Pediatric sleep: current knowledge, gaps, and opportunities for the future

Social determinants of health at multiple socio-ecological levels and sleep health in adolescents: A scoping review

Heightened sleep disturbances occur in adolescence, yet existing research has predominantly focused on individual factors linked to poor sleep and a limited set of sleep outcomes, such as sleep duration and timing. This scoping review aimed to identify the multilevel social determinants of adolescent sleep health across domains, including regularity, satisfaction/quality, alertness/sleepiness, timing, efficiency/continuity, duration, and behavior. Social determinants of health (SDoH) were categorized through a socio-ecological lens, while sleep health domains were aligned with the RU-SATED and Peds B-SATED sleep health frameworks. A systematic database search resulted in 57 studies of non-clinical adolescent and young adult populations (age 10-24 y) in North America, published between 2014 and 2022. Research gaps include 1) absence of other sleep health domains other than duration which is predicated on the included studies using a limited set of sleep outcome measures rather than a more comprehensive measurement strategy that align with the multifaceted domains of sleep health, and 2) inconsistent terminology and/or absent conceptual and operational definitions of subjective sleep reports. The findings highlight the multilevel SDoH that influence adolescent sleep health, underscoring the need for more comprehensive research. Such efforts will facilitate the development of interventions focused on fostering optimal adolescent sleep health this populations.

Sleep Disturbance and Subsequent Suicidal Behaviors in Preadolescence

Importance

Suicide is a leading cause of death among adolescents, who demonstrate high rates of sleep disturbance. Poor sleep appears to confer risk for suicide, but longitudinal investigation of suicidal behaviors remains rare, particularly in the transition from childhood to early adolescence.

Objective

To evaluate sleep disturbances in preadolescent children (aged 9 and 10 years) in association with longitudinal risk for suicidal ideation and suicide attempts at the 2-year follow-up.

Design, Setting, and Participants

This cohort study used data from the Adolescent Brain Cognitive Development Study between June 2016 and January 2021. This dataset included children aged 9 or 10 years at baseline and their parents or caregivers who were recruited at 21 sites across the US. Data were analyzed July 2023 to June 2024.

Exposures

The Sleep Disturbance Scale for Children, a 26-item parent-reported inventory, was administered at baseline, generating a total score and 6 subscales. Central covariates included the Child Behavior Checklist Anxiety and Depression subscale and demographic variables.

Main Outcomes and Measures

The computerized Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-COMP) assessed parent- and youth-reported suicidal behaviors and outcomes (none; passive, active nonspecific, and active specific suicidal ideation; and suicide attempt) at the 2-year follow-up. Sleep disturbance was further grouped by symptom severity (minimal, moderate, elevated, high, and severe).

Results

Of the 10 136 youths who reported no baseline suicidal ideation or behavior, 8807 youths (mean [SD] age, 9.9 [0.6] years; 4507 males [51.2%]; 197 Asian individuals [2.2%], 1273 Black individuals [14.5%], and 5775 White individuals [65.6%]) completed the K-SADS-COMP assessment at the 2-year follow-up and were included in the analysis. At the follow-up, 8044 participants (91.3%) had no suicidal behavior, 317 (3.6%) had passive suicidal ideation, 258 (2.9%) had active nonspecific suicidal ideation, 130 (1.5%) had active specific suicidal ideation, and 58 (0.7%) had a first-time suicide attempt. Baseline sleep disturbance was associated with increased incidence risk for suicidal behavior at age 12 years (odds ratio, 2.68; 95% CI, 1.44-4.98; P = .002), adjusting for covariates. Individual subscales or items demonstrating associations with risk included disorders of excessive somnolence and frequency of nightmares.

Conclusions and Relevance

Results of this longitudinal cohort study revealed that disturbed sleep at age 10 years was associated with risk for suicidal thoughts and behaviors in the next 2 years. The findings highlight the potential importance of sleep as a visible risk factor and intervention target in the prevention of youth suicide.

Trajectories of actigraphy-derived sleep duration, quality, and variability from childhood to adolescence: downstream effects on mental health

STUDY OBJECTIVES

We examined growth trajectories of four actigraphy-derived sleep parameters (sleep minutes, sleep efficiency, and variability in sleep minutes and efficiency across a week of assessments) across childhood and adolescence and examined individual differences in trajectories according to participants' race/ethnicity and sex. We also assessed the predictive effect of growth trajectories of sleep parameters on growth trajectories of mental health outcomes and moderation by race and sex.

