International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

The Mediating Role of Emotion Dysregulation and Problematic Internet Use in the Relationship Between Negative Affect and Excessive Daytime Sleepiness: A Structural Equation Model

PURPOSE

The present study aimed to explore the mediating role of emotion dysregulation and problematic Internet use in the relationship between negative affect and excessive daytime sleepiness.

METHODS

This cross-sectional study included 664 Italian adults aged between 18 and 70 years (M = 32.13; SD = 11.71). Participants were asked to complete the Depression Anxiety Stress Scale, the Difficulties in Emotion Regulation Scale, the Compulsive Internet Use Scale-7, and the Epworth Sleepiness Scale to assess negative affect, emotion dysregulation, problematic internet use, and excessive daytime sleepiness, respectively.

RESULTS

According to our results there are significant associations between negative affect, emotion dysregulation, problematic Internet use, and daytime sleepiness. Moreover, the structural equation model showed good fit indices. Emotion dysregulation and problematic Internet use partially mediated the relationship between negative mood and excessive daytime sleepiness.

CONCLUSION

By exploring the role of emotion dysregulation on the association between excessive daytime sleepiness and its possible predictors, our study might represent an important step toward the implementation of psychological intervention for reducing excessive daytime sleepiness. Emotion dysregulation appears to play a significant role in explaining the relationship between negative affect, problematic Internet use, and excessive daytime sleepiness. Thus, it should be considered a treatment target for reducing excessive daytime sleepiness.

Physical activity and sleep: An updated umbrella review of the 2018 Physical Activity Guidelines Advisory Committee report

Physical activity (PA) is widely considered to improve sleep, but a comprehensive review of the research on this topic has not been performed. In this umbrella review, conducted initially for the 2018 Physical Activity Guidelines for Americans Advisory Committee and updated to reflect more recent research, we examined whether PA enhances sleep outcomes across the lifespan as well as among individuals with sleep disorders. Systematic reviews and meta-analyses were utilized to assess the evidence. We also examined dose-response considerations and whether the association between PA and sleep was moderated by various factors (e.g., timing, sociodemographic characteristics). We found strong evidence that both acute bouts of PA and regular PA improved sleep outcomes. Moderate evidence indicated that longer bouts of PA (both acute and regular) improved sleep, and that the effects of PA on sleep outcomes were generally preserved across adult age groups and sex. Finally, moderate evidence demonstrated that PA improved sleep in adults with insomnia symptoms or obstructive sleep apnea. Several important areas in need of future research were also identified. Overall, the review supported the claim that PA improves sleep, but highlighted gaps that need to be addressed to facilitate more widespread utilization of PA for improving sleep.

Bi-directional relationships between co-morbid insomnia and sleep apnea (COMISA)

Insomnia and obstructive sleep apnea (OSA) commonly co-occur. Approximately 30-50% of patients with OSA report clinically significant insomnia symptoms, and 30-40% of patients with chronic insomnia fulfil diagnostic criteria for OSA. Compared to either insomnia or OSA alone, co-morbid insomnia and sleep apnea (COMISA) is associated with greater morbidity for patients, complex diagnostic decisions for clinicians, and reduced response to otherwise effective treatment approaches. Potential bi-directional causal relationships between the mechanisms and manifestations of insomnia and OSA could play an integral role in the development and management of COMISA. A greater understanding of these relationships is required to guide personalized diagnostic and treatment approaches for COMISA. This review summarizes the available evidence of bi-directional relationships between COMISA, including epidemiological research, case studies, single-arm treatment studies, randomized controlled treatment trials, and objective sleep study data. This evidence is integrated into a conceptual model of COMISA to help refine the understanding of potential bi-directional causal relationships between the two disorders. This theoretical framework is essential to help guide future research, improve diagnostic tools, determine novel therapeutic targets, and guide tailored sequenced and multi-faceted treatment approaches for this common, complex, and debilitating condition.

Prevalence and associations of co-morbid insomnia and sleep apnoea in an Australian population-based sample

INTRODUCTION

Insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders, and frequently co-occur (COMISA) in sleep clinic samples. However, few studies have investigated the prevalence or associations of COMISA in the general population.

