SHS Pada Asma

7/30/2019 SHS Pada Asma

1/10

DOI: 10.1542/peds.2009-0690; originally published online January 18, 2010;2010;125;e261Pediatrics

Beebe and Judith OwensKimberly Yolton, Yingying Xu, Jane Khoury, Paul Succop, Bruce Lanphear, Dean W.

ChildrenAssociations Between Secondhand Smoke Exposure and Sleep Patterns in

http://pediatrics.aappublications.org/content/125/2/e261.full.html

located on the World Wide Web at:The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2010 by the American Academypublished, and trademarked by the American Academy of Pediatrics, 141 Northwest Point

publication, it has been published continuously since 1948. PEDIATRICS is owned,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on May 1, 2012pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/content/125/2/e261.full.htmlhttp://pediatrics.aappublications.org/content/125/2/e261.full.htmlhttp://pediatrics.aappublications.org/content/125/2/e261.full.htmlhttp://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/content/125/2/e261.full.html


2/10

Associations Between Secondhand Smoke Exposureand Sleep Patterns in Children

WHATS KNOWN ON THIS SUBJECT:Adult and adolescent

smokers report difficulties with sleep. Young children who are

exposed to tobacco smoke have poorer sleep quality. Children

with asthma report more sleep problems and are more sensitive

to the respiratory effects of tobacco smoke.

WHAT THIS STUDY ADDS: We report significant associations

between SHS exposure, as measured with a biological marker

(serum cotinine levels), and sleep problems in children with

asthma. Reduction in SHS exposure is an area with the potential

for significant impact in the pediatric population.

abstractOBJECTIVES: The objective of this study was to investigate the relation-

ship between exposure to secondhand smoke (SHS) and child sleep

patterns among a group of children with asthma who were exposed

regularly to tobacco smoke at home.

METHODS: We studied 219 children who were enrolled in an asthma

intervention trial and were exposed regularly to SHS. Serum cotinine

levels were used to measure exposure to tobacco smoke, and sleep

patterns were assessed through parent reports using the ChildrensSleep Habits Questionnaire. Covariates in adjusted analyses included

gender, age, race, maternal marital status, education, and income,

prenatal tobacco exposure, maternal depression, Home Observation

for Measurement of the Environment total score, household density,

asthma severity, and use of asthma medications.

RESULTS: Exposure to SHS was associated with sleep problems, in-

cluding longer sleep-onset delay (P .004), sleep-disordered breath-

ing (P .02), parasomnias (P .002), daytime sleepiness (P .022),

and overall sleep disturbance (P .0002).

CONCLUSIONS: We conclude that exposure to SHS is associated with

increased sleep problems among children with asthma. Pediatrics2010;125:e261e268

AUTHORS:Kimberly Yolton, PhD,

a

Yingying Xu, MS, MA,

a

Jane Khoury, PhD,b Paul Succop, PhD,c Bruce Lanphear,

MD, MPH,d Dean W. Beebe, PhD,e and Judith Owens, MDf

Divisions of aGeneral and Community Pediatrics andbBiostatistics and Epidemiology, andeBehavioral Medicine and

Clinical Psychology, Department of Pediatrics, Cincinnati

Childrens Hospital Medical Center, Cincinnati, Ohio;cDepartment of Environmental Health, University of Cincinnati,

Cincinnati, Ohio;dFaculty of Health Sciences, Simon Frasier

University and British Columbia Childrens Hospital, Vancouver,

Canada; andfDepartment of Pediatrics, Brown University,

Providence, Rhode Island

KEY WORDS

passive smoking, environmental exposure, sleep, child, asthma

ABBREVIATIONS

CSHQChildrens Sleep Habits Questionnaire

ORodds ratio

CIconfidence interval

SHSsecondhand smoke

HOMEHome Observation for Measurement of the Environment

www.pediatrics.org/cgi/doi/10.1542/peds.2009-0690

doi:10.1542/peds.2009-0690

Accepted for publication Aug 3, 2009

Address correspondence to Kimberly Yolton, PhD, Cincinnati

Childrens Hospital Medical Center, Division of General and

Community Pediatrics, 3333 Burnet Ave, ML 7035, Cincinnati, OH

45229-3039. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2010 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have

no financial relationships relevant to this article to disclose.

ARTICLES

PEDIATRICS Volume 125, Number 2, February 2010 e261at Indonesia:AAP Sponsored on May 1, 2012pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/


3/10

Appropriate sleep quality and quantity

are increasingly being recognized as

critical elements for many aspects

of child health and development. For

children, inadequate sleep has been

linked with poor school performance,1

somatic complaints,1 behavior prob-lems,25 and mental health problems.1,6

In addition, sleep problems during

childhood are associated with in-

creased incidence of anxiety and de-

pression, aggressive behaviors, and

attention problems in adulthood,

which suggests a lasting impact of

sleep problems on mental health.7

Poor childhood sleep also predicts the

development of obesity and its associ-

ated morbidities,8,9 which indicatesan important influence on health

outcomes.

