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Year : 2021  |  Volume : 39  |  Issue : 3  |  Page : 251-256

Prevalence of sleep practices and sleep problems of schoolchildren in South Kanara

1 Department of Paediatric and Preventive Dentistry, Manikonda, Hyderabad, Telangana, India
2 Department of Paediatric and Preventive Dentistry, AB Shetty Memorial Institute of Dental Sciences, Nitte (Deemed to be University), Mangalore, Karnataka, India

Date of Submission06-Oct-2020
Date of Decision14-Sep-2021
Date of Acceptance14-Sep-2021
Date of Web Publication22-Nov-2021

Correspondence Address:
Dr. Vabitha Shetty
Capitol Apartments, Flat No. 702, Kadri, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisppd.jisppd_433_20

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Background: Disturbances in sleep could affect normal growth as well as behavior of children. It could also impair their cognitive development. Sleep problems have been increasing over the past few years. However, there is a gap regarding information about sleep practices and sleep problems among Indian children. Aim: A sleep questionnaire was designed and validated to assess the frequency of sleep practices and sleep problems in 500 children. Materials and Methods: The study was conducted in 5 local schools in South Kanara district by administering the questionnaire to the parents/caretakers under the guidance of a trained investigator. We also sought to examine the association of demographics, medical/behavior/academic performance, sleep patterns, and home environment to sleep problems in these children. Statistical Analysis: Descriptive statistics were recorded as mean and standard deviation for quantitative data and in frequency and percentage for qualitative data. Results: We found a high prevalence of bedroom sharing (92.4%) and bed-sharing (91.2%). 46.4% of the children exhibited at least one sleep problem, the most prevalent being bed-wetting (17%). Sleep problems were considerably greater in older children and in children with behavioral problems. Practices such as watching TV and using computer after 8 pm/at bedtime were significantly associated with all sleep problems. Conclusion: Our study revealed definite and significant presence of sleep problems in the children of South Kanara. Strong associations were observed between certain sleep practices and problems.

Keywords: Behavioral problems, children, prevalence, sleep disturbances, validated questionnaire

How to cite this article:
Yerra A, Shetty V. Prevalence of sleep practices and sleep problems of schoolchildren in South Kanara. J Indian Soc Pedod Prev Dent 2021;39:251-6

How to cite this URL:
Yerra A, Shetty V. Prevalence of sleep practices and sleep problems of schoolchildren in South Kanara. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2022 Jan 24];39:251-6. Available from: https://www.jisppd.com/text.asp?2021/39/3/251/330712

   Introduction Top

Sleep is vital for an individual's health and existence all through life.[1] A sufficient and good quality sleep is especially important for children to thrive and for their overall development.[2]

Sleep plays a crucial role in children's physical development. Growth hormone is released from the pituitary gland throughout the day. However, in children, it is released mostly after the beginning of deep sleep. Hence, disturbances in sleep can also affect the growth of the child.[3],[4],[5]

Behavior and cognitive problems as well as below-par academic achievements are some possible consequences of sleep deprivation in children.[6],[7],[8],[9],[10],[11],[12] Recently, studies have shown the impact of a single night restricted sleep on the higher cognitive functions such as verbal creativity and abstract thinking leading to their impairment.[6],[13] Furthermore, cardiovascular problems like hypertension have been identified as a future sequela of sleep disturbances in children.[6],[14],[15]

In recent years, sleep disorders in children have increased. However, knowledge and awareness about sleep problems of schoolchildren in our country is scarce among physicians and dentists who are often the first health-care providers to come in contact with these children. Further, parental awareness about sleep problems in their children is unknown. Relatively very less is known regarding sleeping norms, disorders, and quantum of these issues among the preschool as well as school-aged children in the Indian population.

A preliminary study[16] assessed the relationship between nutritive levels and sleep disorders in a group of children, in which a considerably higher proportion of sleep disorders were observed in overweight children. In the present study, we evaluated these children in more detail and sought to ascertain the frequency of sleep practices and sleep problems using a modified validated sleep questionnaire. We also sought to explore connections between demographics, sleep practices, and sleep problems of the children.

   Materials and Methods Top

Source of data

Five hundred children in the age group of 4–10 years (250 – preschool children aged between 4 and 6 years and 250 – schoolchildren aged between 6 and 10 years) of either gender were randomly selected from 5 local public schools: Vidyarathna Primary School, Harekala Primary School, Kunil School, Badriya Primary School, and Kids World Preschool.