METHODS

We used population-based online survey data from 2044 Australian adults. The prevalence and associations of insomnia, OSA and COMISA were investigated according to symptom-level, and disorder-level definitions. Insomnia was defined according to chronic difficulties initiating and/or maintaining sleep (DIMS; symptom-level), and ICSD-3 chronic insomnia disorder (disorder-level). OSA was defined according to self-reported frequent obstructive events, snoring or doctor-diagnosed OSA (symptom-level), and doctor-diagnosed OSA (disorder-level). COMISA was defined if both conditions were met (for symptom-level, and disorder-level threshold). Associations with other conditions, and general health were investigated with Poisson regression analyses.

RESULTS

Chronic insomnia occurred more frequently among participants with doctor-diagnosed OSA (22.3%), compared to those without (14.3%, p = 0.010). Doctor-diagnosed OSA was more common among participants with chronic insomnia (10.2%) compared to those without (6.2%; p = 0.010). DIMS also occurred more frequently among participants with OSA symptoms (66.6%), compared to those without (47.2%; p < 0.001). Participants with symptom-level COMISA reported increased co-morbid conditions, and worse general health compared to participants with symptoms of insomnia-alone, OSA-alone, or neither insomnia/OSA.

CONCLUSIONS

COMISA at symptom and disorder level were common and associated with increased medical and psychiatric co-morbidity, as well as poor general health. More investigation is required to understand bi-directional associations underpinning the high co-morbidity, and improve diagnostic and treatment approaches for COMISA to reduce associated morbidity.

Depressive Symptoms in Comorbid Obstructive Sleep Apnea and Insomnia: An Integrative Review

The purpose of this integrative review was to synthesize evidence concerning the relationship between comorbid obstructive sleep apnea and insomnia (OSA+I), and depressive symptoms. OSA and insomnia are common sleep disorders, recently comorbid OSA+I has been recognized as prevalent in adults. Although each sleep disorder increases the risk and severity of depressive symptoms, the effect of comorbid OSA+I on depressive symptoms remains unclear. A systematic search of PubMed, CINAHL, and PsycINFO identified 15 data-based studies. All the studies were observational with either a cross-sectional (n = 14) or a case-control design (n = 1). Study quality was assessed. Most of the studies (n = 14) indicated that comorbid OSA+I had an additive role on depressive symptoms. Insomnia appeared to have a more important role than OSA in increasing the severity of depressive symptoms in persons with comorbid OSA+I.

Understanding the burden of illness of excessive daytime sleepiness associated with obstructive sleep apnea: a qualitative study

Background

Obstructive sleep apnea (OSA) is associated with excessive daytime sleepiness (EDS), which may go undiagnosed and can significantly impair a patient’s health-related quality of life (HRQOL). This qualitative research examined timing and reasons patients sought medical care for their EDS and OSA symptoms, and the impact of EDS on HRQOL.

Methods

Focus groups were conducted in 3 US cities with 42 participants currently experiencing EDS with OSA. Transcripts were coded and analyzed using an adapted grounded theory approach common to qualitative research.

Results

Over three-fifths of study participants (n = 26, 62%) were currently using a positive airway pressure (PAP) or dental device; one-third (n = 14, 33%) had previously used a positive airway pressure (PAP) or dental device, and the remainder had either used another treatment (n = 1, 2%) or were treatment naïve (n = 1, 2%). Twenty-two participants (52%) reported experiencing OSA symptoms for ≥1 year, with an average duration of 11.4 (median 8.0, range 1–37) years before seeking medical attention. Several (n = 7, 32%) considered their symptoms to be “normal,” rather than signaling a serious medical condition. Thirty participants (71%) discussed their reasons for ultimately seeking medical attention, which included: input from spouse/partner, another family member, or friend (n = 20, 67%); their own concern about particular symptoms (n = 7, 23%); and/or falling asleep while driving (n = 5, 17%). For all 42 participants, HRQOL domains impacted by EDS included: physical health and functioning (n = 40, 95%); work productivity (n = 38, 90%); daily life functioning (n = 39, 93%); cognition (n = 38, 90%); social life/relationships (n = 37, 88%); and emotions (n = 30, 71%).

