Allergic Conditions and Their Impact on Pediatric Sleep: A Narrative Review

ABSTRACT

This narrative review explores the relationship between allergic diseases and sleep disorders in children, highlighting the significant impact allergies have on pediatric sleep quality. Allergic conditions such as allergic rhinitis, asthma, and atopic dermatitis are prevalent in children and are known to contribute to sleep disturbances. These disorders can lead to issues such as sleep fragmentation, obstructive sleep apnea, and excessive daytime sleepiness, which negatively affect cognitive function, behavior, and overall well-being. Studies from Saudi Arabia and other regions indicate a clear association between allergies and impaired sleep, with factors such as nasal congestion, wheezing, and itching playing key roles in disrupting sleep patterns. Treatment options, including pharmacological therapies, immunotherapy, and allergen avoidance strategies, aim to alleviate symptoms and improve sleep outcomes. Further research is needed to better understand the mechanisms behind this relationship and to develop more effective management strategies for children suffering from both allergic diseases and sleep disorders.

INTRODUCTION

Allergies occur when the immune system overreacts to harmless substances, such as pollen or dust, leading to symptoms like sneezing, itching, and rashes.[1] These symptoms can disrupt daily life, challenge everyday activities, and affect sleep and social interactions. Individuals with allergies must continuously manage their environment to avoid triggers, which can be stressful and financially burdensome.[2] The costs associated with medications and allergy tests add to the financial strain, highlighting the need for effective management to improve overall quality of life.[3,4]

The mechanism behind allergic reactions involves the immune system producing IgE antibodies in response to allergens. These antibodies bind to allergens and trigger the release of chemicals like histamine from mast cells, leading to inflammation and allergy symptoms.[5,6] Allergic reactions are categorized into four types. Type I hypersensitivity, or immediate hypersensitivity, is triggered by allergen exposure and leads to conditions such as allergic rhinitis, asthma, and food allergies. Type II hypersensitivity involves the immune system attacking cells, causing disorders like hemolytic anaemia and Goodpasture’s syndrome. Type III hypersensitivity is characterized by immune complexes depositing in tissues, resulting in lupus and rheumatoid arthritis. Type IV hypersensitivity, or delayed-type hypersensitivity, is mediated by T cells and causes delayed reactions such as contact dermatitis and responses to tuberculosis testing.[7,8]

Sleep disorders in children can significantly impact their overall well-being, affecting physical health, cognitive function, and emotional stability.[9] Common disorders include insomnia, characterized by difficulty falling or staying asleep, and sleep apnea, which involves interrupted breathing during sleep and can lead to fatigue and other health problems. Studies have linked childhood insomnia to various factors, including stress, anxiety, and underlying medical conditions.[10,11] Narcolepsy, a neurological disorder, causes excessive daytime sleepiness and sudden sleep attacks. This can significantly disrupt a child’s daily life. While relatively rare in children, narcolepsy often emerges during childhood or adolescence.[12] Restless Legs Syndrome (RLS) involves uncomfortable leg sensations that disrupt sleep, while parasomnias include abnormal behaviors during sleep, such as sleepwalking and night terrors.[13] Circadian rhythm disorders can arise from a misalignment between the body’s natural sleep-wake cycle and the external environment. Factors like shift work, jet lag, and exposure to artificial light at night can disrupt the circadian rhythm, leading to sleep disturbances.[14]

Melatonin and its role in sleep regulation

Melatonin, a hormone the pineal gland produces, plays a crucial role in regulating the sleep-wake cycle. Its levels are the highest at night and lowest during the day. Inadequate sleep or disruptions to the circadian rhythm can lead to low melatonin levels, potentially contributing to various health issues.[15,16] Studies have linked low melatonin levels to an increased risk of sleep disorders, mood disorders, and other health problems.[17,18] Maintaining proper melatonin levels is essential for a healthy sleep-wake cycle, and therapeutic use of melatonin has shown promise in treating certain sleep disorders. Melatonin supplements are commonly used to address sleep disorders and improve sleep quality.[18] Research suggests that melatonin supplementation may benefit children with insomnia, circadian rhythm disorders, and certain neurodevelopmental disorders.[19,20]