More than 25% of children experience

some type of sleep problem during

childhood.1,1012 Among children with

asthma, the prevalence of sleep

problems is higher, with 40% to 60%

having some difficulty.13,14 Children

with asthma are nearly 4 times more

likely to experience sleep-disordered

breathing,15 which results in sleepdisruption and decreased sleep effi-

ciency,16 reduced sleep quality, in-

creased nighttime activity levels,17 and

more difficulties with daytime sleepi-

ness.16,18 Sleep efficiency has been

shown to improve with effective treat-

ment of asthma symptoms,16 but even

children with clinically stable asthma

have worse sleep quality and more

daytime sleepiness than do children

without asthma.19

Tobacco exposure is a risk factor for

sleep problems in adolescents and

adults. Cigarette smoking is associ-

ated with changes in sleep architec-

ture, with smokers experiencing

longer latency to sleep initiation and

lighter sleep.20 Adult and adolescent

smokers report more sleep problems,

such as trouble initiating sleep, main-

taining sleep, difficulty waking, and

daytime sleepiness.2124 Women who

smoke during pregnancy are more

likely to report insufficient sleep, diffi-

culty initiating sleep, early morning

waking, short sleep duration, snoring,

and excessive daytime sleepiness,

compared with pregnant women whodo not smoke. Interestingly, women

who are nonsmokers but are exposed

to secondhand smoke (SHS) during

pregnancy also report more difficul-

ties with sleep, including insufficient

sleep, difficulty initiating sleep, and

short sleep duration, compared with

those not exposed.25

This effect of SHS on sleep in adult

women raises concerns about the po-

tential impact on children whose fam-ily members smoke. There is little re-

search on the influence of tobacco

smoke exposure on sleep patterns in

childhood. Young children who are ex-

posed to tobacco smoke either prena-

tally or postnatally are reported to

have poorer sleep quality26 and more

symptoms of sleep-disordered breath-

ing,27 compared with those who are

not exposed. Because tobacco smoke

is a known contributor to asthma se-verity,2830 exposure to SHS may have a

particularly marked effect on the sleep

of children with asthma. Although this

possibility has received little empirical

investigation, SHS exposure has been

associated with increased night wak-

ings in children with asthma.31 A major

limitation of these studies linking SHS

and sleep difficulties in children26,27,31

is the fact that they relied on parent

reports of exposure, instead of more-precise and more-objective biological

markers of tobacco exposure.

The objective of this study was to ex-

amine the relationship between SHS

exposure and sleep patterns among a

group of children with asthma. We

used a biomarker of tobacco expo-

sure, serum cotinine levels, to quan-

tify exposure objectively and a vali-

dated pediatric sleep survey32 to

characterize sleep patterns. We hy-

pothesized that children with asthma

who were exposed to higher levels of

SHS would exhibit more sleep prob-

lems, as reported by parents, com-

pared with children with lower levels

of exposure.

METHODS

This study used the Cincinnati Asthma

Prevention Study, an asthma interven-

tion trial based on environmental mod-

ifications to the home in the form of

high-efficiency particulate air clean-

ers, and outcomes focused on asthma

symptoms, health care utilization, and

pulmonary function. For the current

study, SHS exposure, child sleep pat-terns, and potential covariates were

measured before initiation of the

asthma intervention.

Recruitment and enrollment proce-

dures for the 6- to 12-year-old children

are described in detail elsewhere.33

Briefly, all children in the sample had

physician-diagnosed asthma that had

been treated within the previous year

and exposure to SHS from 5 ciga-

rettes per day at home, according toparent report. Children were identified

on the basis of hospital and clinic bill-

ing records, and parents of 1678 chil-

dren were contacted for completion of

a screening survey and request for

participation, if eligible. Children were

excluded if they had other respiratory

diseases, heart disease, mental retar-

dation, or other serious conditions

barring participation in the study. Of

the 348 eligible participants, 232 en-rolled and completed the main study

(67% participation rate), and 219 had

complete data pertinent to the current

study and were retained for the analy-

sis. Protocols were approved by the in-

stitutional review board.

We collected detailed survey data re-

garding the childs daily exposure to

SHS in the home, car, and other loca-

tions, including hours of exposure,

e262 YOLTON et alat Indonesia:AAP Sponsored on May 1, 2012pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/


4/10

number of cigarettes per day, whether

the child was in the same room during

smoking, and whether windows were

open during car exposure. SHS expo-

sure also was measured objectively by

using serum cotininelevels detected in

samples collected at the baselinehome visit, which represent our pri-

mary measure of exposure. Cotinine, a

metabolite of nicotine, is a reliable

biomarker of exposure to tobacco

smoke.34 Serum levels provide a short-

term view of exposure over the previ-

ous 48 to 72 hours. However, because

of stability of exposure patterns over

time, a one-time cotinine measure-

ment is considered representative of

typical daily exposure.34 Cotinine levelsin serum were measured by the Cen-

ters for Disease Control and Preven-

tion with published methods involving

high-performance liquid chromatog-

raphy linked to atmospheric-pressure

chemical ionization-tandem mass

spectrometry.35 We applied a logarith-

mic base 2 transformation for analysis

of serum cotinine levels because of

the skewed distribution of the raw

data. This provides for simpler inter-pretation of the coefficients from the

regression analyses, in which there is

an increase in the sleep scale equal to

the coefficient for log cotinine level for

each doubling of the cotinine level.

