Saturday, March 17, 2012

Sleep Guidance for Kids and Teens Is Based on Sound Science


Dr. Rotenberg, among other other sleep specialists, signed on to this letter regarding recent articles in Pediatrics. - JR


Sleep Guidance for Kids and Teens Is Based on Sound Science

Posted: 03/16/2012 8:31 am

Representing scores of scientists who study sleep's role in the health and welfare of children, we need to be clear: Current expert recommendations for the sleep needs of children may not be perfect or immutable, but they are based on sound and rigorous science. For the sake of children whose parents, pediatricians and teachers may have seen recent media reports on two papers that call this into question, we're compelled to offer the context of what decades of research has produced.

Perhaps the best service is to describe current recommendations for healthy child sleep and then to describe why the pediatric sleep community of health care professionals is concerned that parents and other stakeholders have become misinformed about how well research supports these recommendations.

First of all, abundant research shows that sleep is a vital component of physical and mental health in children and adolescents. That and other research provides solid scientific grounding for current recommendations. Experts acknowledge that there is some individual variability in sleep needs, and therefore these recommendations are offered as guidelines for parents. They should be viewed in the context of potential signs of insufficient sleep in children and teens (difficulty waking in the morning, daytime sleepiness, sleeping longer on weekends and school vacations). Also, the recommendations for sleep amounts, such as those posted by the National Sleep Foundation (NSF), should always be applied in conjunction with other healthy sleep practices (such as regular bedtimes and wake times and bedtime routines).

As much as we care about children ourselves, we know we owe it to their parents to make (and defend) any recommendations on the basis of research, rather than intuition. We also need to be clear about the health effects of inadequate sleep, given the outward appearance that sleep cuts into "productive" time. Many lay people may not know that sleep is an enormously productive time -- especially for the developing brain -- when the brain organizes itself and consolidates the day's learning.

Here are the stakes. A large number of studies have shown associations between insufficient sleep and adverse health outcomes in teens and younger children. These include increased obesity risk, higher rates of motor vehicle accidents and accidental injuries, reduced cardiovascular health, and increased risk of depression and suicidal ideation. Many other studies have demonstrated the negative outcomes of sleep restriction and the positive impact of sleep extension on cognitive function of children and teens.

In a recent paper in the Eastern Economic Journal, two Brigham Young University economists dismiss such serious medical findings when they purport to determine an "optimal" amount of sleep for kids based on one question -- "How many hours of sleep do you usually get a night?" -- and a small set of standardized test scores. They report that that teens who got less sleep than experts recommend got better scores. We take issue with aspects of their methodology, but even if their paper were technically unassailable, as health professionals we would still be compelled to ask why a narrow set of test scores should be any parent's benchmark for optimal sleep when so many vital health conditions are endangered by too little sleep.

Ultimately, the key issue is to define how much sleep kids and teens need. That's long been a priority of our field because parents and health care professionals have always worried about this question and have needed science to provide answers. What has changed over time has been the increasing quantity and quality of science we've been able to apply. Many rigorous pediatric sleep research studies have done much to help address the issue of optimal sleep duration and healthy sleep practices in children and adolescents. These studies include large epidemiologic approaches as well as rigorous field tests and in-lab brain wave monitoring.We've posted a selected list of these studies and those referenced above, as well as more than 70 co-signers among our colleagues to this essay, on our website.

For all these reasons, we feel we should put in context a recent paper in Pediatrics that gained substantial and unduly credulous media attention. By looking at historical recommendations for sleep and measured sleep durations, the authors claimed that "there is almost no empirical evidence for the optimal sleep duration for children," and that "no matter how much sleep children are getting, it has always been assumed that they need more."

A careful look at the paper shows that almost all of their findings are driven by data in infants, for whom recommendations around the turn of the last century were hugely different from those around the turn of this century. Meanwhile, the sleep recommendations at other ages are pretty much on par across the century. Fundamentally, by ignoring many strong studies that provide a quantitative basis for current sleep recommendations, the authors do a serious disservice to parents, pediatricians, other health professionals, educators and, ultimately, to children. 

