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

Evolving trends in novel sleep tracking and sleep testing technology publications between 2020 and 2022

STUDY OBJECTIVES

To update sleep medicine providers regarding (1) published research on the uses and performance of novel sleep tracking and testing technologies, (2) the use of artificial intelligence to acquire and process sleep data, and (3) research trends and gaps regarding the development and/or evaluation of these technologies.

METHODS

Medline and Embase electronic databases were searched for studies utilizing screening and diagnostic sleep technologies, published between 2020 and 2022 in journals focusing on human sleep. Studies' quality was determined based on the Study Design criteria of The Oxford Center for Evidence-Based Medicine Levels of Evidence.

RESULTS

Ninety-six of 3,849 articles were included. Most studies were adult performance evaluation (validation) studies, often comparing a novel technology to polysomnography. Sleep tracker publications tended to be Unites States-based, nonindustry-funded, performance studies on healthy adults using non-Food and Drug Administration-cleared technologies. Sleep apnea testing technologies were more frequently industry-funded and Food and Drug Administration-cleared. All studied technologies utilized software with an algorithm and/or artificial intelligence. Few studies used randomized control designs, or accounted for recruitment/attrition biases associated with participants' age, race/ethnicity, or comorbid health conditions.

CONCLUSIONS

Evidence-based publications have not kept pace with the proliferation and landscape of consumer and clinical sleep technologies. Due to the variance in technologies used within sleep research, careful review of the software used within studies is recommended. Future publications may fill identified gaps by including underrepresented populations, maintaining independence from industry, and through rigorous study design.

CITATION

Holfinger S, Schutte-Rodin S, Ratnasoma D, et al. Evolving trends in novel sleep tracking and sleep testing technology publications between 2020 and 2022. J Clin Sleep Med. 2025;21(5):891-905.

Sedentary Time Patterns Among Preschoolers: Do Sex Disparities Exist?

Background: Examining sedentary time (ST) by disaggregating the day into periods such as before, during, and after preschool allows interventionists to understand when sedentary behaviors are most severe. This study aimed to determine if there are sex differences in ST before, during, and after preschool hours in US preschoolers. Methods: A secondary analysis of a two-cohort study with a sample size of 292 preschoolers (67% African Americans/Blacks; 100% from low-income families) was used. Measures were collected in Fall 2017 and Fall 2018. Preschoolers wore an accelerometer on the non-dominant wrist for 8 consecutive days to obtain ST minutes before, during, and after preschool periods. Three separate linear regressions were conducted to test sex differences in ST before, during, and after preschool hours. ST for each period of the day was considered the outcome variable predicted by sex and covarying for BMI percentile. Results: Girls were more sedentary than boys during preschool (F (1, 226) = 5.15, p = 0.006; b = -0.09 [-0.15, -0.03]), but not before preschool (F(1, 225) = 0.98, p = 0.32; b = 2.50 [-2.46, 7.45]) nor after preschool (F(1, 227) = 3.62, p = 0.06; b = 6.60 [-0.21, 13.42]). Conclusions: This difference in ST could have an unfavorable health impact among preschool girls. Given that childhood obesity prevalence dramatically increases from preschool age to childhood, there is a need to design family-based interventions that provide parents/caregivers strategies to develop habits around healthy eating and physical activity that they can carry into later life stages.

The association between maternal sleep and circadian rhythms during pregnancy and infant sleep and socioemotional outcomes

Studies have established that maternal sleep and circadian rhythm disturbances during pregnancy are associated with poor prenatal and perinatal outcomes for mothers and offspring. However, little work has explored its effects on infant sleep or socioemotional outcomes. The current study examined the relationship between maternal sleep and circadian rhythm disturbances during pregnancy and infant sleep and socioemotional outcomes in a diverse sample of N = 193 mothers and their infants (51% White; 52% Female; Mage = 11.95 months). Maternal sleep and circadian rhythms during pregnancy were assessed using self-reports and actigraphy. Mothers reported on infants' sleep and socioemotional outcomes when infants were one year old. When controlling for infant sex, age, gestational age at birth, family income-to-needs ratios, and maternal depression, mothers who reported more sleep problems during pregnancy had infants with more sleep disturbances when they were one year old. Moreover, mothers who had later sleep timing (i.e., went to bed and woke up later, measured via actigraphy) during pregnancy had infants with more dysregulation (e.g., increased feeding difficulties, sensory sensitivities) and externalizing problems, and mothers with increased intra-daily variability in rest-activity rhythms (as measured via actigraphy) had infants with more externalizing problems. Findings suggest that maternal sleep and circadian rhythm disturbances during pregnancy may be a risk factor for infant sleep problems and socioemotional difficulties.