Conclusions

Findings suggest that patients may be unaware that their symptoms could indicate OSA requiring evaluation and treatment. Even following diagnosis, EDS associated with OSA can continue to substantially affect HRQOL and daily functioning. Further research is needed to address diagnostic delays and unmet treatment needs for patients with EDS associated with OSA.

Differences in electroencephalographic spectra during pre-sleep wakefulness, N1, and R sleep between comorbid insomnia and obstructive sleep apnea

PURPOSE

The neuropsychobiological effects of the comorbidity of insomnia and obstructive sleep apnea are not well studied. Our objective was to compare electroencephalographic spectra of patients with comorbid insomnia and sleep apnea syndrome to those of patients with sleep apnea syndrome alone during pre-sleep wakefulness and the N1 and R sleep periods.

METHOD

We performed electroencephalography and polysomnography on 10 patients with comorbid insomnia and sleep apnea and 10 with only sleep apnea. Electroencephalography spectra analysis was performed for absolute power in clinical bands in six derivations.

RESULTS

Compared to sleep apnea patients, comorbid patients had lower sleep efficiency and total sleep time, higher beta-1 power in the left frontal and central derivations during pre-sleep wakefulness, higher delta power in the left frontal and central derivations during the N1 stage, and higher beta-2 power in the left frontal and central, and right central derivations during the R stage.

CONCLUSIONS

Data suggest that patients with insomnia and sleep apnea, compared to patients with only sleep apnea, presented higher left high-frequency rhythms during pre-sleep wakefulness and R sleep stage, and may be for increased emotional and cognitive-related activity, while in stage N1, presented higher left delta power, which suggest some slowing after sleep deprivation.

The economic and societal burden of excessive daytime sleepiness in patients with obstructive sleep apnea

Excessive daytime sleepiness (EDS) is common in patients with obstructive sleep apnea (OSA) and continues to persist in many patients despite adequate OSA treatment. EDS in OSA is associated with decreased quality of life (QOL) as well as increased societal burden, which may impact health care utilization and costs. However, economic burden is often not the primary focus in the treatment of EDS in OSA. This targeted literature review aimed to examine the published literature on the economic burden of EDS in OSA. This review identified available literature using a targeted PubMed search strategy using search terms related to EDS in OSA in adults. Results demonstrate that there are few studies that detailed the direct costs associated with EDS in OSA, though several studies indicated an association between EDS in OSA and indirect economic burdens, including motor vehicle accidents (MVAs), near misses, work productivity, mood, and QOL. Data from the literature confirmed that persistent EDS in OSA following continuous positive airway pressure persists in 12%-65% of patients. Future studies should further describe the direct costs of EDS in OSA, quantify the cost associated with MVAs and lost work productivity, and detail QOL and social impacts of the condition.

Combination of obstructive sleep apnoea and insomnia treated by continuous positive airway pressure with the SensAwake pressure relief technology to assist sleep: a randomised cross-over trial protocol

INTRODUCTION

Obstructive sleep apnoea (OSA) is a common sleep breathing disorder affecting up to 17% of the middle-aged population. Continuous positive airway pressure (CPAP) is the primary treatment for patients with OSA, but acceptance and adherence to therapy is suboptimal in specific subgroups particularly those with insomnia or poor sleep quality (40%-80% of patients with OSA). Pressure intolerance, particularly during periods of wakefulness, inhibiting sleep onset or return to sleep, is one reason for poor CPAP adherence. AutoCPAPs continually monitor airflow changes and only increase the pressure when the upper airway requires it. Reducing the pressure during wakefulness-sleep transition and wakefulness-after-sleep-onset (WASO) may improve therapy comfort and potentially adherence without compromising therapy efficacy. We hypothesise that SensAwake, a pressure relief function that reduces CPAP pressure on the transition from sleep to wakefulness and on WASO, may improve objective sleep quality.

