0929 Caregiver-Reported Versus Clinician-Documented Child Sleep Problems and Sleep-Related Health Behaviors in Primary Care

Introduction

Sleep problems are highly prevalent in early childhood but often under-identified in pediatric primary care. This study identified the prevalence of caregiver-reported versus primary care provider (PCP)-documented sleep problems and sleep-related health behaviors in young children presenting to well child visits (WCVs).

Methods

Caregivers (85.4% mothers) of 198 young children (2-5 years, M = 3.3, 53.7% female, 62.9% Black) presenting to urban (74.1%) and suburban (25.9%) primary care sites for well child visits (WCVs) completed research surveys on child behavioral sleep problems, snoring, and sleep-related health behaviors (e.g., caffeine consumption) on the day of their child’s WCV. Electronic medical record review was used to identify the rate of PCP-documented sleep problems and related recommendations in the WCV progress note.

Results

Fifteen percent of caregivers reported a child sleep problem according to questionnaire data, which did not significantly differ from the 12.0% of children with a PCP-documented sleep problem in the WCV progress note (p = .31). However, significantly more caregivers (28.3%) reported bedtime difficulties (resistance; tantrums) on questionnaires (p <.001), which were not captured in the 12.0% of WCVs noting sleep problems. A total of 8% of WCVs included child sleep recommendations. Child snoring was reported by 17.0% of caregivers, but was less frequently documented in WCVs (4.5%, p <.001). Although many caregivers reported poor child sleep-related health behaviors, including daily child caffeine consumption (21.1%) and bedroom electronics (62.9%), significantly fewer PCPs documented these issues (caffeine: 2.0%; electronics: 6.6%) or related recommendations (decrease caffeine: 1.0%; eliminate electronics: 3.5%) in the progress note (all p-values <.001).

Conclusion

Although caregiver-endorsed child sleep problems on surveys did not differ from PCP-documented concerns, there are gaps in documenting other problematic sleep-related health behaviors, such as caffeine consumption and electronics use. More resources to address sleep-related health behaviors, as well as sleep problems, in pediatric primary care are needed.

Support

Sleep Research Society Foundation and K23HD094905 (AAW)

0924 Adolescent Perceptions of Insomnia Treatment

Introduction

Approximately 10% of adolescents meet diagnostic criteria for insomnia, which is associated with increased health problems, academic difficulties, and psychological morbidity. Empirical evidence supports cognitive-behavioral treatments for insomnia, yet research suggests adolescent insomnia is undertreated. Thus, the goal of this study was to evaluate adolescent perceptions about insomnia treatment seeking and strategies.

Methods

Adolescents ages 13-18 years with self-reported insomnia symptoms completed an online survey assessing treatment-seeking behaviors and management strategies. English-speaking participants were recruited using targeted Facebook advertising. Descriptive statistics were used to summarize results.

Results

Of the 3,014 survey respondents, participants were predominantly female (77%) and white non-Hispanic (71%), with a mean age of 16±1.3 years. Most (87%) met DSM-V diagnostic criteria for insomnia, but only 29% reported seeking professional help for insomnia. Of these, participants reported waiting an average of 1-2 years after symptom onset to seek treatment. Participants most often sought help from a mental health professional (18%) or primary care provider (13%), while <2% saw a sleep specialist. Across adolescents, the most commonly endorsed strategies to manage insomnia symptoms were daytime caffeine consumption (48%), staying out of bed except when trying to sleep (38%), and daily exercise (28%). Nearly half of participants endorsed currently using medications to help with sleep, most commonly melatonin (18%) and antihistamine-based sleep aids (10%). Participants reported greatest preference to take medication (64%), meet individually with a sleep specialist (48%), or use a phone or tablet application (40%) to help with sleep. While 30% of participants felt that sleep researchers should prioritize increasing access to insomnia treatment, 20% encouraged developing new modes for treatment delivery (e.g., online).

Conclusion

Adolescents with insomnia reported using behavioral and pharmacological strategies to help with sleep, with very few receiving treatment from a sleep specialist. Further research is needed to increase accessibility and acceptability of interventions for adolescent insomnia.

Support

N/A

0946 Parent-Perceived Sleep Problems Associated with Common Medical Issues During Infancy

Introduction

Sleep problems are highly prevalent during infancy. However, little research has been conducted on associations between these sleep issues and common medical concerns in early development. Thus, the purpose of this study was to assess the prevalence of parent-perceived sleep problems in infants with common medical problems.

Methods

Participants were 5,097 children from the Longitudinal Study of Australian Children—Birth Cohort. Caregiver-reported child sleep problems and medical concerns were assessed at ages 0-1 year. Chi-square analyses were used to examine associations between the presence of a parent-perceived sleep problem and medical concerns.

