Seeing the Whole Elephant: a scoping review of behavioral treatments for pediatric insomnia

The Sleep Train Program: Efficacy of a Behavioral Sleep Intervention for Children with Externalizing Problems

OBJECTIVES

The study objective was to examine the impact of a brief behavioral sleep intervention (The Sleep Train Program) on sleep and behavior in children with externalizing behavior problems.

METHOD

Children (3-8 years) presenting to a behavioral health clinic for externalizing problems were randomized to receive a behavioral sleep intervention or a mealtime intervention (active control). Families then completed parent management training followed by the cross-over intervention. Outcomes included parent-reported child sleep and behavior and actigraphic sleep, and were examined in the full sample and in a subsample of children with comorbid sleep difficulties.

RESULTS

In a subsample of children with both externalizing and sleep difficulties, children randomized to behavioral sleep intervention showed reduced externalizing problems (t = -2.75, p < .05), reduced night wakings (t = -2.21, p < .05), and improved parent-child interactions (t = 2.99, p = .01) and child behavior (t = -2.42, p < .05) at bedtime, compared to active control. In the full sample, in which some children did not present with sleep difficulties, behavioral sleep intervention, compared to active control, did not yield significant improvements in most sleep and behavior outcomes. Comparing sleep and behavior before and after behavioral sleep intervention across groups, children had fewer externalizing behaviors (t = 4.98, p < .001), improved sleep habits (t = -3.24, p < .05) and improved parent-child bedtime interaction (t = -3.24, p < .01), but no changes in sleep patterns.

CONCLUSION

A brief behavioral sleep intervention was efficacious in improving both sleep and behavior outcomes for children with comorbid sleep and externalizing difficulties, but not for children with only externalizing difficulties.

Melatonin use in typically developing (TD) children: International Pediatric Sleep Association (IPSA) Expert Consensus Recommendations for Healthcare Providers

Although melatonin is widely used globally for the management of insomnia in children and adolescents, there are few clinical guidelines available for healthcare practitioners, particularly in typically developing (TD) children. Because existing data are either sparse or inconclusive, a task force comprised of pediatric sleep researchers and clinicians was established by the International Pediatric Sleep Association (IPSA) to first examine the available literature and to then develop a set of evidence-based (when possible) and consensus-based recommendations to guide practitioners in decision-making regarding melatonin use in pediatric insomnia. The following recommendations regarding appropriate indications for melatonin in children, considerations regarding timing and dosage, safety issues and caveats in recommending use of melatonin in pediatric clinical settings, are presented as a companion to a Technical Report summarizing the available literature.

Contribution of the Brief Family Strength-Oriented Therapeutic Conversation Intervention to Early Childhood Sleep Health: A Quasi-Experimental Study

The family context is an important factor for sleep health in early childhood. About 40% of children between 0 and 3 years have problems regarding sleep that can affect their development. The aim of this study was to investigate the contribution of the brief family strength-oriented therapeutic conversation intervention to early-childhood sleep health. Data were collected in 2020-2021 from 57 primary caregivers of young children with moderate or severe sleep difficulties. The intervention was delivered through (a) a one 60-min face-to-face family educational and support session and (b) one to six 20- to 40-min telephone sessions based on the families' needs. After the intervention, primary caregivers reported greater family support, more helpful beliefs about their infant's/child sleep patterns, better family quality of life (QOL), better self-regulation regarding learning to fall and staying asleep among infants, and longer sleep periods at night in infants. These findings may prevent infants sleep difficulties from increasing and becoming more serious.

The Management of Chronic Insomnia in Young Children: A Survey of UK General Practice

OBJECTIVES

Chronic insomnia (CI), the most common sleep disorder in young children, is associated with negative outcomes for the child and family. This study explores the beliefs, current practice, and understanding of UK primary health care professionals (PCPs) regarding CI in children under 5 years.

METHOD

An online survey of UK PCPs (e.g. general practitioners (GPs), practice nurses) recruited through Clinical Research Networks. The survey consisted of Likert-style and closed- questions regarding beliefs, current practice, and training/knowledge. Data were analyzed descriptively.

RESULTS

Two hundred and ninety-five PCPs took part (mostly GPs, n = 244). Respondents believe that CI has a large impact on children and family. 80% agreed that CI should be managed in health care and 66.3% in primary care. However, consultations with families regarding CI were reported as infrequent. 91.6% agreed that CI should be managed with behavioral approaches, and more than  85% of respondents recommend positive bedtime routines. Respondents had varied confidence and knowledge about management. They had received little to no professional education about CI.

CONCLUSIONS

PCPs recognize the importance of CI and understand some principles of management, though they lack training and confidence. Improved training and awareness of evidence-based resources for support would improve management in primary care.