METHODS AND ANALYSIS

This is a multicentre, randomised double-blind crossover clinical trial on patients with both OSA and insomnia. Insomnia is defined as Insomnia Severity Index >15 at screening. Baseline data, including actigraphy, are collected for 1 week before randomisation (1:1) to either conventional AutoCPAP or AutoCPAP with SensAwake for 4 weeks. After an evaluation visit, patients are switched to the other treatment arm for a further 4 weeks. Allowing for 20% dropout, 48 patients are required. If applicable, repeated measures analysis of variance will be used to assess differences in WASO measured by actigraphy (primary outcome), other actigraphy measures, AutoCPAP compliance, subjective questionnaire scores (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Short-Form 12 Health Survey) and 24 hours blood pressure (secondary outcomes).

ETHICS AND DISSEMINATION

The protocol was approved by the regional Ethics Committee (CPP Sud-Est-V, IRB N°6705) on 9 December 2015, is registered on ClincalTrials.gov (NCT02721329) and started in June 2016 with expected publication of primary outcome results in 2018.

TRIAL REGISTRATION NUMBER

NCT0272132; Pre-results.

Repercusiones psiquiátricas del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS)

La apnea del sueño es un síndrome que afecta múltiples sistemas y produce variados síntomas. En el presente artículo se revisan las enfermedades psiquiátricas más frecuentes asociadas a este y la necesidad de realizar un diagnóstico adecuado y un tratamiento interdisciplinario. La entidad que más se ha podido encontrar en los pacientes con apnea del sueño es la depresión y se piensa que se debe a la fragmentación del sueño, la cual altera la producción de neurotransmisores a nivel cerebral. La ansiedad es la segunda entidad con mayor frecuencia, quizás debido a la liberación de catecolaminas durante la noche. Existen otras sintomatologías asociadas a la apnea del sueño que deben ser revisadas y que mejorarían con un tratamiento adecuado, así como también mejoraría la calidad de vida de los pacientes, pues la atención, la concentración y la memoria incrementarían o disminuirían la irritabilidad y otros síntomas.

Increased severity of sleep-disordered breathing is associated with insomnia and excessive somnolence in primary school children

OBJECTIVE

The aim of the study was to investigate the prevalence of difficulty with initiation or maintenance of sleep (DIMS) and excessive daytime sleepiness (EDS) in a general pediatric population, and to evaluate the relationship between these conditions and sleep-disordered breathing (SDB) symptom intensity.

METHODS

This population-based cross-sectional study from 27 primary schools in a medium-sized city in Poland was based on use of a questionnaire regarding demographic data, symptoms of SDB, DIMS, and EDS. Data were collected between September and December 2014. In all, 2940 caregivers were recruited and were asked to fill-out questionnaires and written consent.

RESULTS

A total of 68% of the questionnaires (n = 1987) were returned and analyzed. Habitual snoring (HS) was reported in 104 (5.3%) children. DIMS and EDS were seen in 137 children (6.9%) and 117 children (5.9%), respectively. The prevalence of DIMS increased from 3.5% in children who never snored to 28.6% in children who snored very often or always. Similarly, the prevalence of EDS was 2.7% in children who did not snore and increased to 19% in children who snored very often or always. No correlation was seen between increasing DIMS (r = 0.006, p > 0.05) or EDS (r = -0.031, p > 0.05) scores and body mass index.

CONCLUSIONS

This study is the first to measure the symptoms of both DIMS and EDS in a general pediatric population and to assess the relationship between both DIMS and EDS and SDB in children. We found that children with more frequent snoring had a higher prevalence of DIMS as well as EDS; however, there was no correlation between body mass index and either DIMS or EDS symptom severity.

