Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in children: guidance from the American Academy of Sleep Medicine

The American Academy of Sleep Medicine commissioned a task force of clinical experts in pediatric sleep medicine to review published literature on performing the Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test for diagnosis and management of central disorders of hypersomnolence among children and adolescents. This paper follows a format similar to that of the paper "Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in adults: guidance from the American Academy of Sleep Medicine" that was published in 2021. Since there is insufficient evidence to specify a recommended protocol for the Maintenance of Wakefulness Test in children and adolescents, this paper focuses only on the MSLT protocol. This protocol paper provides guidance to health care providers who order, sleep specialists who interpret, and technical staff who administer the MSLT to pediatric patients. Similar to the adult protocol paper, this document provides guidance based on pediatric expert consensus and evidence-based data when available. Topics include patient preparation, evaluation of medication and substance use, sleep needs before testing, scheduling considerations, optimal test conditions for youth, and documentation. Specific changes recommended for pediatric MSLT protocols include (1) provision of a minimum of 7 hours of sleep (with a minimum 8-hour recording time) on polysomnography the night before the MSLT, ideally meeting age-based needs; (2) use of clinical judgment to guide the need for sleep-disordered breathing treatments before polysomnography-MSLT testing; and (3) shared patient-health care provider decision-making regarding modifications in the protocol for children and adolescents with neurodevelopmental/neurological disorders, young age, and/or delayed sleep phase.

CITATION

Maski KP, Amos LB, Carter JC, Koch EE, Kazmi U, Rosen CL. Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in children: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med. 2024;20(4):631-641.

Modifiable dietary factors in adolescent sleep: A systematic review and meta-analysis

OBJECTIVE

Sleep problems are prevalent during adolescence, and modifying dietary factors may contribute to better sleep outcomes in adolescents. This systematic review and meta-analysis aimed to evaluate the impact of modifiable dietary factors on sleep health among adolescents.

METHODS

A systematic search of records from six databases including MEDLINE, PubMed, Embase, Scopus, CINAHL, and the CENTRAL from inception up to November 2023, identified 33 peer-reviewed publications that assessed the relationship between modifiable dietary factors and sleep outcomes in adolescents aged 12-18 years. The NIH Quality Assessment Tools were used to assess the quality of the included studies. Meta-analysis was performed on a sub-group of studies (n = 6) to ascertain the effect of dietary factors on sleep health.

RESULTS

Although the included studies were predominantly cross-sectional and exhibited heterogeneity, relying mainly on self-reported measures, it was observed that consumption of healthy foods was consistently linked with improved sleep outcomes among adolescents, whereas higher intake of fat-rich or sugar-rich foods and red meats or processed food was associated with poorer sleep features. The meta-analysis further substantiated that adolescents with higher caffeine intake faced increased odds of sleep problems (OR = 1.67, 95% CI: 1.28-2.17), while alcohol consumption was significantly associated with insomnia (OR = 1.17, 95% CI: 1.07-1.27).

CONCLUSION

Overall, despite high heterogeneity among studies, this systematic review underscores the promising role of healthy dietary factors in enhancing both the quality and quantity of sleep in adolescents. The meta-analysis results also highlight that reducing caffeine and alcohol intake holds potential for supporting better sleep in this population. However, further validation through intervention studies is warranted.

Caffeine intake and its association with nutrition, sleep, and physical activity among schoolchildren in the United Arab Emirates: a national cross-sectional study

PURPOSE

Recent surveys indicate a significant increase in total caffeine intake among schoolchildren. Limited research has been published concerning the total intake of caffeine among schoolchildren in the Middle East and Gulf Cooperation Council (GCC) countries, including the UAE.

METHODS

This cross-sectional survey estimated the total caffeine intake from foods and beverages among 10,275 schoolchildren in the UAE. Caffeine intakes were related to the European Food Safety Authority's level of no safety concern (3.0 mg/kg BW) and level of effects on sleep (1.4 mg/kg BW).

RESULTS

More than half (56.2%) of the students consumed more than 100 mg (the upper limit allowed) of caffeine from dietary sources. High intake of caffeine (> 100 mg/day) was significantly associated (p = 0.001) with reduced sleep duration, difficulty falling asleep, infrequent exercising, using smart devices for more than 2 h a day, getting a lower GPA, skipping breakfast, eating fewer servings of vegetables than recommended, frequent consumption of fast food and more frequent snack consumption.

CONCLUSION

Excessive intake of caffeine from different dietary sources coexists with unhealthy dietary and lifestyle behaviors and sleep problems. Tailoring educational programs and intervention strategies is warranted to correct the unhealthy intake of caffeine and the associated unhealthy dietary and lifestyle behaviors among schoolchildren in the UAE.

Caffeinated energy drink consumption among Emirati adolescents is associated with a cluster of poor physical and mental health, and unhealthy dietary and lifestyle behaviors: a cross-sectional study

Background

Consumption of caffeinated energy drinks (CED) has escalated during the last few years, especially among schoolchildren, with evident adverse health sequelae in this critical age group.

Objective

This study examined the prevalence of CED consumption and its associations with sleep, physical and mental health, and dietary and lifestyle habits among schoolchildren in the United Arab Emirates (UAE).

Method

A structured self-administered online questionnaire was developed and disseminated among schoolchildren aged 14-18 years, selected from schools of the seven emirates of the UAE.

Results

More than 4,500 (N= 4,648) responses received. A relatively low prevalence of CED consumption (20%) was found among schoolchildren in the UAE. However, those who reported CED consumption were more likely to report unhealthy dietary (skipping breakfast, frequent snacking, and eating fast foods, low fruit, and vegetable intake) and lifestyle behaviors (long screen time, poor sleep health), in addition to poor self-reported mental and physical health than non-users. CED consumption was significantly and variably associated with multiple sociodemographic factors such as students' nationality, parental companionship, sex, school type, education level (children's and parents'), daily allowance, academic performance, screen time, sleep quality parameters, self-reported physical and mental health, and parents' employment. Sources of knowledge about CED were social media (55%), friends/schoolmates (52%), and family members (52%). Students believed that CED constitute sugar (87%), caffeine (69%), artificial flavors (67%) sweeteners (54%), and stimulating components (43%). The majority (70%) of students reported that CED consumption increases the risks for heart disease, diabetes, high blood sugar (65%), addiction (64%), high blood pressure (59%), and obesity (57%).

Conclusion

These results offer important insights for health professionals, child health specialists, policymakers, and parents in the UAE regarding adolescents' attitudes, knowledge and behaviors toward CED consumption.