The relationship between allergic diseases and sleep disorders

Numerous studies have shown that allergic diseases, such as type I hypersensitivity reactions, are frequently associated with sleep disorders.[21,22,23] The relationship between these conditions underscores the impact of allergic diseases on sleep patterns and overall sleep quality, particularly in children. This discussion explores evidence from various studies and outlines key findings regarding the connection between allergic diseases and sleep disorders. Allergic rhinitis, characterized by nasal inflammation, has been linked to sleep disorders such as Obstructive sleep apnea (OSA). Allergic rhinitis can contribute to developing or worsening OSA, though the exact mechanisms are not fully understood.[24,25] It is believed that nasal congestion and inflammation caused by allergic rhinitis can lead to upper airway obstruction during sleep. Increased nasal resistance can affect the collapsibility of the upper airway, and nasal congestion may lead to mouth breathing, further increasing the risk of upper airway collapse and OSA. Disrupted sleep patterns and decreased sleep quality are common consequences of OSA, as individuals often experience frequent awakenings due to breathing difficulties, leading to fragmented sleep and cognitive impairment.[26] Similarly, studies have found that allergic rhinitis can exacerbate sleep-disordered breathing, including OSA, by contributing to upper airway obstruction and disrupting sleep.[24,27]

Asthma, a respiratory condition, is also associated with sleep disorders in children. Pediatric patients with asthma often experience disruptions in sleep patterns, which impact their overall well-being. These disturbances may include difficulty falling asleep, frequent awakenings throughout the night, and daytime fatigue.[28,29] Asthma symptoms can worsen at night, impairing sleep quality, and the frequent use of rescue inhalers or other medications during the night can further interfere with sleep. The inflammatory nature of asthma can have systemic effects, releasing inflammatory mediators that impact sleep regulation and trigger heightened arousal responses, making it challenging for children to achieve and maintain restful sleep. Sleep disturbances in children with asthma can lead to daytime sleepiness, decreased cognitive function, impaired academic performance, mood changes, and overall emotional well-being issues.[29,30,31] Managing asthma and sleep disorders simultaneously is crucial for optimal health outcomes, involving asthma control and addressing sleep issues through appropriate interventions and strategies.

Research indicates that children with atopic dermatitis often experience difficulties falling asleep and increased nighttime awakenings, leading to poorer sleep quality.[32,33] The severity of atopic dermatitis correlates with worse sleep quality and increased disturbances. The relationship between atopic dermatitis and sleep disturbances is complex, as both can exacerbate each other, creating a challenging cycle. Inadequate sleep can lead to increased stress, weakened immune function, and heightened skin inflammation, while atopic dermatitis symptoms can directly interfere with sleep quality.[34] Effective management of both conditions is crucial for improving overall well-being. Treatment for atopic dermatitis often involves topical creams and good skincare practices to manage skin inflammation and relieve itching. Addressing sleep disturbances may include developing a bedtime routine that promotes relaxation, minimizes itching, and creates a comfortable sleep environment. Personalized treatment options tailored to the individual’s needs are essential for optimal outcomes.[35,36]

The impact of allergic diseases on sleep extends beyond physical symptoms to affect psychological well-being. Allergic diseases and sleep problems are associated with increased psychological distress in children.[37] Research indicates that children with allergic rhinitis, asthma, and atopic dermatitis are more likely to experience sleep disorders, which can lead to difficulties falling asleep, frequent awakenings, and poor sleep quality.[21,32] These disturbances negatively affect a child’s life, including mental health and well-being. The connection between allergic diseases, sleep disorders, and psychological distress is multifaceted. Physical discomfort from allergic diseases, such as itching, pain, and breathing difficulties, can disrupt sleep and lead to chronic sleep deprivation, contributing to psychological distress.[38] Inflammatory processes involved in allergic diseases can also affect the brain and central nervous system, potentially leading to mood and cognitive function alterations.[39] Furthermore, the impact of allergic diseases and sleep disorders on daily functioning, including academic performance and social interactions, can exacerbate psychological distress. Children with chronic health conditions and disrupted sleep patterns may experience increased stress, frustration, and a sense of isolation, further affecting their mental health.[40]