METHOD

Youth (N = 199, 49% female, 65% white, 32% black, 3% biracial) and their parents participated in five waves of data (M ages were 9, 10, 11, 17, and 18 across waves). Participants were from a diverse range of socioeconomic backgrounds.

RESULTS

Across participants, sleep minutes, sleep efficiency, and variability in sleep minutes and efficiency demonstrated significant linear change across childhood and adolescence. Whereas sleep duration shortened over time, sleep efficiency improved. Youth exhibited increases in night-to-night variability in sleep minutes and reductions in night-to-night variability in sleep efficiency. Highlighting the importance of individual differences, some race- and sex-related effects emerged. Black youth and male youth experienced steeper declines in their sleep duration across development relative to their respective counterparts. Black youth also demonstrated smaller improvements in sleep efficiency and greater variability in sleep efficiency compared to white youth. Finally, trajectories of sleep efficiency and variability in sleep minutes predicted trajectories of internalizing symptoms and externalizing behaviors.

CONCLUSIONS

Findings showed significant changes in developmental trajectories of four sleep parameters across childhood and adolescence. We discuss the empirical and translational implications of the findings.

"I'm not sure if it works": School nurses' experiences of sleep-promoting work in Sweden

OBJECTIVES

Lack of sleep is a common problem in children and adolescents of school age (students), and it is a health aspect that affects the ability to assimilate into the school's education and thereby falls within the school nurses promoting work. This study aimed to describe school nurses' experiences of sleep-promoting work.

METHOD

Data were collected by n = 61 school nurses' written narratives of their sleep-promotion work. Data were analyzed using qualitative content analysis.

RESULTS

The results describe school nurses' experiences of sleep-promoting work in three main categories: (1) Informing and providing knowledge is the primary task. School nurses do it systematically, through dialogs with an individual student, with several students simultaneously, or with parents. (2) Benefits take place when the needs of the student guide the work. Through curiosity about the personal story, the keys to sleep-promoting work can be found, appropriate strategies can be given, and the student can be guided further if needed. (3) Barriers challenge the outcome of the work. The school nurses experience these barriers in the form of unmotivated students, unsupportive parents, and lack of prerequisites, which make the school nurses unsure of their performance.

CONCLUSIONS

School nurses experience a significant benefit in their sleep-promoting work when the needs of the student guide the sleep-promoting information, strategies, and follow-ups. To avoid feeling insecure in sleep-promoting work, school nurses need updates on the state of knowledge and evidence-based tools. Further research on sleep-promoting work at school is necessary.

Psychiatric comorbidities and prescribing tendencies of sleep medications and related medications in young people with insomnia: a United States commercial claims-based analysis

STUDY OBJECTIVES

To characterize children and youth newly diagnosed with insomnia and to describe their use of sleep and other related prescription medications.

METHODS

Within a commercial claims database (January 1, 2016-December 31, 2021), we identified children and youth (2-24 years) with a newly recorded insomnia diagnosis (G47.0x; F51.0x) and examined psychiatric diagnoses in the prior 6 months. We evaluated sleep and related prescription medications dispensed in the week after new insomnia diagnoses (i.e. trazodone, other antidepressants, hydroxyzine, alpha-agonists, benzodiazepines, non-benzodiazepine hypnotics "z-drugs," antipsychotics, and others). Analyses were stratified by age and psychiatric comorbidities.

RESULTS

Among 68 698 children and 108 118 older youth (18-24 years) with a new insomnia diagnosis, three-quarters had a diagnosed comorbid psychiatric condition; anxiety disorders, depression, and ADHD were the most common. Among those without comorbid psychiatric diagnoses, 20.2% of children and 37.4% of older youth had a sleep or related medication dispensed in the following week. In children without a comorbid psychiatric diagnosis, alpha-agonists, hydroxyzine, and trazodone were the most common medications; in older youth, trazodone was the most common medication followed by hydroxyzine, z-drugs, and SSRIs. Sleep and related prescription medications were more commonly dispensed to those with psychiatric comorbidities. From 2017 to 2021, there was an increase in hydroxyzine prescriptions following a new insomnia diagnosis and decline in z-drug and benzodiazepine prescriptions.

