Pediatric motor activity during sleep as measured by actigraphy.

Study Objectives: Provide actigraphic reference values for motor activity during sleep for children and adolescents ages 8-17 years. Methods: Participants were 671 healthy community-dwelling children and adolescents (52% female, mean age 13.5 + 2.4 years) from the United States (64%) and Australia (36%). All participants wore an Ambulatory-Monitoring Inc. (AMI, Ardsley, NY) actigraph on their nondominant wrist for ≥5 nights and completed daily sleep diaries. Actigraphy data were scored with standard methods and a validated algorithm. Reference values were calculated for three outcome variables: percent sleep (sleep minutes/sleep period), mean activity count (average activity count over the sleep period), and restlessness measured by the activity index (% of epochs in sleep period > 0). Between-group differences were examined for sex and age group. In addition, changes to activity level across the sleep period were explored. Results: All participants had a minimum of three scorable nights of data, with 95% having at least five scorable nights. Reference values are presented by age group and sex, and reference percentiles are provided. Boys were found to have more activity in sleep across the three outcome variables. Age differences were also found for the three outcomes, but a consistent pattern was not detected across variables. Conclusions: This study is the first to examine motor activity from actigraphy in a large sample of healthy community-dwelling children and adolescents. Reference tables and percentiles, as well as sample actigrams highlighting different outcomes, are provided for clinicians and researchers who utilize actigraphy in pediatric populations.

Development and validation of the PROMIS Pediatric Sleep Disturbance and Sleep-Related Impairment item banks.

Study Objectives: To develop and evaluate the measurement properties of child-report and parent-proxy versions of the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Sleep Disturbance and Sleep-Related Impairment item banks. Methods: A national sample of 1104 children (8-17 years old) and 1477 parents of children 5-17 years old was recruited from an internet panel to evaluate the psychometric properties of 43 sleep health items. A convenience sample of children and parents recruited from a pediatric sleep clinic was obtained to provide evidence of the measures' validity; polysomnography data were collected from a subgroup of these children. Results: Factor analyses suggested two dimensions: sleep disturbance and daytime sleep-related impairment. The final item banks included 15 items for Sleep Disturbance and 13 for Sleep-Related Impairment. Items were calibrated using the graded response model from item-response theory. Of the 28 items, 16 are included in the parallel PROMIS adult sleep health measures. Reliability of the measures exceeded 0.90. Validity was supported by correlations with existing measures of pediatric sleep health and higher sleep disturbance and sleep-related impairment scores for children with sleep problems and those with chronic and neurodevelopmental disorders. The sleep health measures were not correlated with results from polysomnography. Conclusions: The PROMIS Pediatric Sleep Disturbance and Sleep-Related Impairment item banks provide subjective assessments of child's difficulty falling and staying asleep as well as daytime sleepiness and its impact on functioning. They may prove useful in the future for clinical research and practice. Future research should evaluate their responsiveness to clinical change in diverse patient populations.

Validation of Actigraphy in Middle Childhood.

STUDY OBJECTIVES: Few studies have examined the validity of actigraphy in school-aged children. The objective of this study was to examine the validity of a commonly used actigraph compared to polysomnography (PSG) in a sample of children age 5 to 12 y born prematurely, sleeping in their natural home environment. METHODS: 148 children born preterm (85 boys and 63 girls), ages 5-12 y (mean = 9.3 y, standard deviation = 2.0) wore the Philips Respironics Actiwatch-2 for 1 night concurrently with comprehensive, ambulatory PSG in the child's home. Sleep outcome variables were sleep onset latency, total sleep time (TST), and sleep efficiency. Epoch-by-epoch comparisons were used to determine sensitivity, specificity, and accuracy. Secondary analyses examined differences between children with no sleep issues, obstructive sleep apnea syndrome, and periodic limb movements in sleep (PLMS). RESULTS: Actigraphy significantly underestimated TST (30 min) and sleep efficiency (5%). Actigraphy underestimated or overestimated sleep onset latency by at least 10 min for a third of the children. Sensitivity and accuracy were good at 0.88 and 0.84, respectively, whereas specificity was lower at 0.46. Differences between actigraphy and PSG for TST and sleep efficiency were greatest for children with PLMS. CONCLUSIONS: This study adds to the small existing literature demonstrating the validity of actigraphy in middle childhood. Although actigraphy shows good sensitivity (ability to detect sleep), specificity (ability to detect wake) is poor in this age group. Further, the results highlight the importance of considering whether a child has PLMS when interpreting actigraphic data, as well as the difficulties in accurately capturing sleep onset latency with actigraphy.

Comparison of a Commercial Accelerometer with Polysomnography and Actigraphy in Children and Adolescents.

