Sleep in hospitalized children and adolescents: A scoping review

Sleep Disruptions in Hospitalized Adults Sustaining a Traumatic Brain Injury: A Scoping Review

OBJECTIVE

Adults sustaining a traumatic brain injury (TBI) are at risk of sleep disturbances during their recovery, including when such an injury requires hospitalization. However, the sleep-wake profile, and internal and external factors that may interfere with sleep initiation/maintenance in hospitalized TBI patients are poorly understood. This review aimed to: (1) identify/summarize the existing evidence regarding sleep and sleep measurements in TBI adults receiving around-the-clock care in a hospital or during inpatient rehabilitation, and (2) identify internal/external factors linked to poor sleep in this context.

METHODS

A scoping review was conducted in accordance with the PRISMA Scoping Review Extension guidelines. A search was conducted in MEDLINE, PsycINFO, CINAHL, and Web of Science databases.

RESULTS

Thirty relevant studies were identified. The most common sleep variables that were put forth in the studies to characterize sleep during hospitalization were nighttime sleep time (mean = 6.5 hours; range: 5.2-8.9 hours), wake after sleep onset (87.1 minutes; range: 30.4-180 minutes), and sleep efficiency (mean = 72.9%; range: 33%-96%) using mainly actigraphy, polysomnography, and questionnaires (eg, the sleep-wake disturbance item of the Delirium Rating Scale or the Pittsburgh Sleep Quality Index). Twenty-four studies (80%) suggested that hospitalized TBI patients do not get sufficient nighttime sleep, based on the general recommendations for adults (7-9 hours per night). Sleep disruptions during hospitalization were found to be associated to several internal factors including TBI severity, cognitive status, and analgesia intake. External and modifiable factors, such as noise, light, and patient care, were consistently associated with sleep disruptions in this context.

CONCLUSION

Although the literature on sleep disturbances in hospitalized TBI patients has been increasing in recent years, many gaps in knowledge remain, including phenotypes and risk factors. Identifying these factors could help clinicians better understand the multiple sources of TBI patients' sleep difficulties and intervene accordingly.

Children's satisfaction with nursing care during hospitalization: A cross-sectional study

PURPOSE

To assess hospitalized children's satisfaction with nursing care.

DESIGN AND METHODS

Cross-sectional study using the "Children Care Quality at Hospital" questionnaire. 61 children admitted to the Pediatrics Department of a hospital in the Northern Region of Portugal were enrolled.

RESULTS

The ranged age of the participants was 6 to 15 (10,61 ± 2,66 years), and most were male (52.46%; n = 32). The mean score in the three domains was 128 (77.11%), reflecting children's high satisfaction with the nursing care provided during hospitalization. The domain most valued was Nurse Characteristics, while the least valued was Nursing Environment.

CONCLUSION

Results provide essential input for the dimensions to be considered when planning nursing care for children, managing care, and the physical environment in the wards.

IMPLICATIONS FOR PRACTICE

These results highlight the need to hear children's voices. This must encourage nurses to reflect on how children evaluate nursing care and, by doing so, to increase the quality of nursing care provided in Pediatrics settings.

A nursing perspective on inpatient sleep and circadian disruptions for pediatric stem cell transplant patients

BACKGROUND

Children treated with stem cell transplant (SCT) are routinely hospitalized for long periods where they are exposed to significant sleep and circadian disruptions. As nurses play a primary role in symptom management during SCT, we sought to understand their perspective on patient sleep and circadian disruptions, perceived barriers to a good sleep and circadian environment, and suggestions for improvement.

PROCEDURE

Four focus groups were conducted with pediatric SCT nurses (N = 25 participants). A semistructured focus group guide was administered, with the discussions recorded and transcribed. A multistage thematic analysis combining prefigured and emergent dimensions was conducted. Our analysis focused on drawing comparisons within and across focus groups to understand the unique work experiences that participants had related to the patient's sleep and circadian environment.

