This paper is part of the September 2016 Pediatrics Special Issue. Read the entire issue or download it.
Rönnlund H, Elovainio M, Virtanen I, Matomäki J, Lapinleimu H. Poor parental sleep and the reported sleep quality of their children. Pediatrics. 2016;137(4);e20153425.
A cross-sectional, observational study
To assess the association of parental sleep quality with the reported sleep quality of their children
In this study, parents and their biological children aged 2 to 6 years were recruited from 16 daycare centers in Finland. A total of 108 children were enrolled and evaluated between January 2014 and February 2015. The mean age of the children was 4 years and the sex distribution was even. The sample included mainly Caucasian, highly educated families.
Parents completed questionnaires regarding socioeconomic status, their own well-being, and their child’s well-being and illnesses.
An actigraphy bracelet was provided for the child to wear on their nondominant hand for a period of 7 days. Parents were instructed to press the event button on the bracelet when the child went to sleep and when they woke up. While the actigraph does not differentiate between stages of sleep, it does estimate periods of sleep using a threshold for lack of movement. With consideration for the restless nature of children’s sleep, studies indicate that the actigraph shows good sensitivity (the ability to detect sleep), but poorer specificity (the ability to detect wake) in pediatric populations.1,2 However, the authors note that the accuracy can be enhanced using an appropriate algorithm.
Parents kept a sleep diary for the duration of the time that the child wore the actigraphy bracelet, which included the details of when and why the actigraphy bracelet was removed during this period.
Along with the sleep diaries, parents also completed the Sleep Disturbance Scale for Children (SDSC) which, in addition to the total score, evaluates 6 different sleep domains: disorders of initiating and maintaining sleep; sleep breathing disorders; disorders of arousal; sleep-wake transition disorders; disorders of excessive somnolence; and sleep hyperhidrosis.
With respect to their own health, parents completed both the Jenkins’ sleep scale and a 12-item General Health Questionnaire in order to assess parental sleep quality as well parental psychiatric symptoms, including anxiety and depression.
The authors found that parents who reported having sleep difficulties themselves were more likely to experience their children as having more sleep difficulties. Furthermore, they found that this association was not supported by the study’s objective measure, the actigraph, indicating that the child’s sleep may not actually be as poor as parents perceived. The perception of children’s sleep difficulties was not explained by the child’s age, sex, number of siblings, chronic illness, or medication, nor was it related to parental psychiatric symptoms, education, socioeconomic status, marital status, or time of year.
Many factors influence children’s sleep, including social and cultural environments, parental knowledge, and the child’s pre-existing medical conditions. Poor sleep and sleep disorders can have detrimental effects on a child’s anxiety level, mood, behavior, physical development, and weight, as well as academic competence.3 Thus, there is a need for screening and early intervention in sleep disorders. However, sleep screening and intervention may not be occurring as frequently and as effectively as one would hope.
Large epidemiological studies reveal that approximately 30% of children suffer from sleep problems.4 Despite this prevalence, the rates of screening and management of these concerns are low. Both primary care providers and parents frequently have gaps in knowledge when it comes to the topic of sleep in the pediatric population.5
Children depend on their parents’ understanding of their sleep needs in order to foster a healthy sleep regimen that is developmentally appropriate. In turn, parents rely on their healthcare providers to inquire about a child’s sleep habits routinely, identify problems, and provide education on the subject. Parental education is often the first line of intervention, and increasingly clinicians are recognizing that parental knowledge impacts child sleep behavior. However, primary care providers receive minimal training about sleep. This may result in missed opportunities for discussion during visits, unless parents are reporting problems or asking questions pertaining to sleep.3
Studies indicate that sleep disorders are more prevalent in single-parent families, and/or those with low parent education. This means there is more need for practitioner inquiry and education in patient visits where these conditions exist.4
When assessing sleep, there are 4 dimensions to consider: amount, quality, timing, and state of mind. BEARS is a useful acronym to use when asking parents and care providers about children’s sleep: (B) bedtime resistance (sleep onset delay); (E) excessive daytime sleepiness; (A) awakening at night (parasomnias); (R) regularity, patterns, and duration; and (S) snoring and other symptoms.4,6
While there are many pediatric sleep disturbances, among the most common is pediatric insomnia, which affects approximately 6% of typical children and as many as 75% of children with developmental impairments. In cases of pediatric insomnia, it is frequently the parent rather than the child who is frustrated, and the parent is often the one experiencing negative effects on daytime performance and increased stress levels.6
It is easy to see how, especially in cases such as these, parental emotions may influence prescribing behaviors of providers. The National Ambulatory Medical Care Survey demonstrated that, in visits involving sleep difficulties, 81% of children leave with a prescription compared to 48% of adults. What is particularly concerning about this statistic is that there are currently no medications on the market that are FDA-approved for treating sleep problems in children.6 While integrative practitioners would be unlikely to suggest prescription sleep aids, it would be interesting to know whether a similar percentage would give children homeopathic, botanical, or nutritional supplements for sleep. Of course, when multiple behavioral interventions fail, both naturopathic and prescription treatments may be appropriate; however, a sedated sleep does not equate with a normal restorative sleep.7
The authors found that parents who reported having sleep difficulties themselves were more likely to experience their children as having more sleep difficulties.
As a naturopathic doctor, this study reminds me of two core principles we uphold: tolle tausam (find the cause) and docere (teach). In addition, the therapeutic order for all patients is to remove disturbing factors and institute a healthful regime before interventions of any kind. In cases of pediatric sleep concerns, we should be addressing the entire family unit and ensuring that there are no unnecessary interventions that carry the possibility of harm. We must consider that parents may be over-reporting their children’s sleep disturbances because of their own sleep disorders. In addition to this, we must discuss the expectations that parents and caregivers have for their children’s sleep, in comparison with the developmental norms for their respective age groups. This leads to a natural segue to provide education surrounding these norms, including sleep requirements and good habits, understanding the signs of sleep problems, and suggestions on how to improve sleep for the whole family.
Parents with greater knowledge about sleep are more likely to establish better sleep hygiene routines for their children, including a regular, early bedtime, regular wake times, falling asleep without an adult, and no TV in the bedtime routine.3
Instead of simply relying solely on parental reporting of sleep disturbances and immediately treating children with sedative, nervine, and adaptogenic botanicals or supplements such as melatonin, it may have a greater impact on the family unit to assess and treat the parents’ sleep. Addressing healthy sleep hygiene with the whole family will only have a positive impact. While parents generally recognize the importance of a bedtime routine for their children, we may need to remind them that an established routine is essential for their sleep and health as well.
Further studies on preconception and perinatal sleep habits and sleep quality of parents may also prove to be of interest. While the assumption is that parents who were sleeping poorly in the preconception and perinatal periods are over-reporting sleep disturbances in their children, it is equally possible that parents who were good sleepers before they had children are the ones who have poorer sleep after having children. These “good sleepers” may feel more “interrupted” compared to parents who were already used to poorer quality sleep. This is an unknown, and further research is warranted to investigate whether children with sleep disturbances have parents with historically poor sleep or good sleep. This may also inform us about whether sleep disturbances are influenced by genetic or learned behaviors.