STUDY OBJECTIVES: To evaluate the reliability and validity of the commercially available Fitbit Ultra (2012) accelerometer compared to polysomnography (PSG) and two different actigraphs in a pediatric sample. DESIGN AND SETTING: All subjects wore the Fitbit Ultra while undergoing overnight clinical polysomnography in a sleep laboratory; a randomly selected subset of participants also wore either the Ambulatory Monitoring Inc. Motionlogger Sleep Watch (AMI) or Phillips-Respironics Mini-Mitter Spectrum (PRMM). PARTICIPANTS: 63 youth (32 females, 31 males), ages 3-17 years (mean 9.7 years, SD 4.6 years). MEASUREMENTS: Both "Normal" and "Sensitive" sleep-recording Fitbit Ultra modes were examined. Outcome variables included total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE). Primary analyses examined the differences between Fitbit Ultra and PSG using repeated-measures ANCOVA, with epoch-by-epoch comparisons between Fitbit Ultra and PSG used to determine sensitivity, specificity, and accuracy. Intra-device reliability, differences between Fitbit Ultra and actigraphy, and differences by both developmental age group and sleep disordered breathing (SDB) status were also examined. RESULTS: Compared to PSG, the Normal Fitbit Ultra mode demonstrated good sensitivity (0.86) and accuracy (0.84), but poor specificity (0.52); conversely, the Sensitive Fitbit Ultra mode demonstrated adequate specificity (0.79), but inadequate sensitivity (0.70) and accuracy (0.71). Compared to PSG, the Fitbit Ultra significantly overestimated TST (41 min) and SE (8%) in Normal mode, and underestimated TST (105 min) and SE (21%) in Sensitive mode. Similar differences were found between Fitbit Ultra (both modes) and both brands of actigraphs. CONCLUSIONS: Despite its low cost and ease of use for consumers, neither sleep-recording mode of the Fitbit Ultra accelerometer provided clinically comparable results to PSG. Further, pediatric sleep researchers and clinicians should be cautious about substituting these devices for validated actigraphs, with a significant risk of either overestimating or underestimating outcome data including total sleep time and sleep efficiency.

Sleep patterns, sleep instability, and health related quality of life in parents of ventilator-assisted children.

STUDY OBJECTIVES: Parents of children with chronic illnesses have poorer health related quality of life (HRQoL), shorter sleep duration, and poorer sleep quality than parents of healthy children. However, night-to-night variability of sleep in parents has not previously been considered. This study compared the sleep patterns of parents of ventilator-assisted children (VENT) and healthy, typically developing children (HEALTHY), and examined the relationship between sleep variability and perceived HRQoL. METHODS: Seventy-nine mothers and 33 fathers from 42 VENT families (n = 56) and 40 HEALTHY (n = 56) families completed the SF-36 and wore an actigraph for 2 weeks. Reported bedtime and wake time, along with actigraphic total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE) were examined using both average values and night-tonight instability (mean square successive differences). RESULTS: VENT parents showed significantly later bedtimes, shorter TST, longer WASO, and lower SE than HEALTHY parents. VENT parents also exhibited greater instability in their reported wake time, WASO, and SE. Adjusting for family type and gender, greater instability of wake times, WASO and SE were related to poorer SF-36 subscale scores, while averaged sleep values were not. CONCLUSIONS: Many parents of ventilator-assisted children experience deficient sleep and show significant instability in their sleep, which was related to HRQoL. Similar to shift workers, variable sleep schedules that may result from caregiving responsibilities or stress may impact parental caregivers' health and well-being. Additional studies are needed to determine how support and other interventions can reduce sleep disruptions in parental caregivers.

Sleep problems and sleep disorders in pediatric primary care: treatment recommendations, persistence, and health care utilization.

STUDY OBJECTIVE: This study examined documented treatment recommendations provided for sleep disorders and sleep problems in pediatric primary care, the persistence of sleep problems and sleep disorders in children and adolescents, and the relationship between sleep issues and health care utilization. METHODS: In-depth chart review of pediatric primary care patient visits (n = 750 patients) from 2007 through 2010. RESULTS: Only 26 children (5.2% of those with a sleep disorder/ problem) received a treatment recommendation, with half of these recommendations behavioral in nature. Sleep disorders and sleep problems were highly persistent across time for up to a third of children. Children with sleep disorders had significantly more sick visits/calls (mean = 8.84, 95% CI 7.77-9.90) than children without a sleep disorder (mean = 6.34, 95% CI 5.56-7.12). CONCLUSIONS: Very few children or adolescents were found to have documented treatment recommendations or referrals for diagnosed sleep disorders or sleep problems. In addition, given that sleep disorders and sleep problems are highly persistent, as well as result in more sick visits/calls, it is important that pediatric primary care providers screen for and identify these issues across development. Furthermore, it is essential to provide health care providers with more education and support on sleep disorders and sleep problems in pediatric primary care.

Sleep Patterns in Children with Cystic Fibrosis.

This study examined sleep patterns and the association between sleep and perceived health for children with and without CF. Ninety families (45 CF) completed questionnaires about the child's sleep and health. Significant group differences were found for sleep patterns (bedtime, wake time, total sleep time), symptoms of sleep disordered breathing, and sleep disturbances. Poorer perceived health was associated with sleep disturbances among children with CF, but not for children without CF. This study highlights the importance of including sleep in the evaluation of children with CF, as both medical and behavioral interventions can improve the sleep of children with CF.