Abstract
Background
Insufficient quality and quantity of sleep has dangerous neurodevelopmental outcomes in the form of poor concentration, poor scholastic performance, hyperactivity and obstructive sleep apnea. There is no structured data on prevalence of various sleep behaviours and sleep related disorders in children in India. We aim to study sleep behaviour of children to know the common paediatric sleep related disorders.
Methods
We enrolled 270 children between the age of 1 to 18 years visiting pediatric OPDs for minor ailments between June 2022 to June 2023 using Children Sleep habit questionnaire – (NICHD SECCYD, Wisconsin). Children having clinical features suggestive of obstructive sleep apnoea were further subjected to overnight level 1 Polysomnography study.
Results
Most children had bed time consistency with average sleep duration of Mean ± 2SD (8.58 ± 1.35 h, N=270), which was shorter than global average. Allergic disorders were significantly high with prevalence of allergic rhinitis up to 30 % and asthma between 8-10 % in our study. Prevalence of obstructive sleep apnea on Polysomnography study was 5.6%, parent reported snoring 10 %, restless leg movements 30% and open mouth breathing in 35% Indian children. In our study, Asthma had statistically significant association with sleep disordered breathing and obstructive sleep apnea with p value < 0.01.
Conclusions
Asthma has statistically significant association with obstructive sleep apnoea in our study. Proper asthma treatment may reduce the burden of obstructive sleep apnoea in children. There is a growing need to screen children regularly for sleep related issues on routine visits.
Keywords: Obstructive sleep apnea, Hypopnea, Childhood sleep questionnaire, Pulse oximetry, Polysomnography
Introduction
Pediatric sleep disorders, though common, are often underdiagnosed due to lack of awareness on the part of patients as well as health care providers. These disorders can manifest from infants to adolescents with variable severity. The most common sleep disorder reported in infants and young children is insufficient sleep or behaviour insomnia of childhood.1,2 Poor quality as well as poor quantity of sleep can lead to dangerous neurodevelopmental outcomes in the form of poor concentration, poor scholastic performance, hyperactivity and inattention.3 In addition, children with fragmentation of sleep or poor quality of sleep may be having underlying serious disorders such as obstructive sleep apnea or nocturnal hypoventilation syndrome. These serious sleep disorders have adverse outcomes such as increased cardiovascular mortality, pulmonary artery hypertension and heart failure.4,5 Despite these adverse consequences, pediatric sleep disorders are unrecognised by and large. As of now, there is no structured data on prevalence of various sleep disorders in India particularly in children. We aimed to study the epidemiological and clinical profile of children at a tertiary care center in southwest Maharashtra to ascertain sleep related behaviors and various pediatric sleep disorders.
Aims and objectives
Primary and secondary aims and objectives of our study are mentioned as below:
Primary objectives
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1)
To study the prevalence of various pediatric sleep related behaviors in children attending OPD clinics at a tertiary care center.
Secondary objectives
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2)
To identify the risk factors associated with sleep-disordered breathing/obstructive sleep apnea in children attending Pediatric OPDs.
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3)
To identify prevalence of obstructive sleep apnea in pediatric patients.
Material and methods
Expected global prevalence of sleep disorders is 2–5% in general population. Exact prevalence and incidence of pediatric sleep disorders is unknown in India.
The inclusion and exclusion criteria of our study were as below:
Inclusion criteria: Following children were included in the study:
Developmentally normal children between 1 and 18 years of age.
Exclusion criteria: The children with following disorders were excluded:
Neurodevelopmental disorders including.
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Autism spectrum disorders
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Attention deficit hyperactivity disorder
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Developmental delays
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Children with major medical illness requiring hospitalisation
We enroled 270 children between 1 year and 18 years of age fulfilling our inclusion criteria who visited pediatric OPDs for nutrition counselling, immunisation and routine health visits between June 2022 and June 2023 after taking due parental consent. The paediatrician asked the parents about their children's sleep patterns and habits using a validated questionnaire called Children Sleep habit questionnaire (CHSQ) - National Institute of Child Health and Human Development (NICHD) Study of Early Child Care and Youth Development - Wisconsin (SECCYD) (Fig. 1).6 The children sleep habit questionnaire includes items relating to a number of key sleep domains that encompass the major presenting clinical sleep complaints in children: Bedtime behaviour and sleep onset; sleep duration; behaviour occurring during sleep and night waking; and morning waking/daytime sleepiness. Parents were asked to recall sleep behaviours occurring over a ‘typical’ recent week. Items were rated on a three-point scale: always if something occurs every night, usually if it occurs 5 or 6 times a week, sometimes if it occurs 2 to 4 times a week, rarely if it occurs once a week, and never if it occurs less than once a week.