The scientific literature shows that children and adolescents experience better learning and academic success and greater physical and mental health when their sleep is protected and supported to levels recommended by a consensus of experts, such as those posted on the NSF website. Our hope is that by understanding the scientific record and context beyond these two recent splashes in the literature, the pediatric sleep community's service to parents and health professionals can be restored.


Mary A. Carskadon, PhD Judith Owens, MD MPH
Professor, Psychiatry and Human Behavior Director of Sleep Medicine
EP Bradley Hospital Children's National Medical Center
Alpert Medical School of Brown University Washington DC 20010-2970
Providence, RI 02906
                                           
1
 A list of references is provided after the list of sleep professionals endorsing the essay.3
Links to Media Coverage
Stories based on the original articles
Challenging 100 Years of Sleep Guidelines for Children - WSJ.com
Children are sleep-deprived, experts have fretted for 100 years - latimes.com
No science, just expert guesses on how much sleep kids need - USATODAY.com
Kids and Sleep Through History: They Have Never Gotten Enough, but Who's to Say How Much They 
Really Need? | Healthland | TIME.com
Scientists say kids throughout history have never had enough sleep | Mom Houston | a Chron.com blog
Responses to media coverage
How Much Sleep Do Kids Need? Not Such A Mystery After All : Shots - Health Blog : NPR
Sleep Expert Stands By Current Sleep Advice for Kids | Parents News Now, by Holly Lebowitz Rossi
Articles
Articles Referred to Directly in the Essay
• Eide, ER & Showalter MH.  Sleep and student achievement.  Eastern Econ J 2012; 1-13.  
Doi:10.1057/33j.2011.33
• Matricciani LA, Olds TS, Blunden S, Rigney G, Williams MT. Never Enough Sleep: A Brief 
History of Sleep Recommendations for Children. Pediatrics. 2012;129:548-556.
Selected Additional Articles on Childhood & Adolescent Sleep
1. Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy to adolescence: 
reference values and generational trends. Pediatrics. 2003;111:302-7.
2. Iglowstein I, Latal Hajnal B, Molinari L, Largo RH, Jenni OG. Sleep behaviour in preterm children
from birth to age 10 years: a longitudinal study. Acta Paediatr. 2006;95:1691-3.
3. Eaton DK, McKnight-Eily LR, Lowry R, Perry GS, Presley-Cantrell L, Croft JB. Prevalence of
insufficient, borderline, and optimal hours of sleep among high school students - United States, 
2007. J Adolesc Health. 2010;46:399-401.
4. Galland BC, Taylor BJ, Elder DE, Herbison P. Normal sleep patterns in infants and children: A
systematic review of observational studies. [published online ahead of print July 23, 2011]. Sleep 
Med Rev 2011. http://www.sciencedirect.com/science/article/pii/S1087079211000682. Accessed 
February17, 2012
5. Wolfson AR, Carskadon MA. Understanding adolescents' sleep patterns and school performance: a
critical appraisal. Sleep Med Rev. 2003;7:491-506.
6. Beebe DW. Cognitive, behavioral, and functional consequences of inadequate sleep in children and4
adolescents. Pediatr Clin North Am. 2011;58:649-65.
7. Berger RH, Miller AL, Seifer R, Cares SR, Lebourgeois MK. Acute sleep restriction effects 
onemotion responses in 30- to 36-month-old children. [published online ahead of print October 11, 
2011]. J Sleep Res. 2011. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2869.2011.00962.x/full. 
Accessed February 17, 2012
8. Arman AR, Ay P, Fis NP, Ersu R, Topuzoglu A, Isik U, et al. Association of sleep duration with
socio-economic status and behavioural problems among schoolchildren. Acta Paediatr. 
2011;100:420-4.
9. Gruber R, Laviolette R, Deluca P, Monson E, Cornish K, Carrier J. Short sleep duration is associated 
with poor performance on IQ measures in healthy school-age children. Sleep Med. 2010;11:289-94.
10. Feinberg I, Campbell IG. Sleep EEG changes during adolescence: an index of a fundamental brain
reorganization. Brain Cogn. 2010;72:56-65.
11. Nevarez MD, Rifas-Shiman SL, Kleinman KP, Gillman MW, Taveras EM. Associations of early life
risk factors with infant sleep duration. Acad Pediatr. 2010;10:187-93.