Sleep Disorders during Adolescence

Sleep disorders during adolescence period increase each year and adversely affect the physical and mental health of adolescents. After-school social activities and various work outside the school may cause delays in bedtime. In addition, there can be shifts in the circadian rhythm due to a number of biological changes seen in the transition to adolescence, which can result in a wide range of sleep problems, such as not being able to fall asleep at night, difficulty waking up in the morning, daytime sleepiness, sleep deprivation and deterioration in sleep quality. It is important to know the causes of sleep disorders, possible effects on physical health and mental health, and protective and risk-forming factors seen in adolescent period; to intervene in these disorders and to develop preventive measures. Preventive measures, such as increasing awareness about sleep disorders in adolescents, informing families and adolescents about the issue, and organizing school start-up times for this age group, may contribute significantly to solving this important issue, which has increased year-to-year.

Secondary School Students and Caffeine: Consumption Habits, Motivations, and Experiences

Adolescents may be particularly vulnerable to the effects of caffeine due to a lack of tolerance, their small size, changing brain physiology, and increasing independence. Concerns about adolescent caffeine consumption relate to potentially serious physiological and psychological effects following consumption. Motivations driving caffeine intake are not well understood among adolescents but are important to understand to reduce harmful behavioural patterns. This study explored caffeine consumption habits (sources, amount, frequency) of New Zealand adolescents; and factors motivating caffeine consumption and avoidance. The previously validated caffeine consumption habits questionnaire (CaffCo) was completed by 216 participants (15-18 years), with most (94.9%) consuming at least one caffeinated product daily. Chocolate, coffee, tea, and kola drinks were the most consumed sources. The median caffeine intake was 68 mg·day^-1. Gender (boy) and being employed influenced the source, but not the quantity of caffeine consumed. One-fifth (21.2%) of adolescents consumed more than the recommended European Food Safety Authority (EFSA) safe level (3 mg·kg^-1·day^-1). Taste, energy, and temperature were the main motivators for consumption, and increased energy, excitement, restlessness, and sleep disturbances were reported effects following caffeine consumption. This study provides information on caffeinated product consumption among New Zealand adolescents, some of whom consumed caffeine above the EFSA safe level. Public health initiatives directed at adolescents may be important to reduce potential caffeine-related harm.

Perceived sleep quality predicts aggressive offending in adolescence and young adulthood

BACKGROUND

There are profound consequences when developing youth do not get adequate sleep. Adolescents who experience poor sleep may be more likely to engage in offending behavior. While there is a documented association between the number of hours youth sleep and their likelihood of offending, it is unclear how youths' perceptions of their sleep quality contribute to offending. Further, scholars have yet to rigorously examine the relation between sleep problems and offending in young adulthood, a developmental stage, which is both critical for desistance and in which sleep may play an important role.

METHODS

Using a sample of 1,216 justice-involved male youth, this study uses within-individual longitudinal methods (fixed-effects Poisson regression models) to examine the relation between changes in perceptions of sleep quality and changes in offending behavior from ages 13 to 24.

RESULTS

Increases in sleep problems are associated with increases in offending, particularly aggressive/person-related offenses, for both adolescents and young adults. This holds true even after controlling for time-varying anxiety, substance use, and violence exposure.

CONCLUSIONS

Improving sleep quality may be critical for reducing aggressive behavior in at-risk adolescents and young adults. Interventions that address sleep quality, and not just quantity, may be particularly beneficial.

Caffeine Motives and Expectancies for Individuals with High Anxiety Sensitivity

Background: Anxiety Sensitivity (AS) is a transdiagnostic risk factor that includes fear of the potential physical and psychological consequences of anxiety-related symptoms. Caffeine consumption in high amounts is associated with symptoms of anxiety. Research on the relationship between AS and caffeine consumption has yielded inconsistent results. Objectives: In this study, we conducted an exploratory analysis to examine whether caffeine motives moderated the relationship between AS and high caffeine consumption. We also examined whether caffeine expectancies moderated the relationship between AS and high caffeine consumption. In addition, we assessed the bivariate relationships between AS and caffeine motives and between AS and caffeine expectancies. N = 317 participants completed an online survey using Amazon Mechanical Turk. Results: Results revealed that neither expectancies nor motives interacted with AS to predict high caffeine consumption. There was also no significant main effect of AS on high caffeine consumption. The only significant main effect in the prediction of high caffeine consumption was the use of caffeine for symptom management motives. In our follow-up analyses, high AS participants in the study expected that caffeine consumption would provoke anxiety. They also reported using caffeine for symptom management, taste, and social reasons. Conclusions: These findings suggest that the utility of AS as a predictor or foundation for higher amounts of substance use is not uniform across substances but rather depends on the type of substance in question.

Characteristic Sleep Patterns and Associated Obesity in Adolescents

Poor sleep adversely affects health and may cause obesity. Poor sleep includes short sleep duration, low quality of sleep, and sleep discrepancy. Although most studies have focused on the association between sleep duration and obesity, poor sleep is a significant risk factor for obesity. Adolescents have characteristic sleep patterns which correspond to poor sleep. Adolescents sleep late due to various biological and psychosocial factors; also, they wake up early to be on time for school. This causes them to sleep less. To make up for this sleep debt, adolescents sleep more on non-school days, which causes sleep discrepancies. Therefore, since adolescents have characteristic sleep patterns, an in-depth investigation is needed to identify whether poor sleep is a risk for obesity. This article presents an overview of the characteristic sleep patterns of adolescents, and reviews studies on the association of each sleep pattern with obesity.

Recent advances in the utilization of tea active ingredients to regulate sleep through neuroendocrine pathway, immune system and intestinal microbiota

Sleep disorders have received widespread attention nowadays, which have been promoted by the accelerated pace of life, unhealthy diets and lack of exercise in modern society. The chemical medications to improve sleep has shown serious side effects and risks with high costs. Therefore, it is urgent to develop efficient nutraceuticals from natural sources to ensure sleep quality as a sustainable strategy. As the second most consumed beverage worldwide, the health-promoting effects of tea have long been widely recognized. However, the modulatory effect of teas on sleep disorders has received much less attention. Tea contains various natural sleep-modulating active ingredients such as L-theanine (LTA), caffeine, tea polyphenols (TPP), tea pigments, tea polysaccharides (TPS) and γ-aminobutyric acid (GABA). This review focuses on the potential influence and main regulating mechanisms of different tea active ingredients on sleep, including being absorbed by the small intestine and then cross the blood-brain barrier to act on neurons in the brain as neurotransmitters, manipulating the immune system and further affect sleep-wake cycle by regulating the levels of cytokines, and controlling the gut microbes to maintain the homeostasis of circadian rhythm. Current research progress and limitations are summarized and several future development directions are also proposed. This review hopes to provide new insights into the future elucidation of the sleep-regulating mechanisms of different teas and their natural active ingredients and the development of tea-based functional foods for alleviating sleep disorders. HighlightsNatural sleep-modulating active ingredients in tea have been summarized.Influences of drinking tea or tea active ingredients on sleep are reviewed.Three main regulating mechanisms of tea active ingredients on sleep are explained.The associations among nervous system, immune system and intestinal microbiota are investigated.The potential of developing delivery carriers for tea active ingredients is proposed.