Early bedtime routines and behavioral outcomes among children from low-income families: Mediating role of emotion regulation

The establishment of early bedtime routine is essential for children's emotion and behavioral outcomes. Less is known, however, about the longitudinal effects and mechanisms predicting behavioral outcomes through early bedtime routine and emotion regulation in school-age children from low-income families. Thus, the present study examined emotion regulation at age three as a potential mediator in the longitudinal links between early bedtime routine and behavioral outcomes among racially diverse school age children from low-income families. Participants include a subsample of families (n = 2977) participating in the Early Head Start Research and Evaluation Project (EHSRE). Structural equation modeling with bootstrapping techniques was used to examine the models. The early bedtime routine index was created from parents' reports at 14, 24, and 36 months. Children's emotion regulation was drawn from interviewer assessments at 36 months and problem behaviors were reported by mothers when the child was approximately at age 10. Results indicated that children with consistent early bedtime routine were better able to regulate their emotions at age three. Also, emotion regulation at age three mediated the associations between early bedtime routine at 14-36 months and internalizing and externalizing behaviors among fifth-grade children. Findings indicated that consistent early bedtime routine helps children to regulate their emerging emotions which in turn has long-term benefits on their emotional and behavioral outcomes. These findings have important implications for pediatricians, nurse practitioners, nurses, and early childhood educators who can provide education and resources to support families in establishing consistent bedtime routine for their young children.

Sleepless nights, troubled futures: The association between insufficient sleep and child flourishing

OBJECTIVE

To examine associations between sleep and flourishing among children ages 0-5 years in the United States and whether these differ by age, developmental needs, and family resilience.

STUDY DESIGN AND METHODS

Cross-sectional data from the 2020-2021 National Survey of Children's Health (N = 31,095) were used with survey-weighted logistic regression to explore associations between insufficient sleep (defined as not meeting age-recommended daily sleep guidelines: 12-16 h for 4- to 12-month-olds, 11-14 h for 1- to 2-year-olds, and 10-13 h for 3- to 5-year-olds) and flourishing (using four markers combined and categorized into two groups). Tests of effect measure modification (EMM) were performed on the multiplicative and additive scales.

RESULTS

Weak but notable evidence was found that children with insufficient sleep had decreased odds of flourishing (aOR = 0.76; 95 % CI: 0.60, 1.00). No evidence of EMM by child age or family resilience was found. However, the sleep-flourishing association differed significantly by children's developmental needs, suggesting that the combined effect of sleep and developmental needs impact flourishing more than either factor alone.

CONCLUSIONS

Approximately 38 % of children ages 0-5 years in the United States are estimated to have insufficient sleep. This study provides evidence that insufficient sleep is associated with decreased flourishing among children with special health care needs (CSHCN).

FUTURE IMPLICATIONS

Increasing sleep interventions among children under five is warranted among children with special health care needs. The association between sleep and flourishing within specific CSHCN categories, including emotional, behavioral, or developmental (EBD) criteria, should be explored to optimize sleep policies.

Maternal Sleep Quality and Executive Function are Associated with Perceptions of Infant Sleep

OBJECTIVES

This study examined the associations among maternal sleep quality, executive function, and perceptions of infant sleep in a sample of families recruited from human service and public health systems.

METHODS

Seventy-three mothers of infants 5-14 months old were included in the study. Mothers racially and ethnically identified as American Indian/Alaskan Native (4.1%), Asian (4.1%), Black/African American (12.3%), Latina (23.3%), more than one race (12.3%), Pacific Islander (1.4%), and White (42.5%). Mothers completed questionnaires assessing their own sleep (Pittsburgh Sleep Quality Index) and executive function (Behavior Rating Inventory of Executive Function) as well as their perceptions about their infant's sleep (Brief Infant Sleep Questionnaire).

RESULTS

Results of the path analysis indicated significant direct effects among maternal sleep quality, executive function, and perceptions of infant sleep. Significant indirect effects were found such that poor maternal sleep quality was linked to poorer perceptions of infant sleep through maternal executive dysfunction, adjusting for infant sleep patterns, infant age, and maternal race and ethnicity.