12. Spilsbury JC, Storfer-Isser A, Drotar D, Rosen CL, Kirchner LH, Benham H, et al. Sleep behavior in
an urban US sample of school-aged children. Arch Pediatr Adolesc Med. 2004;158:988-94.
13. Magee L, Hale L. Longitudinal associations between sleep duration and subsequent weight gain: A
systematic review. [published online ahead of print July 23, 2011]. Sleep Med Rev. 2011.
http://www.sciencedirect.com/science/article/pii/S1087079211000608. Accessed February 17, 2012.
14. Vorona RD, Szklo-Coxe M, Wu A, Dubik M, Zhao Y, Ware JC. Dissimilar teen crash rates in two
neighboring southeastern Virginia cities with different high school start times. J Clin Sleep Med.
2011;7:145-51.
15. Boto LR, Crispim JN, de Melo IS, Juvandes C, Rodrigues T, Azeredo P, et al. Sleep deprivation and
accidental fall risk in children. Sleep Med. 2012;13:88-95.
16. Gangwisch JE, Malaspina D, Babiss LA, Opler MG, Posner K, Shen S, et al. Short sleep duration as 
a risk factor for hypercholesterolemia: analyses of the National Longitudinal Study of Adolescent
Health. Sleep. 2010;33:956-61.
17. Lin JD, Tung HJ, Hsieh YH, Lin FG. Interactive effects of delayed bedtime and family-associated
factors on depression in elementary school children. Res Dev Disabil. 2011;32:2036-44.
18. Fitzgerald CT, Messias E, Buysse DJ. Teen sleep and suicidality: results from the youth risk
behavior surveys of 2007 and 2009. J Clin Sleep Med. 2011;7:351-6.
19. Gruber R, Wiebe S, Montecalvo L, Brunetti B, Amsel R, Carrier J. Impact of sleep restriction on
neurobehavioral functioning of children with attention deficit hyperactivity disorder. Sleep.
2011;34:315-
20. Beebe DW, Rose D, Amin R. Attention, learning, and arousal of experimentally sleep-restricted
adolescents in a simulated classroom. J Adolesc Health. 2010;47:523-5.
21. Randazzo AC, Muehlbach MJ, Schweitzer PK, Walsh JK. Cognitive function following acute sleep
restriction in children ages 10-14. Sleep. 1998;21:861-8.
22. Sadeh A, Gruber R, Raviv A. The effects of sleep restriction and extension on school-age children:
what a difference an hour makes. Child Dev. 2003;74:444-55.
23. Van den Bulck J. The effects of media on sleep. Adolesc Med State Art Rev. 2010;21:418-29, vii.
24. Bryant Ludden A, Wolfson AR. Understanding adolescent caffeine use: connecting use patterns with 
expectancies, reasons, and sleep. Health Educ Behav. 2010;37:330-42.
25. Hale L, Berger LM, LeBourgeois MK, Brooks-Gunn J. A longitudinal study of preschoolers'
language-based bedtime routines, sleep duration, and well-being. J Fam Psychol. 2011;25:423-33.
26. Mindell JA, Telofski LS, Wiegand B, Kurtz ES. A nightly bedtime routine: impact on sleep in young
children and maternal mood. Sleep. 2009;32:599-606.
27. Mindell JA, Meltzer LJ, Carskadon MA, Chervin RD. Developmental aspects of sleep hygiene:  
findings from the 2004 National Sleep Foundation Sleep in America Poll. Sleep Med. 2009;10:771-5
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28. Wolfson, A.R. and Carskadon, M.A.  Sleep schedules and daytime functioning in adolescents.  Child 
Development 1998;69(4):875-887.  PMID: 9768476
29. Carskadon, M.A., Harvey, K., Duke, P., Anders, T.F., Litt, I.F., and Dement, W.C.  Pubertal changes 
in daytime sleepiness.  Sleep  1980; 2: 453-460.  PMID: 7403744  PMID: 12224838
30. Carskadon, M.A., Wolfson, A.R., Acebo, C., Tzischinsky, O., and Seifer, R.  Adolescent sleep 
patterns, circadian timing, and sleepiness at a transition to early school days.  Sleep 1998; 21(8):871-
881.  PMID: 9871949
31. Carskadon, M.A., Harvey, K., and Dement, W.C.  Acute restriction of nocturnal sleep in children.  
Percept. Motor Skills  1981; 53: 103-112.
32. Fallone, G., Acebo, C., Arnedt, J.T., Seifer, R., and Carskadon, M.A.  Effects of acute sleep 
restriction on behavior, sustained attention, and response inhibition in children.  Percept. Motor 
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33. Ohayon, M.M., Carskadon, M.A., Guilleminault, C., and Vitiello, M.  Meta-analysis of quatitative 
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34. Fallone, G., Acebo, C., Seifer, R., Carskadon, M.A.  Experimental restriction of sleep opportunity in 
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Link to Essay here
Huffingotn post published  here