Impact of daily caffeine intake and timing on electroencephalogram-measured sleep in adolescents

STUDY OBJECTIVES

Caffeine use is ubiquitous among adolescents and may be harmful to sleep, with downstream implications for health and development. Research has been limited by self-reported and/or aggregated measures of sleep and caffeine collected at a single time point. This study examines bidirectional associations between daily caffeine consumption and electroencephalogram-measured sleep among adolescents and explores whether these relationships depend on timing of caffeine use.

METHODS

Ninety-eight adolescents aged 11-17 (mean =14.38, standard deviation = 1.77; 50% female) participated in 7 consecutive nights of at-home sleep electroencephalography and completed a daily diary querying morning, afternoon, and evening caffeine use. Linear mixed-effects regressions examined relationships between caffeine consumption and total sleep time, sleep-onset latency, sleep efficiency, wake after sleep onset, and time spent in sleep stages. Impact of sleep indices on next-day caffeine use was also examined.

RESULTS

Increased total caffeine consumption was associated was increased sleep-onset latency (β = .13; 95% CI = .06, .21; P < .001) and reduced total sleep time (β = -.17; 95% confidence interval [CI] = -.31, -.02; P = .02), sleep efficiency (β = -1.59; 95% CI = -2.51, -.67; P < .001), and rapid eye movement sleep (β = -.12; 95% CI = -.19, -.05; P < .001). Findings were driven by afternoon and evening caffeine consumption. Reduced sleep efficiency was associated with increased afternoon caffeine intake the following day (β = -.006; 95% CI = -.012, -.001; P = .01).

CONCLUSIONS

Caffeine consumption, especially afternoon and evening use, impacts several aspects of adolescent sleep health. In contrast, most sleep indicators did not affect next-day caffeine use, suggesting multiple drivers of adolescent caffeine consumption. Federal mandates requiring caffeine content labeling and behavioral interventions focused on reducing caffeine intake may support adolescent sleep health.

CITATION

Lunsford-Avery JR, Kollins SH, Kansagra S, Wang KW, Engelhard MM. Impact of daily caffeine intake and timing on electroencephalogram-measured sleep in adolescents. J Clin Sleep Med. 2022;18(3):877-884.

Consumption and effects of caffeinated energy drinks in young people: an overview of systematic reviews and secondary analysis of UK data to inform policy

BACKGROUND

This overview and analysis of UK datasets was commissioned by the UK government to address concerns about children's consumption of caffeinated energy drinks and their effects on health and behaviour.

METHODS

We searched nine databases for systematic reviews, published between 2013 and July 2021, in English, assessing caffeinated energy drink consumption by people under 18 years old (children). Two reviewers rated or checked risk of bias using AMSTAR2, and extracted and synthesised findings. We searched the UK Data Service for country-representative datasets, reporting children's energy-drink consumption, and conducted bivariate or latent class analyses.

RESULTS

For the overview, we included 15 systematic reviews; six reported drinking prevalence and 14 reported associations between drinking and health or behaviour. AMSTAR2 ratings were low or critically low. Worldwide, across reviews, from 13% to 67% of children had consumed energy drinks in the past year. Only two of the 74 studies in the reviews were UK-based. For the dataset analysis, we identified and included five UK cross-sectional datasets, and found that 3% to 32% of children, across UK countries, consumed energy drinks weekly, with no difference by ethnicity. Frequent drinking (5 or more days per week) was associated with low psychological, physical, educational and overall well-being. Evidence from reviews and datasets suggested that boys drank more than girls, and drinking was associated with more headaches, sleep problems, alcohol use, smoking, irritability, and school exclusion. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) assessment suggests that the evidence is weak.

CONCLUSIONS

Weak evidence suggests that up to a third of children in the UK consume caffeinated energy drinks weekly; and drinking 5 or more days per week is associated with some health and behaviour problems. Most of the evidence is from surveys, making it impossible to distinguish cause from effect. Randomised controlled trials are unlikely to be ethical; longitudinal studies could provide stronger evidence.

PROSPERO REGISTRATIONS

CRD42018096292 - no deviations. CRD42018110498 - one deviation - a latent class analysis was conducted.

SODA MAPS: A Framework for Understanding Caffeinated Sugary Drink Consumption Among Children

Excess sugary drink (SD) consumption is associated with childhood obesity and development of cardiometabolic disease. In addition to having high added sugar content, many SDs also contain caffeine, which may further encourage excess SD consumption among children. The objective of this study was to develop a conceptual framework of children's caffeinated SD consumption using group concept mapping, an applied social research multimethodology that collectively harnesses qualitative and quantitative data from participants to generate a visual representation of their ideas and input. Children, 8–14 years old, who reported consuming ≥12 ounces of caffeinated SDs (e.g., sodas, sweet teas) per day were recruited throughout Washington, D.C. and invited to participate. Concept mapping included three participant-driven activities: (1) brainstorming (n = 51), during which children reported reasons for their SD consumption, from which 58 unique reasons were identified; (2) sorting (n = 70), during which children sorted each of the reported reasons into categories and named each category; and (3) rating (n = 74), during which children rated the influence of each reason on their own caffeinated SD consumption. Similarity matrices, multidimensional scaling, and hierarchical cluster analysis were used to generate concept maps (hereafter “SODA MAPS”), which display the 58 reasons organized within eight overarching clusters. Among these eight clusters, Taste and Feel, Something to Do, and Energy were rated as particularly influential. Children's caffeinated SD consumption is encouraged not only by the palatable taste and reported preferences for these beverages (e.g., Taste and Feel), but also by psychological (e.g., Mood and Focus), biological (e.g., Energy), social (e.g., Something to Do) and environmental reasons (e.g., Nothing Better Available). Thus, the SODA MAPS can inform the development of tailored, multi-level SD reduction interventions that incorporate strategies to address important and currently overlooked reasons for caffeinated SD consumption among children.

