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 Table of Contents  
Year : 2017  |  Volume : 20  |  Issue : 3  |  Page : 98-101

Sleep hygiene of children in Abakaliki, Ebonyi State, Southeast Nigeria

1 Department of Paediatrics, Federal Teaching Hospital Abakaliki, Abakaliki, Ebonyi State, Nigeria
2 Department of Paediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria

Date of Web Publication16-Jan-2018

Correspondence Address:
Dr. Maria-Lauretta Orji
Department of Paediatrics, Federal Teaching Hospital Abakaliki, Abakaliki, Ebonyi State
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DOI: 10.4103/1118-8561.223168

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Background: Sleep hygiene may be defined as a set of habits and guidelines that promote consistently restful and sufficient sleep at night, consequently leading to alertness during the day. The study was aimed at determining the pattern of sleep hygiene and factors contributing to poor sleep among children attending children outpatient clinic in Federal Teaching Hospital Abakaliki (FETHA). Materials and Methods: In this cross-sectional descriptive study, data were collected from May 2012 to September 2012. Structured questionnaire was administered to parents of children aged 2–16 years. Participants were recruited from the children's outpatient clinic of FETHA. Results: A total of 354 children were recruited, of which 60.8% do not have a regular bedtime and wake time. A total of 56 children (15.8%) had bedtime problems (problems going to bed and problems falling asleep), 10.7% experienced daytime sleepiness, 15% had frequent night waking, and snoring was noted in 30 (8.5%) children. More females had a regular bedtime and wake time 40.0% than males 28.7%. Problems with going to bed, falling asleep, frequent night waking, and daytime sleepiness were more prevalent in children aged 6–10 years. Children less than 6 years had the highest prevalence of daytime naps, regular bedtime, and wake time. Watching television before bedtime was significantly associated with frequent night waking, problems with falling asleep, and daytime sleepiness (P = 0.000, P = 0.001, and P = 0.002, respectively). Conclusion: Findings from this study showed that poor sleep hygiene is common among children in this environment. Health education to parents and their children aged 7 years and above on the importance of good sleep hygiene is, therefore, necessary.

Keywords: BEARS parameters, sleep hygiene, variables influencing sleep hygiene

How to cite this article:
Orji ML, Anyanwu OU, Ibekwe R, Onyire NB. Sleep hygiene of children in Abakaliki, Ebonyi State, Southeast Nigeria. Sahel Med J 2017;20:98-101

How to cite this URL:
Orji ML, Anyanwu OU, Ibekwe R, Onyire NB. Sleep hygiene of children in Abakaliki, Ebonyi State, Southeast Nigeria. Sahel Med J [serial online] 2017 [cited 2021 Jul 24];20:98-101. Available from: https://www.smjonline.org/text.asp?2017/20/3/98/223168

  Introduction Top

Sleep hygiene refers to diverse routine practices that are necessary to have normal, quality nighttime sleep and full daytime alertness.[1] Every child deserves a good sleep hygiene, as it is a necessity and a vital sign of good health. Poor sleep hygiene not only predisposes children to mood, behavioral, and cognitive impairment but also has an impact on physical health, which may further predispose them to sleep difficulties.[2],[3],[4] Ofovwe and Ofovwe [1] reported poor sleep hygiene in 48.1% of the participants and observed lower mean scores on the cognitive, bedtime, and sleep stability subscales compared to those with good sleep hygiene. Sleep hygiene encourages habits that are consistent with restorative sleep. Good sleep hygiene entails regular bedtime and wake time, avoidance of stimulant at bedtime, and avoidance of the use of technological gadgets before bedtime.[5],[6] When sleep impairment is observed, a review of sleep habits such as bedtime routine and the sleeping environment may reveal factors contributing to the sleep problems. These factors may include technologies in the bedroom such as television and computers, eating a heavy meal just before night sleep, and ingesting of stimulants (such as sodas, chocolate, tea, and coffee). Stimulants such as coffee taken at night can increase sleep latency on an average of 6.3–12.1 min, reduce sleepiness, and improve the ability to sustain wakefulness.[7] A study by Hershner and Chervin [8] noted that the effect of caffeine lasts for 5.5–7.5 h, suggesting that caffeine consumed even in the afternoon can impair the ability to fall asleep at night. Smith [9] observed that watching television to induce sleep and consuming caffeine before going to bed were significantly associated with sleep problems.

