Abstract
Background: Type 1 Diabetes Mellitus (T1DM) is a common chronic illness of childhood involving intensive daily management. An emerging body of literature has reported on sleep disturbances in children/adolescents with T1DM and their parents, with the potential to adversely affect daytime functioning and health. However the evidence in this area for both children and parents is limited and mixed, prompting further research exploring the impacts of T1DM and its management on sleep in both of these groups.
Aims: To investigate habitual sleep patterns, sleep states and awakenings in children and adolescents with T1DM; to examine associations between sleep, glucose levels, and glycaemic control in this population; to explore maternal and paternal perceptions of childhood T1DM related parental sleep disturbance; and to consider potential solutions advocated by these parents to improve their sleep and provision of night-time T1DM care.
Methods: Study 1 (observational) included 41 children/adolescents (5-18 years) with T1DM (cases) and 41 controls. Sleep was measured with in-home polysomnography (PSG), 7-days of actigraphy and the Paediatric Sleep Questionnaire (PSQ). Participants with T1DM had 7-days of continuous glucose monitoring and haemoglobin A1c (HbA1c) collected. Regression analyses were used to model within and between group comparisons. Study 2 (qualitative) included 10 mothers and 10 fathers of children with T1DM (≤ 18 years of age). Semi-structured interviews were audio-recorded, transcribed, and systemically coded for themes. Sleep was assessed with 7-days of actigraphy and the Pittsburgh Sleep Quality Index (PSQI).
Results: In study 1, cases had significantly later sleep onset and offset than controls (both p < 0.05) and greater parental report of daytime sleepiness on PSQ. Cases with suboptimal glycaemic control (HbA1c ≥ 58mmol/mol) had significantly shorter total sleep time as measured by PSG (mean difference [MD] =-40 minutes, 95% CI = -77, -3) and actigraphy, compared to those with optimal glycaemic control. Cases with mean CGM glucose levels ≥10 mmol/L on the PSG night had significantly more non rapid-eye movement (NREM) stage 3 (%) sleep (MD = 6.0; 95% CI = 0.4, 11.7; p = 0.037) and less stage REM (%) sleep (MD = -4.4; 95% CI = -7, -1.7; p = 0.002) than cases with mean CGM glucose levels <10mmol/L. In study 2, the PSQI revealed poor sleep quality in 75% of parents. A range of diabetes-related factors similarly contributed to maternal and paternal sleep disturbance, including glucose monitoring and fear of hypoglycaemia. In general, mothers described greater night-time care burden and sleep disturbance. Two distinct time periods were associated with greater sleep disturbance, namely, following a child’s T1DM diagnosis and when transitioning to using a new diabetes technology. The use of diabetes technologies were generally advocated to improve parental sleep and the provision of nocturnal T1DM care, but were also perceived to contribute to sleep disturbance.
Conclusions: Suboptimal glycaemic control, and aspects of T1DM and its management appear to impact upon sleep in children with T1DM and their parents. Paediatric care teams should be aware of the potential interrelationship between sleep and T1DM, and the potential for parental sleep to be impacted due to night-time caregiving. Sleep assessment and education in the context of optimising glycaemic control in children may be warranted. Diabetes technologies may improve parental sleep and nocturnal T1DM care, but families should be warned of the potential for these devices to also contribute to sleep disruption.