Exclusion criteria

  • Children on long-term medication
  • Children having:

    • Psychological/neurological illness
    • Muscle weakness
    • Genetic disorders
    • Metabolic disorders.

The ethical committee of the institution had approved the ethical clearance for the study.

Sleep questionnaire

An ordered questionnaire was developed based on previous studies[1],[17],[18],[19] to evaluate the sleep practices and sleep problems in healthy children aged 4–10 years. The questionnaire consisted of both open- and closed-ended questions. The questionnaire was validated and modified by experts in the field and also by a feasibility study done among ten parents of randomly selected children belonging to the same age group.

Questionnaire consisted of four sections:

  • The first section recorded the demographic data of the child and the parents/caregivers
  • The second section recorded the medical history, specific behavioral patterns, and academic performance of the child
  • The third section assessed the sleep practices and home environment of the child and family
  • The fourth section determined the presence and frequency of specific sleep problems in the children.

Sleep environment

Parents/caregivers reported yes/no on questions regarding specific queries such as bed-sharing, watching TV at bedtime, and other details.

Sleep problems

Snoring, difficult/noisy breathing during sleep, observable lapses in breathing during sleep, and frequent awakening were deemed present if the problem occurred at least three times weekly during the past 6 months. Problems occurring at least once a week were recorded as a problem.[17] These parameters are based on previous literature.[1],[17],[18],[19]

The research protocol was explained in detail to school authority and parents during a parent's teachers meeting. Authorization to conduct the survey was acquired from the concerned. In our study, informed written consent from parents was obtained for children aged 4–7 years. Oral assent was obtained from older children aged 7 to 10 years in the presence of their parents. Informed written consent from the parents of these children was also obtained. Parents were grouped into small clusters of five and questionnaire administered to them. One trained investigator supervised the entire process with a teacher in attendance. To ensure consistency, a single trained investigator conducted the interview and collected all data. All children reporting sleep problems were further evaluated by a thorough dentofacial examination and specialist referrals when necessary.

Statistical analysis

The sample size was calculated to be 499 and rounded off to 500 (at prevalence of 40%, precision 4.3% set to α =5%). Data were analyzed using SPSS (IBM Corp. Released 2013. IBM SPSS statistics for windows, version 22.0, Armonk, NY: IBM Corp.) on a microcomputer. Descriptive statistics were recorded as mean and standard deviation (SD) for quantitative data and in frequency and percentage for qualitative data. The association of age, frequent cold, frequent sore throat, behavior problems, academic performance, and various sleep practices with sleep problems was analyzed using Chi-square test. P <0.05 was considered to be statistically significant.

   Results Top

Two hundred and fifty-eight girls (51.6%) and 242 boys (48.4%) with an average age of 6.49 ± 1.79 participated in the investigation and completed the questionnaires. The children ranged from kindergarteners to Grade 5 pupils.

Using the revised Kuppuswamy scale[20] as a reference for socioeconomic status, we found that 219 (43.8%) children belonged to the lower-middle class and 281 (56.2%) belonged to upper-middle class. Two hundred and seventy-nine (55.8%) of them belonged to nuclear families and 221 (44.2%) of them to joint families.

Birth history analysis showed that 465 children had full-term birth while 35 of them had preterm birth. Developmental delays were found only in 5 children (1%).

The data from our study showed that 20 children (4%) had either food or dust allergies, while 125 children (25.2%) had frequent cold and 60 children (12%) had frequent sore throat. Ear pain was found in 31 children (6.2%).

Analysis of behavioral problems revealed that 105 children (21%) had at least one behavioral problem, out of which 29 children (5.8%) displayed aggressive behavior, 62 children (12.4%) had hyperactivity, 4 children (0.8%) had attention deficit, and 10 children (2%) had anxiety. However, 83 children (16.6%) had both aggressive behavior and hyperactivity.

Analysis of academics showed that 337 children (67.4%) performed well in their studies, whereas 144 (28.8%) showed an average academic performance while 19 (3.8%) performed poorly.

The average bedtime and wake-up time on weekdays were 9 h 15 min (9:15 pm; SD = 43 min) and 6 h 45 min (6:45 am; SD = 44 min), respectively. The average sleep duration on weekdays was approximately 9 h 30 min (SD = 58 min).

Scrutiny of sleep problems revealed 232 children (46.4%) exhibited at least one sleep problem. Bed-wetting and sleep talking were most frequently reported at 17% and 12.4%, respectively [Table 1]. We found no significant difference in the occurrence of sleep problems between boys and girls.
Table 1: Frequency of sleep problems in the children

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A significant increase in sleep problems (P = 0.002) was seen in the older children (6–10 years). Sleep practices such as watching TV or using computer after 8 pm or at bedtime and irregular bedtime were found significantly higher (P < 0.05) in older children whereas practices such as keeping light on at night and door open at bedtime were found significantly higher (P < 0.05) in younger children (4–6 years).