Melatonin use in managing insomnia in typically developing (TD) children: A technical report

Although melatonin is widely used globally for the management of insomnia in children and adolescents, there are few clinical guidelines available for healthcare practitioners, particularly in typically developing (TD) children. Because existing data are either sparse or inconclusive, a task force comprised of pediatric sleep researchers and clinicians was established by the International Pediatric Sleep Association (IPSA) to first examine the available literature and to develop a set of evidence-based (when possible) and consensus-based recommendations to guide practitioners in decision-making regarding melatonin use in pediatric insomnia. A summary of the evidence pertaining to melatonin's use in pediatric clinical settings, and efficacy and safety in TD children is presented below as a companion to an accompanying list of specific recommendations.

Sleep and adjustment in foster environments for toddlers and preschoolers (SAFE-T): Initial efficacy of a trauma-informed sleep intervention for young children in foster care

BACKGROUND

This study presents findings from a randomized controlled trial of Sleep and Adjustment in Foster Environments for Toddlers and Preschoolers (SAFE-T), a telehealth-delivered, trauma-informed sleep intervention for children in or adopted from foster care.

METHODS

N = 45 caregivers of children aged 2 to 5 years (M = 4.01; SD = 1.04) were randomized to SAFE-T or Sleep Education Support (SES), an active control condition. Assessments, including one-week parent-report sleep diaries, were completed at pre- intervention, post- intervention, and 3 months follow-up.

RESULTS

Results indicated improvements in multiple sleep outcomes at post-intervention and three months later, including nighttime sleep duration, nighttime awakenings, and overall sleep problems in the SAFE-T group only. Sleep-based improvements were largely maintained or strengthened over time. Several secondary outcomes, including child emotional and behavior problems and parenting stress, also improved considerably in the SAFE-T but not the SES group.

CONCLUSIONS

Findings suggest SAFE-T to be a promising intervention for improving sleep health among children currently or previously placed in foster care.

Review of implementation models for children's sleep support services in the UK

Sleep deprivation has a serious impact on physical and mental health. Children with neurodevelopmental disorders are frequently affected by chronic insomnia, defined as difficulty in either initiating sleep, maintaining sleep continuity or poor sleep quality which can lead to long-term detrimental effects on behaviour, learning and development.Interventions to address chronic insomnia in children include both pharmacological and non-pharmacological approaches. While some children unequivocally benefit from pharmacological treatment, recommendations suggest an intervention based on cognitive-behavioural techniques involving a thorough assessment of the child's sleep pattern, environment and psychosocial factors supporting the child to learn to self-soothe as first-line treatment. Evidence from sleep clinics delivered by trained community practitioners supports the efficacy of an intensive programme, whereby education, practical advice and follow-up support were key factors; however, these services are inconsistently resourced. In practice, sleep support interventions range from verbal advice given in clinics to healthy sleep leaflets to tailored and non-tailored parent-directed interventions. Delivery models include promotion of safe sleep within a wider health promotion context and targeted early intervention within sleep clinics delivered in health and community services or by the third sector but evidence for each model is lacking.We describe a comprehensive whole systems city-wide model of sleep support, ranging from awareness raising, universal settings, targeted support for complex situations to specialist support, delivered according to complexity and breadth of need. By building capacity and quality assurance into the existing workforce, the service has been sustainable and has continued to develop since its initial implementation in 2017. With increasing access to specialist sleep services across the UK, this model could become a widely generalisable approach for delivery of sleep services to children in the UK and lead to improved outcomes in those with severe sleep deprivation.

Advancing Patient-Centered Care: An International Survey of Adolescent Perspectives on Insomnia

OBJECTIVE

The study objective was to inform patient-centered care for adolescent insomnia by describing adolescents' perspectives on insomnia. Specific constructs of interest included: 1) factors that contributed to insomnia development or maintenance, 2) impact of insomnia on day-to-day life, 3) recommended research priorities, and 4) overall experience living with insomnia.

METHOD

A convenience sample of adolescents (ages 13-18 years) self-identifying with insomnia symptoms was recruited through social media. Respondents (n = 3,014) completed an online survey. Responses to an open-ended item assessing patient experience were coded using thematic analysis.

RESULTS

Participants identified as 70.8% White non-Hispanic, 77.0% female, and lived in one of five English-speaking countries (United States, United Kingdom, Canada, Australia, or New Zealand). Most (87.5%) met DSM-V diagnostic criteria for insomnia. The most common contributory factors to insomnia endorsed were stress (72.1%) and depressed mood (63.6%), while common impact areas were mood (72.2%), focus (61.0%), and pain (49.7%). Patient-centered research priorities were identifying insomnia causes (66.4%) and early detection (66.1%). Common adolescent experiences included high distress levels, feelings of invalidation, and helplessness about their insomnia.

CONCLUSIONS

Adolescents with insomnia offer a unique perspective that should inform patient-centered research and care. There is a need for heightened screening and awareness about insomnia as a condition that causes significant distress and impairment for adolescents. To provide validating care, providers should recognize the multifaceted causes of insomnia.