The Childrens Sleep Habits Question-

naire (CSHQ)3 was used to measure

child sleep patterns within the previ-

ous 2 weeks, as reported by the pri-

mary caregiver. The CSHQ yields a to-

tal sleep disturbance score and scoresfor 8 scales (ie, bedtime resistance,

sleep-onset delay, sleep duration, sleep

anxiety, night wakings, parasomnias,

sleep-disordered breathing, and daytime

sleepiness). This instrument is used in

clinical and research settings to pro-

vide a broad description of child sleep

patterns. Internal consistency mea-

sures for the entire scale are high

( 0.68 for a community sample and

0.78 for a clinical sample), and

test-retest reliabilities among the

scales are high (r 0.620.79). A total

CSHQ score of41 has sensitivity of

0.80 and specificity of 0.72, properly

classifying 80% of a group with clini-

cally relevant sleep disorders. To en-sure uniform thorough completion,

this measure was administered in

an interview in which caregiver re-

sponses were recorded by a trained

research assistant.

Asthma severity was reported as mild,

moderate, severe, or very severe by

the childs caregiver. Severe and very

severe categories were combined be-

cause of small group sizes. Parent

report of asthma symptoms is an ef-fective means of characterizing child

asthmaand is notenhancedby asthma

diaries or pulmonary function test-

ing.36 Parents also reported asthma

medication use by the child, includ-

ing use of short-acting bronchodila-

tors, long-acting inhaled steroids,

and orally administered steroids

prescribed for treatment of acute

exacerbations.

Other measured covariates were ma-ternal depression (Beck Depression In-

ventory II)37 and quality of the home en-

vironment, measured with the Home

Observation for Measurement of the

Environment (HOME) instrument for

elementary school-aged children.38

The HOME instrument is primarily an

observational tool that assesses the

quality of the home environment, in-

cluding physical characteristics, vari-

ety of stimulation, and nurturing be-havior from the parent, and was

completed at a 12-month follow-up

visit. For 14 participants, this assess-

ment was missing and imputed values

generated with SOLAS 3.0 (Statistical

Solutions, Cork, Ireland), on the basis

of age, race, and gender, were used.

Univariate analyses involved inspec-

tion of frequencies and estimation of

means and associated SDs. Because of

nonnormal distributions, serum cotin-

ine levels are reported as geometric

means and 95% confidence intervals

(CIs), and household income is re-

ported as median and 25th and 75th

percentile values. We used linear re-

gression for the daytime sleepinessand total sleep disturbance scales. The

distributions of the other sleep scales

reflected varying degrees of nonnor-

mality; therefore, responses were di-

chotomized, at approximately the 75th

percentile value, and logistic regres-

sion was used. For each outcome mea-

sure, 3 models were developed, to

reflect (1) the simple bivariate associ-

ation between exposure and sleep, (2)

the association after adjustment forall covariates (age, gender, race, ma-

ternal smoking during pregnancy,

marital status, maternal education,

household income, household density,

number of siblings, maternal depres-

sion, HOME score, asthmaseverity, and

asthma medication use), and (3) the

association after adjustment for im-

portant covariates, representing the

most statistically parsimonious final

model. For the final models, age, gen-

der, and asthma severity were re-

tained irrespective of statistical signif-

icance. Other covariates were retained

if they accounted for significant vari-

ance on the given sleep scale (P .05).

Also, if removal of the covariate from

the model was associated with a

10% change in the regression coeffi-

cient for serum cotinine levels, then it

was retained in the model. SAS 9.1

(SAS Institute, Cary, NC) was used for

all analyses.

RESULTS

Descriptive information on the sample

is summarized in Table 1. The mean

age of the subjects at the baseline visit

was 9.4 years. Sixty-one percent of the

children were boys, and 56% were re-

ported to be black. Childrenin thesam-

ple were exposed to a median of 13

cigarettes per day in their homes, as

ARTICLES



5/10

reported by their parents, and the geo-

metric mean serum cotinine level for

the sample was 1.16 ng/mL. The corre-

lation between serum cotinine levelsand parent-reported exposure was

0.39 (P .0001) for the full sample.

Mean values for overall sleep distur-

bance and sleep scale scores for

children in our sample fell between

the clinical and control samples re-

ported by Owens et al.32 Internal con-

sistency for the sleep measure also

was comparable to the findings of

Owens et al.32 Surprisingly, 93% of

the children in the sample had a

CSHQ total sleep disturbance score

(41) that would be considered clin-

ically relevant. The mean sleep timereported by parents was 9.6 hours

per night.

In bivariate analyses, the associations

between the logarithm of serum cotin-

ine levels and child sleep patterns

were significant for bedtime resis-

tance, sleep anxiety, parasomnias,

sleep-disordered breathing, daytime

sleepiness, and total sleep distur-

bance but not for sleep-onset delay or

sleep duration (Table 2). There was no

association between total duration of

nighttime sleep and serum cotinine

levels.

