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Introduction
Sleep is a vital function for health. It is as important as nutrition and has profound implications for people’s well-being1. Good quality sleep is necessary throughout the human life cycle to restore the physical and psychological conditions of the organism after waking up2,3. Sleep deprivation weakens the body’s immune system, decreases cognitive performance, and difficulties the children and adults’ concentration while learning 4,5.
Sleep deprivation can cause disorders in the regulation of emotions and behavior; it can also cause depression and anxiety5, increased risk of domestic and traffic accidents6, obesity7, among other problems. As the mentioned disorders show, low quality and shortened sleep has a negative impact on health and the overall quality of life8. However, sleep disorders and sleep deprivation remain highly common in contemporary society6.
Sleep disorders in children may negatively impact the parents' and caregivers’ sleep patterns as well; the need for nocturnal awakenings to take care of the child’s health needs increases the frequency of sleep interruptions8.
Notwithstanding, the parents’ sleep-vigil pattern, especially the mothers’ one, may also be a predictive element of the children’s sleep-vigil pattern due to the connection that these behaviors have between each other and the feedback between themselves9.
Parents have to now deal with the responsibility of monitoring their own activities and distractions that interfere in the sleep and/or care of their children (e.g.watching television or using electronic devices). However, some parents are unaware of the ideal amount of sleep for children, and some others do not have the disciplinary skills to effectively manage their child’s behavior and encourage their sleep either10.
A study in Iran showed that cell phone use at night was associated with poorer quality of sleep in children, and those physically active children had better quality and longer sleep. Furthermore, the participants with a higher body mass index also had shorter total sleep time11. A similar study also found that children who did not exercise and had access to tablets, television, or smartphones had lower sleep quality, and this, in turn, generated sleep disturbances12.
Caring for a child with a sleep disorder or a chronic illness is hard work for parents and can affect their sleep13. Given the extenuating efforts required to take care of children with one of these conditions, caregivers are more likely to suffer from physiological and psychiatric problems14. Nevertheless, children in the care of parents who suffer from chronic illnesses-or who have poor sleep patterns-tend to display more sleep problems.
As the previous paragraphs suggest, it is inferred that the problems related to the children's sleep patterns can also have a direct relationship with the parents' and caregivers’ poor quality sleep. During adulthood, sleep restriction-in addition to the already mentioned problems-also affects role performances and impairs parental relationships8.
Another consulted study infers that family context contributes to the quality of sleep of children because of the influence that each family’s patterns/routines and socioeconomic conditions-among other factors-have on the children's habits15. Sociodemographic factors, such as family income, place of residence, and work, can also significantly increase the negative perception of sleep in children and their caregivers.
Facing this, the following research question arises: “Are the sociodemographic factors and the sleep of parents and/or caregivers associated with children`s sleep disorders?” This study hypothesizes that there is a link between sleep disorders in children, the caregivers’ sleep, and the influence of sociodemographic conditions.
The study aimed to analyze the relationship among children's sleep disorders, sociodemographic factors, and caregivers' sleep.
Method
Design and sample
An epidemiologic, transversal and analytic study with a quantitative approach was carried out in two public schools from Redenção (Northeast Brazil). The sample size was defined using a simple random sampling technique without replacement. The researchers calculated the sample from a finite population with a prevalence of sleep disorders in children of 30%16 and obtained an n valueof 211; in this case, a confidence level of 95% was selected. Students with cognitive and/or reading or writing disabilities-as reported by the caregivers and/or teachers-were excluded from the study.
The final sample was 222 students of both sexes, aged between 6 and 11 years old, and 123 caregivers.
Eligibility criteria
Children (and their respective caregivers) who met the following criteria were included:
Being a resident of the municipality of Redenção (CE)
Being properly enrolled in school
Being in the age range of the classification relating to childhood (6 to 12 years)
Attending school during the pre-established period for data collection
Children diagnosed with cognitive and/or reading or writing-related impairments were excluded from the study; students on sick leave during the study period were excluded as well.Each caregiver was identified by the school's registration forms.
Independent variables
Gender, age, weight, height, body mass index (BMI), neck circumference (NC), waist circumference (WC), waist-height relation (WHR), systolic (SBP) and diastolic (DBP) blood pressure, possession of electronic devices (television, personal computer, cell phone, and/ortablet), amount of hours facing a screen, physical activity, sleep hours, defined hour to go to bed and the caregivers’ sleep.
Dependent variables
Sleep disorders during childhood through the SDSC.
