Fragmented Sleep Common Among Children and Adolescents With Juvenile Idiopathic Arthritis

Sleep disturbances and complaints are common among children and adolescents with juvenile idiopathic arthritis (JIA), including difficulties maintaining sleep and increased sleep onset latency, according to study results published in Sleep.

Multiple studies have shown an association between sleep and immune function, pain perception, and body energy restitution. Research has also suggested that sleep disturbances may be more common in patients with JIA. However, limited quantitative data exist on sleep outcomes in this population.

The objective of the current systematic review and meta-analysis was to compare sleep duration, quality, and architecture in patients with JIA compared with their healthy peers.

Study authors conducted a systematic search of the PubMed, Embase, Cochrane, and PsycINFO databases from 1990 to 2020 to identify case-control studies in which sleep quantity or quality parameters were measured in children and adolescents with JIA compared with healthy control participants.

The primary outcome was sleep duration, as measured by subjective (ie, diary, self-reported, and questionnaires) and objective (ie, polysomnography [PSG], electroencephalography [EEG], and accelerometry) methods between patients with JIA and their healthy peers.

Secondary outcomes included sleep quality (sleep efficiency, sleep onset latency, and wake after sleep onset) and sleep staging, assessed by PSG or EEG.

Study authors identified 19 publications chosen for fulltext quality assessment and data extraction, including 9 studies exclusively using subjective sleep assessments, 3 studies exclusively using objective methods, and 7 studies using both subjective and objective methods.

A total of 10 studies were included in the current meta-analysis.

Overall, subjective scores of sleep disturbances were higher among patients with JIA, with sleep complaints reported in 20% to 70% of patients, including sleep delay, waking up after bedtime, parasomnias, anxiety, and sleep-disordered breathing. Sleep quality was shown to be altered, according to subjective methods, in most of the studies, while data on sleep duration were limited and less conclusive.

Studies using accelerometry to objectively assess sleep reported mixed results on sleep duration, but noted limitations in using this method to assess sleep in patients with JIA. More recent studies showed sleep disturbances were more common in patients with JIA than matched control participants. 

Laboratory PSG studies, the gold standard method for assessing sleep disorders and architecture, also provided mixed results. While several studies suggested increased arousals, more shifts from deeper to lighter stages of sleep and higher rate of disturbed slow-wave sleep, others showed no alterations in sleep among patients with active JIA.

Functional disability and/or daytime sleepiness were worse during days following nights of poorer sleep quality among children and adolescents with JIA. Pain, sleep duration, and sleep quality were predictors of fatigue severity.

According to the meta-analysis, multiple sleep disturbances were more common among children with JIA vs their healthy peers, with consistent findings in all the studies based on subjective methods (standardized mean differences [SMD], -1.28; 95% CI, -2.10 to -0.47; P <.001). While sleep disturbance analysis indicated considerable heterogeneity, sleep time was unchanged (SMD, -0.10; 95% CI, -0.29 to 0.09; P =.30).

Objective methods were associated with more heterogeneity than subjective methods, but studies were consistent and showed a significantly increased difficulty initiating sleep, according to sleep onset latency (SMD, -0.44; 95% CI, -0.86 to -0.01; P =.04). No increase in wake after sleep onset was reported.

Regarding sleep architecture, no major alteration in the distribution of sleep stages was found, although time spent in stage N2 tended to decrease in children with JIA.

The study had several limitations, including publication bias, large heterogeneity, and the potential impact of associated sleep disorders, comorbidities, and medication status on the findings.

“Although included studies were methodologically diverse, the summarized results of our review and meta-analysis bring evidences that children with JIA present more fragmented sleep compared to healthy peers. Thereby, the implementation of strategies to manage and improve sleep in this population are needed and might have a beneficial effect on the symptoms and functions of JIA,” the study authors concluded.

Reference

Saidi O, Rochette E, Bourdier P S, et al. Sleep in children and adolescents with juvenile idiopathic arthritis: a systematic review and meta-analysis of case-control studies. Sleep. Published online September 15, 2021. doi:10.1093/sleep/zsab233