Melatonin use in infants and toddlers

Background Melatonin use in the pediatric population is on the rise in the United States, where it is available as an over-the-counter and online supplement. There are no data regarding the safety and efficacy of melatonin in children less than 2 years old. The aim of this study was to examine various aspects of melatonin use by caregivers of infants and toddlers in the US. Methods Caregiver users of the Nanit baby monitoring system with a child aged 0-36 months were invited to complete an online survey regarding melatonin use, sources of information/recommendations about melatonin, formulations used and reasons for administering melatonin to their child. Participants also completed the Brief Infant Sleep Questionnaire-Revised (BISQ-R). Results A total of 3063 caregivers (1.93%) responded to the survey, of whom 1.7% had ever used melatonin for their child. About half of those caregivers had received a recommendation for melatonin from a source other than a healthcare professional. Caregiver perception of 'sleep as a problem' as assessed by the BISQ-R was not significantly different between those who had or had not used melatonin for their child, and reasons for use included non-supported indications such as sleeping later or promoting "more restful and better sleep". Conclusions The results of this study support mounting concerns regarding the widespread use of melatonin in the US pediatric population, especially given the lack of regulatory oversight and the documented inaccuracy of label claims versus actual melatonin content.

Exploring the association between income inequality and sleep in Canadian adolescents: A path analysis approach

OBJECTIVES

An estimated 30% of Canadian adolescents do not get the recommended 8-10hours of sleep. No prior study has examined the role of income inequality, the gap between rich and poor within a society, in adolescent sleep. The aim of this study is to examine the association between income inequality and sleep duration among Canadian adolescents, how this association differs by gender, and whether depressive symptoms, anxiety, and social cohesion mediate this relationship.

METHODS

Multilevel path models were conducted using cross-sectional survey data from 74,501 adolescents who participated in the Cannabis, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary behavior (COMPASS) study in 2018-2019. Income inequality was measured at the census division level and sleep duration, gender, depressive symptoms, anxiety, and social cohesion were measured at the individual level.

RESULTS

A 1% increase in income inequality was associated with a 3.67-minute decrease in sleep duration (95% CI=-5.64 to -1.70). The cross-level interactions between income inequality and gender were significant, suggesting that income inequality has more adverse associations with sleep among females than males. Both depressive symptoms and anxiety were significant mediators, wherein greater income inequality was associated with higher levels of depressive symptoms and anxiety, which were in turn, associated with a shorter sleep duration.

CONCLUSION

Interventions that reduce income inequality may prevent depressive symptoms and anxiety and improve sleep in adolescents. Reducing societal income gaps may improve adolescent sleep especially in those attending school in high income inequality areas, females, and those experiencing depressive symptoms and anxiety.

Five-year follow-up of a clinic-based sleep intervention for paediatric epilepsy: A randomized clinical trial

Sleep disturbances in children with epilepsy are prevalent, and are associated with substantial adverse medical and psychosocial consequences. This study is a 5-year follow-up of a clinic-based sleep intervention study that randomized 100 toddlers and preschool-age children with epilepsy to a usual care group or a sleep intervention group. The intervention group received standard paediatric neurology care plus three education sessions during the child's routine clinic visit. The outcomes measured were: (1) child sleep by actigraphy and parental report; and (2) maternal sleep and depression. We aimed to evaluate the long-term benefits of a clinic-based sleep intervention for paediatric epilepsy. In total, 42 families (42.0%) participated. The average child's age at follow-up was 9.55 years. Thirty-eight (90.5%) children were not obtaining sufficient sleep at baseline, and 40 (95.2%) at the 5-year follow-up. The numbers of children with clinically significant sleep disturbances were 40 (95.2%) at baseline and 36 (85.7%) at the 5-year follow-up. Fourteen mothers (33.3%) had poor sleep quality and high depressive symptoms at both assessment time points. There were no differences (P > 0.05) in the child and maternal outcomes between the two trial arms. Overall, there was no evidence that a clinic-based sleep intervention that effectively improved multiple aspects of sleep in toddlers and preschool-age children with epilepsy had long-lasting beneficial effects. Our findings suggest that sleep interventions for families of children with epilepsy require ongoing reinforcement and monitoring during routine paediatric neurology care to prevent sleep problems from persisting or recurring.

The Tension Between AAP Safe Sleep Guidelines and Infant Sleep

OBJECTIVES

To understand tension mothers experience when attempting to follow American Academy of Pediatrics safe sleep guidelines and enhancing infant and parental sleep.

METHODS

Surveys and focus groups were conducted from November 2022 and March 2023 with United States-based English-speaking mothers of infants <6 months of age recruited via social media and who reported a nonrecommended sleep position and/or location ≥2 times the prior week.

RESULTS

Twenty-five mothers participated in focus groups and surveys. A total of 80% reported holding or rocking their infant to sleep; 76% fed their infant to sleep. Almost all were aware of the ABCs (Alone, Back, Crib) of safe sleep and intended to follow them before delivery. Many felt that ABCs were unrealistic and placed their infants in nonrecommended locations or positions because they perceived them as more comfortable and helping their infant fall and stay asleep. Mothers were more likely to use nonrecommended practices when they were awake or sleeping nearby and believed they could closely monitor their infant. Some questioned whether ABCs were the only way to achieve safe sleep. Some prioritized other safety concerns (eg, fall prevention) over sudden infant death syndrome or sudden unexpected infant death prevention. Mothers expressed confidence about getting their baby to sleep in general but were less confident that they could do this while following guidelines.

