The impact of screen use on sleep health across the lifespan: A National Sleep Foundation consensus statement.

OBJECTIVE: To achieve consensus on whether screen-based digital media (1) in general, (2) via prebedtime content, and (3) via prebedtime light impairs sleep health in (a) childhood, (b) adolescence, and (c) adulthood. Furthermore, to address whether employing behavioral strategies and interventions may reduce the potential negative effects of screens on sleep health. METHODS: The National Sleep Foundation convened a 16-person multidisciplinary expert panel ("Panel"). Panelists met virtually 5 times throughout 2023, during which they followed a modified Delphi RAND/UCLA Appropriateness Method to reach consensus. RESULTS: The Panel conducted a literature review starting with 2209 articles, narrowed down to 522 relevant empirical articles and 52 relevant review articles. The search was refined to include 35 experimental/intervention studies that examined whether there was a causal link between screen-based digital media and sleep. In addition, panelists reviewed 5 recent relevant systematic review articles. After reviewing the summarized current literature, panelists voted on 10 candidate statements about whether screen use impairs sleep health. The Panel met virtually to discuss the results of the first round of votes, which was then followed by a second round of voting, ultimately achieving consensus on 5 out of the 10 statements. CONCLUSIONS: The Panel achieved consensus that (1) in general, screen use impairs sleep health among children and adolescents, (2) the content of screen use before sleep impairs sleep health of children and adolescents, and (3) behavioral strategies and interventions may attenuate the negative effects of screen use on sleep health.

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.

Differences in the Pupillary Responses to Evening Light between Children and Adolescents.

Purpose: To assess differences in the pupillary light responses (PLRs) to blue and red evening lights between children and adolescents. Methods: Forty healthy participants (8-9 years, n=21; 15-16 years, n=19) completed a PLR assessment 1 h before their habitual bedtime. After a 1 h dim-light adaptation period (<1 lux), baseline pupil diameter was measured in darkness for 30 s, followed by a 10 s exposure to 3.0×1013 photons/cm2/s of either red (627 nm) or blue (459 nm) light, and a 40 s recovery in darkness to assess pupillary re-dilation. Subsequently, participants underwent 7 min of dim-light re-adaptation followed by an exposure to the other light condition. Lights were counterbalanced across participants. Results: Across both age groups, maximum pupil constriction was significantly greater (p< 0.001, ηp2=0.48) and more sustained (p< 0.001, ηp2=0.41) during exposure to blue compared to red light. For adolescents, the post-illumination pupillary response (PIPR), a hallmark of melanopsin function, was larger after blue compared with red light (p= 0.02, d=0.60). This difference was not observed in children. Across light exposures, children had larger phasic (p< 0.01, ηp2=0.20) and maximal (p< 0.01, ηp2=0.22) pupil constrictions compared to adolescents. Conclusions: Blue light elicited a greater and more sustained pupillary response than red light across participants. However, the overall amplitude of the rod/cone-driven phasic response was greater in children than in adolescents. Our findings using the PLR highlight a higher sensitivity to evening light in children compared to adolescents, and continued maturation of the human non-visual photoreception/system throughout development.

Pediatric sleep: current knowledge, gaps, and opportunities for the future.

This White Paper addresses the current gaps in knowledge, as well as opportunities for future studies in pediatric sleep. The Sleep Research Society's Pipeline Development Committee assembled a panel of experts tasked to provide information to those interested in learning more about the field of pediatric sleep, including trainees. We cover the scope of pediatric sleep, including epidemiological studies and the development of sleep and circadian rhythms in early childhood and adolescence. Additionally, we discuss current knowledge of insufficient sleep and circadian disruption, addressing the neuropsychological impact (affective functioning) and cardiometabolic consequences. A significant portion of this White Paper explores pediatric sleep disorders (including circadian rhythm disorders, insomnia, restless leg and periodic limb movement disorder, narcolepsy, and sleep apnea), as well as sleep and neurodevelopment disorders (e.g. autism and attention deficit hyperactivity disorder). Finally, we end with a discussion on sleep and public health policy. Although we have made strides in our knowledge of pediatric sleep, it is imperative that we address the gaps to the best of our knowledge and the pitfalls of our methodologies. For example, more work needs to be done to assess pediatric sleep using objective methodologies (i.e. actigraphy and polysomnography), to explore sleep disparities, to improve accessibility to evidence-based treatments, and to identify potential risks and protective markers of disorders in children. Expanding trainee exposure to pediatric sleep and elucidating future directions for study will significantly improve the future of the field.

Creating the Cave: Conducting Circadian Science in Early Childhood.