SLEEP DISORDERS IN SAUDI CHILDREN: HEALTH IMPACTS AND TREATMENT APPROACHES

Saudi Arabia reports a high prevalence of allergic diseases in children, including allergic rhinitis, asthma, and atopic dermatitis.[41] Also, the issue of sleep disorders among children in Saudi Arabia is becoming increasingly important.[42] Recent studies reveal a high prevalence of sleep disorders in Saudi children. Thabet and Tabarki found that conditions such as sleep apnea, insomnia, and restless leg syndrome are common among the pediatric population in Saudi Arabia.[43] These disorders can severely affect a child’s health in multiple ways. Children suffering from sleep disturbances often experience increased irritability, mood swings, and behavioural issues such as hyperactivity and aggression. Long-term sleep deprivation can also contribute to mental health disorders like depression and anxiety. Accurate assessment and effective management of sleep disorders are crucial. Assessment typically involves subjective measures, such as sleep diaries, questionnaires, and interviews, and objective measures, such as polysomnography (PSG) and actigraphy.[44] Treatment approaches depend on the specific disorder. Behavioural interventions are often recommended for insomnia, including establishing consistent bedtime routines and creating a conducive sleep environment. Cognitive-behavioural therapy for insomnia (CBT-I) may be used for underlying psychological issues. Sleep apnea is commonly treated with Continuous Positive Airway Pressure (CPAP) therapy, and surgical options like adenotonsillectomy may be considered for severe cases. RLS can be managed through lifestyle changes, such as avoiding caffeine and maintaining a regular sleep schedule, alongside medications like dopamine agonists or iron supplements. Parasomnias may require creating a safe sleep environment and addressing stress or anxiety with medication or specialized interventions in severe cases.

While no studies directly address the link in Saudi Arabia, research from other regions suggests a strong connection between allergies and sleep disorders in children. Allergic rhinitis, asthma, and atopic dermatitis are prevalent and can severely impact sleep quality. Studies have explored how allergic rhinitis contributes to sleep disorders by causing symptoms like nasal congestion, which disrupts sleep and exacerbates other sleep issues.[45,46] Aljomah et al.[47] reported that a significant proportion of Saudi adults who had allergic rhinitis had considerably poorer sleep quality, with severity correlating with increased sleep disturbances. Alanazi et al. reported that poorly controlled asthma significantly worsens sleep quality, leading to increased rates of obstructive sleep apnea and daytime sleepiness. Nocturnal asthma exacerbations contribute to sleep disturbances, highlighting the need for effective asthma management to improve sleep and overall well-being.[48] In Al-Ahssa, research indicates a significant prevalence of allergic rhinitis, with 48% of participants diagnosed with the condition and a notable association between allergic disorders and sleep disturbances.[49] A multi-country study also emphasized that while the prevalence of allergic rhinitis in the Middle East is lower than in Western countries, the impact on quality of life and sleep is substantial.[50] This underscores the need for better awareness and management strategies to address allergic rhinitis and its effects on sleep.

Treatment approaches for allergic diseases and their implications

Pharmacological interventions play a crucial role in treating these conditions. Antihistamines are frequently used to alleviate symptoms like sneezing, itching, and nasal congestion, while inhaled corticosteroids and bronchodilators are prescribed for asthma to reduce inflammation and improve breathing.[51] In cases of atopic dermatitis, topical corticosteroids and emollients help control skin inflammation and maintain hydration.[52,53] Besides medication, managing allergic diseases involves identifying and avoiding allergens that trigger symptoms. This includes reducing exposure to dust mites, pet dander, pollen, and certain foods, creating home allergen-free environments, and making dietary adjustments to alleviate symptoms.[5]

Immunotherapy is another critical aspect of treating allergic diseases, which aims to desensitize the immune system to specific allergens over time. Subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) are commonly used approaches, with SCIT involving allergen injections and SLIT using allergen extracts placed under the tongue.[54,55] Both methods have effectively reduced allergic reactions and improved quality of life. Recent developments in the field have introduced emerging techniques like epicutaneous immunotherapy (EPIT) and intralymphatic immunotherapy (ILIT), which offer promising advancements in treatment convenience and effectiveness.[56,57] Additionally, biologics and immunomodulatory agents are being explored to enhance the immune response and improve the efficacy of immunotherapy.[58]

Conflicts of interest

Nil.

Funding Statement

Nil.