Data collection
The data were collected from March to December 2017 using an instrument with the already mentioned dependent and independent variables. An evaluation team performed the anthropometric evaluation and blood pressure measurements. The parents and/or caregivers were interviewed to collect the data by evaluating the children’s sleep and theirs.
For the children’s sleep evaluation, the study used a Brazilian Portuguese translation of the Sleep Disturbance Scale for Children (SDSC)17. Since its creation, this instrument has been used as an evaluation tool for clinical samples18 and the monitoring of healthy children19, thus being an object of translation to different languages20,21.
The SDSC is a survey with 26 Likert-type items21 (Never, Occasionally (1 or 2 times a month), Sometimes (1 or 2 times a week), Almost always (3 or 5 times a week), Always (every day)) that evaluates the sleep of children and adolescents from 3 to 18 years old in the last six months. The main research points on sleep disturbances are the following: onset and maintenance, respiratory, on awakening, during the sleep-wake transition, excessive daily sleepiness, and hyperhidrosis. The final SDSC score can vary from 26 to 130; higher numerical values reflect greater clinical severity of symptoms. As the SDSC does not determine a cutoff point, the average value reached by the students (38.2 points) was adopted as the cutoff value that separates the good quality and poor sleep quality groups. The students with poor sleep quality were considered to have higher-than-average scores, and the prevalence was 38.2%. Children with scores ≤ 38.2 were considered to have good sleep quality.
A pilot test was performed on five children to identify possible weaknesses or difficulties during the application of the instruments. After the analysis by two specialists, no adjustments to the data collection instrument were necessary.
For the caregivers’ sleep, the study used a Brazilian Portuguese version of the Pittsburgh Sleep Quality Index (PSQI). The internal consistency study carried out for this instrument revealed reasonable values (0,698) for the global Cronbach’s alpha. The PSQI was created by Buysse et al. (1989) and evaluates the individuals’ sleep quality in the last 30 days, based on 19 self-administered questions that generate seven components: 1: Subjective sleep quality; 2: Sleep latency; 3: Duration of sleep; 4: Usual sleep efficiency; 5: Sleep disorders; 6: Use of medication to sleep; 7: Daytime sleepiness and dysfunction during the day22. The maximum score is 21 points; scores higher than 5 already determine a poor quality of sleep pattern. The global index, based on the sum of the scores for each component classifies individuals into “good sleepers” (PSQI <5) or “bad” sleepers (PSQI ≥ 5). Scores greater than five denote that the individual may be having great difficulty in at least two components or moderate difficulty in more than three components22.
The assessment of daily excessive sleepiness was performed using the Epworth Sleepiness Scale (ESE). The ESE is a valid and reliable instrument for the assessment of daytime sleepiness. It is a self-administered questionnaire that assesses the probability of falling asleep in eight situations involving daily activities, some of which are known to be highly soporific23,24. The global score ranges from 0 to 24; those scores above 10 may suggest the existence of ESE24. The internal consistency, measured by Cronbach’s alpha, was 0.76 and 0.79, respectively, for the ESE-BR and the original ESE.
The ESE assesses the likelihood of a person to start napping while:
Sitting and reading, watching TV, sitting quietly in a public place
Riding in the car for an hour without stopping as a passenger
Sitting quietly after lunch without drinking alcohol
Being in a car stopped in a traffic jam for a few minutes
This instrument has a Likert scale (0 - no probability of falling asleep; 1 - slight probability of falling asleep; 2 - moderate probability of falling asleep; 3 - strong probability of falling asleep)15. The interviewees who presented a total sum in the ESE from 0 to 5 points were classified as normal (good sleep); the ones who obtained between 6 to 8 points were considered to be displaying medium drowsiness. The ones who got between 9 and 24 points were considered to be suffering from excessive drowsiness26.
Regarding the anthropometric examination, the weight was obtained using a digital G-Tech® scale of with a capacity of 200 kg and an accuracy of 0.05 kg; the participants were barefoot and wore light clothing during the measurements. The height was measured with an inextensible and flexible anthropometric measuring tape whose total size was 1.5 m with 0.1m divisions. This tape was attached to the wall at 90º from the floor. For both measures, the participants were told to stand up with their arms extended along their body and the head adjusted into Frankfurt’s plane.
