The Sleep Environment, Napping, and Sleep Outcomes among Urban Children With and Without Asthma.

OBJECTIVES: Children with asthma living in U.S. urban neighborhoods experience increased risk for asthma morbidity and poor sleep outcomes. In addition to asthma, environmental factors (e.g. noise, uncomfortable temperature, light exposure) related to urban poverty may disturb children's sleep. This study examined the association between environmental factors and sleep outcomes among urban children with and without asthma, and whether napping underlies the environment-sleep link. Additionally, the study tested whether these associations differed by health status (i.e. asthma) or race/ethnicity. METHOD: Participants included urban children aged 7-9 years with (N = 251) and without (N = 130) asthma from Latino, Black, or non-Latino White (NLW) background. Caregivers reported sleep environmental factors and naps. Sleep duration, efficiency, and nightly awakenings were assessed via actigraphy. RESULTS: Regardless of health status, frequent exposure to noise and light was associated with poorer sleep outcomes only among Latino children. In the full sample with and without asthma, noise exposure during nighttime sleep was related to more frequent daytime naps, which were linked to shorter nighttime sleep duration. CONCLUSIONS: Exposure to noise and light may play a particularly influential role in shaping urban children's sleep outcomes. Racial/ethnic differences and the potential mediating role of napping in this environment-sleep association may inform tailored interventions.

Characteristics of Melatonin Use Among US Children and Adolescents.

This survey study describes parent-reported sleep practices, such as prevalence, frequency, and timing of melatonin use, among young people aged 1 to 13 years.

Factors contributing to U.S. parents' decisions to administer melatonin to children.

OBJECTIVE: Pediatric melatonin use is increasingly prevalent in the U.S. despite limited research on its efficacy and long-term safety. The current study investigated factors contributing to parents' decisions whether to give children melatonin. METHODS: Parents of children 1.0-13.9 years completed an online questionnaire on children's health, sleep, and melatonin use. Parents who reported giving melatonin to their child were asked open-ended follow-up questions on why their child takes melatonin and why they stopped (if applicable). Responses were assigned to categories through thematic coding. RESULTS: Data were analyzed on 212 children who either consumed melatonin in the past 30 days (n = 131) or took melatonin previously (n = 81). Among children who recently took melatonin, 51.1 % exhibited bedtime resistance and 46.2 % had trouble falling asleep. Parents most commonly gave children melatonin to: help them fall asleep (49.3 %), wind down before bedtime (22.7 %), facilitate changes in their sleep routine (17.5 %), and/or change their circadian rhythm (11.4 %). Parents stopped giving melatonin because their child did not need it anymore (32.0 %), experienced negative side effects (9.3 %), and/or concerns about health and safety (13.3 %). Finally, parents initiated melatonin use on their own (50.0 %), were encouraged by a friend or family member (27.4 %), and/or followed the recommendation of a health provider (48.1 %). CONCLUSIONS: Parents administered melatonin to children for a number of reasons and discontinued melatonin based on their own observations of a variety of effects. Parents frequently initiated use without the recommendation of a medical professional. Further research on indications and efficacy of melatonin and wider dissemination of guidelines are needed to help parents make informed decisions regarding children's sleep health.

A Pilot Randomized Control Trial Demonstrating the Efficacy of the SIESTA Sleep Hygiene Intervention.

Shorter sleep duration can negatively impact children's daytime functioning and health. Latino children living near urban areas in the Mainland U.S. and Island Puerto Rico (PR) can be exposed to urban poverty and sociocultural stressors that challenge optimal sleep outcomes. Interventions to improve urban Latino children's sleep health should consider families' cultural background and environmental context to enhance acceptability and feasibility. This work describes our stepwise, multimethod approach to adapting a culturally and contextually tailored "School Intervention to Enhance Latino Students' Time Asleep (SIESTA)" for sixth- to eighth-grade Latino children residing in Greater Providence and San Juan and findings from a pilot randomized control trial (RCT) demonstrating SIESTA's efficacy. Results indicated high acceptability and greater improvement of sleep duration and behaviors in SIESTA versus control participants. The SIESTA shows potential to improve sleep outcomes in urban Latino middle schoolers. Results will inform a large-scale RCT to evaluate SIESTA's effectiveness and barriers to implementation.

