Adverse Childhood Experiences May Dampen the Protective Role of Sleep Duration on Adolescent Obesity Risk.

The purpose of this study was to explore Adverse Childhood Experiences (ACEs) as a moderator between sleep duration/irregularity and overweight/obesity in U.S. adolescents. Using the National Survey of Children's Health 2017-2018 cross-sectional dataset, we included adolescents with available sleep and Body Mass Index (BMI) data. In a sample of 24,100 adolescents (mean age = 13.56 years, 49.35% female; 51% White), parents reported adolescent's sleep duration/irregularity, and number of ACEs. Logistic regression estimated the interaction between sleep duration/irregularity and the number of ACEs on overweight/obesity risk (BMI ≥ 85th percentile-for-age) using a stepwise approach and accounting for complex survey design. In the 24,100 adolescents, 33% were overweight/obese, 50% had ≥ 1 ACE, 37% slept < 8-10 h/night, and 14% had irregular sleep. Accounting for covariates and ACEs, every hour increase in sleep duration was associated with 6% decrease in overweight/obesity odds. There was a significant interaction between sleep duration and ACEs; the association between increasing sleep duration and decreasing odds of overweight/obesity was significant only in adolescents without ACEs (OR = 0.87, 95% CI [0.80, 0.95], p < 0.001). Increasing sleep duration is a recognized intervention target to decrease obesity risk, yet in adolescents experiencing ≥ 1 ACE, this protective role may be dampened. Future work may explore mechanisms for overweight/obesity development to inform interventions for adolescents facing adversity.

Exploration of Sex and Age as Moderators Between Social Cumulative Risk and Sleep in a Representative Sample of Children and Adolescents Living in the United States.

BACKGROUND: Youth who face adversity are at a disproportionate risk for poor sleep health across the life course. Identifying whether the association between adversity and poor sleep varies based upon age and sex is needed. This study aims to explore sex and age as moderators between social risk and sleep in a sample of U.S. youth. METHODS: This study analyzed data of 32,212 U.S. youth (6-17 years) whose primary caregiver participated in the 2017-2018 National Survey of Children's Health. A social cumulative risk index (SCRI) score was calculated from 10 parental, family, and community risk indicators. Nighttime sleep duration was the number of hours the child slept during the past week. Weeknight sleep irregularity was operationalized as whether the child sometimes/rarely/never went to bed at the same time. Generalized logistic regression models estimated associations between SCRI and sleep duration/irregularity, with age and sex as moderators. RESULTS: Age moderated the association between SCRI and short sleep (OR = 1.12, p < 0.001), such that the magnitude of the SCRI-sleep relationship was 12% greater in school-age children. Sex was not a significant moderator. In stratified models by age group, age was positively associated with short sleep in both groups, with a greater magnitude in school-age children. Female school-age children were less likely to have short sleep than males. CONCLUSIONS: Younger children with greater social cumulative risk factors may be more vulnerable to short sleep duration. Further research into the mechanisms underlying the relationships between social risk and sleep health in school-age children is needed.

Daytime Sleepiness in Children With Asthma: Examining Respiratory and Non-respiratory Factors.

Objective Daytime sleepiness is common in youth with asthma (YWA). Treatments designed to mitigate daytime sleepiness in YWA require an understanding of the primary causes of this problem. We examined respiratory- and non-respiratory-related factors associated with daytime sleepiness in YWA. Methods One hundred YWA (eight to 17 years old) were included in a cross-sectional study. Daytime sleepiness, quality of life, anxiety, bedtime cellphone use, and respiratory symptoms were self-reported. Asthma severity, lung function, and the number of prescribed medications were obtained from electronic medical records. Multivariable regression models identifying variables associated with daytime sleepiness were generated. Results Participants were 54% male and 45% Black, with a mean age of 12.1 years. The multivariable regression model showed decreased quality of life (b = -0.328, p = 0.004) and increased bedtime cellphone use (b = 0.300, p = 0.004)were significantly related to daytime sleepiness, while anxiety (b = 0.213, p = 0.05), prescribed asthma medications (b = 0.173, p = 0.05), and worse lung function (b = -0.173, p = 0.05)were marginally related to daytime sleepiness. Conclusions In addition to optimizing asthma control, strategies targeting anxiety, quality of life, and nocturnal cellphone use are important to mitigate daytime sleepiness in YWA.

Associations between sleep and overweight/obesity in adolescents vary by race/ethnicity and socioeconomic status.

