring medical, neurodevelopmental, or behavioral health conditions. Girls and boys were generally equally likely to be diagnosed with any sleep disorder. In Medicaid-insured children, white children were more likely to have any sleep diagnosis compared to all other racial and ethnic groups. Black/African American children were more likely than white children to have oSDB.

CONCLUSIONS

Compared to diagnostic estimates, claims data suggest sleep disorders are under-diagnosed, with notable sociodemographic disparities. Findings suggest a need for clinical resources to identify and address sleep disorders and to understand biases potentially driving disparities, given that sleep is a modifiable determinant of child wellbeing.

Racial/ethnic disparities in the trajectories of insomnia symptoms from childhood to young adulthood

STUDY OBJECTIVES

To examine differences in the longitudinal prevalence of childhood insomnia symptoms across black/African American, Hispanic/Latinx, and non-Hispanic white groups.

METHODS

Participants were 519 children from the Penn State Child Cohort (baseline [V1] from 2000-2005) who were followed up 8 years later as adolescents (V2) and 15 years later as young adults (S3). Mean age at S3 was 24.1 ± 2.7 years. Approximately, 76.5% identified as non-Hispanic white, 12.9% as black/African American, 7.1% as Hispanic/Latinx, and 3.5% as "other" race/ethnicity. Insomnia symptoms were defined as parent-reported (childhood) or self-reported (adolescence and young adulthood) moderate-to-severe difficulties initiating/maintaining sleep. Longitudinal trajectories of insomnia symptoms were identified across three-time points and the odds of each trajectory were compared between racial/ethnic groups, adjusting for sex, age, overweight, sleep apnea, periodic limb movements, psychiatric/behavioral disorders, and psychotropic medication use.

RESULTS

Black/African Americans compared to non-Hispanic whites were at significantly higher odds of having a childhood-onset persistent trajectory through young adulthood (OR = 2.58, 95% CI [1.29, 5.14]), while Hispanics/Latinx were at nonsignificantly higher odds to have the same trajectory (OR = 1.81, 95% CI [0.77, 4.25]). No significant racial/ethnic differences were observed for remitted and waxing-and-waning trajectories since childhood or incident/new-onset trajectories in young adulthood.

CONCLUSIONS

The results indicate that disparities in insomnia symptoms among black/African American and, to a lesser extent, Hispanic/Latinx groups start early in childhood and persist into young adulthood. Identifying and intervening upon upstream determinants of racial/ethnic insomnia disparities are warranted to directly address these disparities and to prevent their adverse health sequelae.

CLINICAL TRIAL INFORMATION

N/A; Not a clinical trial.

Eyes Wide Open: Sleep as a Potential Contributor to Racial and Ethnic Disparities in Cancer

U.S. racial and ethnic minoritized groups face disproportionate cancer burdens compared to White Americans. Investigating modifiable factors, such as sleep, that are socially patterned and inequitably distributed by race and ethnicity may advance understanding of cancer disparities and provide intervention opportunities. Emerging data suggest poor sleep health is associated with cancer. Yet, its contribution to racial and ethnic cancer disparities is understudied. In this narrative review, we explored the sleep-cancer relation through a disparities lens. We (i) summarized literature reporting on associations between sleep and cancer among racial and ethnic minority populations; (ii) examined potential sleep-cancer mechanisms; and (iii) discussed future directions. We identified five studies reporting on sleep-cancer associations among minoritized groups. Poor sleep health was associated with aggressive breast cancer among Black women, increased breast cancer risk among Asian women, and increased risk of breast and total cancer among Hispanic/Latinx Americans. Sleep and cancer disparities have similar socioeconomic and behavioral determinants, suggesting racial and ethnic minoritized groups may be vulnerable to poor sleep health and its adverse health impacts. Evidence indicates that the sleep-cancer disparities relation is an emerging, but important area of research that warrants further investigation, as sleep may be an avenue for reducing cancer disparities.

Trying to Do What's Best: Maternal Perspectives About Toddler Sleep Health Among an Underresourced Sample of Mothers With Diverse Racial and Ethnic Identities

INTRODUCTION

This study describes mothers' knowledge, attitudes, beliefs, and practices about their toddler's sleep health among an underresourced sample of mothers with diverse racial and ethnic identities.

METHOD

This was a descriptive qualitative study with 16 mothers and their 12- to 36-month-old child. Mothers completed a semistructured, audio-recorded interview about their toddler's sleep health. Data were analyzed using inductive content analysis on the basis of established methods.

RESULTS

Mothers self-identified as 18.8% Black, 43.8% White, 12.5% multiracial, 25.0% other race, and 37.5% Hispanic. Of the mothers, 80.0% reported a past year household income of ≤ $40,000. A core construct, "Trying to do What's Best," emerged from the interview data, and this construct included three domains: Getting Good Sleep, Getting Thrown Off, and Rolling With It.

DISCUSSION

Findings support future strengths-based and multilevel sleep health-promoting interventions.

Maternal Perceptions of Evidence-Based Early Childhood Sleep Health Promotion Recommendations: An Explanatory Sequential Study

OBJECTIVES

The purpose of this explanatory sequential design study was to better understand caregivers' perceptions about and interest in evidence-based early childhood sleep health promotion recommendations.

METHOD

A purposeful sample of mothers of 20 1-5-year-old children (10 children exhibiting optimal sleep and 10 children exhibiting insufficient/fragmented sleep) attending a preschool serving a low socio-economic (SES) status metropolitan community were invited to participate in qualitative interviews. Data were coded according to a grounded theory approach and themes were identified within the optimal and suboptimal sleeper groups.

RESULTS

Mothers reported different approaches to managing electronics by optimal/suboptimal sleeper group, with mothers of optimal sleepers limiting access to electronics more than mothers in the suboptimal sleep group. Other themes of sleep health practices did not differ meaningfully between groups.

CONCLUSIONS

Maternal perspectives about early childhood sleep health were similar across optimal and suboptimal sleepers on most elements of child sleep health. Managing child sleep was contextually influenced and these results highlight the complexities of how families living in lower SES environments perceive common sleep recommendations. Thus, sleep health education efforts should be tailored to the needs and values of specific families and communities.

The Feasibility of Screening for Sleep Problems in Early Childhood Education Programs

OBJECTIVES

Assess the feasibility and staff experience of screening for behavioral sleep problems (BSP) and sleep disordered breathing (SDB) in early childhood education (ECE) settings; examine BSP/SDB prevalence and caregivers' knowledge/attitudes, perception of child sleep problems, and sleep health engagement in this sample.

METHOD

Eight staff representatives from four ECE sites involved with sleep problem screening procedures within a larger RCT on ECE sleep health, discussed their experiences in a focus group; transcript content reviewed. A random subset of caregiver-child dyads (n = 59) from the four ECE sites completed sleep problem measures (BSP: Children's Sleep Habits Questionnaire, Short form [SF-CSHQ], Tayside Children's Sleep Questionnaire [TCSQ-sleep disturbance and difficulty] and SDB: Pediatric Sleep Questionnaire [PSQ], in addition to RCT measures (Parent Knowledge/Attitude/Self-efficacy/Beliefs survey and sleep health goals). Caregiver sleep health engagement was measured by the sleep health goals set.

