Clinical reviewSleep disorders in children with cerebral palsy: An integrative review
Introduction
Sleep disorders occur in approximately 25% of typically developing children and are often reported by parents [1]. In samples of children with disabilities, the etiologies of sleep disorders are diverse [2]. Causes may include the extent and location of brain abnormalities, severity of developmental delay, any accompanying sensory loss, epilepsy, intellectual deficits, cerebral palsy (CP), attention-deficit–hyperactivity disorder (ADHD), autism, eating difficulties, and other neuropsychiatric health problems such as anxiety, hyperactivity, aggressive behavior, depression, and pain [3].
Environmental factors and caregivers' behaviors can also contribute to children's sleep disorders. Because treatments for sleep disorders associated with particular features vary it is vitally important to identify factors related to sleep disorders [4] in homogeneous samples of children with CP [5].
CP is a term representing a group of disorders relating to motor development due to non-progressive lesions of the developing brain, often accompanied by disturbances of sensation, cognition, and/or a seizure disorder [6]. Depending on the type of CP, 25–80% of children have additional impairments. Of those children, a large proportion has some level of intellectual impairment; the prevalence varies with the type of CP but increases when epilepsy is present [7]. Odding and colleagues indicated that epilepsy is present in 20–40% of CP cases and is most common among children with hemiplegic or quadriplegic CP. They also reported that up to 80% of children diagnosed with CP have some impairment of speech and almost 75% have low visual acuity. Half of all children diagnosed with CP have gastrointestinal and feeding problems, with inadequate growth occurring in 25%, while being under or overweight characterizes about 50% of children [7].
The higher prevalence of sleep disorders in children with CP has typically been represented by the following characteristics: sleep–wake transition disorders, excessive daytime sleepiness, and arousal disorders. Active epilepsy in children with CP has had the strongest correlation with sleep disorders, specifically with excessive daytime sleepiness [5].
When children experience sleep deprivation they evidence mood, behavioral, and cognitive impairments [8], [9]. Insufficient or inefficient sleep adversely affects cognitive tasks, such as executive control, attention regulation, and working memory [10].
Lower quality of life in children with CP has been associated with insomnia and excessive daytime sleepiness. Lower quality of life is linked with impaired physical, emotional, social, and school functioning; considering effects of sleep disorders in general is important to raise awareness about managing sleep in children with CP [11]. Therefore, it is important to review and synthesize scientific evidence about the nature of children's sleep disorders associated with CP and related factors.
Section snippets
Study question and purpose
This integrative review aims to provide a comprehensive review and synthesis of the research literature about sleep disorders and factors related to those disorders in children with CP. For the purposes of the review, a child is defined as a person between 0 and 18 y. The research questions were: What is the nature of sleep disorders and what factors are related to sleep disorders in children with CP?
Methods
An integrative review represents a method to summarize past research literature and to provide comprehensive understanding of an area [12]. In contrast to systematic reviews that include only quantitative studies, this method includes all study designs while still adhering to rigorous review processes [12], [13], [14]. It involves identification of research questions, a literature search, categorization and assessment of studies, interpretation of results, and synthesis of knowledge [14], [15].
Quality appraisal and synthesis
The articles were classified according to level of evidence: Level I (systematic review or meta-analysis of randomized controlled clinical trials or clinical guidelines based on systematic reviews of randomized controlled trials); Level II (at least one well-designed randomized controlled trial); Level III (well-designed clinical trials without randomization); Level IV (well-designed cohort and case-control studies); Level V (systematic reviews of descriptive and qualitative studies); Level VI
Study sample
By using the broad search terms sleep and child*, and sleep and cerebral palsy, in eight databases, 36,361 abstracts were identified. Based on a review of titles and study abstracts, 36,324 were excluded because they included primarily adults (n = 20,300), did not pertain to purpose of this study (n = 16,000) and/or represented heterogeneous disabilities in samples (n = 24). Based on the specified inclusion criteria, 37 papers were selected. Following more in-depth examination using the
Discussion
This review provided a comprehensive synthesis of the research literature about the nature of sleep disorders for children with CP and factors related to their sleep disorders. We have identified eleven types of sleep disorders and twenty-one factors linked to sleep disorders for children with CP. Our findings extend previous descriptions of sleep disorders experienced by children with CP ∗[5], ∗[17], ∗[18], ∗[19], ∗[20], ∗[21], ∗[22], ∗[23], [24], ∗[25], ∗[26], [27], thereby potentially
Conflicts of interest
The authors do not have any conflicts of interest to disclose.
Support
No financial support.
Acknowledgments
We acknowledge funding of a PhD-Scholarship for Ana Luíza Paula de Aguiar Lélis from CAPES-Program, Brazilian Ministry of Education.
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