For the classification of BMI, the researchers employed the World Health Organization (WHO) Z score curves for individuals aged 5 to 19 years27. The measures of the neck circumference (NC) andwaist circumference (WC) were taken with an inextensible and flexible Sanny® measuring. After positioning the participants standing position, the WC was taken in the midpoint between the last floating rib and the superior border of the iliac crest, at the end of exhalation. The NC was measured in the neck’s midpoint, just below the laryngeal prominence28. For the WChe cut-off points proposed by the WHO for the population aged 3 to 19 years were considered29. Likewise, for the NC, the cut-off points proposed for the pediatric population23.
For the WHR, the study used cutoff points for children and adolescents between 6 to 14 years old24. For both genders, the participants that displayed WHR values above 0.48 were classified as overweight; in the case of obesity, the values considered were those above 0.5 for women and 0.51 for men.
To verify the BP, the study used aneroid Tycos ® sphygmomanometers and WelchAllyn ® arm cuffs of different sizes. In addition, a Littman ®biauricular stethoscope was also used. The student’s handling and the BP classification followed the VII Brazilian Guideline for Arterial Hypertension30.
Data analysis
The data were tabulated on Excel spreadsheets and analyzed with the SPSS software (version 24). Absolute and relative frequencies were calculated for the qualitative variables. The quantitative variables were summarized through the following dispersions: median, standard deviation, quartiles, minimum, and maximum.
The significance between the independent (or explanatory) and dependent variables was verified using Fisher’s exact test or the Chi-square test. Variables that showed a descriptive level lower than 0.20 were confronted again with the outcomes through a multiple analysis with Poisson’s regression model.
The magnitude of the associations between the variables in the Poisson regression model and the outcome were expressed with point estimates and intervals of prevalence ratios. Variables with a descriptive level below 0.05 remained in the model (Caregiver who works outside the home, shift that the child studies, report of the child’s illness).
Ethical aspects
The research was approved by the ethics committee for research with human beings from the Universidade da IntegraçãoInternacional da Lusofonia Afro-Brasileira under the embodied report 2.296.842/2017. All parents and/or caregivers signed the terms of consent to participate in the study.
Results
Children’s Characterization
Most of the children were females (55.4%) without a diagnosis of diseases (87.8%); they displayed normal arterial blood pressure (94.1%) and had a sedentary lifestyle (60.8%). They also reported that they studied in the evenings (55%) and had brown skin (62.2%). The age varied between 6 - 8 (44.1%) and 9 - 11 years old (55.9%); the average value for the age was 8.6 ± 1.4 years old. Regarding inactivity, most of the children (52.7%) stated that they did physical activities during their free time.
Almost half of the participants were eutrophic (48.2%) whereas 16.2% and 18.9% of the participants were classified as cases overweight and obesity respectively. The anthropometric evaluation revealed that most of them (70.3%) had normal abdominal circumference and waist-height relation (59.5%). A percentage of 59.5% of the investigated children presented altered neck circumference for their age.
Most of the children (93.2%)had a meal before going to school, under the supervision of the parents at their homes (91.9%).In these cases, the habit of watching television was common (72.5%). Most of the children (81.1%) accepted school meals.
Regarding access to the Internet, approximately, half of the children reported having this service at home (51.4%); they also stated that they used tablets and/or cell phones (68.5%). Most children (83.3%) spend >2 hours in front of screens. Notwithstanding, most of these children (56.8%) had no television or personal computer in their sleep place.
Most of the children did not wet their bed (72.1%); they did not report suffering from sleep hyperhidrosis (99.1%) or respiratory complaints during vigil (90.5%) either. Moreover, no children reported problems to initiate or maintain their sleep; they did not report problems related to awakenings or sleep-vigil transition either.
Regarding bedtime, 65.3% of the children had a defined hour to go to bed, and 64.9% reported having an adequate amount of sleep. The global SDSC ≤ 39 was 60.8% (MD: 38.2 ± 6.6).
Caregivers’ characterization
Most of the caregivers (86.9%) were females; more specifically, they were mothers (80.2%) taking care of their home (66.2%). The majority did not report any diagnosis of chronic disease (73%). They did not report the use of continuous medications (70.3%). The group is characterized by young caregivers in the average age group of 36.9 ± 8.6 years old.
Regarding their sleep, 55% had a good quality sleep, did not show excessive daily drowsiness (84.2%), and did does not use medication to sleep (82%). A total of 41.4% evaluated their children’s sleep as good (41.4%) whereas 34.2% of them evaluated it as particularly good. On average, their PSQI score was 4.8 ± 2.8 points.