RESULTS

ECE staff reported sleep problem screening as self-explanatory and doable but sometimes administratively burdensome. BSPs were identified in 44% (SF-CSHQ) to 63% (TCSQ-sleep disturbance) of children; SDBs in 13%. Only 11% of caregivers endorsed their child having a sleep "difficulty" (TCSQ). Sleep health goals were set by 85% of caregivers; 63% employed educational materials' language.

CONCLUSION

Sleep problem screening in ECE is feasible, and problems are elicited. While caregivers readily engage in setting healthy sleep goals, few endorse sleep as difficult. ECE education could improve caregiver understanding/recognition of sleep problems.

Neighborhood predictors of short sleep duration and bedtime irregularity among children in the United States: results from the 2019-2020 National Survey of Children's Health

BACKGROUND

Environmental factors may contribute to short sleep duration and irregular bedtime in children. Neighborhood factors and children's sleep duration and bedtime regularity remain a less investigated area. The aim of this study was to investigate the national and state-level proportions of children with short sleep duration and irregular bedtime and their neighborhood predictors.

METHODS

A total of 67,598 children whose parents completed the National Survey of Children's Health in 2019-2020 were included in the analysis. Survey-weighted Poisson regression was used to explore the neighborhood predictors of children's short sleep duration and irregular bedtime.

RESULTS

The prevalence of short sleep duration and irregular bedtime among children in the United States (US) was 34.6% [95% confidence interval (CI) = 33.8%-35.4%] and 16.4% (95% CI = 15.6%-17.2%) in 2019-2020, respectively. Safe neighborhoods, supportive neighborhoods, and neighborhoods with amenities were found to be protective factors against children's short sleep duration, with risk ratios ranging between 0.92 and 0.94, P < 0.05. Neighborhoods with detracting elements were associated with an increased risk of short sleep duration [risk ratio (RR) = 1.06, 95% CI = 1.00-1.12] and irregular bedtime (RR = 1.15, 95% CI = 1.03-1.28). Child race/ethnicity moderated the relationship between neighborhood with amenities and short sleep duration.

CONCLUSIONS

Insufficient sleep duration and irregular bedtime were highly prevalent among US children. A favorable neighborhood environment can decrease children's risk of short sleep duration and irregular bedtime. Improving the neighborhood environment has implications for children's sleep health, especially for children from minority racial/ethnic groups.

Age, sex and race distribution of accelerometer-derived sleep variability in US school-aged children and adults

Sleep variability (e.g. intra-individual variabilities in sleep duration or sleep timing, social jetlag, and catch-up sleep) is an important factor impacting health and mortality. However, limited information is available on the distribution of these sleep parameters across the human life span. We aimed to provide distribution of sleep variability related parameters across lifespan by sex and race in a national representative sample from the U.S. population. The study included 9981 participants 6 years and older from the National Health and Nutrition Examination Survey (NHANES) 2011-2014, who had 4-7 days of valid 24-h accelerometer recording with at least one day obtained during weekend (Friday or Saturday night). Of the study participants, 43% showed ≥ 60 min sleep duration standard deviation (SD), 51% experienced ≥ 60 min catch-up sleep, 20% showed ≥ 60 min sleep midpoint SD, and 43% experienced ≥ 60 min social jetlag. American youth and young adults averaged greater sleep variability compared to other age groups. Non-Hispanic Blacks showed greater sleep variability in all parameters compared to other racial groups. There was a main effect of sex on sleep midpoint SD and social jetlag with males averaging slightly more than females. Our study provides important observations on sleep variability parameters of residents of the United States by using objectively measured sleep patterns and will provide unique insights for personalized advice on sleep hygiene.

Sociodemographic, temporal and bedtime routine correlates of sleep timing and duration in South Asian and white children: A Born in Bradford study

Objective

The study aimed to examine sociodemographic, temporal and bedtime routine correlates of parent-reported sleep duration and timing in a biethnic sample of 18 month and 36 month old children from a disadvantaged location.

Methods

Between October 2010 and September 2012, parents completed a bespoke three day sleep diary when their child was approximately 18 months (n = 276) and 36 months of age (n = 262) (45.1% South Asian; 54.9% white). Parents reported their child's overnight sleep duration (h/day), the time their child fell asleep, their wake time and their child's bedtime and napping routines. Data were available at both time points for 135 children.

Results

In line with previous literature, South Asian children had shorter overnight sleep duration and later sleep and wake times than white children. In both ethnic groups, children slept and woke up later on weekends, and children went to bed earlier and slept longer in winter. In white children only, napping duration was associated with overnight sleep period. No significant associations were found between napping frequency and overnight sleep duration. Based on parent-reported data, children who consistently adhered to regular bedtimes and had set times for sleeping tended to go to sleep earlier, wake earlier and have longer overnight sleep.

Conclusions

The data showed parent-reported variation in sleep patterns between two ethnic groups within a single geographical and deprived area. It is important that researchers, clinicians and early years workers are considerate of cultural norms in sleep practices.

Rest-activity rhythms across the lifespan: cross-sectional findings from the US representative National Health and Nutrition Examination Survey

STUDY OBJECTIVES

Rest-activity rhythms (RAR) may mark development, aging, and physical and mental health. Understanding how they differ between people may inform intervention and health promotion efforts. However, RAR characteristics across the lifespan have not been well-studied. Therefore, we investigated the association between RAR measures with demographic and lifestyle factors in a US nationally representative study.

METHODS

RAR metrics of interdaily stability (IS), intradaily variability (IV), relative amplitude (RA), and mean amplitude and timing of high (M10) and low (L5) activity were derived from 2011 to 2012 and 2013 to 2014 National Health and Nutrition Examination Survey (NHANES) actigraphy data. Population-weighted linear and logistic regression models were fit to examine the associations of age, gender, smoking, alcohol, season, body mass index (BMI), income-to-poverty ratio, and race/ethnicity with RAR. Significance was based on a false-discovery rate-corrected P-value of <0.05.

RESULTS

Among n = 12 526 NHANES participants (3-≥80 years), IS (higher = greater day-to-day regularity) and RA (higher = greater rhythm strength) generally decreased with age and were lower among males, whereas IV (higher = greater rhythm fragmentation) increased with age (p < 0.05). Dynamic changes in RAR trajectories were observed during childhood and adolescence. Income, BMI, smoking, and alcohol use were associated with RAR metrics, as well as season among children and teenagers (p < 0.05). RAR also differed by race/ethnicity (p < 0.05), with trajectories initially diverging in childhood and continuing into adulthood.

CONCLUSIONS

RAR differed by demographic and health-related factors, representing possible windows for public health intervention and sleep health promotion. RAR differences by race/ethnicity begin in childhood, are evident in early adolescence, and persist throughout adulthood.