Caffeine Use and Associations With Sleep in Adolescents With and Without ADHD

OBJECTIVE

The objective of this study was to compare caffeine consumption in the morning, afternoon, and evening in adolescents with and without attention-deficit/hyperactivity disorder (ADHD) and examine associations with sleep functioning.

METHODS

Participants were 302 adolescents (ages 12-14) with (N = 140) and without (N = 162) ADHD. Adolescents wore actigraph watches to assess total sleep time and wake after sleep onset and reported on sleep-wake problems and the number of caffeinated beverages consumed per day in the morning, afternoon, and evening. Parents reported on adolescents' difficulties initiating and maintaining sleep. Chi-square tests, odds ratios, and path analyses were conducted.

RESULTS

Analyses controlled for sex, medication status, and pubertal development. Adolescents with ADHD were 2.47 times more likely to consume caffeine in the afternoon and evening than adolescents without ADHD. Path analyses indicated significant associations between afternoon caffeine use and more self-reported sleep problems for adolescents with and without ADHD, and an association between evening caffeine use and self-reported sleep problems only in adolescents with ADHD. Afternoon caffeine use was associated with parent-reported sleep problems in adolescents with ADHD only. Caffeine use was not associated with actigraphy-assessed sleep.

CONCLUSION

This is the first study to show that adolescents with ADHD consume more caffeine than peers during later times of the day. Additionally, caffeine use is more consistently associated with poorer subjective sleep functioning in adolescents with ADHD. Pediatricians and mental health professionals should assess for caffeine use in adolescents with ADHD and co-occurring sleep problems.

The challenges of adolescent sleep

Sleep is vital for our physical, emotional and cognitive health. However, adolescents face many challenges where their sleep is concerned. This is reflected in their sleep patterns including the timing of their sleep and how much sleep they achieve on a regular basis: their sleep is characteristically delayed and short. Notably, insufficient sleep is associated with impairments in adolescent functioning. Endogenous and exogenous factors are known to affect sleep at this age. Alterations in the bioregulation of sleep, comprising the circadian timing system and the sleep/wake homeostatic system, represent the intrinsic mechanisms at work. Compounding this, environmental, psychosocial and lifestyle factors may contribute to shortened sleep. This review discusses the amount of sleep gained by adolescents and its implications, the challenges to adolescent sleep and the interventions introduced in an effort to prioritize sleep health in this important developmental period.

The dynamic relationship between daily caffeine intake and sleep duration in middle-aged and older adults

The effect of caffeine on sleep has been well documented. However, most studies examined this relationship in laboratories or used a cross-sectional design analysing between-person differences. This study investigated the within-person relationship between caffeine intake and sleep duration at home. In a national database, 377 participants (aged 35-85 years) completed a 7-day diary study. Sleep duration was measured by Actigraphy and caffeine intake was self-reported in sleep logs. Three analytic strategies were used. The average sleep duration and the average caffeine intake were not significantly correlated. Multilevel regressions using daytime caffeine intake to predict night-time sleep, and using night-time sleep to predict next day caffeine intake, also did not detect any significant effect. Then dynamical systems analysis was performed, where the daily change rate and change tendency of caffeine and sleep were estimated, and the relationship among these momentums was examined. Results revealed a significant effect of sleep duration on the change tendency of caffeine use: a shorter sleep duration predicted a stronger tendency to consume caffeine, and this phenomenon was only found in middle-aged adults (aged 35-55 years) not in older adults (aged 55+). This study did not detect any effect of daily caffeine intake on sleep duration, implying that habitual use of caffeine in real life may not coincide with laboratory findings, and that using caffeine to compensate for sleep loss is the habit of middle-aged adults, not the elderly. The advantage of using a dynamic approach to analyse interrelated processes with uncertain time lags is also highlighted.

Caffeinated energy drink consumption and predictors of use among secondary school students over time in the COMPASS cohort study

Consumption of caffeinated energy drinks (CED) by youth is a public health priority, given the lack of regulation and evidence for both short and long-term health effects of CED use. Considering the potential risks associated with excessive caffeine consumption, this paper examined CED consumption and predictors of CED use over time in a large sample of Canadian secondary school students participating in the COMPASS study.

Using linked longitudinal data (n = 4949) from the first three years of the COMPASS study (2012/13 to 2014/15), three logistic Generalized Estimated Equation models were performed to examine predictors of weekday CED use, weekend CED use, and weekly CED use.

The prevalence of weekly CED use remained fairly consistent across the three years of follow-up; 12.5% in year-1, 11.3% in year-2, and 11.4% in year-3. Smokers and marijuana users at follow-up were all at greater odds of weekday or weekly CED use, regardless of baseline use. Binge drinkers at baseline were at greater odds for weekday or weekly CED use, but not if they started binge drinking after their baseline year. Marijuana users at follow-up were all at greater odds of weekend CED use, regardless of baseline marijuana use.

>1 in 10 youth reported consuming CEDs one or more times per week, where specific subpopulations of youth, such as marijuana users, appear to be more frequent CED users. Although CED use remained relatively constant over the three-year period examined, prevalence of CED use remains problematic among secondary school students.

Review: Trends, Safety, and Recommendations for Caffeine Use in Children and Adolescents

OBJECTIVE

Caffeine use is common in children and adolescents, but the recommendations for safe consumption are based on decades-old data collected exclusively in adults. Increased availability of caffeine-containing products and a concerted marketing effort aimed at children and adolescents, has increased interest in understanding the physiological, behavioral, and psychological effects of caffeine within this population. This manuscript provides a review of the literature concerning trends and safety of ingested caffeine in children and adolescents.

METHOD

A search of the National Library of Medicine database was conducted using the terms caffeine, children, adolescents, and safety, in addition to tailored searches on specific topics using combinations of search terms such as energy drinks, cardiovascular, mood, cognitive, mental health, sleep, and regulations.

RESULTS

The majority of the literature reviewed here suggests that typical, moderate caffeine consumption in children and adolescents is relatively safe, but that higher doses of caffeine consumption (>400 mg) can cause physiological, psychological, and behavioral harm, in particular in subgroups of children, such as those with psychiatric or cardiac conditions. More attention is being paid to the potential adverse effects of both acute and chronic caffeine use, and additional regulations surrounding the sale and marketing of highly caffeinated beverages are now being considered.

