Original ArticleFactors associated with insomnia and complementary medicine use in children: results of a national survey
Introduction
The revised International Classification of Sleep Disorders published by the American Academy of Sleep Medicine defines insomnia as “an almost nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode” [1]. While a separate definition for pediatric insomnia is not provided, insomnia in children is unique, in causing widespread disruptions in the family environment. Prevalence of childhood insomnia estimates range from 10% to 40%, depending on the particular definition of sleep difficulties used and the age of children surveyed [2], [3], [4], [5].
Difficulty sleeping in children is associated with many other health problems, particularly behavioral problems. In one cross-sectional study of 4351 children aged 8–11 years, sleep disorders were associated with emotional difficulties, hyperactivity, conduct problems, peer problems and social difficulties [4]. Another study of children aged 5–12 years reported associations between sleep-onset delays and psychiatric and medical comorbidities [6]. A longitudinal study of 943 children found that sleep difficulties in school-age children were associated with anxiety in early adulthood with an odds ratio of 1.60, controlling for a number of covariates (including childhood internalizing problems) [7].
Treatments for sleep difficulties in children range from medication use, behavioral methods, and complementary therapies [8], [9]. One survey study of 671 pediatricians reported that for young children approximately 3% of primary care visits in a typical six month practice period were for sleep concerns [10]. For patients with sleep problems, 75% of these practitioners recommended nonprescription medications, and >50% prescribed a sleep medication. Many providers recommended Melatonin, and herbs were recommended by 15%. While 54% of those surveyed raised concerns about the side effects of the medications prescribed. Although the results of this retrospective survey may be affected by recall bias, it appears that sleep problems in children are commonly treated with medications despite practitioners’ concerns about their safety.
Complementary and alternative medicine (CAM) describes a set of practices and treatments which people choose in addition or as alternatives to Western medical practices [11]. Current figures from the National Center for Complementary and Integrative Health, whose data are derived from the National Health Interview Survey (NHIS), estimate that about 30% of adults and 12% of children utilize CAM therapies [12]. A global survey study of pediatric CAM prescriptions in many countries suggests that up to 17% of all prescription are herbal therapies, and 15% of all prescription are homeopathic remedies [13]. An analysis of the 2002 NHIS data in adults found a 12-month prevalence rate of insomnia or trouble sleeping of 17.4% [14]. Of those with insomnia or trouble sleeping, 4.5% used some form of CAM therapy to treat insomnia.
We aimed to describe the prevalence of insomnia in children in the U.S. and to understand the psychosocial factors and comorbidities associated with insomnia. Given the high rate of medications prescribed for insomnia in children and practitioner concerns about side effects, we aimed to evaluate the prevalence of, and factors associated with, CAM use in children with insomnia. The clinical impact of this analysis would be to identify those children at high-risk for sleep difficulties and understand what CAM treatments are most commonly used in this population.
Section snippets
Study population
We analyzed data from the 2012 NHIS Household, Family, Person, Adult, and Child Core surveys, as well as the CAM supplements. This cross-sectional, in-person survey disproportionately includes underrepresented minorities and uses a complex sampling design to provide estimates for the U.S. civilian, non-institutionalized population. The NHIS 2012 survey interviewed 42,366 households, yielding 108,131 persons from 43,345 families. Overall, there were 8738 children aged 6–17 years. We restricted
Patient characteristics
Children with insomnia or regular trouble sleeping in the last year comprised 6.4% of all children (Table 1). Compared with children without sleep difficulties, children with sleep difficulties were predominantly white (78.3% vs. 74.4%; p = 0.01) and were more likely to have public insurance (42.7% vs. 33.0%, p < 0.001). Among those with sleep difficulties, there was a greater proportion close to the poverty line, with poor health, and with more school days missed (p = 0.004, p < 0.001,
Discussion
We found that 6.4% of children aged 6–17 years, corresponding to an estimated 1.5 million children in the US, reported regular difficulty sleeping in the past year. Factors most strongly associated with insomnia were older age, poorer health status, more missed school days and specific comorbidities (eg, anxiety/stress, migraines/headaches, asthma/respiratory allergies, eczema). In addition, we found that 29% of children with sleep difficulties reported use of at least one CAM therapy, nearly
Conclusions
Using the 2012 NHIS, we have reported the prevalence of sleep difficulties in a representative sample of U.S. children and the rate of CAM use in the affected subpopulation. Additionally, we demonstrated that older age, poor health status, missed school days and a number of comorbidities were associated with sleep difficulties. Among those with sleep difficulties, parental education and CAM use were most strongly associated with child CAM use, and supplements were the most commonly used
Disclosures
Dr. Lee reports a research grant from Pfizer and stock in Express Scripts. No other authors report conflicts of interest.
This work was conducted with support from R01 AR064850 (Lee), T32 AI007512 (Cohen) and K23 AT009218 (Dr. Dossett) from the National Center for Complementary and Integrative Health (NCCIH) as well as Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences,
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