Introduction
Review
Electronic database search
Study selection and characteristics
Data abstraction
Methodological quality assessment
Synthesis
Results
Patient characteristics of included studies
Author (Year) | Country | Study design | Recruitment setting | Sample size (numbers) | Mean age (SD) | % Female | JIA/JRA diagnosis | Disease duration |
---|---|---|---|---|---|---|---|---|
Mean Year (SD) | ||||||||
Zamir (1998) [7] | Israel | Case control | Pediatric rheumatology clinic | JRA: 16 | 12 (4) | 69 | Olig: 4 | 4.5 (3.4) |
Controls: 9 | Poly: 12 | |||||||
Bloom (2002) [25] | USA | Case control | Hasbro Children's Hospital, Pediatric Rheumatology Clinic | JRA: 25 | 8.7 | 80 | Syst: 5 | 3.1 (range: 0.2-5.5 ) |
Controls: 45 | Range: 6-12 | Olig: 9 | ||||||
Poly: 11 | ||||||||
Palermo (2005) [26] | USA | Cross- sectional | Outpatient pediatric rheumatology clinics (NS) | JIA: 20 | NR | 67 | Syst: 2 | 4.49 (NR) |
Olig: 5 | ||||||||
Poly: 7 | ||||||||
ERA: 2 | ||||||||
NS: 4 | ||||||||
Passarelli (2006) [27] | Brazil | Case-control | NR | JRA: 21 | 13 (2) | 57 | Syst: 9 | NR |
Controls: 20 | Poly: 12 | |||||||
Long (2008) [1] | USA | Cross sectional | Four clinical sites during specialty care visits (NS) | JIA: 30 | Range: 8-12 | 56 | Syst: 3 | NR |
Olig:21 | ||||||||
Poly: 6 | ||||||||
Ward (2008) [3] | USA | Cross sectional | Children's Hospital and Regional Medical Centre- Paediatric Rheumatology Clinic | JRA: 70 | 8.5 (1.9) | 84 | Syst: 4 | Inactive JRA: 3.8 (1.7) |
Olig: 26 | ||||||||
Poly: 40 | Active JRA: 3.4 (3.0) | |||||||
Ward (2010) [28] | USA | Cross sectional | Seattle Children's Hospital and University of Washington School of Nursing sleep laboratory | JIA: 69 | 8.5 (1.9) | 84 | Sys: 3 | NR |
Olig: 26 | ||||||||
Poly: 40 | ||||||||
Butbul Aviel (2011) [29] | Canada | Cross sectional | The Hospital for Sick Children | JIA: 92 | 12.7 (0.4) | 66 | Syst: 28 | NR |
Olig: 31 | ||||||||
Poly: 33 | ||||||||
Ward (2011) [30] | USA | Case control | Seattle Children's Hospital Paediatric Rheumatology Clinic | JIA: 70 | 8.5 (1.9) | 76 | Sys: 4 | NR |
Controls: 46 | Olig: 26 | |||||||
Poly: 40 | ||||||||
Bromberg (2012) [31] | USA | Cohort | Pediatric Rheumatology Clinic | JIA: 51 | 12.4 (2.8) | 65 | Poly: 51 | NR |
Methodological quality of studies
Author (YR) | Level of risk of bias due to study participation | Level of risk of bias due to study attrition | Level of risk of bias due to prognostic factor measurement | Level of risk of bias due to confounding measurement and account | Level of risk of bias due to analysis | Outcome assessed | Level of risk of bias due to outcome measurement |
---|---|---|---|---|---|---|---|
Zamir (1998) [7] | Low | N/A | Low | High | Low | Sleep fragmentation | Low |
Bloom (2002) [25] | Low | N/A | Low | Moderate | Low | CHSQ total score | Low |
SSR score | Moderate | ||||||
Palermo (2005) [26] | Low | N/A | Low | Low | Low | Sleep/Wake Behaviour Problems | Low |
Passarelli (2006) [27] | Low | N/A | Low | High | Low | Sleep disorders | Low |
Long (2008) [1] | Low | N/A | Low | Low | Low | Sleep disturbance | Low |
Ward (2008) [3] | Moderate | N/A | Low | Low | Low | Sleep disturbance | Low |
Sleep quality | Low | ||||||
Ward (2010) [28] | Moderate | N/A | Low | Low | Low | Number of wake bouts | Low |
Arousals | Low | ||||||
Apnea/Hypopnea Index (AHI) | Low | ||||||
Butbul Aviel (2011) [29] | Low | N/A | Low | Moderate | Low | CSHQ sleep disturbance | Low |
SSR sleep disturbance | Moderate | ||||||
Ward (2011) [30] | Moderate | N/A | Low | Low | Low | Total Sleep Disturbance score | Low |
Bromberg (2012) [31] | Low | Low | Low | Low | Low | Sleep quality | Low |
Sleep disturbances in children with JIA
Author (YR) | Sleep domains examined | Measurement of sleep outcome | Factors examined | Measurement of factor | Results |
---|---|---|---|---|---|
Sleep wake patterns and behaviours
| |||||