CONCLUSION

More research is needed to fill in gaps in our knowledge, including understanding the relationship between caffeine use and initiation of other substances, such as cigarettes, alcohol, or marijuana, identifying individuals at risk for caffeine toxicity, and developing harm-reduction strategies.

Sleep in Teens With Type 1 Diabetes: Perspectives From Adolescents and Their Caregivers

PURPOSE

The purpose of this study is to identify barriers, facilitators, and consequences of obtaining sufficient sleep in adolescents with type 1 diabetes.

METHODS

Semistructured interviews were conducted with 25 adolescents (52% female, mean age = 15.6 years) and 25 caregivers. Interviews were transcribed and coded using Atlas.ti. A thematic analytic approach was used to identify and organize significant patterns of meaning (themes) and interpret themes across the data.

RESULTS

Several barriers were identified, with the most common being the use of electronics before bed and sleep disturbances related to diabetes management. Caregivers described strategies for helping adolescents achieve sufficient sleep, such as enforcing bedtimes and limiting distractions, but many adolescents could not identify facilitators of sleep. Weekday/weekend discrepancies in sleep timing were commonly disclosed.

CONCLUSIONS

This study is the first to examine the perceptions of barriers and facilitators to obtaining sufficient sleep in adolescents with T1D and their caregivers. Results have the potential to inform providers' recommendations regarding sleep, including possible interventions to promote sleep in this high-risk population.

An update on adolescent sleep: New evidence informing the perfect storm model

The maturation of sleep regulatory systems during adolescence in combination with psychosocial and societal pressures culminate in a "Perfect Storm" of short and ill-timed sleep and the associated consequences for many youngsters. This model, first described by Carskadon in 2011, guides our current thinking of adolescent sleep behavior. Since the original description, the field has moved forward with remarkable pace, and this review aims to summarize recent progress and describe how this new work informs our understanding of sleep regulation and sleep behavior during this developmental time frame.

Sleepy Teens and Energy Drink Use: Results From an Ethnically Diverse Sample of Youth

This study examines the association between use of energy drinks or products (EP), EP expectancies, and the association between EP use and sleep in a racially and ethnically diverse sample (N = 2,485) of adolescents. Prevalence of EP use was approximately 18%, with no statistically significant racial or ethnic differences in prevalence. There were significant racial and ethnic differences in EP expectancies; Hispanic and Multiracial or Other groups endorsed less positive expectancies than Whites and Asians. EP use was significantly associated with later weekend bedtimes, shorter weekend total sleep time (TST), a smaller weekend-weekday difference in TST, and more trouble sleeping, even after adjusting for covariates. There were no significant race or ethnicity interactions between EP use and sleep. EP use is an independent correlate of sleep problems in adolescents across racial or ethnic groups.

Relationships Between Smoking and Sleep Problems in Black and White Adolescents

Study Objectives

The relationship between sleeping and smoking during adolescence remains unclear and is likely complex. We aim to evaluate the longitudinal reciprocal associations between sleep problems, sleep duration, and smoking among non-Hispanic white (NHW) and non-Hispanic black (NHB) youth.

Design

Prospective cohort study.

Setting

NEXT Generation Health Study.

Participants

A national sample (N = 1394) of NHB and NHW 10th graders were surveyed annually between 2009 (Wave 1) and 2012 (Wave 3).

Interventions

N/A.

Measurements and Results

Past 30-day smoking, chronic difficulty falling asleep, recent difficulty falling asleep, difficulty staying asleep, and weekday and weekend sleep duration were measured at each wave. Using structural equation models, we observed significant autocorrelations over time for sleep problems and sleep duration. We found significant reciprocal, prospective relationships between smoking and sleep problems. The strengths of the relationships differed by race, with a stronger association between sleep problems and subsequent smoking for NHB than NHW youth. Conversely, a stronger association between smoking and subsequent sleep problems for NHW than NHB youth was observed. These association were independent of demographics, snoring or sleep apnea, body mass index, depressive symptoms, alcohol use, and soda consumption.

Conclusions

Reciprocal and prospective relationships exist for youth smoking and sleep problems and duration in both NHW and NHB youth. Further research is needed to unravel the complex relationship between the direct effects of nicotine, lifestyle choices that may link smoking and sleep problems, and racial differences.

Interactions Between Energy Drink Consumption and Sleep Problems: Associations with Alcohol Use Among Young Adolescents

Background: Energy drink consumption and sleep problems are both associated with alcohol use among adolescents. In addition, caffeine consumption (including energy drinks) is associated with sleep problems. However, information about how these three constructs may interact is limited. The goal of this study was to examine potential interactions between energy drink consumption and sleep problems in the concurrent prediction of alcohol use among young adolescents. Coffee and soda consumption were also examined for comparison. Methods: Participants from the Camden Youth Development Study were included (n = 127; mean age = 13.1; 68% Hispanic, 29% African American) and questionnaire measures of frequency of caffeinated beverage consumption (energy drinks, coffee, and soda), sleep (initial insomnia, sleep disturbances, daytime fatigue, and sleep duration), and alcohol consumption were used. Regression analyses were conducted to examine interactions between caffeinated beverage consumption and sleep in the concurrent prediction of alcohol use. Results: Energy drink consumption interacted with initial insomnia and daytime fatigue to concurrently predict particularly frequent alcohol use among those with either of these sleep-related problems and energy drink consumption. The pattern of results for coffee consumption was similar for insomnia but reached only a trend level of significance. Results of analyses examining soda consumption were nonsignificant. Conclusions: Young adolescents who both consume energy drinks and experience initial insomnia and/or daytime fatigue are at particularly high risk for alcohol use. Coffee consumption appears to be associated with similar patterns. Longitudinal research is needed to explain the developmental pathways by which these associations emerge, as well as mediators and moderators of these associations.

Consumption of Energy Drinks among Undergraduate Students in Taiwan: Related Factors and Associations with Substance Use

Background: This study aimed to investigate the consumption of energy drinks and associated factors among undergraduate students in Taiwan. Methods: Data came from a cross-sectional survey conducted in 2015. Eligible participants completed a self-administered questionnaire assessing use and perceptions of energy drinks, tobacco, alcohol, and betel nut. Results: Among 606 surveyed undergraduate students, 24.8% reported consuming energy drinks in the past 30 days. The major reasons for use included keeping alert at work (48.7%), being curious about the products (32.0%), enjoying the flavor (31.3%), or preparing for school exams (26.7%). Among energy drink users, half have never read the nutrition label, and 15.3% reported that they had ever mixed energy drinks with alcohol. Most participants showed negative attitudes toward using tobacco, alcohol, or betel nut, while 54.1% reported positive attitudes toward consuming energy drinks. Being male, living away from parents’ home, tobacco use, alcohol use, and positive perceptions of energy drink’s effects significantly predicted energy drink consumption. Conclusions: In addition to exploring motivations of energy drink consumption in undergraduate students in Taiwan, the study findings indicated that energy drink consumption might relate to the use of tobacco and alcohol, which should be taken into account in substance use prevention programs.