Periodontal Disease Is Associated with Insomnia among Victims of the Great East Japan Earthquake: A Panel Study Initiated Three Months after the Disaster

In March 2011, the Great East Japan Earthquake (GEJE), which was followed by a devastating tsunami, destroyed the societal and the public hygiene systems in Japanese coastal areas. Insomnia, the greatest issue among disaster victims, has detrimental effects on both physical and psychological health. Periodontitis causes chronic discomfort and inflammation, and little is known about its impact on insomnia. Three months after the earthquake, a health panel survey was conducted over four surveys, till September 2013, in which information regarding 8,015 adults was collected and used. In addition to the heath-related questionnaire, other variables including subjective symptoms of oral diseases were recorded, and the Athens Insomnia Scale was used to evaluate the severity of insomnia. The association between insomnia and periodontal disease was examined using multilevel logistic models on the panel data, after adjusting for sex, age, economic status, comorbidities, body mass index, post-traumatic stress reactions, habitual smoking and alcohol drinking, and the Kessler Psychological Distress Scale score. In addition to the higher prevalence of insomnia among GEJE victims, significant association was revealed between insomnia and gum problems (OR = 2.16, 95% CI = 1.43-3.26), and difficulty chewing (OR = 2.22, 95% CI = 1.40-3.51), after adjusting for all covariates. The present study revealed significant association between insomnia and periodontal disease among GEJE victims. This indicated that together, integrated oral health care for disaster victims would contribute not only to prevention of oral infectious diseases, but may also help alleviate other problems caused by these harmful events.

Determinants of sexual dysfunction and interventions for patients with obstructive sleep apnoea: a systematic review

AIMS

Obstructive sleep apnoea (OSA) may negatively affect a couple's sexual relationship. This systematic review evaluated what characteristics are determinants of sexual function and dysfunction in women and men with OSA, and what interventions are shown to be effective.

METHODS

A systematic literature review was conducted using PubMed, CINAHL, Cochrane and TRIP, and articles published between January 2004 and December 2014 in English; original research; adults ≥ 18 years; and both experimental and non-experimental designs. The Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies was used to assess study quality. Of 21 studies, six studies (no randomised control trials, RCTs) included women and 15 (with six RCTs) studies included men. Extracted data were scrutinised and adjusted until consensus was reached; suitable quantitative data were pooled in statistical meta-analysis.

RESULTS

Sexual function was affected similarly in both genders, but effective interventions were reported only for men. In some studies, OSA severity and medications contributed to greater sexual dysfunction. In women, menopausal status, hormone levels and SaO2 < 90% were determinants of sexual dysfunction, while for men factors included BMI, hormonal status and inflammatory markers. Continuous positive airway pressure (CPAP) not only improved clinical measures such as excessive daytime sleepiness but also the erectile and orgasmic function. Nevertheless, sildenafil was superior CPAP with regard to erectile dysfunction.

CONCLUSIONS

The findings illustrate important contributors to sexual dysfunction; however, firm generalisations cannot be made. There were limited RCTs and none for women, indicating further RCTs are needed to determine how OSA affects sexual function.

Differential improvement of the sleep quality among patients with juvenile myoclonic epilepsy with valproic acid: A longitudinal sleep questionnaire-based study

Objectives:

The aim of this study was to assess the effect of sodium valproic acid (SVA) on the sleep quality of patients with juvenile myoclonic epilepsy (JME).

Materials and Methods:

Standardized sleep questionnaires viz. Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI) were administered to 30 drug-naïve patients with JME (male:female (M:F) = 14:16; age: 21 ± 3.7 years) and the changes following SVA monotherapy was analyzed using t- and chi-squared tests.

Results:

The mean age at onset of seizures and diagnosis was 15.43 ± 3.8 and 21 ± 5.1, years respectively. All had myoclonic jerks with mean duration of 5.23 ± 2.7 years, aggravated by sleep deprivation (23, 76.7%) and sleep-wake transition (29, 96.7%). Twenty-seven (90%) had generalized tonic-clonic seizures (GTCS), majority (70%) on awakening from sleep. Seizures were controlled in 25 patients (83.33%) with SVA monotherapy. Abnormal ESS was noted in five (16.66%) drug naïve patients compared to six (20%) patients while on SVA (P = 0.782). Mean ESS remained unchanged before and after SVA therapy (6.27 ± 4.4 vs 6.97 ± 4.7, P = 0.262). On the other hand, only four (13.3%) patients had abnormal PSQI scores at follow-up after initiation of SVA, as compared to 14 (46.7%) subjects in the drug naïve state (P = 0.037). Further, we also found significant reduction in mean PSQI scores after initiating SVA monotherapy (6.7 ± 5.6 vs 2.7 ± 2.84, P £ 0.0001).