AIM: To examine the interaction between sleep and social determinants of health (SDOH) [race/ethnicity and socioeconomic status (SES)] on overweight/obesity in adolescents. DESIGN: Cross-sectional. METHODS: We conducted a secondary analysis using the 2017-2018 National Survey of Children's Health data. We included adolescents (10-17 years old) who had sleep and body mass index (BMI) data available (n = 24,337) in analyses (samples with BMI <5th percentile excluded). Parents reported children's sleep duration and regularity. High BMI (≥85th percentile) for age defines overweight/obesity. We selected SDOH (race/ethnicity, family income, primary caregiver education and neighbourhood condition) and covariates (age, sex, smoking, exercise and depression) using a hierarchical model-building approach. Accounting for complex survey design, logistic regression estimated the interaction between sleep and SDOH. RESULTS: There were significant interactions between sleep duration and SDOH. The association between increasing sleep and decreasing odds of overweight/obesity only showed in the following subgroups: White, family income ≥400% federal poverty level (FPL) or primary caregiver' education ≥ high school. Compared with these subgroups, Hispanic adolescents and adolescents whose family income was below 100% FPL and whose caregiver education was below high school had weakened and reversed associations. Sleep regularity was not associated with overweight/obesity. CONCLUSIONS: Increasing sleep duration was associated with a decreased risk of overweight/obesity, but the association was not present in adolescents from racial/ethnic minority groups (i.e. Hispanic) and those with low SES. IMPACT: The study findings suggest that associations between sleep and overweight/obesity vary by race and SES. Identification of additional mechanisms for obesity is needed for racial/ethnic minority groups and those from families with low SES. Also, the complexity of these relationships underscores the importance of community-based needs assessment in the design of targeted and meaningful interventions to address complex health conditions such as poor sleep and obesity.

Waking up to sleep's role in obesity and blood pressure among Black adolescent girls in low-income, US urban communities: A longitudinal analysis.

OBJECTIVE: To identify longitudinal bidirectional associations between unique sleep trajectories and obesity and hypertension among Black, adolescent girls. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal data were from a randomized controlled trial (2009-2013) implemented in schools serving low-income communities aimed at preventing obesity among adolescent girls (mean age = 12.2 years (standard deviation ± 0.72). MEASURES: Nocturnal sleep data were extracted from accelerometers at T1 (enrollment, n = 470), T2 (6-month, n = 348), and T3 (18-month follow-up, n = 277); height and weight were measured at T1-T3; and systolic/diastolic blood pressure at T1 and T3 using an oscillometric monitor. Multilevel models examined longitudinal associations. Finite mixture models identified sleep trajectory groups. Structural equation models examined whether T1 chronic disease risk predicted sleep profiles, and conversely, if sleep trajectories predicted T3 chronic disease risk. Data were analyzed in 2021. RESULTS: For each additional hour of sleep and 1% increase in efficiency there was a 7% lower risk of overweight/obesity at T1 and 6% lower risk at T2, but not at T3. Four sleep trajectories emerged: Worsened, Irregular, Improved, and Regular, with no demographic or metabolic differences between the trajectories. Improved sleep trajectory predicted lower diastolic percentile at T3 (b = -8.81 [95% confidence interval -16.23, -1.40]). CONCLUSIONS: Group-based trajectories of sleep duration and quality provide information on modifiable factors that can be targeted in interventions to evaluate their impact on reducing chronic diseases and addressing disparities. Additional research is needed on samples beyond those recruited in the context of an intervention study.

The contributory role of the family context in early childhood sleep health: A systematic review.

Sleep-wake regulation is established during early childhood and contributes to life-long health. The family context is critical to the development of child sleep-wake regulation. The primary aim of this systematic review was to elucidate family-level constructs (outside of bedtime parenting) that contribute to early childhood (age 0-5 years) sleep health. We identified empirical research articles that investigate these relationships through systematically searching PubMed, Web of Science, and PsycINFO databases. The transactional model of sleep-wake regulation guided the selection of family-level search terms, including socioeconomic status (SES), family structure, household chaos, marital, co-parenting, and social relationships. Sleep search terms included sleep problems, duration, timing, and variability. We searched sleep and family terms in combination with infant, toddler, or preschool developmental age. Sixteen studies satisfied criteria for inclusion. Results indicated that the presence of household chaos and poor quality marital relationships were directly associated with early childhood sleep problems and variable sleep timing. Higher marital satisfaction and the presence of household routines were positively associated with sleep duration. Several, but not all, studies showed an association between lower SES and poor child sleep health. There were no significant direct associations for family structure and limited findings for the role of perceived social support and co-parenting relationship quality. Overall, operationalization and measurement of family and sleep constructs varied across studies, decreasing our ability to make comparisons and draw robust conclusions. Future research should identify modifiable family-level factors that can be targeted, in addition to bedtime parenting, to improve sleep-wake regulation development.

Longitudinal Associations Among Diet Quality, Physical Activity and Sleep Onset Consistency With Body Mass Index z-Score Among Toddlers in Low-income Families.