Variable School Start Times and Middle School Student's Sleep Health and Academic Performance

PURPOSE

Improving sleep health among adolescents is a national health priority and implementing healthy school start times (SSTs) is an important strategy to achieve these goals. This study leveraged the differences in middle school SST in a large district to evaluate associations between SST, sleep health, and academic performance.

METHODS

This cross-sectional study draws data from a county-wide surveillance survey. Participants were three cohorts of eighth graders (n = 26,440). The school district is unique because SST ranged from 7:20 a.m. to 8:10 a.m. Path analysis and probit regression were used to analyze associations between SST and self-report measures of weekday sleep duration, grades, and homework controlling for demographic variables (sex, race, and socioeconomic status). The independent contributions of SST and sleep duration to academic performance were also analyzed.

RESULTS

Earlier SST was associated with decreased sleep duration (χ² = 173, p < .0001) and deficient sleep (≤7 hours) among 45% of students. Students with SST before 7:45 a.m. were at increased risk of decreased sleep duration, academic performance, and academic effort. Path analysis models demonstrated the independent contributions of sleep duration, SST, and variable effects for demographic variables.

CONCLUSIONS

This is the first study to evaluate the independent contributions of SST and sleep to academic performance in a large sample of middle school students. Deficient sleep was prevalent, and the earliest SST was associated with decrements in sleep and academics. These findings support the prioritization of policy initiatives to implement healthy SST for younger adolescents and highlight the importance of sleep health education disparities among race and gender groups.

Sleep timing is associated with self-reported dietary patterns in 9- to 15-year-olds

OBJECTIVE

To examine sleep timing differences in self-reported dietary patterns of children and adolescents.

DESIGN

Cross-sectional.

PARTICIPANTS

Students aged 9-15 years (n=119, 11.7±1.3 years, 76% female) attending a summer program for the gifted. The upper and lower quartiles of reported midsleep time (weighted weekday-weekend average) were used to identify early (n=28) and late (n=27) sleep timing groups.

METHODS

Sleep patterns were assessed via self-report. Participants also rated their likelihood to consume 9 different categories of food and drinks on a 5-point scale ranging from "no likelihood" to "high likelihood." Foods were grouped as follows: (1) sugary and caffeinated beverages; (2) high-energy-dense, nutrient-poor foods (ie, sugary, salty, fatty foods); and (3) low-energy-dense, nutrient-rich foods (ie, vegetables, proteins, carbohydrates, fruits).

RESULTS

Midsleep time was 02:11±00:25 for the early and 06:14±01:00 for the late sleep timing groups. Participants reporting later sleep timing were more likely to consume sugary/caffeinated beverages and high-energy-dense, nutrient-poor foods throughout the day compared with their early sleep timing peers. The late vs the early sleep timing group also had a higher likelihood of overall consumption of foods and drinks from all categories into the evening and nighttime hours.

CONCLUSION

Our findings indicate that children and adolescents who exhibit late sleep timing are more likely to make poorer dietary choices, which may have important implications for understanding pathways to adiposity and obesity risk during this sensitive period of development.

School and Parent Factors Associated With Steroid Use Among Adolescents

BACKGROUND

Steroid use among adolescents is an increasing health concern. Literature examining factors related to steroid use is limited.

METHODS

We investigated steroid use among 9th through 12th grade adolescents in the Greater Cincinnati area. A total of 38,414 adolescents completed the PRIDE Questionnaire. Associations between demographics, school factors, parent factors, sport participation, and steroid use were examined.

RESULTS

A total of 2.6% of adolescents reported using steroids in the past year. Most prevalent was steroid use among male, Junior/Senior, African-American, and Hispanic adolescents. Rates of steroid use differed significantly based on school and parent factors, but not sport participation. Adolescents who reported attendance at schools that frequently set and enforced rules for drug use or whose parents frequently set rules for drug use were at decreased odds for steroid use. School communication about drug use was negatively associated with steroid use.

CONCLUSIONS

School administration and staff, as well as parents, are uniquely positioned to deter steroid use among adolescents. Findings suggest that limiting steroid screening to student athletes might miss a substantial proportion of the population at risk. Thus, broad-based screening and prevention programs may be more effective than programs targeting student athletes alone.

Relationships Between Smoking and Sleep Problems in Black and White Adolescents

Study Objectives

The relationship between sleeping and smoking during adolescence remains unclear and is likely complex. We aim to evaluate the longitudinal reciprocal associations between sleep problems, sleep duration, and smoking among non-Hispanic white (NHW) and non-Hispanic black (NHB) youth.

Design

Prospective cohort study.

Setting

NEXT Generation Health Study.

Participants

A national sample (N = 1394) of NHB and NHW 10th graders were surveyed annually between 2009 (Wave 1) and 2012 (Wave 3).

Interventions

N/A.

Measurements and Results

Past 30-day smoking, chronic difficulty falling asleep, recent difficulty falling asleep, difficulty staying asleep, and weekday and weekend sleep duration were measured at each wave. Using structural equation models, we observed significant autocorrelations over time for sleep problems and sleep duration. We found significant reciprocal, prospective relationships between smoking and sleep problems. The strengths of the relationships differed by race, with a stronger association between sleep problems and subsequent smoking for NHB than NHW youth. Conversely, a stronger association between smoking and subsequent sleep problems for NHW than NHB youth was observed. These association were independent of demographics, snoring or sleep apnea, body mass index, depressive symptoms, alcohol use, and soda consumption.

Conclusions

Reciprocal and prospective relationships exist for youth smoking and sleep problems and duration in both NHW and NHB youth. Further research is needed to unravel the complex relationship between the direct effects of nicotine, lifestyle choices that may link smoking and sleep problems, and racial differences.

Caffeine consumption patterns and determinants among adolescents in Serbia

BACKGROUND

The number of adolescents who use caffeine is constantly increasing. As juvenile age is vulnerable, it is reasonable to expect that they will differently perceive reason and react to caffeine use than adults, and be more prone to unwanted physiological and psychological consequences of its consumption.