Physical Activity Among Urban Children with Asthma: Does Sleep Matter?

The present study examined associations between sleep and physical activity among a diverse sample of 97 urban children (ages 7-9) with persistent asthma. Differences in associations were evaluated by race/ethnicity and weight status. The extent to which sleep moderated the association between lung function and physical activity was also evaluated. Generalized linear models were utilized to examine associations. Findings indicated that, among the aggregate sample, more frequent nighttime awakenings were associated with less time spent engaging in moderate-to-vigorous physical activity (MVPA). Important differences in these associations were identified by both race/ethnicity and weight status. Better lung function was associated with, (a) higher levels of MVPA for children with better sleep efficiency and fewer nighttime awakenings, and (b) lower levels of MVPA for children with poorer sleep efficiency and more frequent nighttime awakenings. In short, sleep mattered with respect to children's physical activity levels in this sample.

Internalizing symptoms and sleep outcomes in urban children with and without asthma.

STUDY OBJECTIVES: This study examines associations between internalizing symptoms and sleep in a sample of urban children with and without asthma, whether asthma status moderates these associations, and whether associations differ by ethnic group. METHODS: Participants were Latino, African American (AA), and non-Latino white (NLW) urban 7- to 9-year-olds with (n = 259) and without (n = 122) persistent asthma. Teacher-reported internalizing symptoms (anxiety, depressive, and somatic) were assessed using the Behavioral Assessment System for Children-2. Sleep duration, variability in sleep duration, and sleep onset latency were assessed with actigraphy. RESULTS: Depressive symptoms were associated with variability in sleep duration and shorter sleep onset latency; somatic symptoms were associated with variability in sleep duration. In Latino children, depressive symptoms were associated with shorter sleep onset latency. In AA children, anxiety, depressive, and somatic symptoms were associated with variability in sleep duration; somatic symptoms were related to variability in sleep duration in NLW children. The association between internalizing symptoms and sleep outcomes did not differ by asthma status. However, asthma status was a significant moderator when examining these associations by ethnic group: among AA children, depressive symptoms were significantly related to variability in sleep duration only in children with asthma, whereas in NLW children, somatic symptoms were related to variability in sleep duration only in children without asthma. CONCLUSIONS: Targeting specific internalizing symptoms and sleep outcomes may be beneficial in the development of interventions tailored for urban children with and without asthma from specific ethnic groups.

Racial and ethnic disparities in sleep outcomes among urban children with and without asthma.

BACKGROUND: Suboptimal sleep has been documented in at-risk groups such as urban minority children, particularly those with asthma. It is therefore critical to examine differences in sleep outcomes across specific racial and ethnic groups and to identify factors that contribute to such variations in sleep outcomes to inform tailored interventions to improve sleep health. OBJECTIVES: The objectives were to examine racial/ethnic differences in sleep outcomes among urban children with and without asthma and to evaluate the extent to which asthma status and aspects of sleep hygiene and the sleep environment contribute to racial/ethnic differences in sleep outcomes in this sample. METHODS: Two hundred and sixteen African American, Latino, or non-Latino white (NLW) urban children, ages 7-9 years, with (n = 216) and without asthma (n = 130) and their primary caregivers were included. Objective sleep duration and efficiency were assessed via actigraphy. Asthma status was assessed by a study clinician. Caregiver-reported sleep hygiene and exposure to noise were assessed using a questionnaire. RESULTS: Minority children in the sample had, on average, shorter sleep duration compared to NLW children during the monitoring period (mean difference Latino vs NLW = -22.10, SE = 5.02; mean difference AA vs NLW = -18.69, SE = 5.28) Additionally, several racial/ethnic group differences in sleep outcomes emerged and were dependent on whether or not children had asthma. Specifically, Latinos had lower mean number of awakenings compared to NLWs but only among control participants with no asthma. Furthermore, specific aspects of sleep hygiene and exposure to nighttime noise in the home and neighborhood contributed to racial/ethnic differences in sleep outcomes. CONCLUSION: Considering urban stressors and asthma status when treating pediatric populations is important, as factors related to urban stress and asthma management may influence sleep hygiene practices and sleep outcomes.