Zamir (1998) [7] | Total number of index arousals, or, stage shifts or leg movements (Sleep fragmentation) | Polysomnography | Number of active joints, Duration of stiffness, ESR | Rheumatologic examination | JRA patients had more arousals and awakenings per hour compared to controls (22.7 ± 9.6 vs 11.7 ± 5.3, p < 0.001) |
Median length of stage 2 sleep was 60% shorter in JRA (8.0 mins) compared to controls (13.5 mins) (p < 0.001) | |||||
Median length of stage 3 sleep was also shorter in JRA patients (5.8 mins) compared to controls (9.8 mins) (p < 0.001) | |||||
Median length of REM sleep was also shorter in JIA patients (9.4 mins) compared to controls (15.1 mins) (p < 0.02) | |||||
Bloom (2002) [25] | Sleep habits | CSHQ | JRA patients compared to controls had a high total score on the CSHQ (45.36 ± 8.01 vs 37.51 ± 6.12, p < 0.0001), as well as higher scores on the following subscales: night wakenings (4.56 ± 1.29 vs 3.42 ± 0.82, p < 0.001), parasomnias (10.0 ± 1.85 vs 8.19 ± 1.11, p < 0.001), sleep anxiety (5.63 ± 1.61 vs 4.89 ± 1.26, p = 0.045), sleep-disordered breathing (3.70 ± 1.02 vs 3.25 ± 0.53 p = 0.036), and morning wakening/daytime sleepiness (11.88 ± 2.80 vs 9.91 ± 2.68, p = 0.007) | ||
Passarelli (2006) [27] | Alpha/delta waves, periodic leg movement, isolated leg movements | Polysomnography | Pain score | Self-assessment of pain on a categorical 5-point face scale ranging from “no hurt” to “hurts worst” | JRA patients exhibited higher indexes of periodic leg movements (p = 0.02), isolated leg movements, and arousals, as well as increases in alpha activity in non-REM sleep (all p < 0.01), in spite of similar frequency of sleep complaints in comparison to controls |
Ward (2011) [30] | Sleep disturbance | CSHQ | JIA patients compared to controls had a statistically significant (P < 0.001) greater mean overall sleep disturbance score (45.0 ± 7.3 vs 39.1 ± 4.9) and higher scores on 6 of 8 subscales including; sleep onset delay (1.6 ± 0.7 vs 1.2 ± 0.4, p = 0.001), sleep anxiety (5.8 ± 2.0 vs 5.0 ± 1.4, p = 0.02), night wakenings (4.0 ± 1.3 vs 3.3 ± 0.7, p = 0.001), parasomnias (9.3 ± 1.8 vs 7.9 ± 1.1, p = 0.001), sleep disordered breathing (2.3 ± 0.6 vs 2.1 ± 0.4, p = 0.03), and daytime sleepiness (13.0 ± 3.5 vs 11.0 ± 3.3, p = 0.004) | ||
Reaction time | CANTAB | There were no group differences on neurobehavioral performance test scores. |
Prognostic factors associated with sleep outcomes examined
Author (YR) | Sleep domains examined | Measurement of sleep outcome | Factors examined | Measurement of factor | Results |
---|---|---|---|---|---|
Sleep wake patterns and behaviours
| |||||
Zamir (1998) [7] | Total number of index arousals, or, stage shifts or leg movements (Sleep fragmentation) | Polysomnography | Number of active joints, Duration of stiffness, ESR | Rheumatologic examination | Multiple linear regression revealed no association between number of active joints, duration of stiffness, or ESR, with the total number or index of arousals or awakening, stage shifts, or leg movements (NS) |
Palermo (2005) [26] | Sleep wake problems | Sleep-Wake Behavior Problems Scale | Functioning | FDI | In multivariate regression functioning was predictive of sleep wake problems (β = 0.665, p = 0.054) |
Pain severity | Faces Pain Scale | In multivariate regression pain severity was not significantly predictive of sleep wake problems (β = 0.593, p = 0.126) | |||
Pain frequency | 6-point scale ranging from less than once a month to daily | In multivariate regression, pain frequency was not significantly predictive of sleep wake problems (β = -0.162, p = 0.665) | |||
Passarelli (2006) [27] | Alpha/delta waves, periodic leg movement, isolated leg movements | Polysomnography | Morning stiffness | Rheumatologic examination | Morning stiffness was significantly correlated to periodic leg movement (rs = 0.75, p = 0.00009) and isolated leg movements (rs = 0.78, p = 0.00003) |
