Asthma-related lung function, sleep quality, and sleep duration in urban children

Published:April 11, 2017DOI:



      Examine (1) the extent to which changes in objectively measured asthma-related lung function (forced expiratory volume in 1 second) within a sleep period are associated with sleep quality and sleep duration during that sleep period in a group of urban children with persistent asthma, (2) associations between morning and evening asthma-related lung function and sleep quality and duration on the adjacent night, and (3) whether these associations differ by ethnic group.


      Cross-sectional, multimethod approach. Children completed a clinic assessment of asthma and allergy status and used home-based objective measurements of asthma-related lung function and sleep.


      Children and their caregivers participated in a clinic assessment at an asthma and allergy clinic and completed additional assessments at home.


      Two hundred and sixteen African American, Latino, and non-Latino white urban children, ages 7-9 years, and their primary caregivers.


      Participants took part in a clinic assessment of asthma and allergy status, completed interview-based questionnaires including a diary to track asthma symptoms and sleep patterns, and used actigraphy and home-based spirometry daily across a 4-week period to assess sleep and lung function.

      Results and conclusions

      Results from analyses using structural equation modeling revealed an association between worsening asthma-related lung function and poor sleep quality in the full sample, as well as better asthma-related lung function at night and more optimal sleep efficiency that night. Ethnic group differences emerged in the association with morning or nighttime lung function measurements and sleep quality. Urban minority children with asthma may be at heightened risk for poorer quality sleep. Timing of lung function worsening may be important when considering when and how to improve both asthma health outcomes and sleep quality within specific groups.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Sleep Health: Journal of the National Sleep Foundation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Beebe D.W.
        Cognitive, behavioral, and functional consequences of inadequate sleep in children and adolescents.
        Pediatr Clin North Am. 2011; 58: 649-665
        • Boergers J.
        • Koinis-Mitchell D.
        Sleep and culture in children with medical conditions.
        J Pediatr Psychol. 2010; 35: 915-926
        • Koinis-Mitchell D.
        • Kopel S.J.
        • Boergers J.
        • et al.
        Good sleep health in urban children with asthma: a risk and resilience approach.
        J Pediatr Psychol. 2015; 40: 888-903
        • Koinis-Mitchell D.
        • Craig T.
        • Esteban C.A.
        • Klein R.B.
        Sleep and allergic disease: a summary of the literature and future directions for research.
        J Allergy Clin Immunol. 2012; 130: 1275-1281
        • Daniel L.C.
        • Boergers J.
        • Kopel S.J.
        • Koinis-Mitchell D.
        Missed sleep, asthma morbidity, and the relationship to socio-demographic factors.
        Ann Allergy Asthma Immunol. 2012; 109: 41-46
        • Fagnano M.
        • Bayer A.L.
        • Isensee C.A.
        • Hernandez T.
        • Halterman J.S.
        Nocturnal asthma symptoms and poor sleep quality among urban school children with asthma.
        Acad Pediatr. 2011; 11: 493-499
        • Strunk R.C.
        • Sternberg A.L.
        • Bacharier L.B.
        • Szefler S.J.
        Nocturnal awakening caused by asthma in children with mild to moderate asthma in the childhood asthma management program.
        J Allergy Clin Immunol Pract. 2002; 110: 395-403
        • Horner C.C.
        • Mauger D.
        • Strunk R.C.
        • et al.
        Most nocturnal asthma symptoms occur outside of exacerbations and associate with morbidity.
        J Allergy Clin Immunol. 2011; 128: 977-982