CONCLUSIONS

The current study highlights the potential role of maternal behavioral and cognitive factors in shaping mothers' perceptions about infant sleep. These findings support the need for health professionals and researchers to consider maternal sleep quality and executive function when addressing mothers' concerns about infant sleep.

Disadvantaged social status contributed to sleep disorders: An observational and genome-wide gene-environment interaction analysis

BACKGROUND

Sleep is a natural and essential physiological need for individuals. Our study aimed to research the associations between accumulated social risks and sleep disorders.

METHODS

In this study, we came up with a polysocial risk score (PsRS), which is a cumulative social risk index composed of 13 social determinants of health. This research includes 239,165 individuals with sleep disorders and social determinants of health data from the UK Biobank cohort. First, logistic regression models were performed to examine the associations of social determinants of health and sleep disorders, including chronotype, narcolepsy, insomnia, snoring, short and long sleep duration. Then, PsRS was calculated based on statistically significant social determinants of health for each sleep disorder. Third, a genome-wide gene-environment interaction study was conducted to explore the interactions between single-nucleotide polymorphisms and PsRS in relation to sleep disorders.

RESULTS

Higher PsRS scores were associated with worse sleep status, with the adjusted odds ratio (OR) ranging from 1.10 (95% Confidence interval [CI]: 1.09-1.11) to 1.29 (95% CI: 1.27-1.30) for sleep disorders. Emotional stress (OR = 1.36, 95% CI: 1.28-1.43) and not in paid employment (OR = 2.62, 95% CI: 2.51-2.74) were found to have significant contributions for sleep disorders. Moreover, multiple single-nucleotide polymorphisms were discovered to have interactions with PsRS, such as FRAS1 (P = 2.57 × 10-14) and CACNA1A (P = 8.62 × 10-14) for narcolepsy, and ACKR3 (P = 1.24 × 10-8) for long sleep.

CONCLUSIONS

Our findings suggested that cumulative social risks was associated with sleep disorders, while the interactions between genetic susceptibility and disadvantaged social status are risk factors for the development of sleep disorders.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL INFORMATION

N/A; Not a clinical trial.

Exploration of the factors influencing the quality of life among adolescents during the COVID-19 pandemic: the data from a cross-sectional study in Shandong

BACKGROUND

The COVID-19 pandemic has sparked unprecedented transformations in the lives of adolescents, with reshaping their routines, social dynamics, educational experiences, and overall well-being. Our study delves into the influence of various factors on adolescents' quality of life (QOL) among the COVID-19 pandemic in Shandong Province, China.

METHODS

Employing a cross-sectional research approach combined with multivariable analysis, we scrutinize the association of demographic factors (age, gender, education level, ethnic groups, urban area, and family economic status) and health-related behaviors (sleep duration, and self-reported health status) with QOL in 9953 students.

RESULTS

During the pandemic, the average QOL for adolescents in Shandong Province was 133. Our analysis revealed that sleep duration and age had statistically significant associations with total QOL, with the OR values of 1.43 (95% confidence interval (CI): 1.03 to 1.83) and 0.44 (95% CI: 0.19 to 0.70), respectively. Notably, we observed that adolescents from economically disadvantaged families, or those with poorer self-reported health status, were more likely to report lower QOL scores.

CONCLUSIONS

Overall, our study highlights the potential association of sleep duration, age, family economic status, and self-reported health with the QOL of adolescents in Shandong Province during the pandemic. During similar public health crises, policymakers, educators, and healthcare providers can actively work through resource allocation and effective intervention measures towards alleviating financial burdens, improving health conditions, and ultimately enhancing the total QOL for adolescents.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Health Disparities in Pediatric Sleep

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

Questionnaire survey on sleep habits of 3-year-old children in Asahikawa City: Comparison between 2005 and 2020

BACKGROUND

Good sleep is essential for children's healthy growth. In 2005, we conducted a questionnaire survey on children's sleep habits and their background, targeting parents who attended health checkups for their 3-year-old children in Asahikawa City, Hokkaido. In 2020, we performed a secondary survey, including additional questions regarding media usage. We analyzed changes in children's sleep environment by comparing the results of both surveys.

METHODS

Children from 500 families (n = 420; 219 males, 201 females; mean age, 3.6 years) who underwent 3.5-year-old health checkups (per the changed schedule in 2015) in Asahikawa City from July 2020 to November 2020 and their parents who had completely answered the questionnaire were included.