Featured Article: Multiple Comorbid Conditions, Sleep Quality and Duration, and Academic Performance in Urban Children With Asthma.

Objective: Common comorbid medical conditions including allergic rhinitis (AR), obesity, and sleep disordered breathing (SDB) have been linked with asthma exacerbations; however, these conditions also impact sleep and academic functioning. The current study sought to examine unique and combined associations of these common comorbidities on sleep and academic performance among urban minority children with persistent asthma. We expected additional comorbid diagnoses would be associated with poorer sleep and academic functioning. Method: Urban children 7-9 years old (n = 249) with persistent asthma from African American, Latino, and non-Latino White backgrounds participated in this cross-sectional study. Asthma and AR were assessed using guidelines-based approaches. Overweight/obesity was assessed using body mass index and parents reported on SDB risk. Sleep quality (sleep efficiency) and sleep duration were assessed via 4 weeks of actigraphy. A cumulative risk index (CRI) score of asthma-related comorbidities (i.e., number of comorbidities for which each child met criteria) was calculated. Results: Comorbid conditions were prevalent (AR, 85%; overweight/obese, 39%; SDB risk, 44%). Lower SDB risk and better AR control were both associated with fewer school absences. A higher CRI score was associated with shorter sleep duration and more absences. For children with 1 comorbid condition, better lung function was associated with better sleep efficiency. Conclusion: Findings suggest increased risk of shorter sleep and more frequent school absences among urban minority children with asthma and more comorbid conditions. Assessment and treatment of this high-risk group must consider how comorbid conditions exacerbate children's asthma and may affect sleep and daytime functioning.

Asthma-related lung function, sleep quality, and sleep duration in urban children.

OBJECTIVES: Examine (1) the extent to which changes in objectively measured asthma-related lung function (forced expiratory volume in 1 second) within a sleep period are associated with sleep quality and sleep duration during that sleep period in a group of urban children with persistent asthma, (2) associations between morning and evening asthma-related lung function and sleep quality and duration on the adjacent night, and (3) whether these associations differ by ethnic group. DESIGN: Cross-sectional, multimethod approach. Children completed a clinic assessment of asthma and allergy status and used home-based objective measurements of asthma-related lung function and sleep. SETTING: Children and their caregivers participated in a clinic assessment at an asthma and allergy clinic and completed additional assessments at home. PARTICIPANTS: Two hundred and sixteen African American, Latino, and non-Latino white urban children, ages 7-9 years, and their primary caregivers. MEASUREMENTS: Participants took part in a clinic assessment of asthma and allergy status, completed interview-based questionnaires including a diary to track asthma symptoms and sleep patterns, and used actigraphy and home-based spirometry daily across a 4-week period to assess sleep and lung function. RESULTS AND CONCLUSIONS: Results from analyses using structural equation modeling revealed an association between worsening asthma-related lung function and poor sleep quality in the full sample, as well as better asthma-related lung function at night and more optimal sleep efficiency that night. Ethnic group differences emerged in the association with morning or nighttime lung function measurements and sleep quality. Urban minority children with asthma may be at heightened risk for poorer quality sleep. Timing of lung function worsening may be important when considering when and how to improve both asthma health outcomes and sleep quality within specific groups.

Sleep Hygiene and Sleep Outcomes in a Sample of Urban Children With and Without Asthma.