Variation in Caregiver-Reported Child Sleep Patterns and Problems by Family Socioeconomic Indicators

OBJECTIVE

Previous studies of sleep patterns, as well as rates and correlates of perceived problems in early childhood, indicate variation by neighborhood-level socioeconomic indicators. The purpose of this study was to examine variation in (1) sleep patterns, behaviors, and problems by family-based socioeconomic indicators (income-to-needs ratio and caregiver education level) and (2) sociodemographic and sleep correlates of a caregiver-endorsed child sleep problem across and within socioeconomic indicator groups in a diverse sample.

METHODS

Two hundred eighty-three caregiver-child dyads (ages 1-5 years) completed the Brief Child Sleep Questionnaire. Family-level socioeconomic indicators included income-to-needs ratio and caregiver educational level.

RESULTS

Sleep patterns varied based on income-to-needs ratio, with children living in poverty experiencing the longest sleep onset latencies and night awakening durations and shortest nighttime sleep durations. Rates of an endorsed child sleep problem were similar across income-to-needs groups. Although sleep patterns did not vary by caregiver education level, caregivers with an education beyond high school were more likely to endorse a child sleep problem; later bedtimes, more frequent night awakenings, and greater bedtime difficulties were the strongest correlates of a perceived sleep problem in this subgroup. No specific correlates of a child sleep problem emerged for those with a high school education or less.

CONCLUSION

Sleep patterns may be more robustly linked to family income-to-needs ratio, whereas perceptions of a child sleep problem may be more linked to caregiver education level. Clinicians should consider expanding sleep screening questions to include specific sleep outcomes to effectively assess child sleep and guide intervention.

State-Level Anti-Immigrant Sentiment and Policies and Health Risks in US Latino Children

BACKGROUND

Although systemic inequities, broadly defined, are associated with health disparities in adults, there is a dearth of research linking contextual measures of exclusionary policies or prejudicial attitudes to health impairments in children, particularly among Latino populations. In this study, we examined a composite measure of systemic inequities in relation to the cooccurrence of multiple health problems in Latino children in the United States.

METHODS

Participants included 17 855 Latino children aged 3 to 17 years from the National Survey of Children's Health (2016-2020). We measured state-level systemic inequities using a factor score that combined an index of exclusionary state policies toward immigrants and aggregated survey data on prejudicial attitudes toward immigrants and Latino individuals. Caregivers reported on 3 categories of child health problems: common health difficulties in the past year, current chronic physical health conditions, and current mental health conditions. For each category, we constructed a variable reflecting 0, 1, or 2 or more conditions.

RESULTS

In models adjusted for sociodemographic covariates, interpersonal discrimination, and state-level income inequality, systemic inequities were associated with 1.13 times the odds of a chronic physical health condition (95% confidence interval: 1.02-1.25) and 1.24 times the odds of 2 or more mental health conditions (95% confidence interval: 1.06-1.45).

CONCLUSIONS

Latino children residing in states with higher levels of systemic inequity are more likely to experience mental health or chronic physical health conditions relative to those in states with lower levels of systemic inequity.

Disparities in Sleep-Disordered Breathing: Upstream Risk Factors, Mechanisms, and Implications

Sleep-disordered breathing (SDB) refers to a spectrum of disorders ranging from habitual snoring without frank episodes of obstructed breathing or desaturation during sleep to obstructive sleep apnea, where apneas and hypopneas repetitively occur with resultant intermittent hypoxia, arousal, and sleep disruption. Disparities in SDB reflect its overall high prevalence in children and adults from racially and ethnically minoritized or low socioeconomic status backgrounds coupled with high rates of underdiagnosis and suboptimal treatment.

Early emergence of racial and ethnic differences in sleep health among toddlers living in low-income families

OBJECTIVES

Emerging evidence suggests racial and ethnic and socioeconomic differences in children's sleep health, yet few have examined these differences among very young children. The purpose of this study is to identify potential racial, ethnic, and sociodeomographic factors associated with multiple dimensions of sleep health in toddlers living in very low-income families.

PARTICIPANTS

Sample included 110 racially and ethnically diverse dyads with toddlers aged 12-15 months living in low-income families.

METHODS

Actigraph data (9 days and nights), caregiver completed sleep diaries, Brief Infant Sleep Questionnaire-extended, and caregiver-reported socioeconomic characteristics were collected.

RESULTS

Toddlers' average sleep duration (10.25 hours; SD = 0.76) was less than the age-based recommendations. There were significant race and ethnic differences in toddler's actigraph-measured bedtime (p < .001) and variability in bedtimes (p = .004). Non-LatinX White toddlers had earlier bedtimes and less variability than Black and LatinX children. These between-group differences remained statistically significant after controlling for measured socioeconomic variables (p's < 0.001). Within racial and ethnic group differences in bedtime and bedtime variability by education, employment, and marital status were identified with medium to large effect sizes.

CONCLUSIONS

Racial and ethnic between-group differences in sleep occurred as early as 12 months of age and were not explained by sociodemographic variables (eg, income-to-needs, education, housing). Further research is necessary to determine structural and contextual factors that explain the racial and ethnic differences in sleep health in early childhood. Identifying these factors may inform the development of socially and culturally tailored interventions to reduce sleep health disparities.

Pediatric sleep: current knowledge, gaps, and opportunities for the future

This White Paper addresses the current gaps in knowledge, as well as opportunities for future studies in pediatric sleep. The Sleep Research Society's Pipeline Development Committee assembled a panel of experts tasked to provide information to those interested in learning more about the field of pediatric sleep, including trainees. We cover the scope of pediatric sleep, including epidemiological studies and the development of sleep and circadian rhythms in early childhood and adolescence. Additionally, we discuss current knowledge of insufficient sleep and circadian disruption, addressing the neuropsychological impact (affective functioning) and cardiometabolic consequences. A significant portion of this White Paper explores pediatric sleep disorders (including circadian rhythm disorders, insomnia, restless leg and periodic limb movement disorder, narcolepsy, and sleep apnea), as well as sleep and neurodevelopment disorders (e.g. autism and attention deficit hyperactivity disorder). Finally, we end with a discussion on sleep and public health policy. Although we have made strides in our knowledge of pediatric sleep, it is imperative that we address the gaps to the best of our knowledge and the pitfalls of our methodologies. For example, more work needs to be done to assess pediatric sleep using objective methodologies (i.e. actigraphy and polysomnography), to explore sleep disparities, to improve accessibility to evidence-based treatments, and to identify potential risks and protective markers of disorders in children. Expanding trainee exposure to pediatric sleep and elucidating future directions for study will significantly improve the future of the field.

Bridging the gap: leveraging implementation science to advance pediatric behavioral sleep interventions

STUDY OBJECTIVES

This review synthesizes the pediatric behavioral sleep intervention (BSI) evidence base, summarizes challenges in translating BSIs from research to practice, and provides recommendations for integrating implementation science methods to advance pediatric BSI research.