AIM

Analysis of the scope and pattern of caffeine consumption among adolescents in Serbia.

STUDY DESIGN

The cross-sectional survey was implemented in the study population of 191 Serbian adolescents during 2010.

RESULTS

The median daily intake of caffeine was 95.6 mg. The major source of caffeine was brewed coffee, and the most common reasons for caffeine intake were leisure, peer influence, or habit. Only 57.6% of the subjects were aware that caffeine is present in consumed beverages. Sex affected the pattern, but not the overall level, of caffeine consumption. No association between caffeine consumption and smoking status, frequency of caffeine use in the family, or negative personal experience with caffeine effects was observed.

CONCLUSION

Our investigation provides first and rather detailed insight into caffeine-containing beverage consumption scope and pattern among Serbian adolescents. For accurate estimation and analysis of caffeine intake in this population, randomized studies with prospective longitudinal design, caffeine content measurement, and more subjects involved are warranted.

Consumption of energy drinks by children and young people: a rapid review examining evidence of physical effects and consumer attitudes

OBJECTIVE

To examine patterns of energy drink consumption by children and young people, attitudes towards these drinks, and any associations with health or other outcomes.

DESIGN

Rapid evidence assessment and narrative synthesis.

DATA SOURCES

9 electronic bibliographic databases, reference lists of relevant studies and searches of the internet.

RESULTS

A total of 410 studies were located, with 46 meeting the inclusion criteria. The majority employed a cross-sectional design, involved participants aged 11-18 years, and were conducted in North America or Europe. Consumption of energy drinks by children and young people was found to be patterned by gender, with boys consuming more than girls, and also by activity levels, with the highest consumption observed in the most and least sedentary individuals. Several studies identified a strong, positive association between the use of energy drinks and higher odds of health-damaging behaviours, as well as physical health symptoms such as headaches, stomach aches, hyperactivity and insomnia. There was some evidence of a dose-response effect. 2 experimental studies involving small numbers of junior athletes demonstrated a positive impact on limited aspects of sports performance. 3 themes emerged from the qualitative studies: reasons for use; influences on use; and perceived efficacy and impact. Taste and energy-seeking were identified as key drivers, and branding and marketing were highlighted as major influences on young people's consumption choices. Awareness of possible negative effects was low.

CONCLUSIONS

There is growing evidence that consumption of energy drinks is associated with a range of adverse outcomes and risk behaviours in terms of children's health and well-being. However, taste, brand loyalty and perceived positive effects combine to ensure their popularity with young consumers. More research is needed to explore the short-term and long-term impacts in all spheres, including health, behaviour and education.

TRIAL REGISTRATION NUMBER

CRD42014010192.

Adolescent energy drink consumption: An Australian perspective

Caffeinated Energy Drinks (EDs) are not recommended for consumption by children, yet there is a lack of age-specific recommendations and restrictions on the marketing and sale of EDs. EDs are increasingly popular among adolescents despite growing evidence of their negative health effects. In the current study we examined ED consumption patterns among 399 Australian adolescents aged 12-18 years. Participants completed a self-report survey of consumption patterns, physiological symptoms, and awareness of current ED consumption guidelines. Results indicated that ED consumption was common among the sample; 56% reported lifetime ED consumption, with initial consumption at mean age 10 (SD = 2.97). Twenty-eight percent of the sample consumed EDs at least monthly, 36% had exceeded the recommended two standard EDs/day, and 56% of consumers had experienced negative physiological health effects following ED consumption. The maximum number of EDs/day considered appropriate for children, adolescents, and adults varied, indicating a lack of awareness of current consumption recommendations. These findings add to the growing body of international evidence of adolescent ED consumption, and the detrimental impact of EDs to adolescent health. Enforced regulation and restriction of EDs for children's and adolescents' consumption is urgently needed in addition to greater visibility of ED consumption recommendations.

Energy drink consumption, health complaints and late bedtime among young adolescents

OBJECTIVES

Energy drinks contain large amounts of caffeine. Their effects on adolescent well-being are poorly known. We examined the relationship of energy drink consumption with health complaints and late bedtime among 13-year-olds.

METHODS

A classroom survey was conducted on all 7th graders in the Helsinki metropolitan region, Finland (73 % responded; n = 9446). Logistic regression analysis and structural equation modeling (SEM) were used.

RESULTS

The prevalence of health complaints increased as energy drink consumption increased from non-consumers to several times/day. Late bedtime (≥11 PM) increased correspondingly. Those consuming energy drinks several times/day exhibited increased odds of experiencing daily health complaints compared with non-consumers: headache OR (adjusted) = 4.6 (2.8-7.7), sleeping problems OR = 3.6 (2.2-5.8), irritation OR = 4.1 (2.7-6.1), tiredness/fatigue OR = 3.7 (2.4-5.7), and late bedtime OR = 7.8 (5.7-10.9). In SEM, energy drink consumption had a direct effect on health complaints and late bedtime and an indirect effect on health complaints via late bedtime.

CONCLUSIONS

Energy drinks, late bedtime, and health complaints form a behavior pattern that is worth considering in schools, home and clinical settings when adolescents complain about headaches, problems with sleeping and corresponding symptoms.

Caffeine Awareness in Children: Insights from a Pilot Study

STUDY OBJECTIVES

Caffeine, a commonly consumed psychoactive substance, can have significant effects on sleep. Caffeine intake among children is increasing, mainly in the form of sodas. However, adolescent caffeine consumers may lack knowledge about the caffeine content in common beverages. If true, this very fact may hamper the assessment of the effects of caffeine consumption on sleep in children if such assessments are a priori dependent on responders being able to reliably distinguish between caffeinated and noncaffeinated beverages. This preliminary study investigated adolescents' caffeine knowledge and intake at a Cleveland-area public middle school.

METHODS

Seventh- and eighth-grade students were surveyed using: (1) the Caffeine Literacy and Sleep Study (CLASS), a 15-question pilot instrument designed to assess caffeine knowledge and intake by type, quantity and timing, as well as sleep habits; and (2) the Cleveland Adolescent Sleepiness Questionnaire (CASQ), a validated survey measuring excessive daytime sleepiness in adolescents. These questionnaires were distributed and collected during a specified class period.