In multivariate analyses including all

potential covariates of child sleep pat-

terns, we found that higher levels of

SHS exposure were significantly asso-

ciated with higher scores (ie, more

problems) on the sleep-onset delay,

parasomnias, daytime sleepiness, and

total sleep disturbance scales. Final

models, including only covariates that

had a relationship with the sleep scale

of interest or affected the coefficient

for cotinine levels, revealed significant

associations between SHS exposure

andincreases in sleep-onset delay, para-somnias, sleep-disordered breathing,

daytime sleepiness, and overall sleep

disturbance (Table 2).

Several covariates remained in our

final models because of associations

with sleep scales. Increasing age

was significantly associated with de-

creased bedtime resistance, more

problems with sleep duration, less

sleep anxiety, and lower overall sleep

disturbance. More-severe asthma was

associated with more problems with

sleep duration and more-frequent

night wakings. Maternal smoking

during pregnancy was associated

with decreased sleep-onset delay. A

nonmarried parent was associated

with fewer parasomnias and in-

creased daytime sleepiness. Lower

family income was associated with de-

creased sleep duration and decreased

daytime sleepiness. Higher levels ofmaternal depression were associated

with more-frequent parasomnias,

increased daytime sleepiness, and

greater overall sleep disturbance.

More siblings and increased housing

density were associated with de-

creased sleep-disordered breathing.

Finally, the use of long-term inhaled

asthma medications was associated

with fewer parasomnias.

TABLE 1 Sample Characteristics (N 219)

Age, mean SD, y 9.4 1.8

Male, n(%) 134 (61.2)

Race, n(%)

Black 122 (55.7)

White 92 (42.0)

Other 5 (2.3)

Parent education, n(%)

High school graduate or less 143 (65.3)

Any college 76 (34.7)

Parent marital status, n(%)

Married or living with someone 91 (41.6)

Divorced, separated, or widowed 37 (16.8)

Single, never married 91 (41.6)

Household income, median (interquartile range), $ 25 000 (15 00045 000)

Asthma severity, n(%)

Mild 51 (23.2)

Moderate 105 (48.0)

Severe/very severe 63 (28.8)

Maternal smoking during pregnancy, n(%)

None 73 (33.3)

Until pregnancy recognition 32 (14.6)

Throughout pregnancy 114 (52.1)No. of cigarettes smoked in home daily, median (interquartile range) 13 (920)

Serum cotinine level

Geometric mean (95% CI), ng/mL 1.16 (0.1013.07)

Median (interquartile range), ng/mL 1.45 (0.562.69)

HOME score, mean SD 46.9 8.1

Maternal depression score, mean SD 12.4 9.9

Behavior Assessment System for Children-2 score within clinical range

(70), n(%)

Externalizing symptoms 41 (18.8)

Internalizing symptoms 58 (26.6)

Behavior symptoms 46 (21.1)

Sleep pattern score, mean SD

Bed resistance 8.9 2.7

Sleep-onset delay 1.6 0.8

Sleep duration 4.4 1.7

Sleep anxiety 5.7 1.8

Night waking 4.3 1.3

Parasomnias 9.6 2.1

Sleep-disordered breathing 4.2 1.4

Daytime sleepiness 15.5 3.3

Total sleep disturbance 51.6 8.2

Total sleep disturbance raw score of41, n(%) 203 (92.7)



6/10

We found cotinine level-gender inter-

actions for the sleep-onset delay (odds

ratio [OR]: 0.63; P .011) and sleep

anxiety (OR: 1.47; P .05) scales;

therefore, we performed gender-

stratified regression analyses for

those scales, controllingfor the covari-

ates retained in the final models for

the full sample. For boys, a statistically

significant relationship was found be-

tween serum cotinine levels and

higher scores for sleep anxiety (OR:

1.54; P .003). For girls, a statistically

significant relationship was found be-

tween serum cotinine levels and sleep-

onset delay (OR: 1.54; P .008).

DISCUSSION

For children with asthma, we found

that SHS exposure was associated

with greater parent-reported sleep

problems. Specifically, as SHS expo-

sure increased, parents reported that

their children had longer delays in

sleep onset, more-frequent parasom-

nias and sleep-disordered breathing,

increased daytime sleepiness, and

greater overall sleep disturbance.

Two sleep scales showed significant

gender-cotinine level interactions. In

regression analyses stratified accord-

ing to gender, greater exposure to SHS

was associated with greater sleep anx-

iety in boys and greater sleep-onset

delay in girls.

SHS exposure was associated with in-

creased incidence of parasomnias in

this sample of children. Parasomnias

reflect partial arousal from either non-

rapid eye movement or rapid eye

movement sleep and, although usually

benign, can be highly distressing tochildren and their families. More than

80% of preschoolers experience para-

somnias, but their incidence de-

creases with age.39 Adult men who

smoke report more nightmares and

disturbing dreams than do men who

do not smoke, but there has been no

reported association for women.24

Boys in our study experienced greater

sleep anxiety with increasing SHS ex-

posure. Nighttime fears are reportedby upto 79% of 8- to 16-year-old youths.

In contrast to our findings, however,

they have been reported more fre-

quently among girls (72%) than boys

(55%).40 For girls in our study, greater

SHS exposure was associated with

greater sleep-onset delay, which is con-

sistent with reports that both men and

women who smoke cigarettes have in-

creased difficulty initiating sleep.41 No

other studies have investigated the rela-

tionship between SHS and sleep-onset

delays among children.