In humans, physiological outputs of the body's internal clock (i.e., saliva, serum, and temperature) can be collected to quantify the timing of the circadian system. In-lab assessment of salivary melatonin in a dimly lit environment is a common approach for adolescents and adults; however, the reliable measurement of melatonin onset in toddlers and preschoolers requires a modification of laboratory methods. For > 15 years, we have successfully collected data from ~250 in-home dim light melatonin onset (DLMO) assessments of children aged 2-5 years. Although in-home studies of circadian physiology may introduce a host of challenges and may increase the risk of incomplete data (e.g., accidental light exposure), in-home studies afford more comfort (e.g., less arousal in children) and flexibility for families. Here, we provide effective tools and strategies to assess children's DLMO, a reliable marker of circadian timing, through a rigorous in-home protocol. We first describe our basic approach, including the study protocol, collection of actigraphy data, and strategies for training child participants to complete procedures. Next, we detail how to convert the home into a "cave", or dim-light environment, and present guidelines for timing the salivary data collection. Lastly, we provide helpful tips to increase participants' compliance based upon behavioral and developmental science tenets.

Evidence of circalunar rhythmicity in young children's evening melatonin levels.

In adults, recent evidence demonstrates that sleep and circadian physiology change across lunar phases, including findings that endogenous melatonin levels are lower near the full moon compared to the new moon. Here, we extend these results to early childhood by examining circalunar fluctuations in children's evening melatonin levels. We analysed extant data on young children's circadian rhythms (n = 46, aged 3.0-5.9 years, 59% female). After following a strict sleep schedule for 5-7 days, children completed an in-home, dim-light circadian assessment (<10 lux). Salivary melatonin was assessed at regular 20- to 30-min intervals until 1 h past each child's scheduled bedtime. Melatonin levels varied significantly across lunar phases, such that melatonin was lower in participants assessed near the full moon as compared to near the new moon. Significant differences were observed at 50 min (meanfull  = 2.5 pg/ml; meannew  = 5.4 pg/ml) and 10 min (meanfull  = 7.3 pg/ml; meannew  = 15.8 pg/ml) before children's scheduled bedtime, as well as at 20 min (meanfull  = 15.5 pg/ml; meannew  = 26.1 pg/ml) and 50 min (meanfull  = 19.9 pg/ml; meannew  = 34.3 pg/ml) after bedtime. To our knowledge, these are the first data demonstrating that melatonin secretion, a process regulated by the human circadian system, is sensitive to changes in lunar phase at an early age. Future research is needed to understand the mechanisms underlying this association (e.g., an endogenous circalunar rhythm) and its potential influence on children's sleep and circadian health.

Evening Light Intensity and Phase Delay of the Circadian Clock in Early Childhood.

Late sleep timing is prevalent in early childhood and a risk factor for poor behavioral and health outcomes. Sleep timing is influenced by the phase of the circadian clock, with later circadian timing linked to delayed sleep onset in young children. Light is the strongest zeitgeber of circadian timing and, in adults, evening light produces circadian phase delay in an intensity-dependent manner. The intensity-dependent circadian phase-shifting response to evening light in children, however, is currently unknown. In the present study, 33 healthy, good-sleeping children aged 3.0 to 4.9 years (M = 4.14 years, 39% male) completed a 10-day between-subjects protocol. Following 7 days of a stable sleep schedule, an in-home dim-light circadian assessment was performed. Children remained in dim-light across 3 days (55 h), with salivary melatonin collected in regular intervals throughout each evening. Phase-shifting effects of light exposure were determined via changes in the timing of the dim-light melatonin onset (DLMO) prior to (Day 8) and following (Day 10) a light exposure stimulus. On Day 9, children were exposed to a 1 h light stimulus in the hour before their habitual bedtime. Each child was randomly assigned to one intensity between 5 and 5000 lux (4.5-3276 melanopic EDI). Across light intensities, children showed significant circadian phase delays, with an average phase delay of 56.1 min (SD = 33.6 min), and large inter-individual variability. No relationship between light intensity and magnitude of the phase shift was observed. However, a greater percentage of melatonin suppression during the light exposure was associated with a greater phase delay (r = -0.73, p < 0.01). These findings demonstrate that some young children may be highly sensitive to light exposure in the hour before bedtime and suggest that the home lighting environment and its impact on circadian timing should be considered a possible contributor to behavioral sleep difficulties.

High sensitivity of melatonin suppression response to evening light in preschool-aged children.