Objective: To assess sleep hygiene and the sleep environment of urban children with and without asthma, and examine the associations among urban stressors, sleep hygiene, and sleep outcomes. Methods: Urban children, 7-9 years old, with (N = 216) and without (N = 130) asthma from African American, Latino, or non-Latino White backgrounds were included. Level of neighborhood risk was used to describe urban stress. Parent-reported sleep hygiene and daytime sleepiness data were collected using questionnaires. Sleep duration and efficiency were assessed via actigraphy. Results: Higher neighborhood risk, not asthma status, was associated with poorer sleep hygiene. Controlling for neighborhood risk, sleep hygiene was related to daytime sleepiness. Asthma status, not sleep hygiene, was related to sleep efficiency. In children with asthma, poorer sleep hygiene was associated with shorter sleep duration. Conclusion: Considering urban stressors when treating pediatric populations is important, as factors related to urban stress may influence sleep hygiene practices and sleep outcomes.

Good Sleep Health in Urban Children With Asthma: A Risk and Resilience Approach.

OBJECTIVES: To identify children demonstrating "good" sleep health in a sample of urban children with persistent asthma; to compare sociocontextual, asthma clinical characteristics, and sleep behaviors in children with "good" versus "poor" sleep health; and to examine protective effects of family-based health behaviors on sleep health. METHODS: Participants were 249 Black (33%), Latino (51%) and non-Latino White (16%) children with asthma, ages 7-9 years, and their primary caregivers. RESULTS: 32 percent of children had "good" sleep health. Well-controlled asthma and better lung function were more likely in this group. In the context of urban risks, sleep hygiene appeared to be a protective factor associated with better sleep quality. The protective effect of asthma management functioned differently by ethnic group. CONCLUSIONS: This study identifies protective processes that may guard against urban risks to optimize sleep health in children with asthma. Intervention programs can be tailored to consider specific supports that enhance sleep health in this high-risk group.

Asthma, allergic rhinitis, and sleep problems in urban children.

OBJECTIVES: In this study, we examine the association of asthma (asthma symptoms, asthma control, lung function) and sleep problems in a group of urban children. The role of allergic rhinitis (AR), a comorbid condition of asthma, on children's sleep problems is also examined. Finally, we investigate whether sleep hygiene moderates the association between asthma and sleep problems, and whether there are differences in these associations based on ethnic background. METHODS: Non-Latino White, Latino, and African American urban children with asthma (n = 195) ages 7-9 (47% female) and their primary caregivers participated in a baseline visit involving interview-based questionnaires on demographics, asthma and rhinitis control, and caregiver report of children's sleep problems and sleep hygiene. Children and their caregivers participated in a clinical evaluation of asthma and AR, followed by a month monitoring period of children's asthma using objective and subjective methods. RESULTS: Total sleep problem scores were higher in children of the sample who were from African American and Latino backgrounds, compared to non-Latino white children. Poor asthma control was predictive of higher levels of sleep problems in the entire sample. Poorer AR control also was related to more sleep problems, over and above children's asthma in the sample. This association was more robust in non-Latino white children. Poor sleep hygiene heightened the association between poor asthma control and sleep problems in the entire sample and in African American children. CONCLUSIONS: Multidisciplinary interventions integrating the co-management of asthma, AR, and the effects of both illnesses on children's sleep, need to be developed and tailored to children and their families' ethnic background.

Depressive symptoms in youth with inflammatory bowel disease compared with a community sample.

BACKGROUND: Previous investigations have produced mixed findings on whether youth with inflammatory bowel disease (IBD) experience elevated rates of depressive symptoms. Our first aim was to compare self-report of depressive symptoms by youth with IBD with a community sample. The second aim was to examine the relationship between symptoms of depression and measures of disease activity. METHODS: Item-level responses on the Children's Depression Inventory among a sample of 78 youth diagnosed with IBD were compared with responses from a community sample using 1-sample t-tests. Particular attention was given to items assessing somatic symptoms of depression given the potential overlap with IBD disease symptoms. The relationship between depressive symptoms and IBD disease activity was evaluated using Spearman's rank correlation coefficients and linear regression. RESULTS: Youth with IBD reported lower levels of depressive symptoms compared with the community sample on the Children's Depression Inventory Total Score, and similar or lower levels of difficulty on items assessing somatic symptoms. Most of the sample had inactive or mild disease activity at the time of participation, with 14% experiencing moderate/severe disease activity. Higher ratings of disease activity were related to greater depressive symptoms. Responses on somatic items from the Children's Depression Inventory were not differentially related to disease activity. CONCLUSIONS: As a group, pediatric patients with IBD did not experience the clinical levels of depressive symptoms or elevations in depressive symptoms when compared with a community sample. Somatic symptoms of depression do not differentiate youth with IBD experiencing elevations in disease activity from youth experiencing nonsomatic symptoms of depression.