METHODS

We briefly review the common behavioral sleep disturbances among youth, discuss the pediatric BSIs with well-established evidence, and identify gaps in pediatric BSI research. We then identify contributors to the dearth of research evaluating pediatric BSIs in accessible settings and present a model for applying implementation science strategies to address identified gaps across the continuum of translational research.

RESULTS

Relatively few BSI trials include older children and adolescents. Similarly, there is limited research evaluating BSIs among racially and ethnically minoritized children and families and/or those of lower socioeconomic status backgrounds. Access to scalable and easily disseminable tools to treat pediatric sleep disturbances early in their development is crucial for promoting positive child outcomes. To address these gaps, researchers should apply implementation science theories, models, and frameworks to design new interventions for implementation, adapt existing interventions with end users and settings in mind, conduct hybrid effectiveness-implementation trials, and test implementation strategies.

CONCLUSIONS

Given the prevalence and consequences of poor sleep across developmental periods, pediatric BSIs must be effective as well as adaptable, scalable, and easily disseminable. Implementation science theories, models, and frameworks can enhance access to, engagement in, and the implementation and dissemination of scalable BSIs across diverse pediatric care settings and heterogeneous populations.

CITATION

Levenson JC, Williamson AA. Bridging the gap: leveraging implementation science to advance pediatric behavioral sleep interventions. J Clin Sleep Med. 2023;19(7):1321-1336.

Prevalence and influencing factors of sleep disorders among preschool children in Urumqi city: a cross-sectional survey

BACKGROUND

Sleep disorders refer to physiological and psychological states that cause adverse consequences due to the inability to fall asleep or poor sleep quality. The prevalence of sleep disorders varies greatly in different countries and regions due to different causes. This study aimed to investigate the prevalence and influencing factors of sleep disorders among preschool children in Urumqi city, China.

METHODS

A cross-sectional study was conducted with stratified random cluster sampling. Children aged 3-6 years old in one kindergarten randomly selected from each of the 8 districts of Urumqi from March to July 2022, and their parents were surveyed with a sleep quality questionnaire.

RESULTS

The prevalence of sleep disorders among preschool children in Urumqi was 14.29% (191/1336), and the prevalence of different symptoms was 42.81% for limb movements, 19.61% for snoring, 18.11% for bruxism, 16.39% for sleep talking, 12.57% for sweating, 11.60% for nocturnal awakening, 8.46% for nightmares, 6.89% for bed wetting, 3.74% for apnea, and 3.29% for sleepwalking. The prevalence of body movements, snoring, sweating, night-wake, nightmares, bed-wetting, apnea, and sleepwalking among different ethnicities were significantly different (P < 0.05). Multivariate analysis revealed that the major risk factors of sleep disorders were difficulty adapting to new environments, unwillingness to express emotions, inconsistent attitudes of the family toward children's education, running before bedtime, strict family education methods, etc. CONCLUSION: The prevalence of sleep disorders in preschool children in Urumqi is lower than the average level reported in other studies. Many factors affect the prevalence of sleep disorders in preschool children, but it is necessary to focus on the ability to adapt to new environments, psychological problems, and the impact of family education on sleep disorders. Further studies on the prevention and treatment of sleep disorders are needed for different ethnicities.

Racial and ethnic disparities in insufficient sleep among US in infants and preschoolers

OBJECTIVE

To examine racial and ethnic disparities and associated factors of insufficient sleep among children from infancy to preschool-aged.

METHODS

We analyzed parent-reported data on US children ages 4 months-5 years (n = 13,975) from the 2018 and 2019 National Survey of Children's Health. Children who slept less than the age-specific minimum hours recommended by the American Academy of Sleep Medicine were classified as having insufficient sleep. Logistic regression was used to estimate unadjusted and adjusted odds ratios (AOR).

RESULTS

An estimated 34.3% of children from infancy to preschool-aged experienced insufficient sleep. Socioeconomic factors (poverty [AOR] = 1.5, parents' education level [AORs] from 1.3 to 1.5); parent-child interaction variables (AORs from 1.4 to 1.6); breast feeding status (AOR = 1.5); family structure (AORs from 1.5 to 4.4); and weeknight bedtime regularity (AORs from 1.3 to 3.0) were significantly associated with having insufficient sleep. Non-Hispanic Black (OR = 3.2) and Hispanic children (OR = 1.6) had significantly higher odds of insufficient sleep compared to non-Hispanic White children. Racial and ethnic disparities in insufficient sleep between non-Hispanic White children and Hispanic children were largely attenuated by adjusting for social economic factors. However, the difference in insufficient sleep between non-Hispanic Black and non-Hispanic White children remains (AOR = 1.6) after adjusting socioeconomic and other factors.

CONCLUSIONS

More than one-third of the sample reported insufficient sleep. After adjusting for socio-demographic variables, racial disparities in insufficient sleep decreased but persistent disparities existed. Further research is warranted to examine other factors and develop interventions to address multilevel factors and improve sleep health among racial and ethnic minority group children.

Health Disparities in Pediatric Sleep

This article reviews disparities in pediatric sleep health and sleep disorders from early childhood through adolescence (birth to age 18 years). Sleep health is a multidimensional construct including sleep duration, consolidation, and other domains, whereas sleep disorders reflect both behaviorally (eg, insomnia) and medically based (eg, sleep disordered breathing) sleep diagnoses. Using a socioecological framework, we review multilevel (ie, child, family, school, health-care system, neighborhood, and sociocultural) factors linked to sleep health disparities. Mechanistic research and studies using an intersectional lens to understand overlapping marginalized identities are needed to inform multilevel interventions to promote sleep health equity in pediatrics.

What daily factors affect the sleep habits of Japanese toddlers?

STUDY OBJECTIVES

Good sleep, especially during early childhood, is important for development. In Japan, the mean nocturnal sleep duration of toddlers is < 10 hours, and even if toddlers slept for > 11 hours/day, as recommended by the National Sleep Foundation, some of them showed late bedtime and late wake-up time or took long naps. Therefore, we provisionally assumed the minimal sleep conditions for Japanese toddlers, named Nenne-criteria, such as bedtime before 10:00 pm, nocturnal sleep duration of ≥ 9 hours, and < 1 average time of awakening after sleep onset, and investigated the important factors for good sleep.

METHODS

We analyzed cross-sectional data from online surveys describing the sleep-related behaviors of 2,124 toddlers and their caregivers. We compared the daily schedules that affect sleep between the Nenne-criteria-meet group and the not-meet group.

RESULTS

The Nenne-criteria-meet group showed better daytime behaviors than the not-meet group. Structural equation modeling on daily schedules revealed that, to increase sleep pressure at the appropriate time, it is important to restrict media viewing, play outdoors in the morning, have an early nap ending time, avoid hyperarousal-inducing behaviors before bedtime, maintain daily schedules regularly, and decrease social jetlag.

CONCLUSIONS

The Nenne-criteria are useful for screening Japanese toddlers who require intervention for sleep hygiene. To improve toddlers' sleep, it is important not only to guide the ideal bedtime but also to provide tips for improving daily schedules and to avoid suboptimal sleep-related behaviors.