The exact mechanism through which

SHS exposure may affect childrens

sleep is not clear. We briefly explore 3

possible explanations, that is, exacer-

bation of respiratory symptoms, nico-

tine arousal mechanisms, and symp-

toms of abstinence. In adults, smokingis known to exacerbate respiratory

disorders such as obstructive sleep

apnea,24,42 and SHS exposure has been

associated with increased snoring in

pregnant women.25 Among children,

parent-reported maternal smoking is

associated with increased snoring,27

and nighttime respiratory symptoms

are exacerbated by exposure to SHS.31

Indeed, higher levels of SHS exposure

were associated with more sleep-disordered breathing among children

in our study. It is likely that SHS

exposure acts as an upper airway

irritant, increasing symptoms of sleep-

disordered breathing and thus contrib-

uting to overall sleep disturbances

among children with asthma.

Although adolescent and adult smokers

report disturbances in sleep,2224,41,43 a

clear causal relationship between to-

TABLE 2 Associations Between Serum Cotinine Levels (Independent Variable) and Childrens Sleep (Dependent Variable) in Logistic and Multiple

Regression Analyses (N 219)

Sleep Scale (Cutoff Point) Bivariate Association Between

Serum Cotinine Levels and Sleep

Outcomes

Full Model of Association

Between Serum Cotinine Levels

and Sleep Outcomes Including

All Covariates

Final Model of Association

Between Serum Cotinine Levels

and Sleep Outcomes Including

Significant Covariates

OR or (95% CI) P OR or (95% CI) P OR or (95% CI) P

Bed resistance (10) 1.29 (1.091.53) .003 1.34 (0.951.88) .093 1.21 (0.9951.47) .056Sleep-onset delay (2) 1.07 (0.921.24) .39 1.50 (1.082.06) .014 1.53 (1.152.03) .004

Sleep duration (5) 1.00 (0.861.17) .98 1.19 (0.871.63) .27 1.12 (0.921.37) .24

Sleep anxiety (7) 1.28 (1.071.53) .006 0.90 (0.651.24) .51 1.06 (0.811.38) .68

Night wakings (5) 1.09 (0.931.28) .28 1.10 (0.811.50) .54 1.09 (0.921.31) .32

Parasomnias (12) 1.62 (1.232.12) .0005 1.91 (1.093.34) .023 1.95 (1.362.79) .0002

Sleep-disordered breathing (5) 1.29 (1.081.54) .005 1.33 (0.941.89) .11 1.26 (1.041.52) .02

Daytime sleepiness 0.40 (0.150.64) .002 0.51 (0.080.94) .021 0.33 (0.050.61) .022

Total sleep disturbance 1.40 (0.811.99) .0001 1.42 (0.372.47) .009 1.14 (0.541.74) .0002

Childage, gender, and asthmaseveritywere included in allanalyses.Other covariateswere included if theywere statisticallyrelevantto the sleepscale of interest and included the following

considerations: maternal race, marital status, education, income, smoking during pregnancy, and depression, HOME inventory total score, household density (house volume per persons),

number of siblings, and use of asthma medication (including short-acting inhaled medicines, long-acting inhaled medicines, and orally administered steroids). Multivariate regression

analyses were used for analysis of daytime sleepiness and total sleep disturbance ( reported); all other analyses used logistic regression analyses of dichotomized sleep scales (OR

reported).

ARTICLES



7/10

bacco and sleep disorders has been

difficult to establish.42 Nicotine is a

stimulant that may contribute to in-

creased arousal and attention among

smokers, likely by stimulating neuro-

transmission of acetylcholine and trig-

gering activation of the dopaminergicsystem in the brain.42,44 Nicotine is as-

sociated with altered sleep architec-

ture, resulting in reduced sleep time

and efficiency, longer sleep latency,

lighter sleep, and reduced rapid eye

movement sleep.20,45

Frequent night wakings among smok-

ers often are attributed to withdrawal

during sleep. During the early stages

of smoking abstinence, adult smokers

experience difficulty falling asleep, re-duced sleep efficiency, and longer la-

tency to rapid eye movement sleep.46

Colrain et al47 reported increased

night wakings and sleepiness as the

most-consistent findings of research

on smoking cessation. Insomnia, sleep

disturbance, and anxiety also are

symptoms of nicotine withdrawal

listed in the Diagnostic and Statistical

Manual of Mental Disorders, Fourth

Edition.48 These symptoms in manyways resemble those reported in our

sample. It is possible that children ex-

posed to SHS experience a degree

of nicotine withdrawal during sleep,

which results in disruptions in the

normal sleep process. Although with-

drawal symptoms among children ex-

posed to SHS have, to our knowledge,

not been noted in the literature, sev-

eral studies presented evidence that

newborns who were exposed prena-

tally to tobacco experienced nicotine

withdrawal shortly after birth.4951 This

area requires further study.

SHS exposure results in a much

smaller amount of nicotine intakethan active smoking. Studies of SHS

effects on sleep have included re-

ports of sleep disturbances among

adult men,41 pregnant women,25 and

preschool-aged children,26 which in-

dicates that even small amounts of ex-

posure to nicotine, as would occur in

SHS exposure, are sufficient to affect

sleep adversely. Our study contributes

additional evidence that SHS affects

sleep among school-aged childrenwith asthma.