CONCLUSIONS

Despite awareness of the ABCs, mothers regularly engaged in nonrecommended practices with the goal of improving their own and their infant's sleep. Interventions focused on improving infant and parental sleep while maintaining sleep safety are needed.

Identifying and developing strategies for implementation of a guided internet- and mobile-based infant sleep intervention in well-baby and community mental health clinics using group concept mapping

BACKGROUND

This study aimed to identify strategies for the implementation of a guided internet- and mobile-based intervention (IMI) for infant sleep problems ("Sleep Well, Little Sweetheart") in well-baby and community mental health clinics.

STUDY DESIGN

We used group concept mapping, a two-phased mixed methods approach, conducted as a two-day workshop in each clinic. We recruited 20 participants from four clinics and collected sorting and rating data for implementation strategies based on the Expert Recommendations for Implementing Change taxonomy and brainstorming sessions. Data were analyzed using descriptive statistics, multidimensional scaling, and hierarchical cluster analysis to create cluster maps, laddergrams, and Go-Zone graphs. Participants were presented with the results and discussed and interpreted the findings at each of the clinics in spring 2022.

RESULTS

Participants identified 10 clusters of strategies, of which Training, Embedding and Coherence, User Involvement and Participation, and Clinician Support and Implementation Counseling were rated as most important and feasible. Economy and Funding and Interactive and Interdisciplinary Collaboration were rated significantly lower on importance and feasibility compared to many of the clusters (all ps < 0.05). There was a correlation between the importance and feasibility ratings (r =.62, p =.004).

CONCLUSIONS

The use of group concept mapping made it possible to efficiently examine well-baby and community clinics' perspectives on complex issues, and to acquire specific knowledge to allow for the planning and prioritization of strategies for implementation. These results suggest areas of priority for the implementation of IMIs related to infant sleep problems.

TRIAL REGISTRATION

The study was pre-registered at Open Science Framework ( www.osf.io/emct8 ).

Maternal beliefs and cognitions about naps in infants and toddlers

Infant and toddler sleep affects family functioning and maternal mental health and well-being. However, little is known about parental perceptions regarding child daytime sleep. The current study aimed to determine maternal beliefs and cognitions of child naps, assessing how naps impact perceived child and maternal functioning. Mothers of 465 infants and toddlers (4-36mos; M = 18.5mos) in the United States completed an online questionnaire addressing those aims, including maternal perception of naps after napping cessation. Most mothers agreed that naps were important (98%). Over two-thirds wanted to change something about their child's naps and one-quarter reported that naps were problematic. About half wished their child fell asleep faster/easier for naps, and one-third wished they napped longer. Few reported that child naps were more trouble than they were worth (4%). Most mothers believed that when their child naps well their child is in a better mood (97%), more easy-going (96%), has fewer tantrums (89%), and listens better (84%, toddlers). Finally, most mothers believed that their child's naps were important for their own day (94%), improved their own mood (87%) made them feel calmer (90%), and enabled them to nap (51%), do more in the house (92%), complete work (87%), spend time with others (78%), and spend time doing things for themselves (80%).   Conclusion: Considering most mothers believed their child's naps were important for their child and themselves, yet many wanted to change something about those naps and/or thought naps were problematic, intervention development is warranted focusing on daytime sleep issues to improve both child and family functioning. What is Known: • Although maternal perceptions of overnight sleep in young children has been well studied, little is known about beliefs and cognitions regarding daytime sleep. What is New: • Mothers of infants and toddlers believe naps are beneficial for their child and are important for child mood, behavior, and sleep. • Mothers find child naps valuable for themselves, allowing time for other activities.

Risk Factors for the Development of Multisite Pain in Children

OBJECTIVE

Chronic pain has economic costs on par with cardiovascular disease, diabetes, and cancer. Despite this impact on the health care system and increasing awareness of the relationship between pain and mortality, efforts to identify simple symptom-based risk factors for the development of pain, particularly in children, have fallen short. This is critically important as pain that manifests during childhood often persists into adulthood. To date, no longitudinal studies have examined symptoms in pain-free children that presage a new, multisite manifestation of pain in the future. We hypothesized that female sex, sleep problems, and heightened somatic symptoms complaints at baseline would be associated with the risk of developing new multisite pain 1 year later.

METHODS

Symptom assessments were completed by parents of youth (ages 9 to 10) enrolled in the Adolescent Brain Cognitive Development study. Multivariate logistic regression models focused on children who developed multisite pain 1 year later (n=331) and children who remained pain free (n=3335).

RESULTS

Female sex (odds ratio [OR]=1.35; 95% CI, 1.07, 1.71; P =0.01), elevated nonpainful somatic symptoms (OR=1.17; 95% CI, 1.06, 1.29; P <0.01), total sleep problems (OR=1.20; 95% CI, 1.07, 1.34; P <0.01), and attentional issues (OR=1.22; 95% CI, 1.10, 1.35; P <0.001) at baseline were associated with new multisite pain 1 year later. Baseline negative affect was not associated with new multisite pain.