Few studies exist on this subject and its associated modifiable factors in our environment, hence the need for the index study.

  Materials and Methods Top

The study was aimed at determining the pattern of sleep hygiene and factors contributing to poor sleep among children attending children's outpatient clinic in Federal Teaching Hospital Abakaliki (FETHA). This cross-sectional prospective study was conducted between May 2012 and September 2012. A total of 354 children aged 2–16 years of age were recruited when they presented at the children's Outpatient Department of FETHA, Ebonyi State. FETHA is the only tertiary hospital in Ebonyi State which has a population of 2,173,501. A self-administered questionnaire which contained biodata, occupation, and literacy level of parents and the BEARS screening tool was used to collect information from the caregivers. The BEARS screening tool is a 5-item pediatric sleep screening instrument assessing bedtime issues (problems going to bed or falling asleep), excessive daytime sleepiness (does the child find it difficult waking up in the morning, does the child sleep a lot during the day, and does he/she take naps during the day), night awakening (does the child wake up a lot at night, does he/she sleepwalk or have nightmare, and does he/she find it difficult getting back to sleep), regularity and duration of sleep (does the child have regular bedtime and wake time), and snoring (does the child snore at night or having difficulty in breathing at night).[10] The BEARS tool was used to obtain sleep-related information and identify sleep problems in this study. Owens and Dalzell [11] reported that the BEARS instrument is user-friendly, brief, easy to remember, and an effective screening tool for pediatric sleep problems.

Consent was obtained from caregivers and assent from children aged 7 years and above before commencement of the study. Ethical approval was not obtained before commencement of the study.

The data obtained were entered in a spreadsheet of Microsoft Excel 2007, and analysis was done using SPSS software version 19 (SPSS Inc., IBM). Descriptive results were expressed as frequencies and percentages. The significance of associations between categorical variables was tested using Pearson's Chi-square and Fischer's exact tests for comparison of proportions. P < 0.005 was considered statistically significant.

  Results Top

Among the 354 children screened for poor sleep hygiene, 209 (59.0%) were males and the majority (49.2%) were between 6 and 10 years of age. More females were found to have a regular bedtime and wake time (40.0%) than males (28.7%). Sleep problems were more common among children aged 6–10 years (52.9%). This age group (6-10) also had the least frequency of regular bedtime and wake time (25.3%). Socioeconomic status of caregivers had no statistically significant relationship with poor sleep hygiene in this study (P = 0.257) [Table 1].
Table 1: Sociodemographic characteristics

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[Table 2] bedtime problems (problems going to bed and problems falling asleep) had a prevalence rate of 15.8%. A total of 38 (10.7%) children had excessive daytime sleepiness. Frequent night awakening was observed in 53 (15.0%) children, and a large number of children, i.e., 215 (60.8%) do not have a regular bedtime and wake time, while 30 (8.5%) children snored at night.
Table 2: Pattern of sleep problems among participants

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A total of 70 (19.8%) of the 354 participants have TV in their bedroom, but TV viewing at bedtime was observed in 148 (41.8%) participants [Table 3]. Watching TV at night was significantly associated with bedtime problems such as difficulty in falling asleep (χ2 = 19.43, P = 0.001), excessive daytime sleep (χ2 = 16.75, P = 0.002), frequent night awakening (χ2 = 33.34, P = 0.000), irregular sleep/wake time (χ2 = 25.4, P = 0.000), and snoring (χ2 = 30.05, P = 0.000).
Table 3: Prevalence of certain sleep-influencing variables

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Feeding 1 h before sleep was associated with excessive daytime sleepiness (χ2 = 24.1, P = 0.003), while taking stimulant (coffee or chocolate drink) was significantly associated with difficulty in falling asleep (χ2= =10.25, P = 0.04) and excessive daytime sleepiness (χ2 = 15.46, P = 0.004).