Fig. 1.
Children's sleep habits questionnaire.
Initially, children were screened to have obstructive sleep apnoea or sleep-disordered breathing based on clinical examination and history. Clinical features suggesting the presence of obstructive sleep apnoea or sleep-disordered breathing included pathological snoring, open-mouth breathing, adenoid facies, parent-witnessed apnoea, and a sleep preference for one side or head extension while sleeping. Children who screened positive for obstructive sleep apnoea or sleep-disordered breathing were further subjected to overnight level one polysomnography study.
All guidelines as per the Declaration of Helsinki and good clinical practice guidelines were followed. The study was approved by the ethical committee of the institute. Informed consent was taken from the parents participating in the study. Quantitative data was presented with the help of mean and standard deviation. Qualitative data was presented with the help of a frequency and percentage tables. Appropriate statistical software including but not restricted to MS Excel, SPSS ver.23 was used for statistical analysis. Chi square test was used to find out association if any, between children's medical problems and obstructive sleep apnoea with p value < 0.05 taken as statistically significant.
Results
The study period spanned between June 2022 to June 2023. Total 270 parents consented to participate in the study. We enroled 270 children who visited paediatric OPD for routine clinical examination, nutrition counselling and minor illness. The epidemiological details are as following:
Age - We enrolled children between1 and 18 years of age. 7.4% (N = 20) children up to 3 years of age, 13.3% (N = 36), children between 3 and 5 years of age group, 55.2% (N = 149) children between 5 and 10 years of age and 24.1% (N = 65) children more than 10 years.
Sex - In our study, 54.8% (N = 148) children were male and 45.2% (N = 122) were females.
Sleep and wake up pattern - We recorded variousparameters based on Children sleep questionnaire as mentioned in Table 1, Table 2, Table 3. Average bedtime in our study during weekdays was 10.54 ± 1.44 P.M. (Mean ± 2SD, N = 270). Average wake up time during weekdays was 8.07 ± 1.30 A.M. (Mean ± 2SD, N = 270). Average duration of sleep was 8.58 ± 1.35 h (Mean ± 2SD, N = 270), average duration of daytime naps were 0.54 ± 0.054 h (Mean ± 2SD, N = 270). Most of the children in our study had regular bedtime with consistency up to 85% in all age groups. Co-sleeping was high in all age groups in up to 75% cases. Clinical snoring was reported highest in 3–5 years of age group in up to 33 % (N = 49) cases. Around 1/3rd parents reported that insufficient sleep may be the cause of poor academic performance across all age groups.
Table 1.
Duration of sleep and associated behaviour at bedtime.
| Age group | 1–3 years (N = 20) | 3–5 years (N = 36) | 5–10 years (N = 149) | >10 years (N = 65) |
|---|---|---|---|---|
| Bedtime | ||||
| <8 pm | 30 % | 50% | 57.0 % | 43.1% |
| 8–10 pm | 65% | 50% | 42.3% | 53.8% |
| 10 pm–12 am | 5% | 0% | 0.7% | 3.1% |
| Consistency of bedtime | 85% | 77.8% | 77.1% | 67.8% |
| Sleep onset (within 20 min) | 65% | 66.7% | 73.9% | 66.7% |
| Co-sleeping with parents | 70% | 75% | 62.5% | 35.4% |
| Needs special objects to sleep (Toys/special blankets) | 5% | 8.4% | 19.4% | 23.8% |
| Need rocking or rhythmic movement to sleep | 25% | 27.8% | 17.4% | 9.2% |
| Amount of sleep per night | ||||
| >9 h | 45% | 41.7% | 20.8% | 9.2% |
| 8–9 h | 25% | 33.3% | 36.2% | 30.8% |
| 7–8 h | 5% | 19.4% | 38.3% | 41.5% |
| <6 h | 5% | 2.8% | 1.3% | 6.2%. |
Table 2.