DISCUSSION

Identifying symptom-based risk factors for multisite pain in children is critical for early prevention. Somatic awareness, sleep and attention problems represent actionable targets for early detection, treatment, and possible prevention of multisite pain in youth.

Helping Clinicians Conceptualise Behavioural Insomnia in Children: Development of the Manifestations and Vulnerabilities of Behavioural Insomnia in Childhood Scale (MAVBICS)

This paper outlines the development and psychometric evaluation of the Manifestations and Vulnerabilities of Behavioural Insomnia in Childhood Scale (MAVBICS), an instrument intended to assess the manifestations of, and factors underpinning, child behavioural insomnia. The MAVBICS comprises two sections: a more general sleep and bedtime information section (Section 1), and a psychometric measure of six theoretically derived factors that underlie, contribute to, and are manifestations of, child sleep problems (Section 2), that is the focus of this research. Study 1 comprised an exploratory factor analysis of Section 2 items (EFA; n = 328 parents of children aged 3-12 years), with a final 25 items found to load highly onto 6 factors; Sleep Maintenance Problems (4 items, α = 0.88), Co-Sleeping Behaviours (4 items, α = 0.93), Bedtime Routines (5 items, α = 0.82), Bedtime Resistance (5 items, α = 0.88), Bedtime Worries (3 items, α = 0.85) and Bedtime Fears (4 items, α = 0.86). Study 2 comprised a confirmatory factor analysis (CFA) of Section 2 items and tests of convergent validity (n = 313), with results confirming the factor structure and providing evidence for convergent validity through correlations in expected directions between MAVBICS scores and other sleep, anxiety and behaviour measures. Study 3 tested the test-retest reliability of Section 2 items (n = 53), and found support for the temporal stability of the MAVBICS over a 2-week period. Overall, the results provide strong preliminary evidence for the validity of the MAVBICS total score and its subscales, although the Bedtime Routines subscale may be less useful.

Sleep Disorders in Childhood

OBJECTIVE

This article provides a comprehensive review of pediatric sleep disorders including the clinical features, diagnosis, and treatment of sleep-disordered breathing, insomnia, parasomnias, restless sleep disorder, restless legs syndrome, narcolepsy in childhood, and Kleine-Levin syndrome.

LATEST DEVELOPMENTS

Our understanding of pediatric sleep pathophysiology continues to evolve, and diagnostic and treatment modalities have expanded. A low-sodium oxybate formulation was approved in July 2020 in the United States to treat cataplexy and excessive daytime sleepiness in patients 7 years old and older with narcolepsy. A validated pediatric hypersomnolence survey for pediatric narcolepsy and idiopathic hypersomnia with high sensitivity, specificity, and interrater reliability is now available.

ESSENTIAL POINTS

The clinical presentation, diagnostics, and treatment of children with sleep disorders differ from those of adults. Untreated sleep disorders in childhood can lead to adverse physical and psychological consequences in adults. Correctly diagnosing and treating sleep disorders in youth can prevent a significant burden of disease in adulthood.

Treating sleep problems in young children: A randomised controlled trial of a group-based, parent-focused behavioural sleep intervention

This study tested the efficacy of a 5 × 1.5 h/session, group-based, parent-focused, behavioural intervention (BI) targeting sleep problems in preschool children. Parents were randomised to either the BI (N = 62) or care as usual (CAU; N = 66) conditions. Outcomes included sleep, anxiety, behavioural problems, internalising and externalising symptoms, transition to school and academic achievement. Assessments were conducted at pre- and post-BI intervention (in the year prior to formal schooling), and then at follow-ups 1 and 2 in the first year of formal schooling. Relative to the CAU, the BI condition demonstrated significantly greater improvements in sleep, anxiety, behaviour problems and internalising and externalising symptoms from pre-to post-intervention. Improvements in sleep, anxiety, and internalising symptoms were maintained, while behaviour and externalising symptoms were further improved upon at school follow-up 2. For the BI group, improvements in sleep at post-intervention were found to mediate improvements in anxiety, internalising, and externalising symptoms, but not behaviour problems, at school follow-ups 1 and 2. There were no significant effects of condition on school transition or academic outcome measures. The results suggest that the BI is effective for sleep, anxiety, behaviour, internalising and externalising symptoms, but not for school transition or academic outcomes. ANZCTR NUMBER: ACTRN12618001161213.

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.

Beyond Polysomnography: Clinical Assessment of Pediatric Sleep Health and Sleep Problems

This chapter reviews the Peds B-SATED model of pediatric sleep health and common pediatric sleep problems. Aspects of pediatric sleep health and sleep problems are considered across development, from infants through adolescents. Finally, information about clinical screening in both primary and specialty care is discussed, and subjective sleep questionnaires are reviewed.

