Abcs of Sleeping a Review of the Evidence Behind Pediatric Sleep Practice Recommendations
Introduction
Healthy sleep represents an essential role of a good for you lifestyle for all ages. In children, adequate sleep is related to amend schoolhouse performance, improved attention and better concrete health.1 Therefore, research into pediatric sleep wellness is a field of growing interest yet rich in adversities and challenges.ii Of annotation, measuring sleep adequacy is specially hard since it is a complex concept defined past a network of interconnected factors with useful dimensions including sleep quality and quantity.3 On the 1 hand, children'due south sleep quality can be evaluated by certain proxies, such as frequency of episodes of parasomnias, difficulties to fall asleep or daytime sleepiness.4 On the other hand, sleep quantity can be defined as sleep elapsing, per se. Finally, another matter of interest in child slumber health is the chronotype, which is a biological feature that is difficult to measure out. Underlying this concept is the circadian rhythm that influences sleep adequacy and determines the child'southward preference to sleep at a detail time. Its role in kid sleep health, as well as the extent to which sleep quality, sleep quantity, and chronotype are interconnected, is a matter of ongoing debate.3 There is an increasing body of prove showing that sleep may represent a relevant health result for preschoolers. Moreover, slumber issues in young children are known to be some of the nigh common issues that parents report to their pediatricians.5 Furthermore, information technology appears that preschoolers have some specific sleeping problems, compared to older children and adolescents, with higher prevalence of parasomnias and awakening due to fears equally for specific determinants of sleep problems.half dozen Finally, slumber issues in children likely influence beliefs which in turn represents a relevant public health threat with increasing related costs.vii
Numerous factors contribute to sleep adequacy in school-historic period children and robust testify points towards a relation betwixt electronic media employ, poor sleep quality and inadequate sleep quantity in children and adolescents between half-dozen and eighteen years.8–10 Yet, media utilise is nowadays as well condign more common in preschoolers, which increases the demand for research aimed at investigating how media use influences sleep adequacy in this critical age period.11,12
So far, existing evidence regarding the investigation into child sleep health is mostly of cross-sectional nature, while prospective studies with adequate sample size are scarce.13–xx Moreover, media utilise has been shown to bear upon sleep duration and may thus likewise shift the midpoint of sleep.21 However, we are unaware of whatsoever study investigating whether these effects bulldoze subsequent damage of sleep quality in preschoolers.
In the present work, data from the Ulm SPATZ Health Study accept been used to evaluate the relation between media use and sleep quality in German preschoolers. To achieve this, the prospective design of SPATZ was exploited using a causal mediation analysis with sleep duration and midpoint of sleep as mediators of the relation between media apply and sleep quality. This approach was chosen according to five unlike objectives. We aimed to evaluate: (1) if preschooler's midpoint of slumber, quantity, and quality of slumber are independently related to media apply or if these factors are related in a causal network with mediated indirect effects; (2) the relation betwixt media utilise and sleep quality in preschoolers; and (3) if this relation is consistent or may alter between four and six years of age. Furthermore, it is widely acknowledged that digital media use is an inferior entertainment for preschool children.i Thus, we evaluated (four) how volume reading, instead of electronic media use, may accept influenced sleep quality and (five) to what extent parental working activities and/or daycare determined the mediation result of sleep duration and midpoint of sleep for the relation between electronic media apply and volume reading on sleep quality.
Materials and Methods
The Ulm SPATZ Health Study
The Ulm SPATZ Health Study is an ongoing prospective birth accomplice study with repeated measures based on 1006 children consecutively recruited after their birth between April 2012 and May 2013 at the University Medical Center Ulm, Southern Deutschland. Following a baseline cess shortly after delivery, the participating families received self-administered written questionnaires yearly at the child's birthday. Participation in SPATZ was completely voluntary and informed consent was collected from all parents. The present results are based on the waves at the children'southward ages of 4, 5, and half-dozen years. Ethical approval was obtained from the ethical review board of Ulm University (No. 311/11). The SPATZ study was conducted in agreement with the Annunciation of Helsinki.
