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Indian Pediatr 2011;48: 221-223 |
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Sleep Problems in Preschool and School Aged
Rural Indian Children |
S R Ravikiran, P M Jagadeesh Kumar and KS Latha*
From the Department of Pediatrics, KVG Medical College
and Hospital, Sullia, Dakshina Kannada 574327; and *Department of
Psychiatry, Kasturba Medical College, Manipal University, Manipal 576 104,
Udupi; Karnataka, India.
Correspondence to: Dr S R Ravikiran, Assistant Professor,
Department of Pediatrics, KVG Medical College and Hospital, Sullia,
Dakshina Kannada 574 327, Karnataka.
[email protected]
Received: March 18, 2010;
Initial review: April 23, 2010;
Accepted: May 24, 2010.
Published online 2010 November 30.
PII: S097475591000234-2
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Abstract
We assessed 513 children (2-6 y = 252; 7-12 y = 261)
who visited the pediatric outpatient of a rural medical college
hospital, for sleep problems using ‘BEARS’ tool. Sleep problems detected
in the BEARS domains for preschool (2-6 years, n=252) and school
children (7-12 years, n=261) were as follows: bedtime problems
(33.3% vs 14.9%, P<0.001), excessive daytime sleepiness
(32.5% vs 1.9%, P<0.001), awakening during night (25%
vs 11.87%, P<0.001), regularity and duration of sleep (19.84%
vs 4.98%, P<0.001), and sleep disordered breathing (4.8%
vs 5%, P=0.1). We conclude that sleep problems are common
among rural Indian children and should be routinely screened for during
health visits.
Key words: Child, India, Rural, Sleep problems.
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Inadequate or poor sleep in children may
have negative consequences on a host of functional domains, including
mood, behavior, learning, and health. Therefore, it is important for
pediatricians to both screen for and recognize sleep disorders in children
during health encounters [1].
BEARS screening tool has been used to identify sleep
problems among preschool and school-aged children [2,3].
A study that compared sleep in preschool and school-aged children using
BEARS tool found that sleep problems and sleep patterns differed between
these groups. The differences were attributed to school schedules, sleep
practices and homework load in the groups [3].
Studies have been reported from urban India on sleep
problems in school-children [4,5] and adolescents [6]. There is no sleep
study reported from rural India. The purpose of our study was to
investigate sleep problems of preschool and school-aged rural Indian
children using BEARS screening tool.
Methods
This cross-sectional study was conducted from July to
December 2009 in the Department of Pediatrics, KVG Medical College, Sullia,
which serves the rural population of neighboring districts. The Research
Ethics Board of KVG Medical College approved the study.
A convenience sample of 582 children (aged 2-12 years)
presenting for general medical problems or well child visits during the
study period was randomly recruited from the pediatric out-patient. None
of the children presented primarily for a sleep problem. 69 children were
excluded from the study. Reasons were – absence of the mother during the
visit (n=50); chronic illness (n=2); severe asthma (n=2);
obesity (n=1) and, neurological problems (n=2). Besides,
children who stayed in hostels (n= 7) and those on long-term
medications (n=5) were also excluded. The remaining 513 children
were divided into two groups i.e., preschool (2-6 years) and school age
(7-12 years) as BEARS questions were different for the groups. After
addressing the primary problem for which the child had come for
consultation, and after obtaining consent, the included subjects were
screened for sleep problems using the BEARS tool.
The BEARS instrument is divided into five major sleep
domains, providing a comprehensive screen for the major sleep disorders
affecting children 2-18 years old (B=Bedtime Issues, E=Excessive Daytime
Sleepiness, A=Night Awakenings, R=Regularity and Duration of Sleep,
S=Snoring). Each sleep domain has a set of age-appropriate "trigger
questions" for use in the clinical interview [1]. The BEARS tool was
translated to Kannada by the principal investigator who is well versed in
both the languages and given to another expert for validation. Both the
parent and the child were asked to reply positively if the problem
occurred on most days in the past two weeks prior to onset of illness.