BACKGROUND: Habits surrounding health behaviors (i.e., sleep, physical activity, diet) are developed in toddlerhood. Lack of consistent health habits may increase obesity risk among toddlers in low-income families. PURPOSE: To compare the role of sleep onset consistency, physical activity and diet quality as mediators between household poverty and toddler weight. METHODS: Two hundred and seven toddlers (mean age = 20.2 months, 46% female, 68.1% Black) participating in an obesity prevention trial were assessed at three time points over 12 months. Using Actical accelerometers, we assessed sleep and physical activity at each time point for up to 1 week. We defined sleep onset consistency as the standard deviation of sleep onset across all days. We calculated the Healthy Eating Index-2015 from a 24-hr dietary recall. We used WHO standards to calculate BMI-for-age z-scores from toddlers' weight/length, and calculated poverty ratio from parent-reported income and family size. Multilevel mediation models tested toddler sleep onset consistency, physical activity, and diet quality as mediators between household poverty and toddler BMI z-score. RESULTS: Toddlers from households with higher poverty ratios had more inconsistent sleep onset times. Toddlers with more inconsistent sleep onset times had higher BMI z-scores across all timepoints, even when accounting for physical activity and diet quality. Sleep onset consistency indirectly explained the association between household poverty and BMI z-score. CONCLUSIONS: Inconsistent sleep schedules could help explain the association between poverty and BMI. Future research should examine strategies to support low-income families to develop and maintain routines as a mechanism to prevent obesity and reduce disparities. TRIAL REGISTRATION NUMBER: NCT02615158.

Objective sleep and physical activity using 24-hour ankle-worn accelerometry among toddlers from low-income families.

OBJECTIVES: Poverty is a risk for short sleep duration and limited physical activity. This study describes sleep, physical activity, and sedentary behavior of Women, Infants, and Children-eligible toddlers and the proportion of toddlers meeting recommendations for sleep and physical activity, and examines associations with body mass index z scores and poverty. PARTICIPANTS/MEASUREMENTS: A total of 101 toddlers (12-32 months) from low-income families (62% African American) wore 24-hour ankle accelerometers over 3-7 consecutive days. Concurrent validity for daytime napping was assessed using parent-reported toddler wake/sleep between 08:00 and 20:00 collected using Ecological Momentary Assessment. Logistic regressions predicted odds of meeting guidelines. RESULTS: Toddlers averaged 10.56 hours of sleep in 24 hours. All toddlers averaged ≥180 minutes of total activity per day, 38% had ≥60 minutes of moderate/vigorous physical activity per day, 32% of toddlers slept between 11 and 14 hours over 24 hours, and 26% had a bedtime before 9:00 pm. Body mass index z score was not associated with meeting guidelines. Poverty was associated with less than 60 minutes of moderate/vigorous physical activity. CONCLUSIONS: Most toddlers were not meeting sleep guidelines. This study provides objective data on sleep and activity among a diverse sample of low-income toddlers. Objective measures of sleep and physical activity facilitate surveillance of children meeting guidelines for sleep and physical activity. Such norms are needed to examine disparities among children from varying racial and economic backgrounds. Future research should examine if meeting guidelines is related to other health indicators.

Toddler Bedtime Routines and Associations With Nighttime Sleep Duration and Maternal and Household Factors.

STUDY OBJECTIVES: The aims of this study were to examine (1) relationships among implementing a bedtime routine, nighttime awakenings, and nighttime sleep duration in toddlers from low-income, minority families and (2) differences in maternal and household characteristics between mothers who did versus those who did not implement a nightly bedtime routine for their toddler. METHODS: Data were collected from mothers of toddlers on maternal and household characteristics and toddler sleep, measured using the Children's HealthWatch Survey and the Extended Brief Infant Sleep Questionnaire (BISQ). A path analysis model was tested to investigate whether nighttime awakenings mediated the relation between implementing a bedtime routine and toddlers' nighttime sleep duration. Chi-square tests were conducted to examine differences in maternal and household characteristics (ie, maternal depressive symptoms, food, housing and energy insecurity) between mothers who did versus those who did not implement nightly bedtime routines over the past 2 weeks. RESULTS: Implementing a bedtime routine was associated with longer toddler sleep duration through a decrease in nighttime awakenings (ß = 5.04, 95% confidence interval = 0.61 to 11.35). More consistent sleep routine implementation was associated with fewer nighttime awakenings and longer sleep duration. Maternal depressive symptoms, housing insecurity, and food insecurity were associated with decreased likelihood of implementing a nightly bedtime routine. CONCLUSIONS: Maternal depressive symptoms, food insecurity, and household insecurity (factors associated with low socioeconomic status) may be associated with a negative sleep environment and poor toddler sleep quality, potentially because of decreased implementation of bedtime routines. COMMENTARY: A commentary on this article appears in this issue on page 821.

Sleep Measurement in Toddlers From Low-income Families.