Conclusion:

This study showed that the mean PSQI as well as the number of patients with abnormal PSQI significantly reduced after initiating SVA therapy, suggesting a significant improvement in night-time sleep quality with SVA treatment. However, SVA therapy did not alter ESS.

Prevalence of excessive sleepiness is higher whereas insomnia is lower with greater severity of obstructive sleep apnea

PURPOSE

The objective of the present study was to investigate the prevalence of insomnia and excessive sleepiness in relation to the presence and severity of obstructive sleep apnea (OSA).

METHODS

The sample consisted of patients referred to a university hospital on suspicion of OSA. In total, 1115 patients with mean age of 48 years were studied. Insomnia (Bergen Insomnia Scale) and excessive sleepiness (Epworth Sleepiness Scale) were diagnosed using validated questionnaires. The insomnia scale permits diagnosing insomnia using both old and new (from 2014) criteria. OSA was diagnosed and categorized based on a standard respiratory polygraphic sleep study using a type 3 portable monitor.

RESULTS

OSA was diagnosed in 59.4 % of the referred patients. The prevalence of excessive sleepiness was higher with greater severity of OSA: 40.5 % in the patients without OSA (apnea-hypopnea index (AHI) <5), 46.5 % in mild OSA (AHI 5-14.9), 52.0 % in moderate OSA (AHI 15-29.9), and 58.0 % in severe OSA (AHI 30 or above). In contrast, the prevalence of insomnia using the 2014 diagnostic criteria showed an opposing prevalence: 54.2 % no OSA, 54.9 % mild OSA, 48.5 % moderate OSA, and 44.6 % severe OSA. Logistic and linear regression analyses showed that sleepiness was positively associated whereas insomnia was negatively associated with OSA severity and AHI.

CONCLUSIONS

Both excessive sleepiness and insomnia were seen in high proportions of the patients referred on suspicion of OSA. Excessive sleepiness was higher whereas insomnia was lower with greater OSA severity.

Frequent nocturnal awakening in children: prevalence, risk factors, and associations with subjective sleep perception and daytime sleepiness

BACKGROUND

Nocturnal awakening is the most frequent insomnia complaint in the general population. In contrast to a growing knowledge based on adults, little is known about its prevalence, correlated factors, and associations with subjective sleep perception and daytime sleepiness in children. This study was designed to assess the prevalence and the correlate factors of frequent nocturnal awakening (FNA) among Chinese school-aged children. Furthermore, the associations of FNA with subjective sleep perception and daytime sleepiness were examined.

METHODS

A random sample of 20,505 children aged 5.00 to 11.92 years old (boys: 49.5% vs. girls: 50.5%) participated in a cross-sectional survey, which was conducted in eight cities of China. Parent-administered questionnaires were used to collect information on children's sleep behaviors, sleep perception, and potential influential factors of FNA from six domains. Univariate and multivariate logistic regression models were performed.

RESULTS

The prevalence of FNA was 9.8% (10.0% for boys vs. 8.9% for girls) in our sampled children. The prominent FNA-related factors inclued biological health problems, such as overweight/obesity (OR = 1.70), chronic pain during night (OR = 2.47), and chronic respiratory condition (OR = 1.23), poor psychosocial condition, such as poor mental and emotional functioning (OR = 1.34), poor sleep hygiene, such as frequently doing exciting activities before bedtime (OR = 1.24) and bedtime resistance (OR = 1.42), and parents' history of insomnia (OR = 1.31). FNA was associated with subjective poor sleep quality (OR = 1.24), subjective insufficient sleep (OR = 1.21), and daytime sleepiness (OR = 1.35).

CONCLUSION

FNA was associated with poor sleep and daytime sleepiness. Compared to sleep environment and family susceptibility, chronic health problems, poor psychosocial condition, and poor sleep hygiene had greater impact on FNA, indicating childhood FNA could be partly prevented by health promotion, by psychological intervention, and by improving sleep hygiene routine.