CITATION

Murata E, Yoshizaki A, Fujisawa TX, Tachibana M, Taniike M, Mohri I. What daily factors affect the sleep habits of Japanese toddlers? J Clin Sleep Med. 2023;19(6):1089-1101.

Sociodemographic Variation in Children's Health Behaviors During the COVID-19 Pandemic

Background: Societal changes during the COVID-19 pandemic may affect children's health behaviors and exacerbate disparities. This study aimed to describe children's health behaviors during the COVID-19 pandemic, how they vary by sociodemographic characteristics, and the extent to which parent coping strategies mitigate the impact of pandemic-related financial strain on these behaviors. Methods: This study used pooled data from 50 cohorts in the Environmental influences on Child Health Outcomes Program. Children or parent proxies reported sociodemographic characteristics, health behaviors, and parent coping strategies. Results: Of 3315 children aged 3-17 years, 49% were female and 57% were non-Hispanic white. Children of parents who reported food access as a source of stress were 35% less likely to engage in a higher level of physical activity. Children of parents who changed their work schedule to care for their children had 82 fewer min/day of screen time and 13 more min/day of sleep compared with children of parents who maintained their schedule. Parents changing their work schedule were also associated with a 31% lower odds of the child consuming sugar-sweetened beverages. Conclusions: Parents experiencing pandemic-related financial strain may need additional support to promote healthy behaviors. Understanding how changes in parent work schedules support shorter screen time and longer sleep duration can inform future interventions.

Age, sex and race distribution of accelerometer-derived sleep variability in US school-aged children and adults

Background

Sleep variability (e.g. intra-individual variabilities in sleep duration or sleep timing, social jetlag, and catch-up sleep) is an important factor impacting health and mortality. However, limited information is available on the distribution of these sleep parameters across the human life span. We aimed to provide distribution of sleep variability related parameters across lifespan by sex and race in a national representative sample from the U.S. population.

Methods

The study included 9,799 participants 6 years and older from the National Health and Nutrition Examination Survey (NHANES) 2011-2014, who had at least 3 days of valid sleep parameters with at least one day obtained during weekend (Friday or Saturday night). These were calculated from 7-day 24-h accelerometer recordings.

Results

Of the study participants, 43% showed ≥ 60 minutes sleep duration standard deviation (SD), 51% experienced ≥ 60 minutes catch-up sleep, 20% showed ≥ 60 minutes midpoint of sleep SD, and 43% experienced ≥ 60 minutes social jetlag. American youth and young adults averaged greater sleep variability compared to other age groups. Non-Hispanic Blacks showed greater sleep variability in all parameters compared to other racial groups. There was a main effect of sex on sleep midpoint SD and social jetlag with males averaging slightly more than females.

Conclusion

Our study provides important observations on sleep irregularity parameters of residents of the United States by using objectively measured sleep patterns and will provide unique insights for personalized advice on sleep hygiene.

Changes in Pediatric Movement Behaviors During the COVID-19 Pandemic by Stages of Lockdown in Ontario, Canada: A Longitudinal Cohort Study

BACKGROUND

Children's movement behaviors have been affected by the COVID-19 pandemic; however, little is known regarding movement behavior patterns over time by government-issued lockdowns. Our primary objective was to evaluate how children's movement behaviors changed by stages of lockdown/reopening in Ontario, Canada, from 2020 to 2021.

METHODS

A longitudinal cohort study with repeated measures of exposure and outcomes was conducted. The exposure variables were dates from before and during COVID-19 when child movement behavior questionnaires were completed. Lockdown/reopening dates were included as knot locations in the spline model. The outcomes were daily screen, physical activity, outdoor, and sleep time.

RESULTS

A total of 589 children with 4805 observations were included (53.1% boys, 5.9 [2.6] y). On average, screen time increased during the first and second lockdowns and decreased during the second reopening. Physical activity and outdoor time increased during the first lockdown, decreased during the first reopening, and increased during the second reopening. Younger children (<5 y) had greater increases in screen time and lower increases in physical activity and outdoor time than older children (≥5 y).

CONCLUSIONS

Policy makers should consider the impact of lockdowns on child movement behaviors, especially in younger children.

Health disparities in pediatric sleep-disordered breathing

Sleep-disordered breathing reflects a continuum of overnight breathing difficulties, ranging from mild snoring to obstructive sleep apnea syndrome. Sleep-disordered breathing in childhood is associated with significant adverse outcomes in multiple domains of functioning. This review summarizes the evidence of well-described ethnic, racial, and socioeconomic disparities in pediatric sleep-disordered breathing, from its prevalence to its treatment-related outcomes. Research on potential socio-ecological contributors to these disparities is also reviewed. Critical future research directions include the development of interventions that address the modifiable social and environmental determinants of these health disparities.

Impact of the COVID-19 pandemic on children's sleep habits: an ECHO study

BACKGROUND

Sleep in childhood is affected by behavioral, environmental, and parental factors. We propose that these factors were altered during the COVID-19 pandemic. This study investigates sleep habit changes during the pandemic in 528 children 4-12 years old in the US, leveraging data from the Environmental Influences on Child Health Outcomes (ECHO) Program.

METHODS

Data collection occurred in July 2019-March 2020 (pre-pandemic) and two pandemic periods: December 2020-April 2021 and May-August 2021. Qualitative interviews were performed in 38 participants.

RESULTS

We found no changes in sleep duration, but a shift to later sleep midpoint during the pandemic periods. There was an increase in latency at the first pandemic collection period but no increase in the frequency of bedtime resistance, and a reduced frequency of naps during the pandemic. Qualitative interviews revealed that parents prioritized routines to maintain sleep duration but were more flexible regarding timing. Children from racial/ethnic minoritized communities slept less at night, had later sleep midpoint, and napped more frequently across all collection periods, warranting in-depth investigation to examine and address root causes.

CONCLUSIONS

The COVID-19 pandemic significantly impacted children sleep, but parental knowledge of the importance of sleep might have played a significant protective role.

IMPACT

During the COVID-19 pandemic, US children changed their sleep habits, going to bed and waking up later, but their sleep duration did not change. Sleep latency was longer. Parental knowledge of sleep importance might have played a protective role. Regardless of data collection periods, children from racial/ethnic minoritized communities slept less and went to bed later. This is one of the first study on this topic in the US, including prospective pre-pandemic qualitative and quantitative data on sleep habits. Our findings highlight the pandemic long-term impact on childhood sleep. Results warrants further investigations on implications for overall childhood health.

Sleep health among U.S. Hispanic/Latinx children: An examination of correlates of meeting sleep duration recommendations

OBJECTIVES

The objective of this study was to examine the association between sociodemographic, behavioral, and environmental factors and adherence to sleep duration recommendations among 1165 U.S. Hispanic/Latinx children.

METHODS

In this cross-sectional study, the following parent-reported variables were examined as correlates of whether children met age-appropriate nightly sleep duration recommendations: caretaker and child demographics (eg, gender, age, poverty level), presence of TV in child's bedroom, child's daily screen time and bedtime.