CONCLUSIONS

Our findings from a nationwide sample of young people with insomnia highlight the high prevalence of psychiatric comorbidities and variety of sleep and related medications they receive. Characterizing prescribing tendencies informs guideline development and future research.

Sleep Education: A Narrative Review on Barriers and Opportunities to Grow a Diverse Sleep Team

The increased recognition of sleep-wake disorders and their effects, along with the anticipated shortage of sleep medicine specialists, heralds a concomitant need to have more health care providers with dedicated training in the evaluation and management of sleep disorders across the life span. A narrative review of published literature on sleep education was conducted and identified factors related to diversity within the sleep team, barriers to implementation of sleep education, and strides in sleep education. Implementation of novel sleep education strategies will require creative navigation of barriers such as allocation of curricular time, availability of teaching faculty, and funding to train more members of the sleep team. Deliberate coordination within and across health professions programs, with efforts to share resources and leverage technology, will be instrumental to guide the next phase of growth in sleep education.

Machine learning data sources in pediatric sleep research: assessing racial/ethnic differences in electronic health record-based clinical notes prior to model training

Introduction

Pediatric sleep problems can be detected across racial/ethnic subpopulations in primary care settings. However, the electronic health record (EHR) data documentation that describes patients' sleep problems may be inherently biased due to both historical biases and informed presence. This study assessed racial/ethnic differences in natural language processing (NLP) training data (e.g., pediatric sleep-related keywords in primary care clinical notes) prior to model training.

Methods

We used a predefined keyword features set containing 178 Peds B-SATED keywords. We then queried all the clinical notes from patients seen in pediatric primary care between the ages of 5 and 18 from January 2018 to December 2021. A least absolute shrinkage and selection operator (LASSO) regression model was used to investigate whether there were racial/ethnic differences in the documentation of Peds B-SATED keywords. Then, mixed-effects logistic regression was used to determine whether the odds of the presence of global Peds B-SATED dimensions also differed across racial/ethnic subpopulations.

Results

Using both LASSO and multilevel modeling approaches, the current study found that there were racial/ethnic differences in providers' documentation of Peds B-SATED keywords and global dimensions. In addition, the most frequently documented Peds B-SATED keyword rankings qualitatively differed across racial/ethnic subpopulations.

Conclusion

This study revealed providers' differential patterns of documenting Peds B-SATED keywords and global dimensions that may account for the under-detection of pediatric sleep problems among racial/ethnic subpopulations. In research, these findings have important implications for the equitable clinical documentation of sleep problems in pediatric primary care settings and extend prior retrospective work in pediatric sleep specialty settings.

Validation of the newly developed Sleep Screening Questionnaire Children and Adolescents (SSQ-CA) with objective sleep measures

OBJECTIVES

Objectively validated pediatric sleep questionnaires covering a broader age range and different sleep disturbances are lacking, therefore we developed the Sleep Screening Questionnaire Children and Adolescents (SSQ-CA) and compared it with objective sleep parameters.

METHODS

This child-reported questionnaire was developed by a multidisciplinary panel and face validated. In a cross-sectional prospective design, participants aged 6-17, answered the questionnaire twice with 21-28 days in between, wore actigraphy (AG) and kept a sleep diary for seven nights and home-polysomnography (PSG) for one of these nights. Exploratory factor analyses (EFA), reliability and validity assessments were performed.

RESULTS

Of the 139 participants, 128 (F:47.7%, AG: n = 128, PSG: n = 59), were included in the analyses. Mean age: 11.3 years (SD: 2.9). EFA revealed 11 factors and 40 items loading above r = 0.4. Subscale internal consistency: 0.54-0.92. Subscale test-retest reliability: r = 0.71-0.87. Total sleep time (TST) from SSQ-CA on weekdays correlated with PSG (r = 0.48, p = 0.001) and with AG (r = 0.75, p < 0.001). The subscale total score for "Sleep duration and latency" correlated with TST from AG (r = -0.19, p = 0.03) and sleep latency (r = 0.31, p < 0.001), but not for PSG variables. The subscale "Awakenings" showed no correlation with objective measures whereas "Circadian rhythm" correlated to AG-derived mid-sleep time (r = 0.34, p < 0.001).

CONCLUSIONS

The SSQ-CA shows adequate reliability for the 6-17-year-olds and acceptable criterion validity for two subscales. It appears to be a useful tool for screening for sleep disturbances in combination with objective tools as the subjective and objective parameters seem to uncover different aspects of sleep.