Association between the sleep of children and caregivers
Most children that studied during the evening (p<0.001), that spent > 2 hours in front of screens (p=0.024), and that did not report pre-existing diseases (p=0.018) reported adequate sleep hours (Chart 1 and 2.)
There was a significant statistical association between the variables “do not go to work” and “the child’s adequate amount of sleep” (p=0.048). There was no association between the classification of the children’s sleep hours and the caregivers’ sleep quality and drowsiness (Chart 3).
Bladder eliminations in bed were common in the participants with SDSC values > 39 points, that is, with bad sleep quality (p = 0.018).
The variables of physical practice during free time (p = 0.049) and acceptance of school meals (p=0.008) seemed to be linked with SDSC values ≤ 39 points (good sleep quality) (Chart 4 and 5).
Among the caregivers that did not show excessive daily drowsiness (p=0.046) and did not report suffering from diseases (p=0.009), predominated the children with SDSC ≤ 39 points (good sleep quality).
There was a relationship between the variables “evaluation of the child’s sleep” and SDSC (p=0.010). In this case, one perceives that most of the cases of SDSC ≤ 39 points are common in the caregivers that evaluated their child’s sleep quality as good or very good (Chart 6).
In the proposed regression model, one observes that the factors associated with “inadequate number of sleeping hours in children” were:
Caregiver goes to work (p=0.015): 54% of these cases showed higher values of inadequate sleeping hours.
Ver en PDFChart 1 Association between the classification of sleep hours of children and sociodemographic variable.Brazil, 2018 , Chart 2 Association between the classification of sleep hours of children and children’s health.Brazil, 2018 y Chart 3 Association between the classification of the children’s sleep hours and variables related to the caregiver. Brazil, 2018
The child studies during the morning period (p<0.001): participants with this feature exceeded by 139% the cases of inadequate sleeping hours if compared to the ones that studied during the evening period (this can also be interpreted as 2.39 times bigger).
The child has a disease (p=0.008) PR=1.77 (Chart 7).
On another regression model-whose outcome was an SDSC > 39 (bad quality sleep)-the following
associated factors were identified: positive report of diseases from the parents (p=0.010), bedwetting (p=0.011), and the non-acceptance of school meals (p=0.005).
Ver en PDF Chart 4 Association between Childrens’ sleep disorders (global SDSC) and sociodemographicvariable. Brazil, 2018, Chart 5 Association between Childrens’ sleep disorders (global SDSC) and children’s health variables. Brazil, 2018 y Chart 6 Association between children's sleep disorders (global SDSC) and caregivers-related variables. Brazil, 2018.
Chart 7 Poisson’s regression for inadequate sleeping hours (child) as a dependent variable. Brazil. 2018.
| Model’s variables | PR1 | CI 95%2 | P-value |
|---|---|---|---|
| Caregiver goes to work | 0.015 | ||
| Yes | 1.54 | 1.09 - 2.17 | |
| No | 1 | - | |
| Period where the child studies | <0.001 | ||
| Morning | 2.39 | 1.63 - 3.51 | |
| Evening | 1 | - | |
| Report of disease (child) | 0.008 | ||
| Yes | 1.77 | 1.16 - 2.69 | |
| No | 1 | - |
PR: Prevalence Ratio; CI: Confidence Interval of 95%
Discussion
The present study shows a global SDSC ≤ 39 (good sleep quality) of 60.8%; this is consistent with other similar studies in which most children proved to have good sleep quality12,31. Sleep quality is crucial for well-being during the day and for improving performance in each child’s activities. Childhood is characterized by a large number of changes in neuromotor growth; therefore, physical rest and recovery is extremely important for children due to their impact on child growth and development32.
Children with adequate hours of sleep studied in the afternoon, spent less than two hours on screens, and had no reports of illness. Studying on the afternoon shift can provide more hours of sleep as there is no need to wake up early to arrive in time for school. Some consulted studies reveal the negative influence of screens (smartphones, television, tablets) on sleep quality33. Furthermore, healthy children have less damage to the sleep-wake pattern12.
Children whose caregivers had no employment relationship outside the home were classified as having adequate hours of sleep. When caregivers-especially mothers-are dedicated exclusively to the activities of the home, they can pay more attention and time to the development and care of their children’s actions; this includes even sleep hygiene habits. The fact is that the regression model showed that among caregivers who work outside the home, inadequate hours of sleep prevailed. One consulted study reports that mothers who worked between 20-40 hours a week have children with sleep deprivation34.