RESULTS

Of the 635 seventh- and eighth-grade students who attended school on the day of the study, 555 (87%) participated. Lack of knowledge about caffeine content of particular drinks was noted in seventh and eighth graders of both sexes with nearly 29% unaware that their favorite drinks contain caffeine and more than 50% unable to correctly identify the drinks with the most caffeine. A low percentage of students correctly identified light-colored sodas lacking caffeine: 7-Up (24.1%), Sierra Mist (38.9%), ginger ale (39.8%), Sprite (39.8%), and Fresca (53.7%). The percentages of students correctly identifying caffeinated light-colored beverages were: Arizona Green Tea (43.5%), Mello Yellow (50.9%), and A&W cream soda (67.6%). However, Mountain Dew was correctly identified by most (93.5%) as caffeinated.

CONCLUSIONS

Students were not consistently able to identify caffeine content or lack thereof in some common beverages. The results of this pilot study show that caffeine literacy in adolescents warrants further investigation and educational intervention.

Effect of energy drink and caffeinated beverage consumption on sleep, mood, and performance in children and adolescents

The increasing availability of highly caffeinated beverages, including energy drinks, in the United States has resulted in a rise in consumption by children and adolescents. In addition, there is mounting evidence that these products are often consumed by youth for their perceived fatigue-mitigating and mood- or performance-enhancing effects. Although such perceptions by children and adolescents about the potential consequences of caffeine consumption are highly likely to influence decision making regarding the use of such products, there is still a relative paucity of studies that focus on the effect of caffeinated beverages on sleep, mood, and performance in the pediatric population. This review summarizes the following aspects of this topic, as derived from the information currently available: 1) the perception, among youth, of caffeine's risks and benefits and the sources of information about caffeine, particularly with regard to sleep, mood, and performance; 2) the bidirectional effect of caffeine on sleep in children and adolescents and the association of caffeine with other sleep-related practices, and 3) the evidence that supports caffeine as a performance and mood enhancer as well as a countermeasure to sleepiness in the pediatric population. Finally, gaps in knowledge are identified, and a direction for future research is outlined.

Adolescent Bullying and Sleep Difficulties

This study evaluated whether adolescents who report having been bullied, being bullies, or report both being a bully and being bullied experience more sleep difficulties than children uninvolved in bullying. The study drew upon cognitive theories of insomnia, investigating whether the extent to which young people report worrying about bullying can moderate associations between victimization and sleep difficulties. Participants were 5420 adolescents who completed a self-report questionnaire. Pure Victims (OR = 1.72, 95% CI [1.07, 2.75]), Pure Bullies (OR = 1.80, 95% CI [1.16, 2.81]), and Bully-Victims (OR = 2.90, 95% CI [1.17, 4.92]) were all more likely to experience sleep difficulties when compared to uninvolved young people. The extent to which young people reported worrying about being bullied did not moderate the links between victimization and sleep difficulties. In this way, bullying is clearly related to sleep difficulties among adolescents but the conceptual reach of the cognitive model of insomnia in this domain is questioned.

An integrative review of sleep for nutrition professionals

Sleep is an essential lifestyle factor that contributes to overall health. The inverse relation between sleep duration and weight status has revealed the importance of sleep in nutritional health. This integrative review builds foundational knowledge with regard to sleep vis-à-vis nutrition by summarizing the importance and process of sleep, current sleep recommendations and trends, as well as lifestyle contributors to poor sleep. Additionally, it details the association between sleep and obesity and potential mechanisms for this association. Furthermore, guidance is offered regarding the incorporation of sleep considerations in nutrition counseling, communication, and research. Like many other lifestyle factors that contribute to nutritional health, sleep needs to be considered when examining weight management and health promotion.

Protective and risk factors for adolescent sleep: a meta-analytic review

Teenagers need sufficient sleep to function well daily, yet consolidated evidence advising which factors protect, or harm, adolescents' sleep is lacking. Forty-one studies, published between 2003 and February, 2014, were meta-analysed. Mean weighted r values were calculated to better understand the strength of protective and risk factors for 85,561 adolescents' (age range = 12-18 y) bedtime, sleep onset latency (SOL) and total sleep time (TST). Results showed good sleep hygiene and physical activity were associated with earlier bedtimes. Video gaming, phone, computer and internet use, and evening light related to delayed bedtimes. Good sleep hygiene negatively correlated with sleep latency. Alternatively, sleep latency lengthened as a negative family environment increased. Tobacco, computer use, evening light, a negative family environment and caffeine were associated with decreased total sleep, whereas good sleep hygiene and parent-set bedtimes related to longer sleep length. Good sleep hygiene appears to be protective, whereas a negative home environment and evening light appear to be risk factors. Cautious use of technology (other than television), caffeine, tobacco and alcohol should be considered. These factors, along with pre-sleep worry, are likely to have some negative impact on sleep. Parent-set bedtimes and physical activity may be beneficial. Future research directions are discussed.

Insufficient sleep in adolescents and young adults: an update on causes and consequences

Chronic sleep loss and associated sleepiness and daytime impairments in adolescence are a serious threat to the academic success, health, and safety of our nation's youth and an important public health issue. Understanding the extent and potential short- and long-term repercussions of sleep restriction, as well as the unhealthy sleep practices and environmental factors that contribute to sleep loss in adolescents, is key in setting public policies to mitigate these effects and in counseling patients and families in the clinical setting. This report reviews the current literature on sleep patterns in adolescents, factors contributing to chronic sleep loss (ie, electronic media use, caffeine consumption), and health-related consequences, such as depression, increased obesity risk, and higher rates of drowsy driving accidents. The report also discusses the potential role of later school start times as a means of reducing adolescent sleepiness.

School start times for adolescents

The American Academy of Pediatrics recognizes insufficient sleep in adolescents as an important public health issue that significantly affects the health and safety, as well as the academic success, of our nation's middle and high school students. Although a number of factors, including biological changes in sleep associated with puberty, lifestyle choices, and academic demands, negatively affect middle and high school students' ability to obtain sufficient sleep, the evidence strongly implicates earlier school start times (ie, before 8:30 am) as a key modifiable contributor to insufficient sleep, as well as circadian rhythm disruption, in this population. Furthermore, a substantial body of research has now demonstrated that delaying school start times is an effective countermeasure to chronic sleep loss and has a wide range of potential benefits to students with regard to physical and mental health, safety, and academic achievement. The American Academy of Pediatrics strongly supports the efforts of school districts to optimize sleep in students and urges high schools and middle schools to aim for start times that allow students the opportunity to achieve optimal levels of sleep (8.5-9.5 hours) and to improve physical (eg, reduced obesity risk) and mental (eg, lower rates of depression) health, safety (eg, drowsy driving crashes), academic performance, and quality of life.