Co-sleeping was not found to be significantly associated with all the parameters of BEARS. [Table 3] also showed that many of the subjects ate heavy night meals (66.9%), however eating heavy night meals was not associated with poor sleep hygiene.

  Discussion Top

Sleep plays a crucial role in the physical health and well-being of a person.[2] Poor sleep hygiene operationally defined as irregular bedtime and wake time and a lack of bedtime routine is common in this environment. Irregular sleep schedules can lead to inadequate sleep duration and sleep problems. Of the 354 children studied (aged 2–16 years), a high prevalence rate of 60.8% was noted to have an irregular bedtime and wake time. This is high when compared to the study by Ofovwe and Ofovwe [1] among 162 children aged 2–12 years in Benin City, Nigeria, that reported a prevalence rate of 48.1%. The lower prevalence rate obtained by Ofovwe and Ofovwe [1] may be related to the differences in research tools used to assess sleep hygiene in the two studies.

A study by Zhou et al.[11] reported higher prevalence rates of poor sleep hygiene with increasing age, with adolescent age group having the highest prevalence rate. On the contrary, the index study observed higher prevalence rate of sleep problems among children aged 6–10 years. This difference in prevalence rate with age group may be attributed to the differences in the variables that influenced sleep hygiene in the studies. While stimulant ingestion at bedtime, feeding an hour before bedtime, and television viewing before bedtime were the major risk factors to poor sleep hygiene in this study, Zhou et al.[11] observed a significant association between frequent computer/internet use, more time on homework during weekends, and poor sleep hygiene in their study.

Problems going to bed and problems falling asleep constituted the variable bedtime problems in this study, which was found to be 15.8%. This is comparable to that observed by Owens and Dalzell [12] who reported a prevalence rate of 16.3%. This was significantly associated with ingestion of coffee or chocolate drink before bedtime. It is not surprising as stimulant ingestions improve wakefulness and alertness and reduce sleepiness.[7],[8] Excessive daytime sleepiness which is a reflection of an inadequate quality and quantity of night sleep was associated with ingestion of a coffee or chocolate drink at bedtime.

Television has a powerful influence in the lives of most children. Its presence in the bedroom and bedtime television viewing are significant risk factors for sleep problems.[13],[14],[15] Watching television at bedtime was a significant predictor of poor sleep hygiene in this study, but the mere presence of television in the bedroom was not a significant risk factor. This may be due to the small percentage of children with television in their bedroom (19.8%) compared to a higher percentage of children engaged in television viewing at bedtime (41.8%). This suggests that the television viewing by children in this study may not have been in their bedrooms. This finding is comparable to that reported by Zhou et al.[11] that observed a significant relationship between bedtime television viewing and poor sleep hygiene. Television viewing at night resulted in irregular bedtime and wake time, problems with falling asleep, and consequently daytime sleepiness in this study.

Although 20.0% of healthy children snore from time to time, snoring may be a sign of sleep disorder (obstructive sleep apnea) or a consequence of enlarged adenoids.[1] Snoring was observed in this study in 30 (8.5%) of the 354 children studied. This is comparable to the 10.7% reported by Owen and Dalzell.[12] There was a significant association between television viewing at bedtime and snoring. Sleep position such as sleeping on your back may lead to snoring in some people.[16] Because 41.8% of the participants in the index study view television at bedtime, they may have slept off in the course of watching TV and probably on their backs. This may explain the association between television viewing at bedtime and snoring.

Owens and Dalzell [12] reported a prevalence rate of 18.4% of frequent night awakening; this was consistent with the finding in this study, with a prevalence rate of 15% of night awakening. Lower prevalence rates of night awakening observed by Bladder et al.[17] (6.5%) and Wang et al.[18] (5.2%) may be attributed to large sample sizes used for their studies.