Assessment of Child Slumber Quality
The overall score of the High german version of the Children's Sleep Habits Questionnaire (CSHQ) was used to measure parent-reported kid'south slumber quality during a typical week. The CSHQ is a multidimensional questionnaire in which parents are asked near bedtime resistance, sleep onset delay, slumber elapsing, slumber anxiety, dark waking, parasomnias, slumber-disordered breathing, and daytime sleepiness. The CSHQ total score is computed by the sum of 34 items scored by a three-level Likert scale. Thus, the CSHQ score ranges betwixt 34 and 102 with college values representing lower sleep quality. The CSHQ questionnaire was validated in German children aged iv to 10 years.22 The CSHQ score was used as a continuous variable. This choice was taken according to the explorative nature of our study and considering higher model efficiency to discover associations.
Cess of Digital Media Use and Book Reading
Parents were asked near the time spent past their kid with electronic media and book reading on weekends and parents' working days using a six-bespeak Likert scale with items coded as: never; up to 1 h/day; ane to <2 h/24-hour interval, 2 to <3 h/day, 3 to <4 h/day and ≥4 h/twenty-four hour period. Fourth dimension spent watching TV or DVD (besides via PC/laptop or Smartphone) as passive activities in forepart of a screen, and fourth dimension actively spent using computer, tablets or smartphones were considered separately. In improver, cumulative time spent using electronic media, actively and passively, was too considered. A farther variable considering time spent in self- or parent-assisted book reading was computed.
Assessment of Sleeping Characteristics
Sleep duration and midpoint of sleep of the SPATZ participants were reported by parents using the Kid Chronotype Questionnaire.23 Sleep duration was computed equally the divergence between wake-up time and slumber onset. Midpoint of sleep was computed every bit the sum of sleep onset and half of the sleep duration. Notably, sleep onset was computed every bit the time at which a subject goes to bed plus slumber latency, which in plough is the time taken to fall asleep. Data regarding gratis days and parents' working days were collected.
Statistical Analysis
Slumber quality scores, electronic media use, book reading, sleep duration and midpoint of sleep were described by report wave, and for weekends and gratuitous days, using medians and 10th to 90th percentiles. A linear tendency test over waves was performed by means of a Wald t-test applied to the slope of the relation between the aforementioned variables, considered as outcome, and a covariate coding for the study wave (Table ane). All variables were converted to normalized Z-scores using Blom'southward changed rank transformation.24 This approach was chosen to reduce variable skewness and to compute standardized regression coefficients, rescaled in a range betwixt −1 and 1. Notably, this enhances model interpretability since the regression coefficients tin can be interpreted as the percentage of explained variance (0.i volition be 10%). Heat maps depict Pearson correlation coefficients of Blom's transformed variables within and between different fourth dimension points.
 | Table 1 Sleep Quality Score and Media Apply of SPATZ Children at Different Time Points |
A mediation analysis was performed in the class of a causal path model having sleep duration or midpoint of sleep equally mediators of the relation between media utilise or book reading and sleep quality (Figure ane). Direct and indirect effects were reported as standardized and rescaled regression coefficients. The total effect of media utilize or book reading on sleep quality was computed equally: total effect = a + b*c, where the term "a" was the gradient of the direct issue, while the terms "b" and "c" were the slopes of the indirect effects.
 | Figure 1 Diagram of mediation model used. |
On the basis of this causal path model, the different fourth dimension points from the repeated measures within SPATZ were taken into business relationship considering four unlike causal models having a first club autoregressive structure. The first model (Model A) considered the prospective relation of media use or volume reading with sleep quality (direct result) and with the mediators sleep duration or midpoint of slumber (indirect result I) betwixt ages four/five and 5/6 years. In this model, the result of slumber elapsing or midpoint of slumber on sleep quality (indirect effect II) was cross-sectional. The 2nd model (Model B) included just a prospective direct effect between ages 4/5 and 5/6 years while all indirect effects were cantankerous-sectional. The final two models (Models C and D) had all effects as cross-exclusive considering the data collected at ages 4/v and at ages 5/vi, respectively. Diagrams of the four causal path models are reported in Supplementary Figure 1.