This study is not without limitations. All

children in the study had asthma, and

the results may not be generalizable

to populations of children without

asthma. However, these results may

be reflective of risks from SHS expo-

sure for the 9% of children in the

United States today who have asthma.52

All children in this study were exposed

to SHS, and we can generalize our find-ings only to exposed children. The de-

gree of exposure varied widely in our

sample, and there was no evidence of

curvilinear or threshold effects that

might suggest a safe level of SHS ex-

posure. In addition, national data sug-

gest that more than one half of chil-

dren are exposed to SHS.53 Our sleep

data were derived from parent reports

only. Additional study in this area

should include use of child-reported

sleep problems and additional mea-

sures of sleep patterns, such as

polysomnography, actigraphy, or de-

tailed sleep diaries. Finally, we had

no information on prematurity in thissample, which could be an important

contributor to sleep problems.54,55

CONCLUSIONS

Among children with asthma, expo-

sure to SHS affects sleep negatively,

as evidenced by greater sleep-onset

delays, more-frequent parasomnias,

more sleep-disordered breathing, in-

creased daytime sleepiness, and

greater overall sleep disturbance. Theconsequences of inadequate sleep in

children are not trivial. Sleep distur-

bances have been linked with in-

creased behavior problems,25 mental

health problems,1,6 and poor school

performance1 in children. In addition,

effects of poor sleep in childhood can

persist into adulthood in the form of

obesity8,9 and behavior and mood dis-

orders.7 Reduction in SHS exposure is

an area with the potential for signifi-cant impact for physical and emotional

health and school performance in the

pediatric population.

ACKNOWLEDGMENTS

This work was supported by grants

from the National Institutes of Health

(grants R21 ES12952-01 and R01

HL65731).

REFERENCES

1. Paavonen EJ, Aronen ET, Moilanen I, et al.

Sleep problems of school-aged children: a

complementary view. Acta Paediatr. 2000;

89(2):223228

2. Aronen ET, Paavonen EJ, Fjallberg M, Soin-

inen M, Torronen J. Sleep and psychiatric

symptoms in school-age children. J Am

Acad Child Adolesc Psychiatry. 2000;39(4):

502508

3. Owens JA, Maxim R, Nobile C, McGuinn M,

Msall M. Parental andself-reportof sleep in

children with attention-deficit/hyperactivity

disorder. Arch Pediatr Adolesc Med. 2000;

154(6):549555

4. Chervin RD, Dillon JE, Bassetti C, Ganoczy

DA,Pituch KJ.Symptomsof sleep disorders,

inattention, and hyperactivity in children.

Sleep. 1997;20(12):11851192

5. PaavonenEJ, Raikkonen K, Lahti J, et al.Short

sleep duration and behavioral symptoms of

attention-deficit/hyperactivity disorder in

healthy 7- to 8-year-old children. Pediatrics.

2009;123(5).Available at: www.pediatrics.org/

cgi/content/full/123/5/e857

6. Johnson EO, Chilcoat HD, Breslau N. Trouble

sleeping and anxiety/depression in child-

hood. Psychiatry Res. 2000;94(2):93102

7. Gregory AM, Van der Ende J, Willis TA, Ver-

hulst FC. Parent-reported sleep problems

during development and self-reported

anxiety/depression, attention problems,

and aggressive behavior later in life. Arch

Pediatr Adolesc Med. 2008;162(4):330335

8. Hart CN, Jelalian E. Shortened sleep duration

is associated with pediatric overweight. Be-

hav Sleep Med. 2008;6(4):251267



8/10

9. Van Cauter E, Knutson KL. Sleep and the ep-

idemic of obesity in children andadults. Eur

J Endocrinol. 2008;159(suppl 1):S59 S66

10. Andres RL, Day MC. Perinatal complications

associated with maternal tobacco use.

Semin Neonatol. 2000;5(3):231241

11. Dahl RE. The development and disorders of

sleep. Adv Pediatr. 1998;45:739012. Owens J. Classification and epidemiology of

childhood sleep disorders. Prim Care. 2008;

35(3):533546

13. Diette GB,Markson L, Skinner EA,Nguyen TT,

Algatt-Bergstrom P, Wu AW. Nocturnal

asthma in children affects school atten-

dance, school performance, and parents

work attendance. Arch Pediatr Adolesc

Med. 2000;154(9):923928

14. Madge PJ, Nisbet L, McColl JH, Vallance A,

Paton JY, Beattie JO. Home nebuliser use in

children with asthma in two Scottish Health

Board Areas. Scott Med J. 1995;40(5):141143

15. Redline S, Tishler PV, Schluchter M, Aylor J,

Clark K, Graham G. Risk factors for sleep-

disordered breathing in children: associa-

tions with obesity, race, and respiratory

problems. Am J Respir Crit Care Med. 1999;

159(5):15271532

16. Stores G, Ellis AJ, Wiggs L, Crawford C,

Thomson A. Sleep and psychological distur-

bance in nocturnal asthma. Arch Dis Child.