The sentiments expressed in the essay were endorsed by the following individuals:
Full Name Affiliation
Candice A. Alfano, Ph.D. University Of Houston
Rosana Alves, MD, PhD Department of Neurology, Sao Paulo Medical 
School, University of Sao Paulo, Sao Paulo, Brazil
Strahil Atanasov, MD 
Kristin T. Avis, Ph.D, CBSM University of Alabama at Birmingham Dept of 
Pediatrics
Robert Beckerman, MD Section Chief, Pediatric Pulmonary and Sleep 
Medicine, Children’s Mercy Hospital, University of 
Missouri in Kansas City School of Medicine
Dean W. Beebe, Ph.D. Cincinnati Children’s Hospital Medical Center and 
University of Cincinnati College of Medicine
Julie Boergers, PhD Alpert Medical School of Brown University, 
Bradley-Hasbro Children’s Research Center
Lee J. Brooks, MD Children’s Hospital of Philadelphia, University of 
Pennsylvania
Tyish S. Hall Brown, Ph.D Assistant Professor, Department of Psychiatry, 
Howard University College of Medicine
Oliviero Bruni, MD Department of Pediatrics and Developmental 
Neurology, Tel-Aviv University
Joseph A. Buckhalt, Ph.D. Auburn University
Margaret A. Cashman, MD, 
FAASM
Harborview Medical Center; Department of 
Psychiatry and Behavioral Sciences, University of 
Washington School of Medicine
Mary Cataletto, MD Director, Children’s Sleep Services, Winthrop 
University Hospital, Mineola, NY
Sangeeta Chakravorty MD Director, Pediatric Sleep Evaluation Center, 
Children’s Hospital of Pittsburgh of UPMC
S.P.Chan MBBS Director of Pediatric Pulmonology, Staten Island 
University Hospital, New York
Barry A. Cohen, MD Pediatric Sleep Specialist, Saint Barnabas Medical 
Center, Livingston, NJ
Heidi V. Connolly, MD Chief, Division of Pediatric Sleep Medicine, 
Associate Professor of Pediatrics and Psychiatry,  
University of Rochester
Penny Corkum, PhD Departments of Psychology, Psychiatry & 
Pediatrics, Dalhousie University, Halifax, Nova 
Scotia, Canada
Flavia Cortesi MD Dept Pediatrics & Child Neuropsychiatry University 
of Rome “La Sapienza”, Italy 
Stephanie Crowley, PhD Assistant Professor, Department of Behavioral 
Sciences, Rush University Medical Center, ChicagoGary Feldman, M.D. Medical Director, Pediatric Sleep Disorders Center, 
Miller Children's Hospital Long Beach, Long 
Beach, CA 
Karyn Gail France, PhD, 
DipClinPsyc
Associate Professor, Programme Coordinator, Child 
and Family Psychology Programme, University of 
Canterbury, Christchurch, New Zealand
Dominic Gault, M.D. Medical Director, Division of Pediatric Sleep 
Medicine, Greenville Hospital System Children's 
Hospital 
Peter Glusker, MD-PhD, FAAN, 
FASM, FACP
Retired Adjunct Clinical Assistant Professor, 
Department of Neurosciences, Stanford Medical 
Center, Texas Childrens Hospital
Roger Godbout, Ph.D., 
psychologist
Professor of Psychiatry, University de Montréal, 
Montreal, Canada and Director of the Sleep 
Laboratory & Clinic, Riviere-des-Prairies, Montreal, 
Canada
David Gozal, MD  The Herbert T. Abelson Professor and Chair, 
Department of Pediatrics, The University of 
Chicago; Physician-in-Chief, Comer Children's 
Hospital 
Michael Gradisar, PhD, 
M.Psyc.(Clin.)
Flinders University, Australia
Madeleine Grigg-Damberger, MD Professor of Neurology, Medical Director of 
Pediatric Sleep Services, Associate Medical 