Finally, a sensitivity analysis was conducted in the course of a fully prospective model. Here, we modeled (i) the relation between media use or book reading at age four years with child sleep quality at age 6 years (direct effect), (ii) the relation between media use or volume reading (age four years) on sleep elapsing or midpoint of sleep at age v years (indirect outcome I), and (three) the relation between slumber elapsing or midpoint of sleep (age 5 years) on sleep quality (age 6 years; indirect effect 2).
All analyses were conducted separately for weekends and weekdays using the corresponding information. All models were adapted for maternal age and educational activity as a proxy for socio-economic condition. Sensitivity analyses to investigate residual confounding were performed adjusting for the child's nutrition, physical activity, torso size (triponderal mass index), and season of birth which also correspond to the season of assessment (yearly questionnaires were administered at or around the altogether). All the statistical tests were two-tailed and the type-I error rate was ready to 5% (α = 0.05). The LAVAAN package of R software version 3.6 was used to behave the mediation analysis. A posteriori ability calculation was performed using the SHINY package of R software version 3.vi.25
Results
Afterwards information management, check for data quality, and deleting subjects with missing values for covariates and upshot variables, the three SPATZ datasets at ages 4, 5, and 6 years had 442, 403, and 359 records, respectively. Merging the three datasets resulted in an analytical dataset of 563 records, overall. Matching the data at ages four and 5, 5 and 6, and iv and vi years resulted in 312, 276, and 279 records, respectively. The baseline median age of the mothers was 33 years, ranging between 21 and 54 years, while the median baseline historic period of the fathers was 35 (10th to 90th range = 29, 43). The majority of parents had a good job position and education level with fifty% having a managerial or higher professional job and at least a high school degree. Among children, the girl-to-boy ratio was abiding over the sample from the three SPATZ waves (Girls to Male child = 0.94, 0.91 and 0.92 for the SPATZ waves 6, 7 and 8, respectively). When looking at body mass index (BMI), we observed a median BMI of 23.iv (10th to 90th range = 19.four, 31.half-dozen) and 25.3 (10th to 90th range = 21.ix, 30.0) for mothers and fathers, respectively. As depicted in Table 1, the overall distribution of slumber quality scores appeared stable across the 3 time points, and no differences were observed when comparing distributions of slumber quality scores betwixt weekends and weekdays. The observed mean of the CSHQ overall score in our sample ranged between 42 and 43, comparable to that of the High german sample (Normal children age iv–10) used for the validation of the questionnaire.22 In contrast, overall media employ and Television receiver/DVD watching on the weekends increased significantly over the three time points, while book reading again seemed stable Overall, book reading and media use occupied more fourth dimension per solar day on weekends. In general, TV/DVD watching represented more than 70% of the time spent with media utilise, regardless of age or weekday/weekend. Further details on slumber quality, media use, volume reading, sleep elapsing and midpoint of sleep on weekdays and on weekends (free days) are given past historic period in Tabular array 1.
As shown in Table ii and Figure 2, on the one hand, we observed weak, borderline meaning correlation betwixt media use of all kinds and sleep quality scores (R=0.08 to 0.20). On the other paw, we found a negative correlation of sleep duration and midpoint of sleep during weekdays with slumber quality at ages 4 and 5 years (R = −0.21 to −0.10), while this correlation was adulterate and no longer significant at age vi years (R = −0.05 to 0.03). The aforementioned design, albeit with weaker correlations, was observed during weekends. Moreover, the ii potential mediators, slumber duration and midpoint of sleep, were strongly positively correlated (R = 0.90 to 0.95 for ages four, 5 and 6 years on weekdays and R = 0.70 to 0.75 for ages four and 5 years on weekends, R = 0.55 for historic period 6 years on weekends).