Additional information collected included age, sex,
co-sleeping, and medical history. Co-sleeping was defined as sharing the
bed with parents, grandparents or siblings on all days.
Data were entered into SPSS for windows, version 11.5
and descriptive statistics were calculated Chi-square test was used to
compare frequencies among the two groups and t test to compare the means,
wherever applicable.
Results
513 children were screened for sleep problems. Of
these, 252 were in preschool group (128 female, 50.8 %) and 261 were in
school-age group (132 female, 50.5%). The mean age in preschool group was
49.6 (±13.7) months and in school-age group was 114.7 (±20.1) months.
Sleep problems were found in 51.1% of 513 children in
the study population in at least one of the BEARS domains. Table
I depicts the distribution of sleep problems across different domains
of BEARS among preschool and school groups. Co-sleeping was significantly
more common in preschool children than school-age children (96% vs
85.8%, P<0.01). School children woke up earlier [6:34 AM (±0.66hrs)
vs 6:49 AM (±0.71hrs), P<0.001] and slept later than their
preschool counterparts [9:21 PM (±0.88hrs) vs 9:06 PM (±0.99hrs),
P=0.003]. The resultant night sleep duration of school-aged
children was less than the preschool children [9.22 hrs (±0.99 hrs) vs
9.75hrs (±1.04 hrs), P<0.001].
Table I
Distribution of Sleep Problems in the Study Population Across Different Domains of BEARS Questionnaire
Domain of BEARS |
Preschool children |
School-aged children |
P value |
questionnaire |
% (n=252) |
% (n=261) |
(Chi-square test) |
Bedtime problems |
33.3% |
14.9% |
<0.001 |
Excessive daytime sleepiness |
32.5% |
1.9% |
<0.001 |
Awakenings during the night |
25% |
11.9% |
<0.001 |
Regularity and duration of sleep |
19.8% |
5% |
<0.001 |
Sleep-disordered breathing |
4.8% |
5% |
0.908 |
Discussion
Fifty one percent of the 2-12 year old children had
sleep problems in at least one of the BEARS domains. Sleep patterns and
sleep problems of preschoolers as compared to school-aged children can be
summarized as follows: (i) the sleep duration of preschoolers was
greater, in agreement with the sleep requirements for age [1,7]; (ii)
co-sleeping was more common among preschool children similar to that in
studies finding greater prevalence with younger age [8]; (iii) they
had more bedtime problems, irregularity in sleep-timings similar to
Iranian preschoolers [3]; (iv) they had frequent awakenings at
night; and (v) daytime napping was common, as expected for age
[1,7].
The sleep problems in Indian children were more than
the United States counterparts in most BEARS domains. Sleep disordered
breathing was an exception, where Indian children had lesser problems [2].
Compared to a study from Iran based on the BEARS tool, sleep problems in
our subjects were lower in most domains [3]. The differences in the
various studies could be due to differences in sleep practices,
co-sleeping, sleep environment and different parental expectations of
sleep.
The study has several limitations. It is a hospital
based cross-sectional study and may not represent the sleep problems of
all rural Indian children. It relied on self-report and socially desirable
responses cannot be ruled out. The results would have been more
informative if details of parental socio-economic status, literacy, number
of siblings were collected. Since data was collected over 6 months,
seasonal influence on sleep could have affected the results [9].
There is a methodological limitation in the study.
BEARS questions for assessing sleep problems in pre-school and school-aged
children were not exactly the same [1]. These discrepancies could have
influenced differences observed between the two groups.
We conclude that sleep problems are common in rural
children and should be routinely screened during health visits.
Contributors: SRR conceived the study, collected
data and drafted the paper. PMJK and KSL revised the manuscript
critically. KSL was also involved in interpretation of data. The final
manuscript was approved by all authors.
Funding: None.
Competing interests: None stated.
What This Study Adds?
• Sleep problems are common among rural Indian children. Sleep
patterns and problems of preschool and school children differ
significantly. |
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