Later school start time is associated with improved sleep and daytime functioning in adolescents.

OBJECTIVE: Chronic insufficient sleep is a growing concern among adolescents and is associated with a host of adverse health consequences. Early school start times may be an environmental contributor to this problem. The purpose of this study was to examine the impact of a delay in school start time on sleep patterns, sleepiness, mood, and health-related outcomes. METHOD: Boarding students (n = 197, mean age = 15.6 yr) attending an independent high school completed the School Sleep Habits Survey before and after the school start time was experimentally delayed from 8:00 a.m. to 8:25 a.m. RESULTS: The delay in school start time was associated with a significant (29 min) increase in sleep duration on school nights. The percentage of students receiving 8 or more hours of sleep on a school night increased to more than double, from 18% to 44%. Students in 9th and 10th grade and those with lower baseline sleep amounts were more likely to report improvements in sleep duration after the schedule change. Daytime sleepiness, depressed mood, and caffeine use were all significantly reduced after the delay in school start time. Sleep duration reverted to baseline levels when the original (earlier) school start time was reinstituted. CONCLUSIONS: A modest (25 min) delay in school start time was associated with significant improvements in sleep duration, daytime sleepiness, mood, and caffeine use. These findings have important implications for public policy and add to research suggesting the health benefits of modifying school schedules to more closely align with adolescents' circadian rhythms and sleep needs.

Stability of Emotional and Behavioral Functioning in Youth with Inflammatory Bowel Disease.

This study prospectively examined stability of psychological and behavioral functioning in two matched cohorts of youth with inflammatory bowel disease (IBD): (1) newly-diagnosed and (2) previously-diagnosed patients. Youth and their parents completed measures of emotional and behavioral functioning at Time 1 and 6-months later. Mean-level analyses indicated that scores at Time 1 and Time 2 were within the nonclinical range. A significant decrease occurred in Internalizing symptoms for previously-diagnosed patients. Both groups demonstrated high levels of profile stability, with no significant differences across groups. Results suggest that emotional and behavioral functioning is generally stable without targeted intervention.

6-Thioguanine levels in pediatric IBD patients: adherence is more important than dose.

BACKGROUND: Thiopurine immunosuppressants such as 6-mercaptopurine (6-MP) are widely used to maintain remission in children with both Crohn's disease and ulcerative colitis. Therapeutic efficacy is associated with higher red blood cell levels of the thiopurine metabolite 6-thioguanine (6-TGN). Studies in both children and adults have inexplicably failed to demonstrate a significant correlation between prescribed dose and level of 6-TGN. We aimed to quantify the relationship between 6-TGN levels and adherence. METHODS: We used electronic monitoring devices to assess adherence in children and adolescents with inflammatory bowel diseases who were prescribed 6-MP. RESULTS: During 3230 days of monitoring in 19 subjects, adherence to 6-MP was 74.2%. Due to the generally low adherence to the prescribed dose of 6-MP, the 6-TGN level was not correlated with the prescribed dose. The 6-TGN level was significantly correlated with the adherence-adjusted dose (R(2) = 0.395). It was also significantly correlated to adherence alone (R(2) = 0.478). Adherence to 5-aminosalicylic acid and 6-MP were significantly positively correlated (r(s)(9) = 0.82, P = 0.00), and a significant relationship was found between 5-aminosalicylic acid adherence and 6-TGN levels independent of 6-MP adherence. Furthermore, low adherence to 6-MP was associated with increased likelihood of escalation of medical therapy. CONCLUSIONS: Red blood cell 6-TGN levels are strongly correlated with the dose, when the dose is actually taken. Lack of efficacy of thiopurines may often be the result of poor adherence. Novel ways of assessing and improving adherence are necessary. Future trials should assess adherence in study participants. Intake of 5-aminosalicylic acid positively influences 6-TGN levels.

