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Sleep Disturbance As a Contributor to Pediatric Obesity: Implications and Screening Gitanjali Srivastava1*, Valerie O’Hara2 and Nancy Browne2

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Sleep Disturbance As a Contributor to Pediatric Obesity: Implications and Screening Gitanjali Srivastava1*, Valerie O’Hara2 and Nancy Browne2 ISSN: 2572-4053 Srivastava et al. J Sleep Disord Manag 2018, 4:019 DOI: 10.23937/2572-4053.1510019 Volume 4 | Issue 1 Journal of Open Access Sleep Disorders and Management REVIEW ARTICLE Sleep Disturbance as a Contributor to Pediatric Obesity: Implications and Screening Gitanjali Srivastava1*, Valerie O’Hara2 and Nancy Browne2 1Department of Medicine, Section of Endocrinology, Diabetes, Nutrition & Weight Management, Nutrition Check for and Weight Management Center, Boston University School of Medicine, Boston, USA updates 2Department of Pediatrics, Eastern Maine Medical Center, WOW Pediatric & Adolescent Weight & Cardiometabolic Clinic, Orono, Maine, USA *Corresponding author: Gitanjali Srivastava, MD, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition & Weight Management, Nutrition and Weight Management Center, Boston University School of Medicine, 720 Harrison Avenue, Doctors Office Building, Suite 801D, Boston, MA 02118, USA, E-mail:[email protected] Abstract lescents is approximately 27% of school-aged children and 45% of adolescents; lower levels of parental edu- Obesity causes more than 200 medical disorders includ- ing cardiovascular disease, diabetes, hypertension, sleep cation, increased caffeine consumption, and presence apnea. In particular, the prevalence and rate of obesity in of electronics in the child’s bedroom overnight may be children and adolescents have increased with over 1/3 of predictive of insufficient sleep duration [2]. the US pediatric population afflicted with overweight and obesity. Though there is a multifactorial etiology including Studies as early as 2002 illustrate a link between complex biological and physiological mechanisms involved obesity in children and sleep duration. Limitations from in energy regulation that may predispose toward an obesity these studies include data collected from parental re- phenotype, we highlight an often missed and overlooked etiology of obesity in clinical assessment in children- sleep port and study design [3-5]; however, later studies ad- disturbance and its causation to weight gain. We also high- dress these concerns resulting in further associations light pertinent findings on clinical history and examination, between sleep disturbances, pediatric obesity, and poor with particular attention to the pediatric population, along metabolic health, including a meta-analyses suggesting with routinely used screening tools for sleep disturbances in that insufficient sleep is associated with increased risk the clinical assessment of the patient with obesity. of obesity in children (range 58-89%) [6,7]. Further, Keywords sleep disturbance is linked to insulin resistance, cardio- Sleep disturbance, Childhood obesity, Adolescent obesity, vascular disease and type 2 diabetes [8-12], which are Sleep apnea, Sleep disorders on children, Metabolic syn- increasingly common in children with obesity [13]. drome Sleep disturbance is identified as a novel risk factor Introduction for increased vulnerability to obesity and cardiometa- bolic disease as a result of dysregulation of appetite, Obesity is one of the leading causes of morbidity and increased glucose intolerance, and elevation of blood mortality in the United States and globally. The preva- pressure [12-18]. Our understanding of sleep as a key lence of overweight and obesity in children in the US modulator of metabolic syndrome and obesity pheno- currently approaches 33% with increasing severity with type provides additional opportunity to intervene early age: 41.5% of US 16-19 year-old adolescents are classi- and provide mitigating strategies to either slow pro- fied with obesity and 4.5% meet the criteria for Class III gression of weight gain or lose weight. Prompt recog- obesity (BMI > 140th of the 95th percentile) [1]. The prev- nition of the association between sleep pathology and alence of chronic sleep restriction in children and ado- obesity, especially in children, paves a potential path- Citation: Srivastava G, O’Hara V, Browne N (2018) Sleep Disturbance as a Contributor to Pediatric Obesity: Implications and Screening. J Sleep Disord Manag 4:019. doi.org/10.23937/2572-4053.1510019 Accepted: July 14, 2018: Published: July 16, 2018 Copyright: © 2018 Srivastava G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Srivastava et al. J Sleep Disord Manag 2018, 4:019 • Page 1 of 8 • DOI: 10.23937/2572-4053.1510019 ISSN: 2572-4053 Table 1: Sleep Disturbances - Classifications, Sub-Types, Characteristics. Classification Sub-Types