RESULTS

Three key themes emerged. First, nurses expressed a high awareness of how disruptive the hospital environment is for patients. Second, nurses described their extensive efforts to try to minimize the impact of these disruptions. Finally, they provided clear recommendations for how to improve upon these concerns, along with barriers that they perceive could impede implementation.

CONCLUSIONS

Front-line caregivers on a pediatric SCT unit describe key contributors to sleep/circadian disturbances for patients. Within the constraints of the considerable medical needs of this patient population and the physical room/hospital environment, nurses strive to minimize these disruptions to the best of their ability. It is crucial that hospitals assess and remediate these disturbances for these children that have important implications for overall health.

Medical clowns improve sleep and shorten hospitalization duration in hospitalized children

Intervention by medical clowns was proven to have a positive effect in reducing stress and anxiety, increasing cooperation and improving the child's experience prior to a medical procedure and during the various stages of hospitalization. Sleep has long been known to be essential for recovery from injury and sickness, improving immune functions, and there is an emerging understanding of the restorative role quality sleep has on health and diseases. Hospitalized children are more exposed to sleep disorders and sleep deprivation due to the hospitalized environment, anxiety, and illness. Different behavioral interventions to promote sleep were previously studied in hospitalized children, some showing potential benefits. In this study, we sought to examine the ability of medical clowns to positively impact the child's sleep during hospitalization. The study is an observational matching (case-control) interventional study which took place at the department of pediatrics in Carmel Medical Center. Forty-two hospitalized children ages 2-17 were included in two equal groups of intervention or control. Children in the control group were recruited based on a method of matching the chief complaint plus the medical diagnosis and age of the children in the intervention group in a 1:1 matching. The children's sleep parameters were objectively evaluated for two consecutive nights using an Actigraph device and subjectively by parent's questionnaire. Additional factors such as hospital length of stay and demographics were also monitored. The study group had an encounter with a medical clown (15-30 min) before bedtime on either the first or the second night, and the control group was not exposed to a medical clown at all. We then compared the data from both groups using unpaired t-tests. Hospitalized children exposed to a medical clown prior to bedtime (n = 21) and children not exposed to a medical clown (n = 21) were comparable in age and clinical characteristics. The study group had a significantly delayed wake-up time compared to the control group (06:59 ± 46 min vs. 07:26 ± 42 min, p < 0.05) (mean difference of 27 min). Night's duration (from bedtime to wake-up) was significantly longer in the study versus the control group (570 ± 76 vs. 500 ± 66.1 min, p < 0.05), a total mean increase of 70 min, and sleep efficiency were significantly increased (92.3 ± 4.6% vs. 87.9 ± 8.7%, p < 0.05). Within the clown group, when comparing nights with and without exposure to a medical clown, total sleep time was prolonged by a mean of 54 min on the night of the intervention (518 ± 74 min vs. 464 ± 59 min, p < 0.01), and the total wake time during the night were reduced (52 ± 27 min vs. 77 ± 61 min, P < 0.05), mean difference of 25 min), mainly by reduction of wake period after sleep onset (WASO) (42 ± 25 min vs. 66 ± 58 min, p < 0.05), mean difference of 24 min). Regarding general medical outcomes, hospital stay was significantly shorter in the clown group vs. control (104 ± 42 h vs. 128 ± 42 h, p < 0.05), a mean reduction of 23 h-nearly an entire day. An encounter with a medical clown before bedtime in hospitalized children positively affects sleep parameters, which may be of great importance for healing in general. The clown intervention was also shown to shorten the hospital stay. Larger scale studies are warranted to establish these findings.

Evaluation of Sleep Practices and Knowledge in Neonatal Healthcare

BACKGROUND

Developmental care is designed to optimize early brain maturation by integrating procedures that support a healing environment. Protecting preterm sleep is important in developmental care. However, it is unclear to what extent healthcare professionals are aware of the importance of sleep and how sleep is currently implemented in the day-to-day care in the neonatal intensive care unit (NICU).

PURPOSE

Identifying the current state of knowledge among healthcare professionals regarding neonatal sleep and how this is transferred to practice.