Rates and predictors of oral medication adherence in pediatric patients with IBD.

BACKGROUND: Symptoms of inflammatory bowel disease (IBD) include bloody diarrhea, fatigue, abdominal pain, and weight loss. Long-term management of remission for most patients requires adherence to taking 1 or more oral medications daily, in the absence of symptoms. We investigated whether disease characteristics and behavioral characteristics predict adherence to prescribed medical regimens. METHODS: : Patients aged 8 to 17.5 years, newly diagnosed with IBD, and a matched cohort previously diagnosed were studied over a 6-month period. Adherence was assessed using medication electronic monitoring devices (Medication Event Monitoring Systems); participants and parents completed questionnaires regarding emotional and behavioral functioning, and biological parameters were monitored. RESULTS: : Adherence was monitored for 45 newly and 34 previously diagnosed patients. In total, 16,478 patient-days (including 12,066 discrete days) were electronically monitored. Overall, 70.6% of 5-aminosalicylic acid and 65.4% of 6-mercaptopurine doses were taken. Only 25% and 15% of older adolescents took at least 80% of their 5-aminosalicylic acid and 6-mercaptopurine, respectively, compared with about 83% and 64% of 8-year-olds to 11-year-olds. Only age and behavioral issues were statistically linked to rates of adherence. CONCLUSIONS: Adherence to commonly prescribed oral medications for IBD is challenging for patients. Screening for emotional and behavioral problems, especially among older adolescents, would be important in identifying patients at risk of poor adherence, who might benefit from interventions. Biological solutions, although critical, when applied without attention to behavioral issues, are not likely to provide the level of therapeutic benefit that can be provided in a combined biobehavioral approach.

Parental interest in a bereavement support visit when a child dies from cancer.

Parents who have experienced the death of a child from cancer have unique bereavement needs. This study evaluated the possibility of instituting a home-based bereavement visit from the oncology team following a child's death. Parents completed a brief anonymous questionnaire measuring preferences regarding visit logistics and content. The majority (84%) of the 31 participants agreed that a home-based bereavement program is desirable. Qualitative analysis of parental comments revealed common themes including processing grief, practical suggestions for visit, recognition of individual differences, perceived risks and benefits of visit, connections with medical staff, and unmet needs for support. In conclusion, a home visit program may satisfy needs for additional support while alleviating barriers to other types of bereavement care.

Missed sleep and asthma morbidity in urban children.

BACKGROUND: Children living in urban environments have many risk factors for disrupted sleep, including environmental disturbances, stressors related to ethnic minority status, and higher rates of stress and anxiety. Asthma can further disrupt sleep in children, but little research has examined the effects of missed sleep on asthma morbidity. OBJECTIVE: To examine the associations among missed sleep, asthma-related quality of life (QoL), and indicators of asthma morbidity in urban children with asthma from Latino, African American, and non-Latino white backgrounds. Given the importance of anxiety as a trigger for asthma symptoms and the link between anxiety and disrupted sleep, the associations among anxiety, asthma morbidity indicators, and missed sleep were also tested. METHODS: Parents of 147 children ages 6 to 13 years completed measures of asthma morbidity and missed sleep, parental QoL, and child behavior. RESULTS: Higher reports of missed sleep were related to more frequent school absences, more activity limitations, and lower QoL across the sample. The associations between missed sleep and asthma morbidity were stronger for Latino children compared with non-Latino white and African American children. For children with higher anxiety, the associations between missed sleep and asthma morbidity were stronger than for children with lower anxiety. CONCLUSION: Results offer preliminary support for missed sleep as a contributor to daily functioning of children with asthma in urban neighborhoods. Missed sleep may be more relevant to Latino families. Furthermore, anxiety may serve as a link between sleep and asthma morbidity because higher anxiety may exacerbate the effects of disrupted sleep on asthma.