RESULTS

Most (61.4%) children (mean age: 6.39 years, SD = 2.66) met sleep duration guidelines. Multivariable regression results revealed the odds of meeting recommendations were significantly higher among children 6-12 years old living above the poverty threshold (odds ratio [OR] = 1.57; 95% confidence interval [95%CI]: 1.08, 2.31) and those with a regular bedtime ("Some of the time:" OR = 2.05; 95%CI: 1.07, 3.92; "Most of the time:" OR = 3.19; 95%CI: 1.77, 5.74; "Always:" OR = 4.46; 95%CI: 2.43, 8.13).

CONCLUSIONS

Sleep health disparities must be addressed through culturally and contextually appropriate interventions that combine individual-level strategies with those that address social and environmental factors.

Racial/ethnic disparities in infant sleep in the COVID-19 Mother Baby Outcomes (COMBO) study

OBJECTIVE

Investigate racial and ethnic differences in infant sleep and examine associations with insurance status and parent-infant bedtime behavioral factors (PIBBF).

METHODS

Participants are part of the COVID-19 Mother Baby Outcomes (COMBO) Initiative, Columbia University. Data on infant sleep (night, day and overall sleep duration, night awakenings, latency, infant's sleep as a problem) were collected at 4 months postpartum. Regressions estimated associations between race/ethnicity, insurance status, PIBBF and infants' sleep.

RESULTS

A total of 296 infants were eligible (34.4% non-Hispanic White [NHW], 10.1% Black/African American [B/AA], 55.4% Hispanic). B/AA and Hispanic mothers were more likely to have Medicaid, bed/room-share, and report later infant bedtime compared to NHW mothers. Infants of B/AA mothers had longer sleep latency compared to NHW. Infants of Hispanic mothers slept less at night (∼70 ± 12 minutes) and more during the day (∼41 ± 12 minutes) and Hispanic mothers were less likely to consider infants' sleep as a problem compared to NHW (odds ratio 0.4; 95% confidence interval: 0.2-0.7). After adjustment for insurance status and PIBBF, differences by race/ethnicity for night and day sleep duration and perception of infant's sleep as a problem persisted (∼32 ± 14 minutes, 35 ± 15 minutes, and odds ratio 0.4; 95% confidence interval: 0.2-0.8 respectively). Later bedtime was associated with less sleep at night (∼21 ± 4 minutes) and overall (∼17 ± 5 minutes), and longer latency. Infants who did not fall asleep independently had longer sleep latency, and co-sleeping infants had more night awakenings.

CONCLUSIONS

Results show racial/ethnic differences in sleep in 4-month-old infants across sleep domains. The findings of our study suggest that PIBBF have an essential role in healthy infant sleep, but they may not be equitably experienced across racial/ethnic groups.

Effects of a Sleep Health Education Program for Children and Parents on Child Sleep Duration and Difficulties: A Stepped-Wedge Cluster Randomized Clinical Trial

IMPORTANCE

Preschool-aged children often lack sufficient sleep and experience sleep difficulties. A consistent bedtime routine, falling asleep alone, and other sleep practices reduce difficulties and increase sleep duration.

OBJECTIVE

To evaluate the effects of a preschool-based sleep health literacy program on children's sleep duration and difficulties and on parent sleep knowledge, attitudes, self-efficacy, and beliefs 9 and 12 months after the program.

DESIGN, SETTING, AND PARTICIPANTS

This stepped-wedge cluster randomized clinical trial was implemented across the 2018-2019 school year. Head Start preschool personnel delivered interventions and collected outcomes data at baseline and 4 follow-ups. Seven Head Start agencies across New York State were randomized to implement interventions in either fall 2018 or winter and spring 2019. Outcomes were ascertained at 9- and 12-month follow-up. From March 19 through September 28, 2018, Head Start staff recruited (a) English- or Spanish-speaking parents (b) of children 3 years of age on or about September 2018 (c) who planned to remain at the site through the school year. Altogether, 519 parent-child (aged 3 years) dyads completed baseline and (any) follow-up data.

INTERVENTIONS

A 2-week classroom curriculum for children, a 1-hour parent workshop, and 1-on-1 parent discussions at home or school.

MAIN OUTCOMES AND MEASURES

Outcomes were the pre- vs postintervention differences measured at baseline and 9-month follow-up for parent-reported child school-night sleep duration per sleep logs, mild or moderate sleep difficulties per a validated questionnaire, and the total and domain scores for parent sleep knowledge, attitudes, self-efficacy, and beliefs. A modified intention-to-treat analysis excluding participants with only baseline data was used.

RESULTS

The mean (SD) age at enrollment of 519 children was 2.7 (0.1) years, 264 (50.9%) were girls, 196 (37.8%) lived in Spanish-speaking households, and 5 (0.9%) identified as Alaskan Native or American Indian, 17 (3.2%) as Asian American or Pacific Islander, 57 (10.8%) as Black, 199 (37.8%) as White, and 63 (12.0%) as other. Mean sleep durations increased nonsignificantly from baseline by 5.6 minutes (95% CI, -2.3 to 13.6 minutes; P = .17) at 9-month follow-up and by 6.8 minutes (95% CI, 0.2-13.7 minutes; P = .06) at 12-month follow-up. There was a slight improvement in parental knowledge (1.13 unit increase from baseline; 95% CI, 0.13-2.12 units), but no significant outcomes for parent sleep attitudes (0.16 unit increase from baseline; 95% CI, -0.46 to 0.77 units), self-efficacy (-0.13 unit decrease from baseline; 95% CI, -1.02 to 0.76 units) and beliefs (-0.20 unit decrease from baseline; 95% CI, -0.56 to 0.16 units). Intervention effects for child sleep difficulties were not significant (odds ratio, 1.13; 95% CI, 0.62-2.09). Fewer than 1 in 4 parents accurately perceived their child's sleep difficulty at 12 months.

CONCLUSIONS AND RELEVANCE

The findings of this large pragmatic, stepped-wedge cluster randomized clinical trial, albeit largely negative, may have implications for the sustained impact, focus, and potential population-level effects of sleep education programs. Future research should evaluate the effects of more recurrent programming that emphasizes recognition of sleep problems and whether small increments of sleep across months and years in early childhood have meaningful effects.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03556462.

Sleep Deficiency in Young Children

There is growing public health concern about the high prevalence of sleep deficiency in early childhood and the associated risk for sleep-associated poor health outcomes, including metabolic, cardiovascular, and mental health. The recent shift to conceptualize sleep health as a multidimensional construct, influenced by socioecological factors, highlights the potential role of sleep in health disparities. Understanding the development of sleep health and the emergence of sleep disorders in early life is a current priority in pediatric sleep research. Future behavioral sleep interventions should consider the multiple socioecological influences on children's sleep health and be tested using inclusive sampling methods.