Periodic leg movements during sleep and iron status in infants with prematurity, Down syndrome and Prader-Willi syndrome

Sleep disturbances including bedtime problems and night awakenings are common during infancy. Polysomnography during the first years of life is performed mainly to rule out sleep-disordered breathing; however, sleep-related movement disorders can constitute a significant contributor to sleep disruption in this age group. Almost no studies have investigated the presence of periodic limb movements during sleep and underlying iron deficiency in infants, especially in those born preterm or with an underlying genetic syndrome. In this retrospective study we included infants 3-24 months referred for polysomnography for snoring or frequent nocturnal awakenings. All children had bloodwork (ferritin and haemoglobin) conducted within 3 months of the overnight sleep study. We studied 79 infants, including 31 (39.2%) full-term without diagnosis, 10 (12.7%) born premature, 16 (20.3%) with Down syndrome, 15 (19.0%) with Prader-Willi syndrome, and the remaining seven (8.9%) had various disorders. Compared with those with Down syndrome, Prader-Willi syndrome and full-term infants, those with prematurity showed a statistically significant elevated periodic limb movement index and lower ferritin levels than the other groups. Both ferritin (r = -0.18) and haemoglobin (r = -0.30) were negatively correlated with periodic limb movement index; however, this correlation reached statistical significance only for haemoglobin. Iron deficiency is associated with increased periodic leg movements during sleep in infants. Infants with prematurity had higher periodic limb movement index and lower ferritin levels than infants with Down syndrome, Prader-Willi syndrome or without diagnosis.

Parents' Experiences of Direct and Indirect Implications of Sleep Quality on the Health of Children with ADHD: A Qualitative Study

Sleep problems represent a significant challenge for children with ADHD. However, lack of knowledge about how sleep affects children with ADHD in terms of their health and everyday life prevents the development and implementation of interventions to promote sleep. The aim of this study was to explore parents' experiences of direct and indirect implications of sleep quality on the health of children with ADHD. The study used an abductive qualitative design, with Tengland's two-dimensional theory of health as a deductive analysis framework. Semi-structured interviews were conducted with 21 parents of children aged 6-13 with ADHD and sleep problems. The parents experienced that sleep influenced their children's abilities to control emotional behaviour related to ADHD and to manage everyday life. Sleep also had an impact on the children's well-being, in relation to both vitality and self-esteem. In conclusion, the results show important direct and indirect implications of sleep quality on the health of children with ADHD. This implies a need for greater focus on sleep, to target both abilities and well-being in promoting health among children with ADHD.

Can a parental sleep intervention in an individual setting improve the maternal and paternal sense of competence and parent-child interaction in parents of young sleep-disturbed children? findings from a single-arm pilot intervention study

BACKGROUND

In early childhood sleep and regulatory problems, parental factors are often impaired but essential to overcoming them. This study aims to examine, in parents of young sleep-disturbed children, whether mothers' and fathers' sense of parenting competence were increased and dysfunctional parent-child interactions reduced with a parental sleep intervention, whether these changes were sustained over a 12-month follow-up period and if children's symptomatic parameters could be related factors.

METHODS

A total of 57 families with sleep-disturbed children aged 6 months to 4 years entered this single-arm pilot study. Each parent pair participated in six weekly individual face-to-face sessions of a multimodal cognitive-behavioral sleep intervention. The Parenting Sense of Competence Scale, Parental Stress Index Short Form, Child's Sleep Diary and Child's Questionnaire on Crying, Eating and Sleeping were obtained pre-, post-, 3, 6 and 12 months after the intervention.

RESULTS

Maternal sense of competence and dysfunctional mother-child interaction improved significantly up to 6 months after the intervention. Factors related to lower maternal competence were the child's more frequent nightly food intake and more crying due to defiance; factors related to dysfunctional mother-child interaction were more frequent crying episodes, more crying due to defiance and more eating difficulties; factors related to increased maternal competence were less duration of child's night waking, less bed-sharing and lower frequency of crying episodes; factors related to increased paternal competence were less child's nightly food intake and fewer episodes of unexplained and unsoothable crying; and factors related to improved father-child interaction were less frequent child's night waking and fewer unexplained and unsoothable crying episodes.

CONCLUSION

For parents of sleep-disturbed young children, an intervention that addresses the child's sleep could be promising to increase the parental sense of competence and reduce dysfunctional parent-child interactions, especially for mothers. Child symptomatic parameters may change, together with the parental sense of competence and parent-child interaction of both parents, after the intervention. Mothers with children with more severe symptomatology perceive their parenting competence as lower on average and their mother-child interaction as more dysfunctional. Future research with a larger sample and a randomized controlled design is needed.

TRIAL REGISTRATION

The study was retrospectively registered at the German Clinical Trials Register (ID: DRKS00028578; registration date: 21.03.2022).

Melatonin Treatment for Pediatric Patients with Insomnia: Is There a Place for It?