OBJECTIVES: (1) To examine toddler sleep in a low-income sample by comparing sleep diaries and actigraphy and (2) to assess whether toddlers are meeting the National Sleep Foundation recommendations (11-14 hours of sleep/24 hours and bedtime before 9 PM). METHODS: A convenience sample of mother-toddler dyads was recruited from 2 health care sites serving low-income communities. An actigraph was placed on the toddler's ankle and was worn for 3 days and nights. Mothers concurrently completed a sleep diary. Bedtime, nighttime sleep duration, nap duration, and 24-hour sleep duration were collected by both measures. Actigraphy data were analyzed using a combination of manufacturer's scoring algorithm and manual editing. Descriptive statistics and paired samples t-tests were conducted to examine the differences between sleep estimates by a sleep diary and actigraphy. RESULTS: Twenty toddlers (aged 13-42 months) were included in the analyses. Based on actigraphy, 1 toddler went to bed by 9 PM on all 3 nights. Six toddlers achieved 11 to 14 hours of sleep measured in a 24-hour period for 1 of the 3 days, but when sleep was averaged across the study, none achieved this goal. Compared with actigraphy, sleep diaries underestimated bedtime by 1 hour, overestimated nighttime sleep duration by 2.5 hours, and overestimated 24-hour sleep duration by 2.3 hours, on average for all 3 nights. CONCLUSION: Mothers reported significantly earlier bedtimes and longer sleep durations for their toddlers compared with actigraphy, suggesting that objective measures differ from sleep diaries in assessing sleep in toddlers from low-income families. Findings should not be generalized to populations of low-income families without replication.

Featured Article: Bidirectional Effects of Sleep and Sedentary Behavior Among Toddlers: A Dynamic Multilevel Modeling Approach.

OBJECTIVE: To examine the bidirectional effects of objectively measured nighttime sleep and sedentary activity among toddlers. METHOD: Actical accelerometer data were analyzed for 195 toddlers participating in an obesity prevention trial (mean age = 27 months). Toddlers wore the accelerometers for up to 7 consecutive days. Nighttime sleep was defined as the number of minutes asleep between the hours of 8 pm and 8 am the following morning. Sedentary behavior (in minutes) was defined using previously established Actical cut points for toddlers. Variables were lagged and parsed into latent within- and between-person components, using dynamic structural equation modeling (DSEM). RESULTS: Toddlers spent an average of 172 min (∼3 hr) in sedentary activity and slept an average of 460 min (∼8 hr) per night. An autoregressive cross-lagged multilevel model revealed significant autoregression for both sleep and sedentary activity. Cross-lagged values revealed that decreased sleep predicted increased next-day sedentary activity, and sedentary activity predicted that night's sleep. For 89% of the sample, the within-person standardized cross-lagged effects of sleep on sedentary were larger than the cross-lagged effects of sedentary on sleep. CONCLUSIONS: Results suggest that, on average, nighttime sleep is a stronger predictor of subsequent sedentary behavior (compared with the reverse), and this is the case for the majority of toddlers. Findings highlight the importance of interindividual associations between sleep and sedentary activity. The present study is an example of how DSEM methods can be used to ask questions about Granger-causal cross-lagged relations between variables, both within and between individuals.

Perceived Toddler Sleep Problems, Co-sleeping, and Maternal Sleep and Mental Health.

OBJECTIVE: Childhood sleep problems are associated with insufficient parental sleep and adverse maternal mental health symptoms, which may be exacerbated when mothers/toddlers co-sleep (i.e., bed/room sharing). This study examines maternal sleep duration as a mechanism linking perceived toddler sleep problems with maternal mental health and examines whether these associations vary by co-sleeping, in addition to exploring alternative models. METHODS: Low-income mothers of toddlers (n = 280) (age 12-32 months) recruited from Women, Infants, and Children and pediatric clinics provided demographic information and completed questionnaires on their toddler's sleep and their own sleep duration and mental health symptoms (depressive symptoms, anxiety, and stress). Indirect and conditional indirect models were conducted to examine the relation between perceived toddler sleep problems and maternal mental health. RESULTS: Perceived toddler sleep problems were associated with an average decrease of 51 minutes in maternal sleep when co-sleeping (mean = 6.1 h). Maternal sleep duration mediated the relation between perceived toddler sleep problems and maternal symptoms of depression, anxiety, and stress for co-sleeping mothers. Maternal sleep duration did not mediate relations between maternal mental health symptoms and perceived toddler sleep problems. CONCLUSION: This study provides a conceptual model by which parent and child sleep is related to parental mental health. Practitioners might consider alternatives to co-sleeping when discussing sleep arrangements with parents. Future studies should replicate results longitudinally and examine whether reducing co-sleeping improves maternal sleep duration and reduces perceptions of toddler sleep problems.