Pain score | Self-assessment of pain on a categorical 5-point face scale ranging from “no hurt” to “hurts worst” | Pain score was significantly correlated with alpha/delta waves (rs = 0.74, p = 0.0001) | |||
Ward (2008) [3] | Wake and sleep stages, apnea/ hypopnea index (AHI), periodic leg movements | Polysomnography | Sleep quality | SSR | In the multivariate regression model testing predictors of the disturbed sleep (arousals), age and medications, anxiety, and evening pain explained 18% of variance, but neither anxiety or pain had a significant effect (both p > .05) |
Anxiety | RCMAS | Anxiety did not predict sleep disturbances (β = -0.30, p = 0.19) | |||
Medications | Parents completed a daily diary of medications their child received | Medications did predict sleep disturbance (β = 0.11, p < .04) | |||
Evening pain | Oucher Faces Rating Pain Scale | Evening pain did not predict sleep disturbances (β = 0.23, p = 0.19) | |||
Ward (2010) [28] | Apnea/ hypopnea index (AHI), awakenings, arousal | Polysomnography | Reaction time | CANTAB | Reaction time was inversely correlated with awakenings and arousals (r = -0.32, p < 0.03) |
Inadequate sleep quality
| |||||
Bloom (2002) [25] | Sleep habits | CSHQ | Function | JAFAR | Functional disability was not significantly correlated with sleep habits (rs = 0.253, p = 0.222) |
Limited joint count | NR | Limited joint count was not significantly correlated with sleep habits (rs = -0.184, p = 0.380) | |||
Active joint count | NR | Active joint count was not significantly correlated with sleep habits (rs = -0.100, p = 0.633) | |||
Parent global rating | Varni Pediatric Pain Questionnaire | Parental global rating was not significantly correlated with sleep habits (rs = 0.262 p = 0.207) | |||
Physician global rating | Overall disease activity on a scale of 0-4 (0 = no disease activity, 4 = very severe disease) | Physician global rating was not significantly correlated with sleep habits (rs = 0.258, p = 0.212) | |||
ESR | Clinical pathology laboratory by standard methods | ESR was not significantly correlated with sleep habits (rs = 0.102, p = 0.628) | |||
SSR | Average pain | VAS | Average pain score was significantly correlated with sleep habits (rs = 0.56, p = 0.005) | ||
Long (2008) [1] | Sleep disturbance | CSHQ | Functioning | FDI - child and parent report | Child report of functional disability was not significantly correlated with sleep disturbance (r = 0.190, NS) |
Parental report of functional disability was significantly correlated with sleep disturbance (r = 0.646, p < 0.01) | |||||
Physical and psychosocial HRQOL | Child’s Health Questionnaire | Physical and psychosocial HRQOL was inversely correlated with sleep disturbance (r = -0.813, p < 0.01) | |||
Disease severity (global rating), daily pain | VAS (100-mm) | Disease severity was significantly correlated with sleep quality (β = 0.05, p > .05) | |||
Butbul Aviel (2011) [29] | Sleep disturbance | CSHQ | Number of tender and swollen joints | Number of swollen and painful joints by parents’ and patients’ self-report joint count—using a pictorial (mannequin) format. | Self reported sleep habits was slightly correlated with number of tender joints (r = 0.241) and swollen joints (r = 0.163) |
Global pain, worst pain | VAS | Self reported sleep habits was significantly correlated with global pain (r = 0.32, p = 0.0003) | |||
Number of painful areas, present pain | SSR | Self reported sleep habits was significantly correlated with (r = 0.32, p = 0.0003) | |||
Fatigue | PedsQL fatigue | Self reported sleep habits were inversely correlated with self reported fatigue (r = -0.45, p < 0.0001) | |||
Ward (2011) [30] | Sleep disturbance | CSHQ | Reaction time | CANTAB | Reaction time on CANTAB was significantly correlated with sleep disturbance (β = 0.18, p = 0.22) |
Bromberg (2012) [31] | Sleep quality | VAS (100-mm, ranging from did not sleep well to slept very well) | Age | Age was inversely correlated with sleep quality (β = -0.39, p > .05) |