Sleep is a vital physiological function that is impaired in ranges from 10% in the typically developing pediatric population to over 80% in populations of children with neurodevelopmental disorders and/or psychiatric comorbidities. Pediatric insomnia disorder is an increasing public health concern given its negative impact on synaptic plasticity involved in learning and memory consolidation but also on mood regulation, hormonal development and growth, and its significant impact on quality of life of the child, the adolescent and the family. While first-line treatment of pediatric insomnia should include parental education on sleep as well as sleep hygiene measures and behavioural treatment approaches, pharmacological interventions may be necessary if these strategies fail. Melatonin treatment has been increasingly used off-label in pediatric insomnia, given its benign safety profile. This article aims to identify the possible role of melatonin treatment for pediatric insomnia, considering its physiological role in sleep regulation and the differential effects of immediate release (IR) versus prolonged release (PR) melatonin. For the physician dealing with pediatric insomnia, it is particularly important to be able to distinguish treatment rationales implying different dosages and times of treatment intake. Finally, we discuss the benefit-risk ratio for melatonin treatment in different pediatric populations, ranging from the general pediatric population to children with different types of neurodevelopmental disorders, such as autism spectrum disorder or ADHD.

Relationship of overweight and obesity to insomnia severity, sleep quality, and insomnia improvement in a clinically referred pediatric sample

STUDY OBJECTIVES

Children with overweight or obesity are more likely to experience sleep disorders, although the role of weight in pediatric insomnia treatment has not been examined. The current study examined the relationships of high body mass with pretreatment insomnia severity and global sleep problems and the potential moderating impact of weight on changes in insomnia severity following insomnia treatment.

METHODS

Participants included 1,133 youth ages 2-18 years clinically referred for insomnia treatment. The Pediatric Insomnia Severity Index was collected at the initial assessment and throughout treatment as part of routine clinical care. Treatment status was coded as no treatment, early termination, and completed treatment. Secondary measures of global sleep problems at the initial assessment included the Adolescent Sleep Wake Scale, Adolescent Sleep Hygiene Scale, and Children's Sleep Habits Questionnaire. Medical chart review of visits within ± 3 months of baseline was used to obtain age-adjusted and sex-adjusted body mass index Z-score.

RESULTS

Among adolescents, regression analyses found that higher body mass index Z-score modestly predicted baseline insomnia severity (P = .021) and worse sleep hygiene (P < .001). For children, higher body mass index Z-score was modestly associated with baseline total sleep problems (P = .006) but not insomnia severity (P = .792). Across ages, body mass index Z-score predicted neither treatment status nor insomnia improvement (P > .05). Findings were similar in categorical analyses comparing patients with overweight/obesity to healthy weight.

CONCLUSIONS

Although there is evidence that children of higher body mass present for insomnia treatment with greater sleep concerns, body mass does not predict treatment completion or insomnia improvement. Data suggest insomnia treatment is effective irrespective of weight status.

CITATION

Duraccio KM, Simmons DM, Beebe DW, Byars KC. Relationship of overweight and obesity to insomnia severity, sleep quality, and insomnia improvement in a clinically referred pediatric sample. J Clin Sleep Med. 2022;18(4):1083-1091.

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 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, mean age = 3.0 years) participated in this multimethod, 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 postintervention, caregivers completed surveys on intervention acceptability and cultural humility (primary outcomes) and completed semistructured interviews. Caregivers also reported on child sleep pre- and postintervention.

RESULTS

Thirteen (86.6%) families completed Sleep Well! and 12 (80.0%) completed pre- and postintervention measures. Caregivers reported strong intervention acceptability and cultural humility. There were preintervention to postintervention 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-socioeconomic status backgrounds 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.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Implementing Behavioral Sleep Intervention in Urban Primary Care; URL: https://clinicaltrials.gov/ct2/show/NCT04046341; Identifier: NCT04046341.

CITATION

Williamson AA, Okoroji C, Cicalese O, et al. Sleep Well! An adapted behavioral sleep intervention implemented in urban primary care. J Clin Sleep Med. 2022;18(4):1153-1166.

Sleep Health Assessment and Treatment in Children and Adolescents with Chronic Pain: State of the Art and Future Directions

Sleep is interrelated with the experience of chronic pain and represents a modifiable lifestyle factor that may play an important role in the treatment of children and adolescents with chronic pain. This is a topical review of assessment and treatment approaches to promote sleep health in children and adolescents with chronic pain, which summarizes: relevant and recent systematic reviews, meta-analyses, and methodologically sound prospective studies and clinical trials. Recommendations are provided for best practices in the clinical assessment and treatment of sleep health in youth with chronic pain. This overview can also provide researchers with foundational knowledge to build upon the best evidence for future prospective studies, assessment and intervention development, and novel clinical trials.

Trajectories of Insomnia Symptoms From Childhood Through Young Adulthood

OBJECTIVES

Insomnia symptoms are transdiagnostic to physical and mental health disorders. Given the lack of population-based cohorts with objective sleep measures and long-term follow-ups, little is known about the chronicity of childhood insomnia symptoms. We determined the developmental trajectories of insomnia symptoms, their evolution into adult insomnia, and the role of objective sleep duration in the transition to adulthood.