1998;78(5):413 419

17. Sadeh A, Horowitz I, Wolach-Benodis L,

Wolach B. Sleep and pulmonary function in

children with well-controlled, stable

asthma. Sleep. 1998;21(4):379384

18. Lanier BQ, Nayak A. Prevalence and impact

of nighttime symptoms in adults and chil-

dren with asthma: a survey. Postgrad Med.

2008;120(4):5866

19. Chugh IM, Khanna P, Shah A. Nocturnal

symptoms and sleep disturbances in clini-

cally stable asthmatic children. Asian Pac J

Allergy Immunol. 2006;24(23):135142

20. Zhang L, Samet J, Caffo B, Punjabi NM. Ciga-

rette smoking and nocturnal sleep archi-

tect ure. Am J Epidemiol. 2006;164(6):

529537

21. Holmen TL, Barrett-Connor E, Holmen J,

Bjermer L. Health problems in teenage

daily smokers versus nonsmokers, Nor-

way, 19951997: the Nord-Trondelag

Health Study. Am J Epidemiol. 2000;

151(2):148 155

22. Patten CA, Choi WS, Gillin JC, Pierce JP. De-

pressive symptoms and cigarette smoking

predict development and persistence of

sleep problems in US adolescents. Pediatrics.

2000;106(2). Availableat: www.pediatrics.org/

cgi/content/full/106/2/e23

23. Phillips BA, Danner FJ. Cigarette smoking

and sleep disturbance. Arch Intern Med.

1995;155(7):734737

24. Wetter DW, Young TB. The relation between

cigarette smoking and sleep disturbance.

Prev Med. 1994;23(3):328334

25. Ohida T, Kaneita Y, Osaki Y, et al. Is passive

smoking associated with sleep disturbanceamong pregnant women? Sleep. 2007;30(9):

11551161

26. Johansson A, Ludvigsson J, Hermansson G.

Adverse health effects related to tobacco

smoke exposure in a cohort of three-year

olds. Acta Paediatr. 2008;97(3):354357

27. Marshall NS, Almqvist C, Grunstein RR,

Marks GB. Predictors for snoring in chil-

dren with rhinitis at age 5. Pediatr Pulmo-

nol. 2007;42(7):584591

28. Gergen PJ, Fowler JA, Maurer KR, Davis WW,

Overpeck MD. The burden of environmental

tobacco smoke exposure on the respiratoryhealthof children 2 monthsthrough 5 years

of age in the United States: Third National

Health and Nutrition Examination Survey,

1988 to 1994. Pediatrics. 1998;101(2). Avail-

able at: www.pediatrics.org/cgi/content/

full/101/2/e8

29. Gilliland FD, Berhane K, Islam T, et al. Envi-

ronmental tobacco smoke and absentee-

ism related to respiratory illness in school-

children. Am J Epidemiol. 2003;157(10):

861869

30. Mannino DM, Homa DM, Redd SC. Involun-

ta ry sm okin g and as th ma seve ri ty inchildren: data from the Third National

Health and Nutrition Examination Survey.

Chest. 2002;122(2):409415

31. Morkjaroenpong V, Rand CS, Butz AM, et al.

Environmental tobacco smoke exposure

and nocturnal symptoms among inner-city

children with asthma. J Allergy Clin Immu-

nol. 2002;110(1):147153

32. Owens JA, Spirito A, McGuinn M. The Chil-

drens Sleep Habits Questionnaire (CSHQ):

psychometric properties of a survey instru-

ment for school-aged children. Sleep. 2000;

23(8):1043105133. Yolton K, Khoury J, Hornung R, Dietrich K,

Succop P, Lanphear B. Environmental to-

bacco smoke exposure and child behav-

iors. J Dev Behav Pediatr. 2008;29(6):

450457

34. Benowitz NL. Cotinine as a biomarker of en-

vironmental tobacco smoke exposure. Epi-

demiol Rev. 1996;18(2):188204

35. Bernert JT Jr, Turner WE, Pirkle JL, et al.

Development and validation of sensitive

method for determination of serum cotin-

ine in smokers and nonsmokers by liquid

chromatography/atmospheric pressure

ionization tandem mass spectrometry. Clin

Chem. 1997;43(12):22812291

36. Sharek PJ, Mayer ML, Loewy L, et al. Agree-

ment among measures of asthma status: a

prospective study of low-income children

with moderate to severe asthma. Pediat-

rics. 2002;110(4):797 80437. Beck AT, Steer RA, Brown GK. Beck Depres-

sion Inventory II. SanAntonio,TX: Psycholog-

ical Corp; 1996

38. CaldwellB, Bradley R. Home Observation for

Measurement of the Environment. Little

Rock, AR: University of Arkansas at Little

Rock; 1984

39. Kotagal S. Parasomnias of childhood. Curr

Opin Pediatr. 2008;20(6):659665

40. Gordon J, King N, Gullone E, Muris P, Ollen-

dick TH. Nighttime fears of children and

adolescents: frequency, content, severity,

harm expectations, disclosure, and copingbehaviours. Behav Res Ther. 2007;45(10):

24642472

41. Nakata A, Takahashi M, Haratani T, et al.

Association of active and passive smok-

ing with sleep disturbances and short

sleep duration among Japanese working

population. Int J Behav Med. 2008;15(2):

8191

42. HtooA, TalwarA, FeinsilverSH, Greenberg H.

Smoking and sleep disorders. Med Clin

North Am. 2004;88(6):15751591

43. Soldatos CR, Kales JD, Scharf MB, Bixler EO,

Kales A. Cigarette smoking associated withsleep difficulty. Science. 1980;207(4430):

551553

44. Boutrel B, Koob GF. What keeps us awake:

the neuropharmacology of stimulants and

wakefulness-promoting medications.