Light at night in adults suppresses melatonin in a nonlinear intensity-dependent manner. In children, bright light of a single intensity before bedtime has a robust melatonin suppressing effect. To our knowledge, whether evening light of different intensities is related to melatonin suppression in young children is unknown. Healthy, good-sleeping children (n = 36; 3.0-4.9 years; 39% male) maintained a stable sleep schedule for 7 days followed by a 29.5-h in-home dim-light circadian assessment (~1.5 lux). On the final night of the protocol, children received a 1-h light exposure (randomized to one of 15 light levels, ranging 5-5000 lux, with ≥2 participants assigned to each light level) in the hour before habitual bedtime. Salivary melatonin was measured to calculate the magnitude of melatonin suppression during light exposure compared with baseline levels from the previous evening, as well as the degree of melatonin recovery 50 min after the end of light exposure. Melatonin levels were suppressed between 69.4% and 98.7% (M = 85.4 ± 7.2%) during light exposure across the full range of intensities examined. Overall, we did not observe a light intensity-dependent melatonin suppression response; however, children exposed to the lowest quartile of light intensities (5-40 lux) had an average melatonin suppression (77.5 ± 7.0%) which was significantly lower than that observed at each of the three higher quartiles of light intensities (86.4 ± 5.6%, 89.2 ± 6.3%, and 87.1 ± 5.0%, respectively). We further found that melatonin levels remained below 50% baseline for at least 50 min after the end of light exposure for the majority (62%) of participants, and recovery was not influenced by light intensity. These findings indicate that preschool-aged children are highly sensitive to light exposure in the hour before bedtime and suggest the lighting environment may play a crucial role in the development and the maintenance of behavioral sleep problems through impacts on the circadian timing system.

Better sleep, better life? How sleep quality influences children's life satisfaction.

PURPOSE: To assess the association between children's sleep quality and life satisfaction; and to evaluate the underlying mechanisms of this relationship. METHODS: Three pediatric cohorts in the National Institutes of Health (NIH) Environmental influences on Child Health (ECHO) Research Program administered Patient-Reported Outcome Measurement Information System (PROMIS®) parent-proxy measures to caregivers (n = 1111) who reported on their 5- to 9-year-old children's (n = 1251) sleep quality, psychological stress, general health, and life satisfaction; extant sociodemographic data were harmonized across cohorts. Bootstrapped path modeling of individual patient data meta-analysis was used to determine whether and to what extent stress and general health mediate the relationship between children's sleep quality and life satisfaction. RESULTS: Nonparametric bootstrapped path analyses with 1000 replications suggested children's sleep quality was associated with lower levels of stress and better general health, which, in turn, predicted higher levels of life satisfaction. Family environmental factors (i.e., income and maternal mental health) moderated these relationships. CONCLUSION: Children who sleep well have happier lives than those with more disturbed sleep. Given the modifiable nature of children's sleep quality, this study offers evidence to inform future interventional studies on specific mechanisms to improve children's well-being.

Light correlated color temperature and task switching performance in preschool-age children: Preliminary insights.

Data from a growing number of experimental studies show that exposure to higher correlated color temperature (CCT) ambient light, containing more blue light, can positively impact alertness and cognitive performance in older children and adults. To date, few if any studies have examined whether light exposure influences cognitive task performance in preschool-age children, who are in the midst of rapid developmental changes in attention and executive function skills. In this study, healthy children aged 4.5-5.5 years (n = 20; 11 females) completed measures of sustained attention and task switching twice while being exposed to LED light set to either 3500K (a lower CCT) or 5000K (a higher CCT). A control group (n = 18; 10 females) completed the tasks twice under only the 3500K lighting condition. Although the lighting condition did not impact performance on the sustained attention task, exposure to the higher CCT light lead to greater improvement in preschool-age children's task switching performance (F(1,36) = 4.41, p = 0.04). Children in the control group showed a 6.5% increase in task switching accuracy between time points, whereas those in the experimental group improved by 15.2%. Our primary finding-that exposure to light at a higher correlated color temperature leads to greater improvement in task switching performance-indicates that the relationship between the spectral power distribution of light and executive function abilities is present early in cognitive development. These data have implications for designing learning environments and suggest that light may be an important contextual factor in the lives of young children in both the home and the classroom.

Transition to success on the model room task: the importance of improvements in working memory.

Previous work has shown that children under age 3 often perform very poorly on the model room task, in which they are asked to find a hidden toy based on its location in a scale model. One prominent theory for their failure is that they lack the ability to understand the model as both a physical object and as a symbolic representation of the larger room. A hypothesized additional component is that they need to overcome weak, competing representations of where the object was on a previous trial, and where it is in the present trial, in order to succeed in their search. Children aged 33-39 months were tested on the model room task, as well as on measures of cognitive inhibitory control, cognitive flexibility, and working memory. Results showed that performance on the model room task was not predicted by measures of inhibitory control or cognitive flexibility, but was predicted by performance on the Delayed Recognition Span Test (DRST), a measure of working memory. These findings lend support to the theory of competing representations and demonstrate the necessity of updating and maintaining strong representations in working memory to succeed in the search task.