Original ArticleThe relationships between asthma control, daytime sleepiness, and quality of life among children with asthma: a path analysis
Introduction
Asthma is one of the most prevalent and chronic pediatric diseases in the United States, affecting an estimated 7 million (approximately 10%) of children in 2007 [1], [2]. Although effective medication is available to treat pediatric asthma, many children are still living with persistent asthma symptoms, including shortness of breath, coughing, wheezing, nighttime awakening, and sleeping difficulties [3], [4]. Underuse of oral corticosteroids and overuse of rescue medicine are important issues contributing to poorly controlled asthma [5], [6]. Previous studies have shown that the prevalence of poorly controlled asthma status is various (37–80%) among children with asthma, depending on different study designs, age of children, severity of asthma, and other factors [7], [8], [9], [10], [11], [12], [13]. For example, one study reported that 46% of the asthmatic children who used inhaled corticosteroids had poorly controlled asthma [13]. Numerous studies have illustrated that poor asthma control in children was associated with activity intolerance leading to impaired functional status, such as attention difficulty [14], poor sleep quality [14], poor peer relationships [15], absence from school [16], academic underperformance [16], and low asthma-specific health-related quality of life (HRQOL) [17], [18].
The relationship between asthma symptoms and HRQOL is well-established. A systematic review found that asthmatic children with poor control were more likely to experience poorer HRQOL compared to those with adequate control [19]. Using the Pediatric Quality of Life Inventory to measure generic HRQOL, a study found that children with asthma had considerable impaired physical, emotional, social, and school functioning compared to healthy children [20]. In addition, a study using the Paediatric Asthma Quality of Life Questionnaire to measure asthma-specific HRQOL reported that HRQOL was significantly impaired in the domains of symptoms, activity limitation, and overall HRQOL among children with unstable asthma control compared to children with stable asthma control [21].
Asthmatic children are more likely to report sleep concerns than healthy children [22], [23], [24]. Airway resistance greatly increases at nighttime when individuals sleep, and this issue is significant for asthmatic children leading to exacerbated coughing, wheezing, and sleeping difficulties [25]. Although 25% of the general US population of children experienced nighttime sleep difficulties [26], 34–40% of asthmatic children experienced nocturnal awakening [27], [28]. Asthmatic children with poor asthma control status had more nocturnal awakening per week compared to children with adequate asthma control status (66% vs 14%) [29]. Children with nighttime sleep concerns had more challenges in growth, development, and functional status, including attention difficulties, daytime sleepiness, poor school performance, missed school days [30], [31], and psychologic dysfunction (i.e., anxiety, depression) [32], [33], [34]. Previous pediatric studies have separately investigated the relationships between asthma control and HRQOL [15], [16], [19], [20], [21], between sleep concerns and HRQOL [30], [32], [33], [34] and between asthma control and sleep concerns [22], [23], [24], yet the complex mechanism among asthma control status, sleep concerns, and HRQOL has not been explored. Sleep concerns including nighttime sleep and daytime sleepiness are equally important to asthmatic children, but the majority of the studies focus on nighttime sleep rather than daytime sleepiness issues [23], [24], [26], [27], [28], [30].
The purpose of our study was to examine the relationships among asthma control status, daytime sleepiness, and asthma-specific HRQOL in asthmatic children. Instead of viewing sleep concerns as nuisance variables, we hypothesized that daytime sleepiness is an important factor to mediate the relationship between asthma control status and HRQOL. Specifically we used path analysis methodology to quantify the direct and indirect effects of asthma control on asthma-specific HRQOL through the mechanism of daytime sleepiness [35].
Section snippets
Population and data collection
This cross-sectional study used data collected from children who were previously diagnosed with asthma between the ages of 8 and 17 years and their parents. Exclusion criteria were parents and children who had any concurrent medical or psychiatric conditions that may have affected the completion of the survey, children who had asthma-like symptoms but were not diagnosed as having asthma, or parents and children who were not able to read and speak English. After the University of Florida’s
Participant characteristics
Table 1 shows the participant characteristics. For children (N = 160), the mean age was 11.6 years (SD, 2.4); the majority were boys (59.4%) and of black descent (55.6%). For parents, the mean age was 40.1 years (SD, 9.6), and the majority were of black descent (54.4%) and had educational background of some college or an Associate degree (41.9%) or above. Approximately 68% of children reported at least one comorbid conditions, and 51.9% of children had poor asthma control status.
Measurement of daytime sleepiness and asthma-specific HRQOL
Table 2 shows the
Discussion
To our knowledge, our study is among the first to articulate the effect of daytime sleepiness on the relationship between asthma control status and asthma-specific HRQOL in asthmatic children. We found poorly controlled asthma was associated with daytime sleepiness and impaired asthma-specific HRQOL. However, we extend the literature and suggest that, although poor asthma control status was directly and significantly associated with impaired asthma-specific HRQOL, 2 daytime sleepiness domains
Funding sources
This work was supported in part by the National Institutes of Health K23 HD057146-01 (IH) and U01 AR052181-06 (LT, DD, ES, and IH).
Conflict of interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.04.002.
Acknowledgments
The authors thank Kathleen Ryan, MD, and Elizabeth LeFave, ARNP, for screening patient eligibility, and Tiffany Brown, RN, Heidi Saliba, BA, Camille Jackson, MPH, and Mary Anderson, BS, for assisting in data collection.