Results

Wheezing (29.6%), eczema (14.9%), and food/digestive allergies (5.0%) were the most commonly identified medical concerns. In addition, 17.1% of caregivers reported a moderate/severe child sleep problem. Infants who had a moderate to severe parent-identified sleep problem experienced higher rates of overall medical care/needs, wheezing, eczema, food/digestive allergies (p<.001), ear infections (p<.05), and other illnesses (p<.01) than those infants without a sleep problem. No differences were observed with regard to hearing problems, vision problems, developmental delay, diarrhea/colitis, anemia, or other (non-ear) infections. Furthermore, parents reported higher rates of sleep problems for infants with medical problems (20.0-37.5%) than for infants without medical problems (16-17%), especially related to needing medical care (sleep problems = 27%), food/digestive allergies (27%), eczema (23%), and wheezing (20%), p=.001.

Conclusion

Overall, common medical issues during infancy, including food/digestive allergies, eczema, and wheezing, are associated with greater parent-endorsed child sleep problems. Primary care providers should assess for and address sleep problems when treating common medical concerns during infancy.

Support

This project was partially supported by Johnson and Johnson Consumer Health (JAM, ESL, and RAG) and NIH K23HD094905 (AAW).

0875 Interrelations Among Race, Socioeconomic Status, Sleep Duration Variability, and Neurobehavior in Children with Obstructive Sleep Apnea Syndrome

Introduction

There are racial and socioeconomic status disparities in child obstructive sleep apnea syndrome (OSAS) and in sleep patterns, but research on sleep patterns in children with OSAS is limited. This project examined interrelations among race, socioeconomic status (SES), sleep duration variability, and neurobehavior in children with OSAS.

Methods

Baseline data were drawn from 464 children with OSAS (M age 7 years, SD 1.4 years; 49% male; 34% Black) participating in the Childhood Adenotonsillectomy Trial. Sleep duration variability was calculated as the coefficient of variation for 5-day sleep diaries. Linear regression was used to examine whether sleep duration variability was associated with child race (Black vs. non-black), SES (family income; maternal education; neighborhood distress index based on US Census data), z-scored body mass index, asthma, prematurity, and secondhand smoke exposure. We then examined whether sleep duration variability was associated with parent-and teacher-reported child neurobehavior including executive functioning (Behavior Rating Inventory of Executive Functioning) and inattention (Conners Rating Scale), adjusting for the variables included in the first regression analysis.

Results

Black race was correlated with increased sleep duration variability (p = .05), but this association was not significant in the adjusted regression model. Secondhand smoke exposure was significantly associated with sleep duration variability (p<.001). Greater sleep duration variability was significantly associated with increased parent-reported neurobehavioral impairments (p=.004 for executive functioning and for inattention), adjusting for race, SES, secondhand smoke exposure, and the other covariates. Sleep duration variability was not associated with teacher-rated child neurobehavior.

Conclusion

In children with OSAS, sleep duration variability is greater in those exposed to secondhand smoke and is linked to increased parent-rated child neurobehavioral impairments. Findings suggest that clinicians should screen for secondhand smoke exposure and that treatment of pediatric OSAS should include a focus on promoting healthy sleep patterns.

Support

Sleep Research Society Foundation and K23HD094905 (AAW).

0921 Insomnia in Adolescents: Patient-Centered Outcomes and Perspectives

Introduction

An estimated 25-40% of adolescents endorse symptoms of insomnia. While research has demonstrated that insomnia is associated with impaired functioning, little is known regarding which insomnia symptoms or outcomes are most burdensome for adolescents. Patient-centered outcomes (PCO) are clinical and research questions and outcomes that are meaningful to patients. This study is the first to evaluate PCOs in adolescents with insomnia.

Methods

We conducted an online survey of adolescents in the USA, UK, Canada, Australia, and New Zealand who were 13 - 18 years old and reported experiencing one or more insomnia symptoms. Participants were recruited using targeted advertising on Facebook. Participants reported on insomnia symptom severity, frequency, and duration, help-seeking behavior, areas of insomnia-related impairment, and research priorities.

Results

Of the N=3034 respondents, 99.3% (n=3014) met inclusion criteria. Participants were predominantly female (77.0%) and white non-Hispanic (70.8%), with a mean age of 16.1 years (SD=1.3). Most (87.5%) met DSM-V diagnostic criteria for insomnia, yet only 29.3% reported seeking professional help. Over half (52.1%) reported a symptom duration of three or more years. Insomnia symptoms reported were sleep initiation difficulties (94.4%), sleep fragmentation (65.3%), premature awakening (54.5%), and difficulty sleeping independently (22.3%). The most burdensome areas of insomnia-related impairment were reported to be mood (72.2%), attentional focus (61.0%), pain (49.7%), worry (46.3%) and sleepiness (38.7%). Adolescents with insomnia most frequently endorsed the following research priorities: causes of insomnia (66.4%), early detection (66.1%), public education about sleep (49.1%) and non-pharmacological treatments (48.3%).