Rates of diagnoses of sleep disorders in children with chronic medical conditions

STUDY OBJECTIVES

This investigation examines sleep disorder (SD) diagnoses in a large population of children and adolescents with chronic medical conditions (CMCs). Little is known about SD diagnoses in this population. The large population used in this study allowed examination of SD rates by CMC type and demographics.

METHODS

Data were from the Coordinated Health Care for Complex Kids (CHECK) project designed for Medicaid-funded children and adolescents with at least one CMC from a large metropolitan area. The study population (N=16,609) was limited to children and adolescents, 0 to 18 years of age. SD and CMC diagnoses were obtained from Medicaid claims data.

RESULTS

Fourteen percent of the population (mean age of 9.1 years [SD= 5.2]; 35.8% African American (AA); 56.4% male; 77 with more than one CMC) received a sleep disorder diagnosis. The most frequent diagnosis was SDB (11.2%), followed by nocturnal enuresis (1.2%), and insomnia (1%). SDs were diagnosed more frequently in those with multiple CMCs than in those with one CMC (19.7% vs. 5.8%; p <0.001). Insomnia rates in Hispanic/Latinx (1.2%) and AA (0.8%) children and adolescents were significantly lower (both p<0.001) than in Caucasians (3.5%). Odds of receiving a sleep diagnosis varied among CMCs.

CONCLUSIONS

Our analysis of Medicaid claims data of a large urban cohort offers detailed information about the rates of sleep diagnoses and suggests under-diagnosis of SDs in this vulnerable, high-risk, primarily ethnic minority population. Under-recognition of sleep disorders have short- and long-term health and economic consequences. Study results may help clinicians implement appropriate SD screening and management for children and adolescents with CMCs.

Associations between Childhood Maltreatment and Behavioral Sleep Disturbances Across the Lifespan: A Systematic Review

Childhood maltreatment has a range of long-term developmental and health consequences. Emerging research suggests that sleep disturbances may be a key behavioral health risk factor implicated in the relationship between maltreatment and poor health across the lifespan. This systematic review examined the association between maltreatment and behavioral sleep disturbances in childhood and adulthood. Studies were identified through PsycINFO, PubMed, and alternative search strategies such as Google Scholar and reference list checks, with an end date of July 2021. Quantitative, peer-reviewed articles examining behavioral sleep outcomes and/or characteristics among maltreatment-exposed samples were included. We assessed the potential risk of bias by examining study design and sleep and maltreatment assessment methods. Across 73 studies included in this review, there was a robust association between childhood maltreatment and behavioral sleep disturbances. Findings suggest that linkages between maltreatment and sleep outcomes diverge with respect to maltreatment characteristics, type of behavioral sleep disturbance assessed, use of subjective versus objective measures, and study design. Given that behavioral sleep disturbances are modifiable, more research is needed that incorporates objective measures of sleep and longitudinal designs to identify specific points of intervention to mitigate the potential long-term impacts of childhood maltreatment on health across socio-demographically diverse populations.

Sleep Well! An adapted behavioral sleep intervention implemented in urban primary care

STUDY OBJECTIVES

To describe the adaptation, feasibility, and initial outcomes of Sleep Well!, an intervention for early childhood insomnia and insufficient sleep, designed for families from lower-socioeconomic status (SES) backgrounds presenting to large metropolitan primary care sites.

METHODS

Fifteen caregiver-child dyads (caregivers: 92.3% mothers; 80.0% Black; 53.3% ≤125% US poverty level; children: 73.3% female; 86.7% Black; M age = 3.0 years) participated this multi-method, single-arm trial. A family advisory board of caregivers (N = 4) and a clinician advisory board of sleep experts, primary care clinicians, and psychologists (N = 13) provided intervention feedback throughout the pilot. Most adaptations were related to intervention delivery methods, with some related to sleep strategies. At post-intervention, caregivers completed surveys on intervention acceptability and cultural humility (primary outcomes) and completed semi-structured interviews. Caregivers also reported on child sleep pre- and post-intervention.

RESULTS

Thirteen (86.6%) families completed Sleep Well! and 12 (80.0%) completed pre- and post-intervention measures. Caregivers reported strong intervention acceptability and cultural humility. There were pre-to-post reductions in child sleep problems, bedroom electronics, sleep onset latency, and night awakening frequency and duration. Nighttime sleep duration and overall insufficient sleep also improved. Qualitative data also showed strong intervention acceptability and perceived flexibility, with few participation barriers.

CONCLUSIONS

A brief, early childhood behavioral sleep intervention delivered in primary care with families from primarily lower-SES and/or racially minoritized backgrounds is feasible to implement, with strong retention rates, acceptability, and perceptions of cultural humility. Child sleep improvements are positive, and warrant replication in a randomized controlled trial.

Daily concordance between ecological stressors and sleep in young minority children during the pre-COVID-19 outbreak period

OBJECTIVE

As the COVID-19 pandemic brings widespread changes in families, the sociology of sleep becomes noticeable. Yet, the socio-contextual determinants of a biopsychosocial phenomenon as sleep are poorly investigated. We examine changes concomitantly occurring in the child's sleep per familial and community stressors.

METHODS

During the pre-COVID-19 outbreak period, in 24 minority children (5.4 ± 1.7 years old, 54.2% girls), sleep was objectively measured 24 h for two consecutive weeks, and this was repeated three times over the study period of three months. The caregiver filled out questionnaires surveying sociodemographic, community and family aspects.

RESULTS

Children went to bed at 22:26 and woke up at 07:04, with each a variability of about 50 min. Money and time were revealed as related key stressors to sleep. Five dimensions best fitted their association. In general, concurrent changes within the individual child indicate that mean sleep variables seem to relate to predominantly features of the stressors (explained variance of 34.7 to 56.7%), while variability of sleep tends to associate to situational aspects of the stressors (explained variance of 30.4 to 61.8%). Associations were best explained in terms of the 24 h dimension, particularly exposing sleep variability.

CONCLUSION

Individual variabilities in a child's sleep are associated with familial resources, such as caregiver's time to self, money and basic needs. Time spent in bed, a modifiable factor by society and shaper of sleep quantity and quality, plays a key role in stressor-sleep associations. Insights from biopsychosocial perspectives may be valuable for understanding COVID-19 sleep studies, and the development of (post-) COVID-19 sleep recommendations.

Sleep, Classroom Behavior, and Achievement Among Children of Color in Historically Disinvested Neighborhoods

Children of color are more likely to have poor sleep health than White children, placing them at risk for behavioral problems in the classroom and lower academic performance. Few studies, however, have utilized standardized measures of both classroom behavior and achievement. This study examined whether children's sleep (parent and teacher report) in first grade concurrently related to independent observations of classroom behavior and longitudinally predicted achievement test scores in second grade in a sample of primarily Black (86%) children (n = 572; age = 6.8) living in historically disinvested neighborhoods. Higher teacher-reported child sleepiness was associated with lower adaptive behaviors and higher problem behaviors in the classroom, and predicted lower achievement. Parent-reported bedtime resistance and disordered breathing also predicted lower achievement.