It is noteworthy to highlight that health professionals can help mothers with an employment contract outside the home to find a model of childcare that keeps the mother at home at night to stay with the child35.
A relationship was observed between enuresis and children with poor sleep quality. Consistent with this finding, Brazilian researchers infer those children with enuresis have sleep disorders that impair the quality of the sleep-wake state36. Nocturnal enuresis and obstructive sleep apnea (OSA) are frequent problems in childhood and appear to be related. A study on the urological outcome of treatment for OSA in enuretic children identified that both disorders have an underlying mechanism which provides altered excitatory response and sleep fragmentation37.
The practice of physical activity during free time and the acceptance of school meals were linked with good sleep quality. This was consistent with one reviewed study in which the practice of physical activity improved the subjective and objective perception of sleep quality38. Previous studies also confirm that physically active children have better sleep quality11,12.
The practice of regular physical activity can also contribute to the quality of life by:
Improving the cardiorespiratory and muscular capacities,
Controlling the body mass
Reducing depression and anxiety
Improving the cognitive functions (memory, attention, and reasoning)
Improving the quality and efficiency of sleep39.
The World Health Organization (WHO) recommends that children and adolescents aged between 5 and 17 years perform at least 60 minutes of physical activity daily, with intensity ranging from moderate to vigorous, and reiterates that the duration of more than 60 minutes may provide additional health benefits40.
Regarding school meals, a study in Finland showed that sleep habits are associated with food consumption patterns. The study determined that there is a link between longer sleep and nutrient-rich foods41. Adequate energy intake and a quality diet-including vitamins and minerals-can result in high quality sleep and help prevent sleep problems42.
It seemed that children with good sleep quality were the ones in the care of caregivers who did not present excessive daytime sleepiness. Caregivers who were good sleepers tended to have a more positive view of the student’s sleep. About this, researchers tested whether the parents’ insomnia symptoms were related to the children’s electroencephalogram and maternal sleep perception. Objectively, maternal insomnia appears to be related to greater sleep deprivation and sleep latency, as well as late awakening. When both parents are identified as insomniac, it is likely for their child to suffer from anxiety and resistance at bedtime, in addition to daytime sleepiness. Thus, children’s sleep may be associated with parental sleep patterns. However, the parents’ own insomnia symptoms can impair the children’s perception of sleep-related problems43.
Another statistical finding of this research was the fact that children with good sleep have caregivers exempt from diseases. As the PSQI score of the caregivers increased (poor sleep quality), there was an increase in the positivity of childhood illness; this may imply a symbiosis between the children’s and their caregivers’ sleep.
In previous studies analyzed, an inverse situation was registered: the parents/caregivers of children with chronic diseases experienced the development of sleep disorders (quality and duration) and fatigue in their daily lives44,45.
In this sample, most health problems were chronic health conditions. Thus, the researchers guess that suffering from a chronic disease is a stressor that can decrease the predisposition of parents and caregivers to monitor their child’s sleep hygiene habits or that it can stimulate anxious behavior in their children (vicarious learning) which can harmful, for example, to sleep latency.
It is observed that the parents-as members of the family and responsible for directing the habits inherent to the family context-play a fundamental role in the children’s sleep/wake process by stimulating the dependence on their presence at bedtime, performing nighttime interventions to restore the child’s sleep and establishing sleep initiation routines15.
This research has some limitations in its design, such as the fact that it is a sectional study that prevents the establishment of cause and effect (caregiver’s sleep versus children’s sleep) relationships. Another limitation was the assessment of the participants’ sleep using psychometric scales; more accurate results could have been obtained by using other resources and techniques such as actigraphy and/or polysomnography. Finally, this research was carried out in a reduced local sample. Thus, it is suggested to replicate this research question by observing the exposed gaps.
Conclusion
Although the quality of sleep was classified as good in most children, several worrying aspects were identified. There seems to be a relationship between the cases of caregivers that perform extra-family work and the cases of children with inadequate sleep hours. Furthermore, there also appears to be a link between the cases of children who wake up early to go to school and those with a certain disease. In addition to the poor quality of children's sleep, there is an association with reports of parental illnesses, enuresis, and refusal to eat in the school environment.
The data found suggest that it is necessary to find new strategies to improve the quality of sleep in children with the support of both caregivers and the preschool educational community. Thus, it is necessary to stratify and identify those children with the greatest need for attention, care and strategies to promote adequate sleep.
CONFLICT OF INTEREST STATEMENT
The authors hereby declare that there is no conflict of interest.