References (54)
- et al.
Trends in asthma prevalence, health care use, and mortality in the United States, 2001–2010
NCHS Data Brief
(2012) - et al.
Summary health statistics for U.S. children: National Health Interview Survey, 2010
Vital Health Stat
(2011) - et al.
Association of asthma with extra-respiratory symptoms in schoolchildren: two cross-sectional studies 6 years apart
Pediatr Allergy Immunol
(2002) - et al.
Similar asthma prevalence estimates obtained from preadolescent and parent survey responses
J Clin Epidemiol
(2008) - et al.
Status of childhood asthma in the United States, 1980–2007
Pediatrics
(2009) - et al.
Use of beclomethasone dipropionate as rescue treatment for children with mild persistent asthma (TREXA): a randomised, double-blind, placebo-controlled trial
Lancet
(2011) - et al.
Parent misperception of control in childhood/adolescent asthma: the room to breathe survey
Eur Respir J
(2012) - et al.
The Childhood Asthma Control Test: retrospective determination and clinical validation of a cut point to identify children with very poorly controlled asthma
J Allergy Clin Immunol
(2010) - et al.
Modifiable risk factors for suboptimal control and controller medication underuse among children with asthma
Pediatrics
(2008) - et al.
Actual asthma control in a paediatric outpatient clinic population: do patients perceive their actual level of control?
Pediatr Allergy Immunol
(2008)
Inadequate therapy and poor symptom control among children with asthma: findings from a multistate sample
Ambul Pediatr
Asthma medication use and disease burden in children in a primary care population
Arch Pediatr Adolesc Med
Limited agreement between current and long-term asthma control in children: the PACMAN cohort study
Pediatr Allergy Immunol
Parent–child agreement in report of nighttime respiratory symptoms and sleep disruptions and quality
J Pediatr Health Care
Measures of asthma control and quality of life: longitudinal data provide practical insights into their relative usefulness in different research contexts
Qual Life Res
Childhood asthma and student performance at school
J Sch Health
Improvements in symptoms and quality of life following exercise training in older adults with moderate/severe persistent asthma
Respiration
The 12-week progressive quadriceps resistance training improves muscle strength, exercise capacity and quality of life in patients with stable chronic heart failure
Int J Cardiol
Asthma severity and child quality of life in pediatric asthma: a systematic review
Patient Educ Couns
Reliability, validity, and responsiveness of the pediatric quality of life inventory (PedsQL) generic core scales and asthma symptoms scale in vulnerable children with asthma
J Asthma
Measuring quality of life in children with asthma
Qual Life Res
Nocturnal symptoms and sleep disturbances in clinically stable asthmatic children
Asian Pac J Allergy Immunol
Assessing sleep quality and daytime wakefulness in asthma using wrist actigraphy
J Asthma
Sleep and psychological disturbance in nocturnal asthma
Arch Dis Child
Nocturnal asthma
Curr Opin Pulm Med
Nighttime sleep and daytime nap patterns in school age children with and without asthma
J Dev Behav Pediatr
Nocturnal asthma in children affects school attendance, school performance, and parents’ work attendance
Arch Pediatr Adolesc Med
Cited by (24)
Asthma control, social jetlag, and sleep impairment in high school adolescents
2022, Sleep MedicineCitation Excerpt :Previously, nocturnal awakenings and perception of severe respiratory problems were associated with daytime sleepiness in 349 asthmatic adolescents [46]. Children and adolescents aged eight to 17 years with poorly controlled asthma were found to have more daytime sleepiness and worse quality of life than controls [47]. Another study in Sweden analyzed data from 25,160 participants aged between 16 and 75 years and identified 1830 asthmatic people.
Impact of sleep opportunity on asthma outcomes in adolescents
2020, Sleep MedicineUnderstanding the Relationship Between Asthma and Sleep in the Pediatric Population
2016, Journal of Pediatric Health CareCitation Excerpt :This review emphasized the importance of assessing asthma severity when health care providers evaluate patients and the importance of controlling asthma symptoms (Everhart & Fiese, 2009). Poor asthma control has been found to be associated with poor quality of life, poor quality of sleep, and daytime sleepiness (Li et al., 2013; van Maanen et al., 2013). The authors emphasize the importance of evaluating nighttime and daytime symptoms when evaluating patients with asthma (Li et al., 2013; Molzon et al., 2013).
Patient-Reported Outcomes Measurement Information System in Children with Crohn's Disease
2016, Journal of PediatricsLongitudinal associations among asthma control, sleep problems, and health-related quality of life in children with asthma: A report from the PROMIS<sup>®</sup> Pediatric Asthma Study
2016, Sleep MedicineCitation Excerpt :Studies on the complex associations among asthma control, sleep problems, and HRQOL are still scarce. Our previous study based on the path analytic approach found that poorly controlled asthma status was associated with great daytime sleepiness and low asthma-specific HRQOL; more important, daytime sleepiness significantly mediated the association between asthma control status and asthma-specific HRQOL [11]. Another study investigating the relationships of self-reported sleep quality and sleep duration assessed by actigraphy with psychological well-being found that variability in sleep duration over seven days rather than sleep-onset latency or awakening time was associated with poorer subjective well-being [12].
Marcel Proust: Genius and insomnia
2016, Sleep Medicine