Maternal Mental Health Symptoms and Clusters Predict Toddler Sleep in Low-Income Homes

The authors examined the association of maternal mental health symptoms and symptom clusters with the sleeping behaviors of toddlers living in low-income homes. The sample is comprised of 174 racially diverse mother and toddler (15-19 months old) dyads who were participating in a longitudinal birth cohort study. Dyads were initially recruited from Women, Infant, and Children clinics in a Midwestern county of the United States. Maternal mental health symptoms were measured with self-reports of depression (Center for Epidemiological Studies-Depression), parenting stress (Parenting Stress Index Very Short Form), and parenting self-efficacy. Toddler sleeping behaviors were measured with an adaptation of the Tayside Children's Sleep Questionnaire that assessed toddler difficulties in initiating or maintaining sleep (DIMS). Maternal mental health symptom clusters were identified with latent profile analysis and toddler DIMS were regressed on maternal mental health symptoms. We found that 1 SD worse maternal depression, parenting stress, or parenting self-efficacy predicted 0.18-0.24 SD worse toddler DIMS (p < .05). Moreover, we found that the cluster of adverse maternal mental health symptoms predicted nearly 0.75 SD worse toddler DIMS as compared with the cluster of good maternal mental health symptoms (p < .05). These findings provide insight into how maternal mental health symptom clusters may be important in understanding sleep behaviors in early toddlerhood, a sensitive period of sleep development, and underscore the need to support mothers with co-occurring adverse mental health symptoms, as their children may be at higher risk for DIMS.

A systematic review of the association between sleep health and stress biomarkers in children

Sleep is intimately linked with the stress response system. While the evidence for this connection has been systematically reviewed in the adult literature, to our knowledge no studies have examined this relationship in young children. Recent scientific interest in understanding the effects of adverse environments in early childhood, including an emphasis on understanding the role of sleep, highlights the importance of synthesizing the current evidence on the relationship between sleep and the stress response system in early childhood. The aim of this systematic review is to examine the relationship between sleep health and biomarkers of physiologic stress (neuroendocrine, immune, metabolic, cardiovascular) in healthy children ages 0-12 y. Following PRISMA guidelines, we identified 68 empirical articles and critically reviewed and synthesized the results across studies. The majority of studies included school-age children and reported sleep dimensions of duration or efficiency. Overall, evidence of associations between sleep health and stress biomarkers was strongest for neuroendocrine variables, and limited or inconsistent for studies of immune, cardiovascular, and metabolic outcomes. Gaps in the literature include prospective, longitudinal studies, inclusion of children under the age of 5 y, and studies using objective measures of sleep.

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.

Socioeconomic disadvantage and sleep in early childhood: Real-world data from a mobile health application

OBJECTIVES

To examine whether increased socioeconomic disadvantage, indexed using a measure of community distress, was associated with variation in caregiver-reported early childhood sleep patterns and problems in a large US sample using a mobile health application (app).

DESIGN

Cross-sectional.

SETTING

Data were collected using the free, publicly available Johnson's Bedtime© baby sleep app.

PARTICIPANTS

A total of 14,980 caregivers (85.1% mothers) of children ages 6-35.9 months (M = 13.88 months; 52.6% boys) participated in this study.

MEASURES

Caregivers reported on child sleep using the Brief Infant Sleep Questionnaire-Revised. Socioeconomic disadvantage was indexed by zip code using the Distressed Communities Index (DCI), which combines seven US census indicators of socioeconomic disadvantage. DCI scores range from prosperous (lowest quintile) to distressed (highest quintile).

RESULTS

Socioeconomic disadvantage was significantly associated with later bedtimes, longer sleep onset latency, and shorter nighttime and 24-hour (total) sleep duration, with children living in distressed communities showing the poorest sleep. However, caregivers living in distressed communities reported a significantly lower prevalence of overall child sleep problems (43% vs 58% in prosperous communities), and more confidence in managing child sleep (42% vs 34% in prosperous communities).

CONCLUSIONS

Children living in the most distressed communities have the poorest reported sleep patterns and bedtime behaviors; however, their caregivers are less likely to report problematic child sleep. These findings highlight the need for community-level sleep health promotion interventions, as well as further investigation of caregiver perceptions about child sleep and sleep health promotion among families living in socioeconomically disadvantaged contexts.

A Systematic Review on Cross-Cultural Comparative Studies of Sleep in Young Populations: The Roles of Cultural Factors

Recent studies have shown that sleep is influenced and shaped by cultural factors, including cultural values, beliefs and practices. However, a systematic understanding of how cultural factors in countries may influence sleep duration and sleep disturbances is still lacking. Therefore, we focused on a comparison of sleep duration and disturbances in young populations between countries. We report cross-cultural differences between the child, parent and environmental factors, and their association with sleep duration and disturbances. The review is based on literature searches of seven databases published until December 2020. Studies were included if they investigated sleep duration and disturbances of individuals up to 18 years across at least two or more countries. The results of this review have shown that sleep duration and disturbances vary between countries and regions and certain factors (e.g., bedtime routines, sleeping arrangement, physical activity and psychological functioning) have been associated with sleep duration or disturbances. This review also demonstrates that certain factors which were associated with sleep duration or disturbances in one country, were not shown in other countries, suggesting a need for recommendations for age-related sleep duration and sleep interventions to consider cultural differences that influence sleep duration or disturbances in individual countries or regions.

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.

Identifying Modifiable Factors Linking Parenting and Sleep in Racial/Ethnic Minority Children

BACKGROUND

Young children from racial and ethnic minority backgrounds are at risk for poor sleep, yet few studies have tested behavioral interventions in diverse samples. This study tests factors that could contribute to associations between parenting skills and child sleep to inform interventions for children at risk of poor sleep outcomes. Specifically, we examined household chaos, caregiver sleep knowledge, and caregiver sleep quality as putative mediators that may be relevant to interventions seeking to improve child sleep.

METHODS

Caregivers (M age 31.83 years; 46.2% African American; 52.1% Hispanic/Latinx, 95% female) of 119 1- to 5-year-old children (M age 3.99 years; 43.7% African American; 42.0% Hispanic/Latinx, 14.3% biracial; 51.3% female) completed measures of parenting practices, child and caregiver sleep, household chaos, and sleep knowledge. Indices of pediatric insomnia symptoms (difficulty falling/remaining asleep) and sleep health (sleep duration/hygiene) were constructed based on previous research. Parallel mediation models were conducted using ordinary least squares path analysis.

RESULTS

Lower household chaos significantly attenuated the relationship between positive parenting skills and better child sleep health, suggesting chaos may serve as a potential mediator. There were no significant contributing factors in the pediatric insomnia model. Sleep knowledge was related to sleep health and caregiver sleep quality was related to pediatric insomnia, independent of parenting skills.

CONCLUSION

Interventions to improve sleep in early childhood may be enhanced by targeting parenting skills and household routines to reduce chaos. Future longitudinal research is needed to test household chaos and other potential mediators of child sleep outcomes over time.