RESULTS

The proportion of children who used childcare support system such as nursery schools or kindergarten increased from 30% in the previous survey to 95% in the present survey. The mean nocturnal sleep duration of children was 9.33 h in the present survey, 0.77 h shorter than that in the previous survey; similar to the previous survey results, it was significantly short (8.71 h) in children who went to bed after 10 PM. Moreover, it was significantly short in children who watched television for more than two hours or used media within two hours before going to bed or if parents used smartphones or watched motion pictures for >30 min/day. The rate of consulting pediatricians regarding sleep problems decreased from 3% to 2.4%.

CONCLUSION

Parents' lifestyles greatly influenced children's sleep habits in 2020. Pediatricians should actively participate in managing children's sleep problems.

Allergen immunotherapy in MASK-air users in real-life: Results of a Bayesian mixed-effects model

Background

Evidence regarding the effectiveness of allergen immunotherapy (AIT) on allergic rhinitis has been provided mostly by randomised controlled trials, with little data from real‐life studies.

Objective

To compare the reported control of allergic rhinitis symptoms in three groups of users of the MASK‐air^® app: those receiving sublingual AIT (SLIT), those receiving subcutaneous AIT (SCIT), and those receiving no AIT.

Methods

We assessed the MASK‐air^® data of European users with self‐reported grass pollen allergy, comparing the data reported by patients receiving SLIT, SCIT and no AIT. Outcome variables included the daily impact of allergy symptoms globally and on work (measured by visual analogue scales—VASs), and a combined symptom‐medication score (CSMS). We applied Bayesian mixed‐effects models, with clustering by patient, country and pollen season.

Results

We analysed a total of 42,756 days from 1,093 grass allergy patients, including 18,479 days of users under AIT. Compared to no AIT, SCIT was associated with similar VAS levels and CSMS. Compared to no AIT, SLIT‐tablet was associated with lower values of VAS global allergy symptoms (average difference = 7.5 units out of 100; 95% credible interval [95%CrI] = −12.1;−2.8), lower VAS Work (average difference = 5.0; 95%CrI = −8.5;−1.5), and a lower CSMS (average difference = 3.7; 95%CrI = −9.3;2.2). When compared to SCIT, SLIT‐tablet was associated with lower VAS global allergy symptoms (average difference = 10.2; 95%CrI = −17.2;−2.8), lower VAS Work (average difference = 7.8; 95%CrI = −15.1;0.2), and a lower CSMS (average difference = 9.3; 95%CrI = −18.5;0.2).

Conclusion

In patients with grass pollen allergy, SLIT‐tablet, when compared to no AIT and to SCIT, is associated with lower reported symptom severity. Future longitudinal studies following internationally‐harmonised standards for performing and reporting real‐world data in AIT are needed to better understand its ‘real‐world’ effectiveness.

Correlates of a caregiver-reported child sleep problem and variation by community disadvantage

BACKGROUND

Previous studies of sleep patterns and perceived problems in early childhood indicate variation by family socioeconomic status. The purpose of this study was to examine variation in correlates of a caregiver-perceived child sleep problem across and within levels of community disadvantage in a large US sample.

METHODS

Caregivers of 14,980 young children (ages 0-35.9 months) in the US completed the Brief Infant Sleep Questionnaire-Revised (BISQ-R) on the freely and publicly available Johnson's® Bedtime® Baby Sleep App. Zip code was used to identify a Distressed Communities Index (DCI) score, which represents community disadvantage based on neighborhood indicators.

RESULTS

Across all levels of community disadvantage, caregivers who reported greater impact of child sleep on their own sleep, bedtime difficulty, more frequent and longer night wakings, and increased total nighttime sleep were more likely to endorse a child sleep problem. These associations varied by level of community disadvantage. For caregivers living in more disadvantaged communities, impact of child sleep on their own sleep and night wakings were the strongest correlates of endorsing a child sleep problem, whereas for those in more advantaged communities the impact of child sleep on their own sleep and night wakings as well as additional aspects of sleep health, such as short sleep duration, were associated with endorsement of a child sleep problem.

CONCLUSIONS

Findings suggest that families living in more distressed communities are most likely to identify the impact of child sleep on their own sleep and night wakings in reporting a child sleep problem, whereas those from more prosperous communities consider these factors as well as other sleep parameters, including sleep duration. Clinicians should consider expanding screening questions for child sleep problems to include the perceived impact on caregiver sleep.