Sleep pattern of children at bedtime.
| Age groups | 1–3 years (N = 20) | 3–5 years (N = 36) | 5–10 years (N = 149) | >10 years (N = 65) |
|---|---|---|---|---|
| Restless/excessive leg movements while sleeping | 30.1% | 38.8% | 20.9% | 26.1% |
| Bruxism | 15% | 8.4% | 10.1% | 3.1% |
| Snoring | 10% | 33.3% | 10.1% | 4.6% |
| Fragmentation of sleep | 10 % | 25.7% | 13.3% | 17% |
| Does your child keep mouth open while sleeping | 15% | 16.7 % | 26.8% | 30.8% |
| Does your child prefers to sleep in side position or keeps the neck extended? | 5% | 19.4% | 32.9% | 38.5% |
| Wake up more than once per night | 15% | 13.9% | 4% | 4.6% |
Table 3.
Day time sleepiness and academic performance of children.
| Age group | 1–3 years (N = 20) | 3–5 years (N = 36) | 5–10 years (N = 149) | >10 years (N = 65) |
|---|---|---|---|---|
| Wake up time | ||||
| <6 am | 35% | 30.6% | 35.6% | 40% |
| 6–8 am | 35% | 55.6% | 60.4% | 52.3% |
| 8–9 am | 25% | 11.1% | 2.0 % | 4.6% |
| >9 am | 5% | 2.8% | 2.0 % | 3.1% |
| Daytime tiredness | 30% | 8.4% | 11.4% | 24.6% |
| Not satisfied with academic performance | – | 50.4% | 30.8% | 46.1% |
| Do you think insufficient sleep is causing poor academic performance? | – | 38.9% | 36.2% | 43.1% |
| Day time naps | 35% | 41.7% | 20.8% | 15.4% |
| Duration of naps | ||||
| <15 min | 15% | 27.7% | 33.5% | 24.6% |
| Up to 30 min | 20% | 16.7% | 12.8% | 13.7% |
| Up to 45 min | 0% | 8.3% | 4% | 5.6% |
| >45 min | 65% | 47.2% | 49.7% | 51.5% |
Medical problems and sleep disordered breathing/obstructive sleep apnoea - Children clinically suspectedto be at risk of sleep disordered breathing or obstructive sleep apnoea reported physician diagnosed medical problems such as Allergic rhinitis, Asthma, atopy, adenoid hypertrophy and frequent headaches as mentioned in Table 4. There was a statistically significant association between asthma and obstructive sleep apnoea with p value < 0.001. Children having clinical features of obstructive sleep apnoea/sleep disordered breathing were further subjected to level 1 polysomnography study (PSG) and results were recorded as per Table 5. Apnoea/hypopnea index (AHI) was used to define the severity of obstructive sleep apnoea with values 1–5 considered as mild, 5–10 as moderate and >10 was considered as severe obstructive sleep apnoea. The prevalence of obstructive sleep apnoea was 5.6% with average Apnoea/hypopnea index of 3.1, suggesting mild obstructive sleep apnoea. Based on polysomnography study, prevalence of restless leg syndrome was 0.74% in our study.
Table 4.
Record of associated medical problems with obstructive sleep apnoea/sleep disordered breathing.
| Medical problems in children with suspected obstructive sleep apnoea/sleep-disordered breathing | Age group | Prevalence frequency | p value (<0.05) |
|---|---|---|---|
| Asthma | Upto 3 years | 5%, (N = 1) | 0.01 |
| 3–5 years | 1.1%, (N = 1) | ||
| 5–10 years | 8.1%, (N = 12) | ||
| >10 years | 4.6%, (N = 3) | ||
| Allergic rhinitis | 1–3 years | 5%, (N = 1) | 0.30 |
| 3–5 years | 13.9%, (N = 5) | ||
| 5–10 years | 16.8%, (N = 25) | ||
| >10 years | 20%, (N = 13) | ||
| Atopy | 1–3 years | 1.1%, (N = 1) | 0.20 |
| 3–5 years | 1.8%, (N = 3) | ||
| 5–10 years | 7.4%, (N = 11) | ||
| >10 years | 13.8%, (N = 9) | ||
| Headaches | 3–5 years | 2.3%, (N = 1) | 0.06 |
| 5–10 years | 11.4%, (N = 17) | ||
| >10 years | 33.8%, (N = 22) | ||
| Adenoid hypertrophy | 3–5 years | 23.4%, (N = 8) | 0.70 |
| 5–10 years | 10.2%, (N = 15) | ||
| >10 years | 7.8%, (N = 5) |
Table 5.