A significant association of frequent cold and sore throat to sleep problems (P < 0.001) was found. There was a definite association (P < 0.05) of behavioral problems to certain sleep problems, i.e. bed-wetting, night terrors, and observable lapses in breathing, and certain sleep practices, i.e. keeping light on at night, intrusive background noise during sleep, difficulty in falling asleep at night/sleep-onset delay, and feeling scared at bedtime.

A definite association (P < 0.05) of the following was also found: watching TV or using computer after 8 pm or at bedtime to sleep problems, child feeling scared at bedtime to sleep problems, restless sleep to fear at bedtime, restless sleep to keeping light on at night, bed-wetting to keeping door open at bedtime, sleep talking to intrusive background noise at night, and watching TV or using computer after 8 pm or at bedtime to fear at bedtime.

   Discussion Top

All human beings require a good amount of sleep for their well-being and survival. For children in particular, sleep is very important as it helps them in their optimal growth, development, and function.[2]

In the recent times, children have shown increasing problems in sleep, a fact which has gained considerable attention. However, there is paucity in the knowledge about sleep practices and sleep problems of Indian children. This is the first study to investigate the frequency of sleep practices and sleep problems of school-going children in South Kanara.

Analysis of sleep problems revealed that almost half the children displayed at least one sleep problem. Bed-wetting was the most frequent sleep problem (17%), followed by sleep talking (12.4%) and restless sleep (11.4%) [Table 1]. We observed snoring in only 4.2% of the children. Barathy et al.[21] in a study of sleep patterns in Indian children aged 1–12 years reported that sleep problems and poor sleep habits are common among children. They further observed that 51% of the children demonstrated sleep problems such as difficulty in falling asleep, snoring, sleep talking, and nightmares.

In our study, children were observed to have adequate duration of sleep as per recommended guidelines.[22] Kulkarni et al.[23] reported that children who had shorter total sleep duration had increased behavioral problems in the dental operatory.

When sleep practices of the children were analyzed, we found that majority of the children (92.4%) shared a bedroom while bed-sharing was seen in 91.2% of the children [Table 2]. This could be with a parent or sibling. This finding might be attributed to societal and cultural norms in our country where it is a commonplace for parents and children to share a bed/bedroom.
Table 2: Prevalence of sleep practices in children

Click here to view

Bed-sharing is frequently seen in other Asian countries as well.[24],[25] Barathy et al.[21] have reported a similar prevalence of co-sleeping (97.5%) in 1–12-year-old children reporting to the outpatient department at a tertiary care hospital in Puducherry, India. This habit of co-sleeping merits more attention and investigation as it seems to be of a higher frequency in our country as compared to other societies. It could also be related to the socioeconomic status of the family.

Children resist going to bed for several reasons. They may want to engage in other preferred activities, or because they do not feel tired. Children could also have nighttime fears that make them frightened of going to sleep alone. We observed that one in four children displayed bedtime resistance (difficulty in going to bed) while 23% of the children had sleep-onset delay (difficulty in falling asleep) [Table 2]. Further up to 41.2% of the children had morning awakening problems. The frequency of bedtime resistance in our study is supported by the prevalence reported by BaHammam et al.[17] in a group of Saudi children (26.2%) and by Blader et al.[26] (27%) in a sample of American children. However, the frequency of sleep-onset delay and morning awakening problems in our study was higher than the prevalence reported by BaHammam et al.[17] (11.7% and 20.7%, respectively) and by Blader et al.[26]

In our study, watching TV or using computer beyond 8 pm or at bedtime was observed to be significantly higher in the older children and was strongly associated with sleep problems. Owens et al.[27] and BaHammam et al.[17] reported similar findings. Chandran et al.[28] found that television use was prevalent in 95% urban and 75% rural students. This bedtime practice could be a consequence of rapidly evolving lifestyles and urbanization occurring in all parts of our country. However, in our study, sleep practices like requiring light on at night and door open at bedtime were significantly higher in the younger children.

In our study, sleep practices such as intrusive background noise, watching TV or using computer after 8 pm or at bedtime, and fear at bedtime were significantly associated with sleep talking. These could be the contributing factors for the higher prevalence of sleep talking observed. However, a significant association of irregular bedtime to sleep talking was reported by Salzarulo and Chevalier[29] in their study.