Conclusion

Adolescents with insomnia report significant insomnia-related distress and impairment, with symptoms often persisting for three or more years. However, adolescents with insomnia often do not seek professional help. Areas perceived as most problematic to adolescents living with insomnia (e.g., mood, focus, pain) should be considered as important outcomes for insomnia researchers.

Support

This publication was made possible with support from Grant Number UL1TR002529 (A Shekhar, PI) from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award and the Indiana University School of Medicine.

0885 Reduction in Emergency Department and Inpatient Hospitalization Visits and Length of Stay in a Cohort of Pediatric Patients Initiated on Positive Airway Pressure for Obstructive Sleep Apnea Syndrome

Introduction

Positive Airway Pressure (PAP) is an efficacious treatment of pediatric obstructive sleep apnea syndrome (OSAS). However, it is unknown whether PAP initiation is associated with reduced healthcare utilization, an important metric of care management. We hypothesized that healthcare utilization would be reduced after initiation of PAP in a cohort of pediatric patients prescribed PAP for OSAS.

Methods

Data were extracted from electronic medical records of 475 patients (Mean±SD age at PAP initiation=7.7±5.7 years; 58.7% male; 40.6% White; 38.3% Black; 18.1% multiracial/other; 12.1% Hispanic/Latinx) prescribed PAP for OSAS and followed in our Sleep Center quality improvement program. We extracted the total number of emergency department (ED) visits and hospitalizations and computed the related average length of stay (LOS) in hours for these visits in the 18 months prior to and 18 months following PAP initiation.

Results

Paired samples t-tests showed that number of ED visits and hospitalizations, and the related visit LOS, were significantly reduced following PAP initiation. The average number of visits reduced from 2.20 pre-PAP to 1.77 post-PAP initiation [t(474) = 3.48, p<.001, effect size = 0.16], while average LOS reduced from 185.14 hours pre-PAP to 42.94 hours post-PAP initiation [t(474) = 4.81, p<.001, effect size = 0.29]. Findings for the significant reduction in LOS held after adjusting for the number of pre and post-PAP ED visits and hospitalizations, average pre-PAP LOS, and patient demographics (age at the time of initiation; sex; race/ethnicity) using multiple linear regression.

Conclusion

PAP initiation was associated with fewer and shorter ED visits and hospitalizations in a large sample of pediatric patients. We speculate that PAP initiation could help reduce morbidity associated with pediatric OSAS, as well as improve healthcare utilization, capacity management and care in this population.

Support

K23HD094905 and Sleep Research Foundation (AAW)

0390 Associations of the Neighborhood Built Environment with Adolescent Sleep Outcomes

Introduction

Over 75% of U.S. high school students obtain insufficient amounts of sleep. Identification of modifiable environmental determinants of adolescent sleep is needed to inform interventions and public health strategies, yet little is known about the influence of the built environment on adolescent sleep. We examined associations of the built environment with objectively-measured adolescent sleep outcomes.

Methods

In this longitudinal, prospective study, we used actigraphy to assess sleep outcomes for 14 days each in 8th grade and 9th grade: duration (hours/night), onset (hours from 00:00), offset (hours from 00:00), and sleeping >8 hours. Home addresses were linked to built environment exposures based on half-mile Euclidian buffers (overall/human-made sound levels, percent tree canopy cover, street density, intersection density) and census block group (population density, housing density). Mixed-effects linear (sleep duration, onset, offset) and logistic (>8 hours) regression estimated associations of each built environment measure with sleep outcomes, adjusting for sex, race, parent education, household income, grade and weeknight status (school or non-school night).

Results

Among 108 adolescents - 53% female and 25% Black - providing 2,388 nights of sleep data across 8th and 9th grades, a 1-standard deviation increase in neighborhood sound (overall and human-made) associated with 11 minutes later sleep onset (β=0.19; 95% CI: 0.01, 0.38) and 20% lower odds of sleeping for >8 hours (OR=0.80, 95% CI: 0.62, 1.02). A 1-standard deviation increase in neighborhood tree canopy cover associated with 11 minutes earlier sleep onset (β= -0.19, 95% CI: -0.35, -0.03) and 7 minutes earlier sleep offset (β= -0.12, 95% CI: -0.23, -0.02). No associations were observed for “density based” exposures.

Conclusion

Higher tree canopy cover associated with more favorable sleep timing while higher neighborhood sound level associated with later timing of sleep onset. These modifiable neighborhood built environment factors should be considered when intervening to support healthier sleep among adolescents.