Findings of polysomnography studies.
| Age, sex and Number (N) | Clinical OSA | PSG diagnosed OSA | Average apnoea/hypopnea index (AHI) | Minimum SpO2 (Average) | Restless leg syndrome (N = 2) | Periodic leg movement score (PLMS) (Average) |
|---|---|---|---|---|---|---|
|
3–5 years (N) = 8 Male- 3 Female-5 |
2.96% | 62.5% | 3.1′ | 90.91% | 2 | 10.1 |
|
>5–10 years (N) = 6 Male: 4 Female: 2 |
2.22% | 83.3% | 3.5′ | 92.20% | – | – |
Discussion
Sleep quantity and quality of Asian children is different from western children due to cultural differences. Sleep duration is increased over weekends which is a popular practice across the globe. In our study, average duration of sleep was 8.58 ± 1.35 h (Mean ± 2SD) which was shorter by 45–60 min than western children.7 In our study, co- sleeping was found in 70 % (N = 14) in 1–3 years, 75% (N = 27) in 3–5 years, 62.5 % (N = 93) in 5–10 years and 35.4% (N = 23) in >10 years of age. Indian children are co-sleeping with parents till adolescence which is again due to cultural differences between Asian and western countries.7,8 Co-sleeping leads to increased prevalence of behavioural sleep disorders in infants due to lack of self-soothing. On the contrary, co-sleeping may help to early identify sleep disorders such as witnessed obstructive sleep apnoea, pathological snoring or parasomnias in older children. Average bedtime in our study during weekdays was 10.54 P.M. ± 1.44 h (Mean ± 2SD). However, particularly school children in 5–10 years of age bracket were sleeping before 8 P.M. This was significantly different from a decade old study done in Indian children by Gupta et al.9 where children were typically found to have late bed time. Current academic requirements, parental perceptions and better awareness amongst urban children might have improved sleep behaviour as compared to the past study.
Bedtime consistency which may consist of brushing teeth at night, reading stories, listening to light music and sleeping at the same time each day can lead to better sleep habits and longer sleep duration.10,11 Bed time routine is instrumental in avoiding several sleep behavioural disorders such as behavioural insomnia of childhood.12,13 In our study, most children had bedtime consistency with 85 % (N = 17) in 1–3 years, 77.8% (N = 28) in 3–5 years, 77.1 % (N = 82.24) in 5–10 years and 67.8% (N = 44) in >10 years which was much better than an earlier study done by Bharti et al.14 In our study, younger children required rocking or rhythmic movement to sleep in 25% (N = 5) and 27.8% (N = 10) in 1–3 years and 3–5 years of age respectively. On the contrary, older children also required special objects such as soft toys or special blankets to sleep in high percentage of 19.4% (N = 29) in 5–10 years and 23.8 % (N = 16) in >10 years of age. Need for specific sleeping conditions can lead to childhood onset behavioural insomnia of association type and should be discouraged by parents.10
Average sleep duration per night was >9 h up to 5 years of age in only 45% (N = 16.2) cases. However, older children had an average sleep duration of only 7–8 h in 38.3% (N = 57) and 41.5% (N = 62) in 5–10 years and (N = 27) > 10 years age groups. Very few children had less than 6 h of sleep with frequency of up to 6.2%. Sleep duration in our study was much less than recommended by American Academy of Sleep Medicine.15 However, it was comparable to earlier study done by Mindell et al. and Bharti et al.8, 14,14
Sleep pattern was significantly altered with restless leg movements reported by parents in about 20–30% (N = 270) cases in all ages, bruxism in 3–15% (N = 270), snoring in 10% (N = 2) in 1–3 years, 33.3% (N = 12) in 3–5 years, 10.1% (N = 15) in 5–10 years and 4.6% (N = 3) in >10 years of age. Parents reported fragmentation of sleep in 10% (N = 2) cases in 1–3 years, 25.5% (N = 9) in 3–5 years, 13.3% (N = 20) in 5–10 years and 17% (N = 11) in >10 years. Younger children had more frequent awakenings at night up to 15 % as compare to 4.6% in older children. Parents reported open mouth breathing was found in older age in up to 30% cases compared to only 15% in younger children up to 5 yrs of age. 32.9% (N = 45) and 38.0% (N = 25) children of 5–10 years and >10 years respectively reported sleep preferences to side position with neck extended. Prevalence of sleep related issues such as bruxism, snoring, open mouth breathing was reported much higher as compared to other Asian children as reported in a Korean study.16 This suggests that Indian children might be at higher risk of sleep related problems as compared to other Asian countries. This may be attributed to lack of awareness and poor paediatric sleep clinic services in India.17
