Original ArticleExcessive daytime sleepiness among children and adolescents: prevalence, correlates, and pubertal effects
Introduction
Excessive daytime sleepiness (EDS) is a global major health concern affecting up to 40% of children and adolescents [1], [2]. As EDS significantly increases with age during adolescence [1], it suggests that puberty may play a critical role in the development of EDS. Puberty is a critical period for a transition from childhood to adulthood, associated with changes in sleep structure [3], delayed circadian phase [4], and increased sleep disturbances including insomnia [5]. Conversely, the etiology of EDS is likely to be complex and interrelated [6], [7], as it may be associated with insufficient sleep [8], [9], [10], eveningness chronotype [4], sleep disturbances [11], and lifestyle factors (eg, electronics use) [12]. Nonetheless, the detailed interactions of puberty with these multiple factors, especially on the occurrence of EDS during adolescence remain unclear.
There has been a consistent female predominance of sleep problems and EDS among adolescent and adult population, but not in children [13], [14], [15], [16]. In this regard, it was reasonable to hypothesize the emergence of female predominance of EDS at some time point during pubertal maturation, albeit there was no current supporting data. However, EDS in the young population is tightly associated with mood dysregulation, behavioral problems, and substance misuse [9], [17], [18], [19]. As insomnia and eveningness chronotype are also found to be associated with mood and behavioral problems [5], [18], [20], it remains unclear whether the association of EDS with these adverse health consequences is independent of those of sleep and chronotype effects.
Thus, we hypothesized that the prevalence of EDS might increase along with pubertal development during which sex difference in EDS emerges. We aimed (1) to explore the prevalence of EDS across pubertal stages and determine the time point at which sex differences emerge; (2) to investigate the correlates of EDS in terms of demography, time in bed, sleep problems, chronotype, daytime activities, lifestyle factors, and mental health consequences; and (3) to investigate the potential interactive effects of sex and puberty with time in bed and chronotype on the occurrence of EDS.
Section snippets
Study design, procedure, and sample recruitment
The present study was part of a large-scale sleep education program (Healthy Sleep, Healthy School Life) which involved students from 31 primary and secondary schools in Hong Kong [21], [22]. Ethical approval was obtained from the Joint CUHK-NTEC clinical research ethics committee (reference no: CRE-2011.249-T). The data collected in this study were from a cross-sectional survey [5], [21]. Baseline questionnaires, a consent form for both parent(s)/caregiver(s), and individual assent were packed
The prevalence of EDS across pubertal stages and its demographic and biological correlates
A total of 19,341 students were eligible to participate in this study, of which 10,671 (55.2%) returned the questionnaires between December 2011 and March 2012. Among the respondents, a total of 10,086 (94.5%) children and adolescents (male, 48.1%) aged from 6 to 18 years old (mean age: 12.3 ± 3.2 years) had a valid PDSS score, and 7373 (69.1%) had both a valid PDSS and Tanner pubertal stage assessment.
EDS was found in 29.2% of the total sample, with a significant gender difference (24.4% in
Discussions
The present large-scale community-based study revealed that EDS was prevalent among children and adolescents in Hong Kong. The prevalence of EDS progressively increased with pubertal maturation, with the emergence of the female preponderance of EDS at mid-puberty. EDS was significantly associated with short weekday time in bed, short and long weekend time in bed, eveningness chronotype, insomnia symptoms, and SDB related symptoms. Furthermore, there was an interaction between puberty and
Conclusion
EDS is prevalent among children and adolescents, with a progressive increase across pubertal maturation. Given that a constellation of complex and interrelated factors may contribute to the high prevalence of EDS, there is a need for families, educational authorities, and health professionals to foster a healthy environment for enhancing sleep health literacy, promoting adequate sleep habits and practices among growing children and adolescents.
Disclosure statement
This was not an industry supported study.
Funding/support
This project was supported by Public Policy Research of the University Grants Committee (Reference number: CUHK4012-PPR-11), Hong Kong SAR, China. Dr. YP Liu was partially supported by the Faculty Postdoctoral Fellowship Scheme of the Chinese University of Hong Kong. The funding body had no role in the conception, design, conduct, interpretation, or analysis of the study nor in the approval of the publication.
Author contributions
Dr. YP Liu conceptualized and conducted the data analyses, drafted the initial manuscript, reviewed and revised the manuscript. Dr. YK Wing conceptualized and designed the study, supervised all the aspects of the research project and critically reviewed the manuscript. Drs. JH Zhang and SX Li managed the data, conducted the data analyses and critically reviewed the manuscript. Ms. NY Chan, Ms. MWM Yu, and Dr. SP Lam designed the data collection instruments, and coordinated and supervised data
Acknowledgment
The authors wish to thank all the principals and teachers of participating schools for approving and accommodating the implementation of the program. We also would like to thank all the parents, teachers and students who participated in the study.
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