METHODS

A total of 502 children (median 9 years old, 71.7% response rate) were studied 7.4 years later as adolescents (median 16 years old) and 15 years later as adults (median 24 years old). Insomnia symptoms were ascertained as moderate-to-severe difficulties initiating and/or maintaining sleep via parent- or self reports at all 3 time points, adult insomnia via self-report in young adulthood, and objective short-sleep duration via polysomnography in childhood and adolescence.

RESULTS

Among children with insomnia symptoms, the most frequent trajectory was persistence (43.3%), followed by remission (26.9% since childhood, 11.2% since adolescence) and a waxing-and-waning pattern (18.6%). Among children with normal sleep, the most frequent trajectory was persistence (48.1%), followed by developing insomnia symptoms (15.2% since adolescence, 20.7% in adulthood) and a waxing-and-waning pattern (16.0%). The odds of insomnia symptoms worsening into adult insomnia (22.0% of children, 20.8% of adolescents) were 2.6-fold and 5.5-fold among short-sleeping children and adolescents, respectively.

CONCLUSIONS

Early sleep interventions are a health priority because pediatricians should not expect insomnia symptoms to developmentally remit in a high proportion of children. Objective sleep measures may be clinically useful in adolescence, a critical period for the adverse prognosis of the insomnia with short-sleep duration phenotype.

A controlled trial of Cognitive Behavioural Therapy-based strategies for insomnia among in-school adolescents in southern Nigeria

BACKGROUND

Sleep difficulties are highly prevalent among adolescents, and are associated with significant impairments. The effectiveness and acceptability of Cognitive Behavioural Therapy-based (CBT-based) treatment for insomnia in adolescents is established for High Income Countries, but unknown for African settings. Thus, the aim of this study was to assess the effect of CBT-based intervention among in-school adolescents with sleep difficulties in Southern Nigeria.

METHODS

This was a pilot controlled trial involving 50 adolescents with highest ranked scores on the Insomnia Severity Index (ISI) recruited from four schools (two government and two privately owned). Balloting was used to assign two schools (public and private) with 25 participants to the intervention group, and the other two schools (public and private) with 25 participants as waiting-list controls. The two groups were dyad-matched for baseline ISI scores, gender, and type of school to reduce baseline differences. The treatment group received weekly group-based manualised CBT-based intervention over 5 weeks. Primary outcome was ISI score at 6th week. Secondary outcomes were sleep onset latency (SOL), Total sleep duration (TSD), depressive symptoms, sleep hygiene, and knowledge about sleep.

RESULTS

Participants were aged 13-17 years (M = 14.9, SD = 1.16) and consisted of 18 males and 32 females. Controlling for baseline scores, the intervention group showed significantly lower post-intervention insomnia scores compared with the control group {F (1, 34) = 1.10, p = 0.0001, (ηp² = 0.59}, shorter SOL {F (1, 33) = 1.41, p = 0.0001, ηp² = 0.39}, longer TSD {F (1, 33) = 1.03, p = 0.0001, ηp² = 0.47}, lower depressive symptoms {F (1, 31) = 1.32, p = 0.002 (ηp² = 0.34}, higher knowledge of sleep {F (1, 34) = 1.02, p = 0.001, ηp² = 0.36}, but no significant change in sleep hygiene {F (1, 32) = 1.08, p = 0.08, ηp² = 0.15}. All participants in the intervention group rated the programme as good or excellent.

CONCLUSION

This pilot CBT-based intervention for adolescents with insomnia was feasible, well received and showed promising efficacy in this setting. Larger controlled trials are recommended to establish the generalisability of these findings in this region. Trial registration Pan African Clinical Trial Registry (Registration Number PACTR202001710494962).

Standing on the shoulders of giants: A decade of research on digital pediatric sleep interventions

The purpose of this letter to the editor is to highlight previous research on digital approaches to managing pediatric insomnia and other sleep problems, to complement a recently published study by Tedford and colleagues that asserts there is a paucity of research in this regard. In this letter, selected studies of Internet- and mobile application-based behavioral sleep interventions designed for pediatric populations are reviewed. This letter aims to provide foundational information about the science of digital pediatric sleep interventions, to avoid contributing to a siloed field of research and to better inform efforts to disseminate evidence-based sleep treatment to children, families, and practicing clinicians.

Pediatric sleep health: It matters, and so does how we define it

In 2014, Buysse published a novel definition of sleep health, raising awareness for the importance of this construct for individuals, populations, clinical care, and research. However, the original definition focused on adults, with the recommendation that it should be adapted for children and adolescents. As children live within a complex and dynamic system, and may not always have control over their own sleep, this theoretical review will examine and apply Buysse's five dimensions of sleep health within the context of pediatrics. In addition, using examples from the pediatric sleep literature we introduce a modified definition that takes into consideration the influence of the socio-ecological system within which children live, and the sleep-related behaviors that are critical in supporting or hindering sleep health. Finally, we discuss how the proposed theoretical framework, Peds B-SATED, can be applied to clinical practice, research, and training in the field of pediatric sleep.