Paediatric Haematology
methodology, frequently used to monitor the occurrence and intensity of pain as well as sleep parameters and subjective reports of sleep quality, nocturnal pain was found to be a frequent occurrence for children and adolescents with SCD, occurring on 12 % of nights.31 Shapiro et al. collected pain and sleep diaries twice a day for an average of 10 months in 18 children and adolescents. Results indicated that sleep quality was affected by SCD pain (which occurred on 30 % of the days studied), with children rating sleep quality as poor on 43 % of days with pain, as compared with 3 % of days without pain.32
In this study, sleep duration was also significantly shorter
examined the relationship between sleep and pain in 20 children of age eight to 12 years by using daily sleep and pain diaries and reports of mood and stress for up to eight weeks. The children reported pain on 21 % of days during the course of the study, and the average pain rating on days with pain was 49.83 (on a 0–100 visual analogue scale). Controlling for demographic factors and disease type, the interaction between stress and pain severity created a model that accounted for 72 % of the variance in sleep quality and indicated that younger female patients with HbSS and greater pain severity were more likely to have poor sleep quality.33
during pain episodes. Valrie et al.33,34
Further
analyses indicated that children experiencing greater stress had a stronger negative relationship between pain intensity and sleep quality. Negative mood was also found to mediate partially the relationship between high pain and poor sleep quality during the night and the following day.34
the strength of the pain and sleep quality relationship decreased the following day.
Another study utilising pain and sleep diaries in 20 adolescents found a cyclical relationship between pain and sleep quality, with poor sleep preceding days with pain and days with pain being followed by poor sleep.35
children with SCD as compared to healthy controls3 of desaturation is related to the severity of SCD,39
and the amount occurring more
frequently in children with HbSS and HbSβ0 thalassaemia subtypes compared to HbSC and HbSβ+ thalassemia.38
Nocturnal desaturation may result in increased occurrences of vaso-occlusive episodes40
and/or stroke.41
saturation of 4 % below baseline have been associated with an average of 2.97 more days of pain per year.40
Decreased nocturnal
oxyhaemoglobin saturation may instigate pain because of the effects of desaturation on bone marrow leading to vaso-occlusive episodes40 or because of an increased tendency for the adhesion of red blood cells to the endothelial cells in children with greater oxyhaemoglobin desaturation.39
Nocturnal haemoglobin saturation together with arterial velocity has also been found to predict time until central nervous system events.41
Cerebrovascular disease caused by
hypoxaemia, a reduction in the threshold for infarction or a combination of the two may be mechanisms between sleep-disordered breathing and stroke.41
Not all research, however,
supports the relationship between hypoxaemia and SCD severity as some studies have described similar sleep architecture and nocturnal desaturation for patients with more severe SCD as indicated by two or more hospitalisations in the previous year compared to patients with no SCD-related hospitalisations.42
Daytime Tiredness and Fatigue As participants’ moods became more positive,
Given disruptions in overnight sleep that can occur in children with SCD, children may experience more daytime sleepiness than peers;43 however, little research exists describing sleepiness and fatigue in children with SCD. In studies that have described sleepiness in children and adolescents with SCD,30,36,44
there are somewhat mixed
Analgesic use moderated the relationship between pain intensity and sleep quality such that, when adolescents used analgesics, the relationship between pain and sleep quality was no longer significant. This sample also reported pain on 22 % of study days, indicating marked and frequent disturbances of sleep. A study using retrospective self-reports to examine sleep in 86 adolescents with chronic pain conditions (i.e. headache, juvenile idiopathic arthritis and SCD) demonstrated a small but significant correlation between pain frequency and daytime sleepiness; also, adolescents with longer pain episodes had later bedtimes.36
There are several proposed mechanisms for increased sleep disruption in the context of pain. Changes in sleep architecture may be due to effects of medications taken for pain, disease processes, pain related discomfort, lowered pain threshold,29
results regarding the level of sleepiness children experience, depending on the peer-group comparison. When compared to normative values, parents report significantly higher daytime sleepiness in children with SCD similar to values of children from a clinical sleep disorders sample.30,44
however, similar to controls demographically matched.44
Levels of daytime sleepiness were, Adolescents
with SCD report similar levels of daytime sleepiness to teens with juvenile rheumatoid arthritis and less sleepiness than adolescents with chronic headaches.36
Increased occurrence of sleep-disordered
breathing in children with SCD may also contribute to higher levels of daytime sleepiness, as indicated in other populations.45,46
Additionally, fatigue is a known side effect of anaemia in SCD.47–49 No
studies have examined the co-occurrence of sleepiness and fatigue in children with chronic pain, and thus it is unclear whether higher levels of daytime sleepiness actually reflect fatigue.30
Describing fatigue or a heightened arousal to bodily
). Insufficient overnight sleep could, in turn, interfere with pain-coping skills and alter the perception of pain the following day.37 Poor sleep before the onset of a pain episode may also be indicative of biological changes occurring that eventually cause the pain episode.35
sensations keep the individual from deeper stages of sleep or a heightened arousal to bodily sensations keep the individual from deeper stages of sleep (for a review of pain and sleep in children see Lewin and Dahl37
Hypoxaemia
Nocturnal oxyhaemoglobin desaturation is common among children with SCD38 events.16
60
and appears to be unrelated to upper airway obstructive Oxyhaemoglobin levels can decrease substantially in
from a biobehavioural framework, Ameringer and Smith describe hypoxaemia and inflammation as disease variables that result in fatigue, which is further exacerbated by pain, stress and depression/anxiety experienced by children with SCD.50
The
relationship between fatigue, sleep and quality of life in children and adolescents with SCD has not been studied to date; thus further research is necessary to understand the effects of fatigue on cognitive functioning and academic performance in these children.
Demographic Factors Contributing to Sleep Children with SCD in the US are typically African American and an estimated 36 % of African American children live in low-income families nationally51
making low socioeconomic status (SES) a EUROPEAN ONCOLOGY & HAEMATOLOGY Dips in oxyhaemoglobin
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