In our study, 41 children reported bed-wetting as well as keeping door open at bedtime. Of these, 21 were preschool children, while 20 were school-aged children. We felt that this association was inconclusive as an age-related function.

Analysis of behavioral problems revealed that almost one in four children had at least one behavioral problem. The most common behavioral problem reported was hyperactivity (12.4% of the children). This is consistent with the prevalence of attention deficit hyperactivity (11.32%) reported by Venkata and Panicker[30] in a group of children while the prevalence of hyperactivity reported by Ramya et al.[31] in a group of Bangalore school-going children was 34.1%. We observed a definite association of behavioral problems to certain disturbances in sleep like observable lapses in breathing (P < 0.05). Observed lapses in breathing means periods of temporary cessation of breathing during sleep. Even though in children these apneic episodes could be very short, repeated such episodes could result in decreased oxygen saturation levels. This eventually could alter normal behavior resulting in behavioral problems. In turn, daytime behavioral problems like hyperactivity could also affect the sleep which could lead to a vicious cycle. The disruption of the sleep process may be a key determinant of the behavioral alteration.[32]

The attention and behavior issues seen in children with obstructive sleep apnea (OSA) syndrome could definitely have an adverse effect on their cognitive and academic performances.[33] Goyal et al.[34] have found a high prevalence of OSA in Indian children with poor academic performance in all subjects. However, most of the children in our study showed good performance in their academics. We could not attribute any particular reasons for this.

In our study, sleep practices such as keeping light on at night, intrusive background noise, sleep-onset delay, and fear at bedtime were significantly higher in children with behavioral problems. Significantly higher sleep problems in these children were observed: in particular bed-wetting, night terrors, and observable lapses in breathing. A similar significant association of behavioral problems to sleep problems was reported by Hoedlmoser et al.[35] in a group of Salzburg School children.

A previous study[16] reported that sleep problems were definitely greater in obese children and found a notable association between obesity and specific sleep problems. In the present study, we observed that sleep problems were significantly higher in children with frequent cold and sore throat. This is in accordance with the association reported by Owens et al.[36] in their study.

Sleep bruxism has been increasingly identified in children with sleep disorders. However, in the present study, we have not evaluated the prevalence of bruxism. Soares-Silva et al.[37] in their study have suggested that there is a need for further investigation of the relationship of oral habits in patients with and without sleep bruxism.

To summarize, in our study, behavioral problems, frequent cold, and sore throat as well as various sleep practices such as irregular bedtime, bedroom sharing and bed-sharing, keeping light on at night, door open at night, watching TV or using computer after 8 pm or at bedtime, sleep-onset delay, and fear at bedtime could be some of the risk factors for the higher frequency of disturbances in sleep.

Results of this investigation showed that problems during sleep are common among children in South Kanara District. We also found strong associations between certain sleep practices and sleep problems. However, no parent was aware of the implications of sleep problems of their children on their well-being impacting academics, behavior, and health of their children and therefore no attempt was made to seek medical help. The results of our study are in agreement with the observations of Narasimhan et al.[38] who found sleep problems in 34% of the children. They felt that apart from lack of parental awareness about sleep disorders, poor parental recall is a key reason for underdiagnosis of these problems. Hence, there is a need to sensitize parents about impact and influence of problems during sleep on overall well-being of their children.

There are certain limitations in our study. First, it completely relied on the parental reports which depended on their perception of the problem and willingness to disclose information. Our study was initiated as a concerted attempt to identify and determine the presence and magnitude of sleep disturbances of children in South Kanara.

More detailed investigation on a larger population of children needs to be carried out followed by timely diagnosis and treatment. Future studies can also focus on and examine in detail the association of sleep practices to specific sleep problems. It is also imperative to elucidate how many of the sleep problems reported are clinically significant. Future studies on the link between pediatric obesity, metabolic syndrome, and other conditions with sleep problems in children should be planned and investigated.

   Conclusion Top

The results of this study showed that majority of the children shared a bed/bedroom with their parents/siblings. Upto one fifth of the children watched TV or used computer after 8pm or at bedtime. These children showed significantly more sleep problems. One fifth of the children had behaviour problems. There was a strong association between these children and specific sleep problems such as bed wetting, night terrors and observable lapses in breathing.

Almost half the children had at least one sleep problem. We found a significant increase in sleep problems with age. Bed wetting was the most common sleep problem followed by sleep talking and restless sleep.

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Conflicts of interest

There are no conflicts of interest.

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