Sleep. 2004;27(6):11811194

45. Davila DG, Hurt RD, Offord KP, Harris CD,

Shepard JW Jr. Acute effects of transder-

mal nicotine on sleep architecture, snoring,

and sleep-disordered breathing in non-

smokers. Am J Respir Crit Care Med. 1994;

150(2):469474

46. Moreno-Coutino A, Calderon-Ezquero C,Drucker-Coln R. Long-term changes in

sleep anddepressive symptoms of smokers

in abstinence. Nicotine Tob Res. 2007;9(3):

389396

47. ColrainIM, Trinder J, Swan GE.The impactof

smoking cessation on objective and subjec-

tive markers of sleep: review, synthesis,

and recommendations. Nicotine Tob Res.

2004;6(6):913925

48. American Psychiatric Association. Diag-

nostic and Statistical Manual of Mental

Disorders. 4th ed, Text Revision. Washing-

ARTICLES



9/10

to n, DC : Amer ic an Ps yc hi at ri c As so c-

iation; 2000

49. Godding V, Bonnier C, Fiasse L, et al. Does

in utero exposure to heavy maternal

smoking induce nicotine withdrawal

symptoms in neonates? Pediatr Res. 2004;

55(4):645651

50. Law KL, Stroud LR, LaGasse LL, Niaura R, LiuJ, Lester BM. Smoking during pregnancy

and newborn neurobehavior. Pediatrics.

2003;111(6):1318 1323

51. Stroud LR, Paster RL, Papandonatos GD, et

al. Maternal smoking during pregnancy and

newborn neurobehavior: effects at 10 to 27

days. J Pediatr. 2009;154(1):10 16

52. Akinbami LJ, Moorman JE, Garbe PL, Sondik

EJ.Status of childhood asthmain theUnited

States, 1980 2007. Pediatrics. 2009;

123(suppl 3):S131S145

53. Centers for Disease Control and Preven-ti on, Di vi si on of Lab orato ry Sc ience s.

Third National Report on Human Expo-

sure to Environmental Chemicals. At -

lanta, GA: Centers for Disease Control and

P reven t i o n ; 2005. NC E H P u b l i c a t i o n

050570

54. Paavonen EJ, Strang-Karlsson S, Raikkonen

K, et al. Very low birth weight increases risk

for sleep-disordered breathing in young

adulthood: the Helsinki Study of Very Low

Birth Weight Adults. Pediatrics. 2007;120(4):

77878455. Stephan-Blanchard E, Telliez F, Leke A, et al.

The influence of in utero exposure to smok-

ing on sleep patterns in preterm neonates.

Sleep. 2008;31(12):16831689



10/10

DOI: 10.1542/peds.2009-0690; originally published online January 18, 2010;2010;125;e261Pediatrics

Beebe and Judith OwensKimberly Yolton, Yingying Xu, Jane Khoury, Paul Succop, Bruce Lanphear, Dean W.

ChildrenAssociations Between Secondhand Smoke Exposure and Sleep Patterns in

ServicesUpdated Information &

tmlhttp://pediatrics.aappublications.org/content/125/2/e261.full.hincluding high resolution figures, can be found at:

References

tml#ref-list-1http://pediatrics.aappublications.org/content/125/2/e261.full.hat:This article cites 48 articles, 21 of which can be accessed free

Citations

tml#related-urlshttp://pediatrics.aappublications.org/content/125/2/e261.full.hThis article has been cited by 3 HighWire-hosted articles:

Permissions & Licensing

mlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhttables) or in its entirety can be found online at:Information about reproducing this article in parts (figures,

Reprintshttp://pediatrics.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright 2010 by the American Academy of Pediatrics. Alland trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elkpublication, it has been published continuously since 1948. PEDIATRICS is owned, published,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on May 1, 2012pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/content/125/2/e261.full.htmlhttp://pediatrics.aappublications.org/content/125/2/e261.full.htmlhttp://pediatrics.aappublications.org/content/125/2/e261.full.htmlhttp://pediatrics.aappublications.org/content/125/2/e261.full.html#ref-list-1http://pediatrics.aappublications.org/content/125/2/e261.full.html#ref-list-1http://pediatrics.aappublications.org/content/125/2/e261.full.html#ref-list-1http://pediatrics.aappublications.org/content/125/2/e261.full.html#related-urlshttp://pediatrics.aappublications.org/content/125/2/e261.full.html#related-urlshttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/content/125/2/e261.full.html#related-urlshttp://pediatrics.aappublications.org/content/125/2/e261.full.html#ref-list-1http://pediatrics.aappublications.org/content/125/2/e261.full.html

SHS Pada Asma

Documents

Transcript of SHS Pada Asma