METHODS

A survey was distributed among Dutch healthcare professionals. Three categories of data were sought, including (1) demographics of respondents; (2) questions relating to sleep practices; and (3) objective knowledge questions relating to sleep physiology and importance of sleep. Data were analyzed using Spearman's rho test and Cramer's V test. Furthermore, frequency tables and qualitative analyses were employed.

RESULTS

The survey was completed by 427 participants from 34 hospitals in 25 Dutch cities. While healthcare professionals reported sleep to be especially important for neonates admitted in the NICU, low scores were achieved in the area of knowledge of sleep physiology. Most healthcare professionals (91.8%) adapted the timing of elective care procedures to sleep. However, sleep assessments were not based on scientific knowledge. Therefore, the difference between active sleep and wakefulness may often be wrongly assessed. Finally, sleep is rarely discussed between colleagues (27.4% regularly/always) and during rounds (7.5%-14.3% often/always).

IMPLICATIONS

Knowledge about sleep physiology should be increased through education among neonatal healthcare professionals. Furthermore, sleep should be considered more often during rounds and handovers.

Sleep problems during and after paediatric brain tumours

Brain tumours are among the most common cancer diagnoses in paediatrics. Children with brain tumours are at risk of developing sleep problems because of direct and indirect effects of the tumour and its treatment, in addition to psychosocial and environmental factors. Sleep has an important role in physical and psychological wellbeing, and sleep problems are associated with many adverse outcomes. In this Review, we describe the state of the evidence regarding sleep in people with paediatric brain tumours, prevalence and types of sleep problems, risk factors, and effectiveness of interventions. Evidence shows that sleep problems, particularly excessive daytime sleepiness, are common in people with paediatric brain tumours, with high BMI emerging as a consistent predictor of sleep disruption. Further intervention studies are needed, and clinical evaluation of sleep is warranted for people with paediatric brain tumours.

Nonpharmacological interventions to promote sleep and rest among hospitalized pediatric patients in general pediatric wards: a best practice implementation project

OBJECTIVES

The aim of this implementation project was to improve compliance with best practice regarding nonpharmacological interventions used to promote sleep and rest in hospitalized pediatric patients in a nonintensive care setting.

INTRODUCTION

Hospitalized children endure numerous hindrances to sleep and rest, including, but not limited to, noise, pain, anxiety, and interruptions for nursing care. Evidence suggests that a multifaceted approach to sleep promotion can reduce the length of time to sleep onset and the length of nighttime awakenings. It is widely accepted, however, rarely practiced, that proven, low-cost, and noninvasive strategies exist to promote sleep and restoration of hospitalized pediatric patients, which fosters healing and recovery.

METHODS

This project used the JBI Evidence Implementation framework. A baseline audit of 22 nurses' and 31 patients'/parents'/caregivers' receipt of education on strategies to promote sleep and rest was obtained via survey; baseline data were also obtained from nurses regarding whether or not a multifaceted approach to sleep promotion is utilized and/or if an evidence-based protocol regarding sleep promotion is in place. Targeted strategies, including a protocol and nurse/patient education of multifaceted approaches to sleep, were then implemented, and a follow-up audit of 25 nurses and 32 patients/caregivers was completed.

RESULTS

Overall, postimplementation audits revealed 93% compliance with best practice, a 78% increase from baseline audits of 15%. Baseline data revealed poor knowledge of and/or compliance with each of the four audit criteria: nurse education on strategies to promote sleep and rest, the use of an evidence-based protocol regarding sleep promotion, a multifaceted approach to sleep promotion, and patient and/or caregiver education regarding sleep promotion. Postimplementation data, however, showed improvement in each of these areas.

CONCLUSION

Deficiencies in best practice recommendations for the promotion of sleep and rest in pediatric patients admitted to general wards were identified, interventions were implemented, and results were beneficial. Further investigation could be taken to assess the long-term effectiveness of interventions and/or sleep quality of patients while hospitalized. Moreover, postimplementation audits should be administered to parents near the end of their stay, after they have had time to implement optional interventions, if they choose.