  Conclusion and Recommendation Top

This study suggests that poor sleep hygiene is common. Helping children to develop good sleep hygiene as well as educating parents on how to shape their children's life to maintain regular sleep habit might be effective means of improving sleep quality in children. These can be achieved by modifying the various variables that can influence sleep hygiene.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ofovwe GE, Ofovwe CE. Sleep hygiene in Nigerian children. IFE Psychologia 2008;16:113-9.  Back to cited text no. 1
National Sleep Foundation. Available from: http://www.sleepfoundation.org/. [Last accessed on 2016 Mar 20].  Back to cited text no. 2
Dahl RE. The impact of inadequate sleep on children's daytime cognitive function. Semin Pediatr Neurol 1996;3:44-50.  Back to cited text no. 3
Bonnet MH. Cognitive effects of sleep and sleep fragmentation. Sleep 1993;16 8 Suppl: S65-7.  Back to cited text no. 4
Stepanski EJ, Wyatt JK. Use of sleep hygiene in the treatment of insomnia. Sleep Med Rev 2003;7:215-25.  Back to cited text no. 5
Brown FC, Buboltz WC Jr., Soper B. Relationship of sleep hygiene awareness, sleep hygiene practices, and sleep quality in university students. Behav Med 2002;28:33-8.  Back to cited text no. 6
Walsh JK, Muehlbach MJ, Humm TM, Dickins QS, Sugerman JL, Schweitzer PK. Effect of caffeine on physiological sleep tendency and ability to sustain wakefulness at night. Psychopharmacology (Berl) 1990;101:271-3.  Back to cited text no. 7
Hershner SD, Chervin RD. Causes and consequences of sleepiness among college students. Nat Sci Sleep 2014;6:73-84.  Back to cited text no. 8
Smith LA. Sleep Hygiene and Problematic Sleep in Early Childhood. Available from: http://www.hdl.handle.net/10523/2201. [Last accessed on 2013 Jun 28].  Back to cited text no. 9
Owens JA. Sleep medicine. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, editors. Nelson Textbook of Pediatrics. 18th ed. Philadelphia: Saunders; 2007. p. 91-9.  Back to cited text no. 10
Zhou HQ, Shi WB, Wang XF, Yao M, Cheng GY, Chen PY, et al. An epidemiological study of sleep quality in adolescents in South China: A school-based study. Child Care Health Dev 2012;38:581-7.  Back to cited text no. 11
Owens JA, Dalzell V. Use of the 'BEARS' sleep screening tool in a pediatric residents' continuity clinic: A pilot study. Sleep Med 2005;6:63-9.  Back to cited text no. 12
Owens J, Maxim R, McGuinn M, Nobile C, Msall M, Alario A. Television-viewing habits and sleep disturbance in school children. Pediatrics 1999;104:e27.  Back to cited text no. 13
Fosarelli PD. Television and children: A review. J Dev Behav Pediatr 1984;5:30-7.  Back to cited text no. 14
BaHammam A, Bin Saeed A, Al-Faris E, Shaikh S. Sleep duration and its correlates in a sample of Saudi elementary school children. Singapore Med J 2006;47:875-81.  Back to cited text no. 15
Snoring Solutions, Aids & Remedies. National Sleep Foundation. Available from: https://www.sleepfoundation.org.snoring. [Last accessed on 2016 Jun 21].  Back to cited text no. 16
Blader JC, Koplewicz HS, Abikoff H, Foley C. Sleep problems of elementary school children. A community survey. Arch Pediatr Adolesc Med 1997;151:473-80.  Back to cited text no. 17
Wang G, Xu G, Liu Z, Lu N, Ma R, Zhang E. Sleep patterns and sleep disturbances among Chinese school-aged children: Prevalence and associated factors. Sleep Med 2013;14:45-52.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3]

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