 | Tabular array 2 Standardized Regression Coefficients of Mediation Analysis Applied to Sleep Quality Score, Media Apply or Book Reading and Sleep Duration or Heart Sleep |
 | Figure 2 Heat maps of Pearson correlation coefficients of Blom´due south transformed variables. Abbreviations: SQ, slumber quality score; BK, volume reading; AM, all media apply; PC, apply of personal computer or video games; TV, Goggle box or DVD watching; MS, midpoint of sleep; SD, sleep elapsing; suffix F, free days (weekend); suffix W, weekday; suffix 6-seven-viii, study moving ridge. |
In the causal mediation analyses (Tables 2–5), we more often than not observed that pregnant effects were present for total digital media use and Telly/DVD watching, while digital gaming and book reading did not touch sleep quality, sleep duration and midpoint of slumber. Moreover, at that place was little bear witness for mediation of the event of media use on slumber quality via sleep elapsing or midpoint of sleep. This indicates that media employ acts independently on slumber duration, midpoint of sleep, and sleep quality. Also, the not-statistically pregnant effects of sleep duration and midpoint of sleep on sleep quality score indicate that slumber quality, slumber quantity, and the midpoint of sleep appear as uncorrelated aspects of sleep capability. The observed furnishings tended to exist stronger during weekends than during the weekdays. Finally, results from the 4 dissimilar causal mediation models suggested that media employ acted on sleep quality through a direct prospective from age four years to age 5 years and only for digital media employ and non for book reading (Tables 2 and 3). Of note, this effect was not detected when because TV/DVD utilize or electronic gaming and internet use separately. Like to the prospective models (Tables ii and 3), the cross-sectional analyses (Tables four and 5) showed significant associations of media use with sleep duration and with the midpoint of slumber at ages 4 and 5 years.
 | Table three Standardized Regression Coefficients of Mediation Analysis Applied to Sleep Quality Score, Media Utilize or Book Reading and Slumber Elapsing or Middle Sleep |
 | Table 4 Standardized Regression Coefficients of Mediation Analysis Practical to Sleep Quality Score, Media Use or Book Reading and Slumber Duration or Centre Sleep |
 | Table 5 Standardized Regression Coefficients of Mediation Analysis Applied to Slumber Quality Score, Media Apply or Volume Reading and Sleep Elapsing or Middle Sleep |
Sensitivity assay using the fully prospective model confirmed the observed indirect consequence of media use with sleep duration and midpoint of slumber, while no statistically significant direct effect between media use at age iv years and sleep quality at historic period half dozen years was observed (data not shown). The same results were substantiated in models further adapted for nutrition, physical action, body size, and seasonality (information not shown).
Word
In the nowadays German accomplice study of preschoolers, electronic media use was associated with dumb sleep quality in longitudinal analyses. In parallel, media utilise also affected sleep duration and midpoint of sleep. These results are in line with observations made in studies on toddlers, preschoolers and adolescents.9,xv,16,20,26,27 Our analyses only weakly support an indirect outcome of electronic media employ on sleep quality mediated through sleep duration or midpoint of slumber. If we have the speculation of considering the midpoint of sleep of costless days as a chronotype proxy, we may infer that media use affects slumber quality, sleep quantity, and chronotype, while the latter two are strongly related to each other. This upshot was confirmed in a previous study in which both chronotype and media utilise were statistically related to sleep quality when present in the aforementioned regression model applied to salubrious, school-age children.28
Investigating the different time points, nosotros detected a significant prospective direct effect between electronic media use at age 4 years and sleep quality at age five years but not between media use at age five and sleep quality at age 6 years. This went along with an effect of media use at historic period 4 years on sleep quantity and on the midpoint of slumber at ages 4 and 5 years. Moreover, a cross-exclusive upshot of media use on sleep quantity and midpoint of sleep was observed at ages iv and 5 only not at historic period half dozen years. Thus, it is possible that electronic media utilize affects sleep quality in the long term, merely only between the ages of 4 and 5 years, while the effects of media use on sleep duration are observed more in the short term or cross-sectionally at the ages of 4 and 5 years. According to our results, the effect of digital media use on sleep quality, sleep quantity, and midpoint of slumber is stronger in children up to the age of five years.