Prevalence and Correlates of Sleep Disorders Among Pediatric Inpatients in a Tertiary Pediatric Hospital

Background It is possible to define sleep disorders as any disturbance in sleep timing, quality, or quantity that results in daytime distress and impairment in functioning that, in turn, affects the baseline functional status of an individual. Our study aimed to describe how sleep disorders might affect pediatric inpatients at King Abdulaziz University Hospital (KAUH) as well as estimate their prevalence (2021-2022). We assessed the sleep habits using questionnaires and analyzed and combined these data to create rankings to compare the different issues affecting sleep habits in pediatric patients. Methodology Two scoring systems were used in this study, namely (a) the Children's Sleep Habits Questionnaire (CSHQ) and (b) the Pediatric Sleep Questionnaire. Analyses of the data were conducted using SPSS version 23 (IBM Corp., Armonk, NY, USA) and GraphPad Prism version 8 (GraphPad Software, Inc., San Diego, CA, USA). Results The prevalence of sleep disorders and their correlations were evaluated among 98 pediatric inpatients at KAUH, Saudi Arabia, between 2021 and 2022. The average duration of hospital stay was 11.97 ± 11.0 days (N = 78), and the average number of previous admissions was 2.85 ± 3.7 (N = 93). Conclusions According to the sleep behavior domain of the CSHQ, most children woke up sweating, screaming, and inconsolable during the night. Furthermore, bedtime resistance and sleep anxiety were the most prevalent sleep disturbances observed in the study population.

The effect of therapeutic touch and music rest on sleep parameters in children with liver transplantation

PURPOSE

This study was conducted to evaluate the effect of therapeutic touch and music rest on the sleep of children with liver transplantation.

DESIGN AND METHODS

The data of the study were collected between February 2021 and November 2021. The study was completed with 50 patients included in the therapeutic touch and music rest groups. Therapeutic touch and music practices were applied for three consecutive days, once a day and 20 min. Before and after the practices, the 24-h sleep of the children was evaluated with actigraphy.

RESULTS

It was determined that the time in bed, total sleep time, and sleep efficiency of the children in the therapeutic touch group increased after the procedure. On the other hand, it was determined that the time in bed, and total sleep time increased, and the onset latency decreased after the procedure in the children in the music rest group. It was determined that the effects of therapeutic touch and music rest applications on sleep parameters after the procedure were similar.

CONCLUSION

It has been determined that therapeutic touch and music rest applications have an improving effect on the sleep of children with liver transplantation.

PRACTICE IMPLICATIONS

Music rest and therapeutic touch, which are non-pharmacological methods that do not increase the burden of the liver, can be used by health professionals to support the sleep of children with liver transplantation.

Sleep in hospitalized pediatric and adult patients – A systematic review and meta-analysis

Background

Sleep is essential for recovery from illness. As a result, researchers have shown a growing interest in the sleep of hospitalized patients. Although many studies have been conducted over the past years, an up to date systematic review of the results is missing.

Objective

The objective of this systematic review was to assess sleep quality and quantity of hospitalized patients and sleep disturbing factors.

Methods

A systematic literature search was conducted within four scientific databases. The search focused on synonyms of 'sleep’ and 'hospitalization’. Papers written in English or Dutch from inception to April 25th,2022 were included for hospitalized patients >1 year of age. Papers exclusively reporting about patients receiving palliative, obstetric or psychiatric care were excluded, as well as patients in rehabilitation and intensive care settings, and long-term hospitalized geriatric patients. This review was performed in accordance with the PRISMA guidelines.

