Elsevier

Sleep Medicine

Volume 14, Issue 7, July 2013, Pages 641-647
Sleep Medicine

Original Article
The relationships between asthma control, daytime sleepiness, and quality of life among children with asthma: a path analysis

https://doi.org/10.1016/j.sleep.2013.04.002Get rights and content

Abstract

Objectives

We aimed to examine the relationships between asthma control, daytime sleepiness, and asthma-specific health-related quality of life (HRQOL) among children with asthma. Path analyses were conducted to test if daytime sleepiness can mediate the effect of asthma control status on asthma-specific HRQOL.

Methods

160 dyads (pairs) of asthmatic children and their parents were collected for analyses. The Asthma Control and Communication Instrument (ACCI) was used to categorize adequate and poor asthma control status. The Cleveland Adolescent Sleepiness Questionnaire (CASQ) was used to measure children’s daytime sleepiness, including sleep in school, awake in school, sleep in evening, and sleep during transport. The Patient-Reported Outcomes Measurement Information System (PROMIS) Asthma Impact Scale was used to measure asthma-specific HRQOL.

Results

Poorly controlled asthma was associated with daytime sleepiness and impaired asthma-specific HRQOL. Asthma control status was directly associated with asthma-specific HRQOL (P < .05), whereas sleep in school and sleep in evening domains of daytime sleepiness significantly mediated the relationship between poor asthma control and impaired HRQOL (P < .01).

Conclusions

Asthma control status was associated with pediatric asthma-specific HRQOL, and the association was significantly mediated by daytime sleepiness. Healthcare providers need to address pediatric sleep needs related to poor asthma control to reduce the negative impact on HRQOL.

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.

. ICMJE Form for Disclosure of Potential Conflicts of Interest form.

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.

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