Average wake up time during weekdays was 8.07 A.M. ± 1.30 h (Mean ± 2SD). About 35–40 % children were waking up before 6 A.M. and only 2–5 % were waking up after 9 A.M. Most Indian children start their school between 7.45 A.M. and 8 A.M. Daytime sleepiness is indicative of insufficient sleep at night. Daytime naps were reported in 20 % (N = 30) children in >5 years and 15% (N = 10) in >10 years of age. Day time napping is an acceptable culture in Asian countries which also helps in recovery of sleep debt.9,18
Up to 30.8 % (N = 46) and 46.1% (N = 30) parents reported dis-satisfaction in academic performance of school going children in 5–10 years and >10 years. Poor academic performance was attributed to poor sleep in 36.2% (N = 54) and 43.1 % (N = 28) children of 5–10 years and >10 years of age. Parents reported poor academic performance attributable to sleep was comparable to an earlier study done by Sivakumar et al.19 Most common associated medical problems were asthma, allergic rhinitis, atopy, headaches and adenoid hypertrophy which were also reported by other studies done by Kumar et al.20, Valero et al.21 and Koinis-Mitchell et al.22 Headache was reported by 33.8% (N = 22) children in >10 years of age and 11.4% (N = 17) in 5–10 years of age. Adenoid hypertrophy was found in 23.4% children (N = 8) in 3–5 years, 10.2% (N = 15) in 5–10 years and 7.8% (N = 5) in >10 years. However, there was no statistically significant association between adenoid hypertrophy and obstructive sleep apnoea on polysomnography. This could be because of small numbers of polysomnography studies that we could perform in our study. A systematic review done by Davies et al. have found significant association of obstructive sleep apnoea and asthma.23 In our study, asthma had statistically significant association with obstructive sleep apnoea with p value < 0.01. Allergic rhinitis was found in up to 20% (N = 13) cases in children >10 years, 16.8 % (N = 25) in 5–10 years, and 13.9% (N = 5) in 3–5 years. This was comparable to prevalence of allergic disorder in other parts of the world as reported by Valero et al.21 A study done by Kumar et al has highlighted that poorly controlled asthma can lead to symptoms of sleep related breathing disorders and affect the quality of sleep.20
We subjected 14 children with clinical features of obstructive sleep apnoea/sleep disordered breathing to level 1 paediatric polysomnography study after taking parental consent. Prevalence of obstructive sleep apnoea in our study was 5.6%. Prevalence of paediatric sleep apnoea varies world-wide with few studies reporting between 1.2 and 5.3 %24 to as high as 9.6% in an Indian study.25 Clinically, obstructive sleep apnoea was found in only 2.96 % and 2.22 % children <5 years and >5 years, respectively. But polysomnography confirmed obstructive sleep apnoea in 62.5% (N = 8) and 83.3% (N = 6) children <5 years and >5 years of age respectively. Average Apnoea hypopnea index (AHI) was 3.1 and 3.5 in less than 5 years and >5 years age groups respectively. Most children in our study had mild obstructive sleep apnoea with average minimum SpO2 levels falling to 90% and 92% at room air in <5 years and > 5 years. Restless leg syndrome was found in only 2 children with average periodic leg movement score of 10.1.
Limitations of the study
This was an observational cohort study representing clientele from urban middle class, which may be different from rural population of India. Secondly, we could perform polysomnography only on few children who were positive for obstructive sleep apnoea/sleep-disordered breathing on initial screening. This was because of high cost of the study, lack of availability of trained technician and lack of parental consent.
Conclusion
Paediatric sleep disorders are underreported due to lack of awareness in general population as well as amongst clinicians. Asthma has statistically significant association with obstructive sleep apnoea in our study. Proper asthma treatment may reduce the burden of obstructive sleep apnoea in children. There is a growing need to screen children regularly for various sleep related issues on routine paediatric visits.
Patient/Guardians consent
Patients informed consent was obtained.
Ethical clearance
Institute/hospital ethical clearance certificate was obtained.
Source of support
Nil.
Disclosure of competing interest
The authors have none to declare.
Acknowledgements
Nil.
References
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