Characteristics Insomnias -Acute -Difficulty initiating & maintaining sleep -Chronic -Chronic: exists > 3 months & > 3 times/week -Comorbid -Comorbid: associated with affective disorders, stimulants, alcohol use Sleep Related Breathing -OSA (chronic vs. short term) -Snoring, labored/breathing Disorders (SRBD) -Central sleep apnea syndromes -Daytime consequences: Sleep deprivation, -Sleep-related hypoventilation -Hypercapnia -Sleep related hypoxemia Central Disorders of -Narcolepsy -Excessive daytime sleepiness disorders which are not Hypersomnolence -Kleine-Levin syndrome -Hypersomnia included in other categories due to medical or psychiatric disorder -Idiopathic Circadian Rhythm Sleep- -Delayed Sleep Phase Disorder -Internal (endogenous) abnormalities of the body’s wake Disorders (DSPD) circadian rhythm (sleep/wake cycle) -Night Eating Syndrome (NES) -Entrained to 24 hours by external factors, specifically light -Short-term circadian rhythm disturbance includes jet lag -Chronic circadian rhythm disturbance exhibited in night- shift workers Parasomnias: NREM: -Disorders associate with sleep stages and partial arousal -Confusional arousals, sleepwalking, Non-Rapid Eye Movement sleep terrors, and sleep-related eating Types (NREM) disorder (SRED) REM: Rapid Eye REM sleep behavior disorder and nightmare disorder Movement Types Other parasomnias include: sleep (REM) enuresis, exploding head syndrome, sleep-related hallucinations Sleep Related Movement -Restless leg syndrome, -Simple, repetitive movements during sleep Disorders -Periodic movement disorder -Associated with dysesthesias or cramps -Myoclonus, bruxism, and sleep- related movements due to medical condition or medicine way for more effective treatment of a chronic, debilitat- cognitive functioning, memory, mood stabilization, and ing disease [19]. any number of neurobiologic and neuroendocrine func- tions. Sufficient, effective sleep is basic to the optimal In this review, we highlight a frequently overlooked functioning for humans [20]. etiology of pediatric obesity in clinical assessment- sleep disturbance and its causation to weight gain. We Conversely, chronic, insufficient sleep is related to emphasize pertinent findings on clinical history or ex- the consequences of the body not meeting this basic amination along with routinely used screening tools for need. These consequences range from mild (drowsi- sleep disturbances in children. Common sleep distur- ness, sluggishness) to more chronic debility (difficulty bances are summarized in Table 1 and Classification sec- maintaining wakefulness, lapses in attention, poor cog- tion; a more in-depth discussion (including screening, nitive performance, and emotional instability); there evaluation, and treatment) of obstructive sleep apnea are a host of behavioral and cognitive conditions that (OSA), restless leg syndrome (RLS), delayed sleep phase may result from chronic, insufficient sleep [21]. disorder (DSPD), sleep related eating disorder (SRED), Sleep patterns and behaviors evolve in infancy, child- and night eating syndrome (NES) follows. A brief discus- hood, and adolescence just as many other physiological sion of the associations between pediatric obesity and and behavioral processes develop; intrinsic (physiolog- pediatric sleep disorders concludes the paper. ical) and extrinsic (environment including parenting) Children and Sleep processes affect each child and their smooth progress through optimal sleep development. It is through this The activity of sleep is life sustaining; it is estimated lens that “normal struggles” in managing sleep tran- that older children and adolescents spend up to 40% of sitions from infancy to toddlerhood and progressing their day in sleep; younger children significantly more. through normal developmental stages is to be expected This complex activity is highly regulated to allow for and part of normal development; these struggles tend restorative functions of the body which include neuro- to be transient. These normal struggles are in contrast Srivastava et al. J Sleep Disord Manag 2018, 4:019 • Page 2 of 8 • DOI: 10.23937/2572-4053.1510019 ISSN: 2572-4053 to sleep disorders which tend to be chronic in nature; A few studies in youth link sleep deprivation and children with chronic diseases are a higher risk for these the development of metabolic syndrome components. sleep disturbances [22]. Weiss, et al. demonstrated a reduction of leptin levels Sleep/Obesity Association in Youth along with increased caloric consumption and slight in- crease in weight in a group of thirty-six 8-11 year-old Youth with the chronic disease of obesity are at par- with sleep restriction [26]. Other studies found associ- ticular risk for associated sleep disorders. The processes ations between sleep deprivation and higher glycemic that contribute to the association
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