Director of the Clinical Neurophysiology 
Laboratory, University of New Mexico School of 
Medicine
Jim Halsey, R.R.T., RPSGT, RST Department of Respiratory Care, Stephens County 
Hospital, Toccoa, GA
Allison Harvey, PhD Professor of Clinical Psychology, University of 
California, Berkeley.
Jacqueline MT Henderson, PhD Canterbury Sleep Programme, Department of 
Psychology, University of Canterbury, Cristchurch, 
New Zealand
 Ibrahim MD Cleveland Clinic, Cleveland OH
Kyle P. Johnson, MD Associate Professor, Departments of Pediatrics and 
Psychiatry, Oregon Health & Science University
Lewis J. Kass, MD Westchester Pediatric Pulmonology and Sleep 
Medicine, Mt. Kisco, NY; Pediatric Sleep Disorders 
Center at Norwalk Hospital, Norwalk, CT
Sharon A. Keenan, Ph.D., 
REEGT, RPSGT
Diplomate of The American Board of Sleep 
Medicine and Director, The School of Sleep 
Medicine, Inc., Palo Alto, CA 
Amit Khanna, MD Adult & Pediatric Sleep Center, Lawrence & 
Memorial Hospital
Suresh Kotagal, M.D. Consultant, Neurology, Pediatrics and the Center for 
Sleep Medicine, Mayo Clinic, Rochester, MinnesotaAndrea M. Landis, PhD, RN Assistant Professor, Family & Child Nursing, 
University of Washington School of Nursing, 
Seattle, WA
Albin Leong, MD Chief, Pediatric Pulmonology, Roseville Kaiser 
Medical Center, The Permanente Medical Group, 
Inc.
Robin M. Lloyd, M.D. Mayo Clinic Center for Sleep Medicine
 Mark W. Maholwald, MD Professor, Department of Neurology, University of 
Minnesota Medical School and Visiting Professor, 
Department of Psychiatry and Behavioral Sciences, 
Stanford University
Cami Matthews, MD General Pediatric and Adolescent Medicine, UW 
Health Pediatric East Clinic, Madison, WI
Lisa J. Meltzer, Ph.D. Assistant Professor of Pediatrics, National Jewish 
Health
Richard P. Millman, MD Professor and Vice Chair of Medicine, Division of 
Biology and Medicine, Alpert Medical School, 
Brown University
Paul Montgomery Professor of Psycho-Social Intervention, University 
of Oxford, Oxford. UK
Cynthia D. Nichols, PhD, 
FAASM, CBSM
Neuropsychologist, Munson Healthcare Sleep 
Disorders Center
Camilo Ortiz, Ph.D. Doctoral Program in Clinical Psychology, Long 
Island University, CW Post
Phillip L. Pearl, M.D. Division Chief, Child Neurology, Children’s 
National Medical Center; Professor of Neurology, 
Pediatrics, and Music, The George Washington 
University School of Medicine and Columbian 
College of Arts and Sciences, Washington, D.C.
Rafael Pelayo, MD Stanford University School of Medicine
Rosa Peraita-Adrados, MD, PhD  Sleep Disorders Unit – Clinical Neurophysiology 
Department, Univeristy Hospital Gregorio Marañón, 
Madrid, Spain
Judi Profant, PhD, CBSM Kaiser Permanente, University of California, Irvine
Brandy M. Roane, Ph.D. Sleep for Science Research Laboratory of Brown 
University
Dominic Roca, MD PhD Stamford Hospital, Stamford CT
Mary Rose, PsyD, CBSM Assistant Professor, Director, Psycho-Oncology, 
Lester & Sue Smith Breast Center, Baylor College 
of Medicine
Carol L. Rosen, MD Professor, Department of Pediatrics, Case Western 
Reserve University, University Hospitals of 
Cleveland, Case Medical Center, Rainbow Babies & 
Children's Hospital
Mark Rosenblum, Psy D, LP, 
CBSM
Director, Insomnia Program, Minnesota Sleep 