Results

Out of 542 full text studies assessed for eligibility, 203 were included, describing sleep quality and/or quantity of 17,964 patients. The median sample size of the studies was 51 patients (IQR 67, range 6–1472). An exploratory meta-analysis of the Total Sleep Time showed an average of 7.2 h (95%-CI 4.3, 10.2) in hospitalized children, 5.7 h (95%-CI 4.8, 6.7) in adults and 5.8 h (95%-CI 5.3, 6.4) in older patients (>60y). In addition, a meta-analysis of the Wake After Sleep Onset (WASO) showed a combined high average of 1.8 h (95%-CI 0.7, 2.9). Overall sleep quality was poor, also due to nocturnal awakenings. The most frequently cited external factors for poor sleep were noise and number of patients in the room. Among the variety of internal/disease-related factors, pain and anxiety were most frequently mentioned to be associated with poor sleep.

Conclusion

Of all studies, 76% reported poor sleep quality and insufficient sleep duration in hospitalized patients. Children sleep on average 0.7–3.8 h less in the hospital than recommended. Hospitalized adults sleep 1.3–3.2 h less than recommended for healthy people. This underscores the need for interventions to improve sleep during hospitalization to support recovery.

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An overview of the magnitude of sleep deprivation in hospitalized patients.

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A meta-analysis of studies reporting on some of the main sleep outcomes.

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An overview of internal and external factors affecting sleep in hospitalized patients.

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Guidance for potential interventions to improve sleep during clinical admission.

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Uncovers a knowledge gap regarding the sleep quality of hospitalized children and daytime sleep of hospitalized adults.

Effect of illuminated musical mobile on sleep quality of children hospitalized in pediatric emergency departments

PURPOSE

The aim of this study is to evaluate the effect of an illuminated musical mobile on the sleep quality of children hospitalized in a pediatric emergency department.

DESIGN AND METHODS

In this randomized controlled study, 124 children presenting to a pediatric emergency department who met the inclusion criteria were included in the study. Patients were randomized into two equal groups. In the intervention group, an illuminated musical mobile was used to help facilitate sleep. In the control group, routine sleep routines were continued. Groups were compared according to sleep quality as evaluated by mothers' observations. Evaluation was performed twice (before intervention - 1st day of hospitalization and on the intervention day - 2nd day of hospitalization).

RESULTS

Average age of children was 1.86 ± 0.78 years. On the intervention day, nighttime sleep duration was longer in the intervention group (p < .0001). Also, the frequency of spontaneous awakening (p < .0001), time to fall asleep after spontaneous awakening (p < .0001) and sleep time problems (p < .0001) were less in the intervention group. CONCLUSıONS: An illuminated musical mobile was used for the first time in the pediatric emergency department and was found to be effective in improving the sleep quality of hospitalized children aged between 1 and 3 years.

PRACTICE IMPLICATIONS

During hospitalization, children's sleep quality can be increased by using methods and objects suitable for the child's developmental level.

A systematic review and proposed conceptual model of sleep disturbances during pediatric hospitalizations

STUDY OBJECTIVES

The current review aims to examine factors that influence pediatric inpatient sleep and determine the effectiveness of sleep promotion interventions among hospitalized children.

METHODS

A systematic literature search was conducted across PubMed, PsycINFO, CINAHL, Cochrane Central, Web of Science, Embase, and Scopus databases. Studies included children with a mean age between 1 and 18 years old that either described factors affecting the sleep of children who are hospitalized on a non-intensive care unit or reported on sleep-related intervention outcomes. We conducted separate narrative reviews for each of the two aims and then synthesized findings from quantitative and qualitative studies across both aims.

RESULTS

Forty-five articles were included for review. Despite most sleep disturbances being attributed to environmental disruptions (e.g. noise, staff interruptions), most interventions targeted the child level using relaxation techniques. Although the majority of interventions were small pilot studies, preliminary findings appear to positively impact sleep duration. The Pediatric Inpatient Sleep Model was proposed to illustrate connections between sleep disturbances, factors influencing sleep, and existing intervention components.

CONCLUSIONS

Replication studies are needed, including larger-scale sleep promotion interventions among hospitalized children. Given the identification of environmental factors as the main cause of night wakings, environmental modifications are crucial. Additional research examining contributors to intraindividual variability in disrupted sleep patterns during hospitalizations as well as the consequences of these disturbances is warranted.