The electric current results possibly support an changed dose–response relation between media use, sleep quality, and age with higher susceptibility to media employ in younger children. This observation in longitudinal data of preschool children is novel but not surprising. On the i paw, a similar inverse dose–response association was previously observed cross-sectionally in toddlers and young adolescents with odds ratios of reduced sleep quantity in relation to increased media use of two.4 and 1.6, respectively.26,27 On the other hand, our study, along with others, supports a stiff correlation between slumber quantity and sleep quality.1,29,30 Hence, information technology was likely that the observed inverse clan between media utilise, slumber quality and historic period may have acted through the sleep quantity of the children. However, our structural equation models do not strongly support the thought of effects of media use on sleep quality mediated by sleep quantity.
In the nowadays work, we reported a non-significant correlation between book reading and sleep quality score. This effect is apparently in dissimilarity to electric current ideas for which active or passive reading is a recommended practise for preschoolers.10,31
Finally, most of the associations appeared to be stronger during the weekends. This could exist due to ii possible reasons. Firstly, child sleep is probable influenced past the parents' working routine. Secondly, we documented higher electronic media use during the weekend so that the stronger evidence of an association between media use and sleeping could be due to a dose–response relation, which would be in agreement with previous studies.32,33
Strengths and Limitations
The nowadays work has many strengths. To our knowledge, this is the starting time prospective written report aimed to understand straight and indirect effects of media use on sleep quality, sleep quantity, and midpoint of sleep of preschoolers. Simultaneously evaluating all these aspects of sleep in the same models goes beyond previously reported studies. Moreover, the electric current work investigates sleep in relation to media use separately on weekends and parents' working days evaluating the function of parents' working routine on child'due south sleep. Still, the limited sample size may have influenced our results, leading to limited statistical power and thus false negative results. Withal, in the absenteeism of clear a-priori show for statistical effects, we were able to perform only a posteriori ability calculation which confirmed that the sample size used (250 to 300 units) was sufficient (1-β ≥ 0.eight, statistical ability >80%) to notice an issue size of at least 0.2 correlation unit with the observed standard fault. Further possible limitations include measurement error or even self-report bias due to the use of self-administered questionnaires. More than specifically, we cannot exclude a possible bias due to the high probability that parents underreport media use and might over-report on activities similar volume reading. While such questionnaire-based cess is common to most previous studies, novel tools integrating sensing technology and diary-based methods are existence developed and could be useful for future work. Moreover, our work, like many observational studies, could have been possibly affected by misreporting or other forms of biases. For case, while a child can pick a book media use is less under their control being controlled by parents. Furthermore, our written report lacked accurateness since we did non collect information regarding parents piece of work during the weekends. We cannot exclude that our piece of work was affected by a possible residuum misreckoning bias due to lack of adjustments related to fathers' features because of a strategical choice due to a number of missing values that would have affected the performances of our analysis. Still, this pick seems equally partially justifiable, according to previous evaluations pointing out a poor father'south child-correlation construction compared to the one between mother and child.34 Another of import information that we did not consider was the use of social media for which the data was not specifically reported into our questionnaire. Still, we consider this to be a negligible source of bias since it does non seem very likely that preschoolers between the age of 4 to half-dozen years are using social media massively. Finally, nosotros employed statistical analysis and an overall approach based on the supposition of causation. Assumptions of causation may not announced as epistemologically correct, particularly because opposite causal effects or bi-directionality may exist since lack of slumber quantity or quality may have influenced digital media use. Nevertheless, nosotros believe that the use of a prospective design may accept limited, at to the lowest degree partially, this possible fallacy.
Conclusions
Electronic media use may have reduced sleep quantity and possibly compromised slumber quality in our sample of German preschoolers, specially before the age of six years. The nowadays work may suggest that electronic media use is not a healthy entertainment for preschoolers, especially for doses every bit observed during weekends in the present study.
Acknowledgments
We give thanks the families for their participation in the Ulm SPATZ Wellness Study. Nosotros thank Jenny Radesky, Academy of Michigan, for expert comments on an earlier draft of this manuscript.
Disclosure
The authors report no conflicts of interest in this work.
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