Institute
Joshua Rotenberg, MD, Diplomate American Board of Psychiatry & Neurology, Child Neurology, & Sleep Medicine, Texas Medical & Sleep Specialists, Houston TX and San Antonio, TX.


Paul A. Rothenberg, Ph.D. Long Island Jewish Medical Center and Greenwich 
Hospital Sleep Disorder Centers
John Saito, MD FAAP FCCP Diplomate in the American Board of Sleep 
Medicine; President, Pulmonary & Sleep Disorder 
Consultants, Irvine, California. 
John N. Schuen, MD Chief, Pediatric Pulmonary and Sleep Medicine, 
Michigan State University-College of Human 
Medicine, Grand Rapids, MI
David C. Schwebel, PhD Professor of Psychology and Associate Dean for 
Research in the Sciences, University of Alabama at 
Birmingham
Yakov Sivan, MD Dana Children's Hospital, Tel Aviv University 
Faculty of Medicine,Tel Aviv Medical Center, Israel
George F. Slade
Kevin C. Smith, PhD University of Missouri -- Kansas City School of 
Medicine, Pediatric Psychologist, Section of 
Developmental and Behavioral Sciences, Section of 
Pediatric Pulmonary and Sleep Medicine, Children's 
Mercy Hospitals and Clinics
Jim Spilsbury, PhD, MPH Assistant Professor & Director, Academic 
Development Core, Center for Clinical 
Investigation,  Case School of Medicine
Kingman P. Strohl MD Case Western reserve University, Cleveland OH
Lisa Talbot, Ph.D. San Francisco VA Medical Center and University of 
California, San Francisco
Douglas M. Teti, Ph.D. Associate Director, Social Science Research 
Institute; Professor of Human Development, 
Psychology, and Pediatrics, The Pennsylvania State 
University; Lead Faculty, Parenting-at-Risk Faculty 
Research Initiative; Associate Editor, Infancy
Amy Walker, PhD, RN Assistant Professor, University of Washington, 
Department of Family & Child Nursing, Seattle
Teresa Ward, RN, Ph Assistant Professor,  Family & Child Nursing, 
University of Washington, Seattle
Shelly Weiss, MD FRCPC Associate Professor, University of Toronto; 
President, Canadian Sleep Society
Luci Wiggs, PhD Reader in Psychology, Oxford Brookes University, 
Oxford, UK
Mark C. Wilson, MD Children’s Hospital and Medical Center, UNMC, 
Omaha, NE
Amy Wolfson, PhD Professor of Psychology, College of the Holy Cross


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