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Sleep in hospitalized children and adolescents: A scoping review

April 2022
The Center For Health Design

Why does this study matter?
Kids in the hospital are at risk of poor sleep and that might result in adverse health effects. Sleep deprivation in pediatric development has been associated with poor brain development, cognitive performance, emotional regulation, depression, and obesity. We don’t know much about actual sleep duration, or what causes disturbances in the pediatric setting.

How was the study done?
As a scoping review, the goal was to systematically identify, categorize, and synthesize the literature on sleep in children and adolescents in an inpatient setting. The authors searched five electronic databases and of the 3,770 references they found through keyword search terms, 28 studies were included in the review. This is not atypical, for those who haven’t done a review like this before. Studies were in English or Scandinavian languages and were published between 1981 and 2020.    

So what do we learn from the study?
In general, the team found that pediatric patients are not getting enough sleep in the hospital, based on age-appropriate recommendations. (But only 4 of 19 studies that reported sleep duration). They did find sleep disruptions result from both internal factors like anxiety or pain, and external factors, like what’s happening in the built environment. They also found that many factors surrounding sleep in pediatric patients were not very well addressed in the current literature.

More specifically, let’s look at those external factors. My read of the paper makes me think of Boris Karloff and the Grinch. The most consistent external factor is noise. The noise, noise, noise, noise. Four studies measured sound levels. The mean sound level ranged from 48.6-60.0 dBA, and you’re probably familiar with the WHO recommendation for 30 dBA, so not even close. Noise sources were a combination of alarms beeping, people talking, other patients if it was a shared room, and doors - doors opening, closing, and slamming. How many times have we heard that before? Other factors for disruptions were: lights being left on at night, as well as room temperatures that were too high.
This last one isn’t about the built environment, but it was interesting anyway. Patient care tasks, like taking vitals and entering the room were also highlighted as an external factor, and it was interesting that caregivers often think the sleep disruption is caused by internal factors, like pain, not a condition they are creating or contributing to.

Can we say the results are definitive?
The review didn’t find any longitudinal studies to link poor in-hospital sleep with longer-term health effects, but we have research on adult populations that suggests it’s an issue. This review also found that the literature on sleep in hospitalized peds patients is heterogeneous. That means the metrics are all different so it’s hard to compare. Sometimes sleep might be measured by an actigraph-type device, other times it might be measured according to a parent’s perception. They also found a risk of bias and low generalizability of findings.

There was a significant age range, and different ages need different lengths of sleep, so again, not so straight-forward. But, the results are similar to what we know from adult acute care environments, so the findings can be considered in that context, and it’s probably more of an issue that we don’t have these longitudinal studies to figure out the role of sleep disruption in hospitals from a developmental perspective.

What’s the takeaway?
So that said, what’s the takeaway?

Beyond our standard “We need more research” mantra, we do come away with something. Maybe you remember that song: “Nobody likes me, Everybody hates me, Guess I go eat worms.” What does that have to do with it? I feel like as architects, designers and built environment researchers, we’re so underappreciated or maybe unknown - we’re the kid in the corner that no one notices!
Of all of the reported promoters of sleep in the study, not one was about improvements to the built environment. Interventions were about behavior and care activities – how to reduce night-time room entries, breathing exercises, reading, etc.  We need to create awareness about what we can contribute and study designs that include the built environment!

Design matters. In fact Design Can make a difference.

So the takeaway is really that this is not so different from adult environments, but it may be even more important because of potential long-term developmental and health issues. We should take what need to be even more vigilant about finishes and materials, sound transmission, in addition to operational issues.  And don’t forget to think about the door closers. This we know, and we need to make sure they’re done right.

Interested in the topic? Visit The Center for Health Design Knowledge Repository for more.

Summary of:
Hybschmann, J., Topperzer, M. K., Gjærde, L. K., Born, P., Mathiasen, R., Sehested, A. M., Jennum, P. J., & Sørensen, J. L. (2021). Sleep in hospitalized children and adolescents: A scoping review. Sleep Medicine Reviews, 59. https://doi.org/10.1016/j.smrv.2021.101496


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