Support

NIH/NHLBI K01HL123612 (JM) and Sleep Research Society Foundation and K23HD094905 (AAW)

0952 Parent-Child Perceptions About Healthy Sleep Promotion in a Mobile Health Sleep Extension Intervention

Introduction

Over half of school-aged children sleep insufficiently and sleep promoting interventions are urgently needed. To effectively promote pediatric sleep health, it is critical to obtain feedback from youth and their families about acceptable intervention strategies. This qualitative study examined perceptions about healthy sleep promotion in parent-child dyads participating in a mobile health sleep extension intervention.

Methods

A total of 26 parent-child dyads (child mean age 11 years, SD = 0.67; 46% non-Latinx White; 19% Black) participated in a mobile intervention to extend child sleep duration over 11 weeks (2-week baseline; 7-week intervention; 2-week follow-up). Participants wore a FitBit during the study, were provided with a sleep duration goal, and received general sleep health-promoting electronic messages using the University of Pennsylvania’s Way to Health platform. Following the intervention, parents and their children separately completed a semi-structured telephone interview to capture perceptions of the intervention strategies. Three coders developed a codebook using an inductive approach to identify emergent themes and conducted coding in NVivo.

Results

Emergent themes fell into domains of intervention acceptability/feasibility and barriers. Mobile messaging about the child’s sleep duration goal was well-received, although child participants in particular desired more personalized messaging, with sleep promotion targeted to their specific sleep habits. Parents and children both discussed ancillary benefits to intervention participation, including an enhanced focus on sleep. Barriers to sleep extension during the intervention and maintenance of any gains post-intervention were related to: competing child academic, social, and extracurricular demands; family factors (work schedules; family rules and norms); and the challenges of limiting ubiquitous electronic devices.

Conclusion

Despite high parent-child acceptability of a mobile child sleep extension intervention, individual and contextual barriers may limit long-term adherence. Tailoring healthy sleep messages to target these factors could improve sustained benefits to child sleep.

Support

Sleep Research Society Foundation and K23HD094905 (AAW); NIH/NCATS UL1TR001878 (JAM and DFD) and K01HL123612 (JAM).

0397 Neighborhood Physical and Social Environments and Sleep Among Children and Adolescents: A Systematic Review

Introduction

Understanding salient environmental determinants of pediatric sleep is essential for informing interventions and public health initiatives. Emerging evidence suggests the neighborhood environment can impact pediatric sleep. We are conducting a systematic review of studies examining associations of neighborhood physical and social environments with sleep among children and adolescents.

Methods

We searched 6 databases (MEDLINE, PubMed, EMBASE, SCOPUS, Web of Science, PsychInfo) using search terms related to sleep, neighborhood environment, and pediatric populations to identify English-language articles with an abstract. We identified and screened 2,581 abstracts. Inclusion criteria included 1) assessing associations of ≥1 neighborhood-level factor with ≥1 sleep outcome and 2) including participants ≤18 years. We excluded review articles, protocols, qualitative and non-human studies. In total, 134 full-text articles were independently reviewed by 2 reviewers each to confirm eligibility. One reviewer abstracted preliminary data from included studies. Next steps include independent data abstraction by two reviewers using a standardized form, synthesis of results, and assessment of study quality according to the study design, sleep assessment method, sampling strategy, and control for confounding.

Results

Sixty-one articles met inclusion criteria. Fourteen articles included children aged 0-5 years, 38 included children aged 6-12 years, and 36 included adolescents aged 13-18 years (25 included multiple age groups). Twenty-two studies (36%) used objective sleep assessment methods (e.g. actigraphy). Seven studies (11%) examined sleep apnea/snoring. The most common neighborhood-level factors were safety/crime/community violence (n=28) and socioeconomic status (n=25), with fewer studies examining other exposures like noise (n=7) and social cohesion (n=4). Results on key associations and study quality are forthcoming.

Conclusion

A growing body of epidemiological data has emerged in recent years to provide insight into how the neighborhood environment can impact pediatric sleep. Preliminary results suggest few studies have examined associations of the built environment with sleep, with most studies focusing on school-aged children and adolescents.

Support

This work was supported by: the Children’s Hospital of Philadelphia’s Possibilities Project (SLM); Sleep Research Society Foundation and K23HD094905 (AAW); NIH/NHLBI K01HL123612 (JAM)

Early rheumatoid arthritis: can we predict its outcome?

The continuing trend towards more aggressive treatment of rheumatoid arthritis (RA) has seen an increasing interest in the early phase of this chronic inflammatory disease. Optimal benefit from present and emerging therapies is limited by our prognostic abilities during this period. The present review attempts to outline first the many methodological issues encountered in studies of early RA, and second the extent to which each major outcome measure can be explained, both by readily available clinical variables and by HLA-DR genotyping. The evidence supporting the clinical usefulness of genotyping is discussed separately. Based on this information, a clinically appropriate approach to the management of early RA and the identification of patients suitable for experimental therapies is suggested.