        • Calhoun S.L.
        • Vgontzas A.N.
        • Fernandez-Mendoza J.
        • et al.
        Prevalence and risk factors of excessive daytime sleepiness in a community sample of young children: the role of obesity, asthma, anxiety/depression, and sleep.
        Sleep. 2011; 34: 503-507
        • Janson C.
        • De Backer W.
        • Gislason T.
        • et al.
        Increased prevalence of sleep disturbances and daytime sleepiness in subjects with bronchial asthma: a population study of young adults in three European countries.
        Eur Respir J. 1996; 9: 2132-2138
        • Diette G.B.
        • Markson L.
        • Skinner E.A.
        • Nguen T.T.
        • Algatt-Bergstrom P.
        Nocturnal asthma in children affects school attendance, school performance and parents' work attendance.
        Arch Pediatr Adolesc Med. 2000; 154: 923-928
        • Catterall J.R.
        • Rhind G.B.
        • Stewart I.C.
        • Whyte K.F.
        • Shapiro C.M.
        • Douglas N.J.
        Effect of sleep deprivation on overnight bronchoconstriction in nocturnal asthma.
        Thorax. 1986; 41: 676-680
        • Ballard R.D.
        • Tan W.C.
        • Kelly P.L.
        • Pak J.
        • Pandey R.
        • Martin R.J.
        Effect of sleep and sleep deprivation on ventilatory response to bronchoconstriction.
        J Appl Physiol. 1990; 69: 490-497
        • Meltzer L.J.
        • Faino A.
        • Szefler S.J.
        • Strand M.
        • Gelfand E.W.
        • Beebe D.W.
        Experimentally manipulated sleep duration in adolescents with asthma: feasibility and preliminary findings.
        Pediatr Pulmonol. 2015; 50: 1360-1367
        • Janson C.
        • Gislason T.
        • Boman G.
        • Hetta J.
        • Roos B.E.
        Sleep disturbances in patients with asthma.
        Respir Med. 1990; 84: 37-42
        • Kozyrskyj A.L.
        • Kendall G.E.
        • Zubrick S.R.
        • Newnham J.P.
        • Sly P.D.
        Frequent nocturnal awakening in early life is associated with nonatopic asthma in children.
        Eur Respir J. 2009; 34: 1288-1295
        • Ranjbaran Z.
        • Keefer L.
        • Stepanski E.
        • Farhadi A.
        • Keshavarzian A.
        The relevance of sleep abnormalities to chronic inflammatory conditions.
        Inflamm Res. 2007; 56: 51-57
        • Morgan W.J.
        • Crain E.F.
        • Gruchalla R.S.
        • et al.
        Results of a home-based environmental intervention among urban children with asthma.
        N Engl J Med. 2004; 351: 1068-1080
        • Garrison M.M.
        • Lozano P.
        • Christakis D.A.
        Controller medication use and sleep problems in pediatric asthma: a longitudinal case-crossover analysis.
        Arch Pediatr Adolesc Med. 2011; 165: 826-830
        • Martin R.J.
        • Banks-Schlegel S.
        Chronobiology of asthma.
        Am J Respir Crit Care Med. 1998; 158: 1002-1007
        • Meijer G.G.
        • Postma D.S.
        • Wempe J.B.
        • Gerritsen J.
        • Knol K.
        • van Aalderen W.M.
        Frequency of nocturnal symptoms in asthmatic children attending a hospital out-patient clinic.
        Eur Respir J. 1995; 8: 2076-2080
        • Koinis-Mitchell D.
        • Kopel S.J.
        • Boergers J.
        • et al.
        Asthma, allergic rhinitis, and sleep problems in urban children.
        J Clin Sleep Med. 2015; 11: 101-110
        • McQuaid E.L.
        • Vasquez J.
        • Canino G.
        • et al.
        Beliefs and barriers to medication use in parents of Latino children with asthma.
        Pediatr Pulmonol. 2009; 44: 892-898
        • Koinis-Mitchell D.
        • Kopel S.J.
        • Salcedo L.
        • McCue C.
        • McQuaid E.L.
        Asthma indicators and neighborhood and family stressors related to urban living in children.
        Am J Health Behav. 2014; 38: 22-30
        • Koinis-Mitchell D.
        • McQuaid E.L.
        • Jandasek B.
        • et al.
        Identifying individual, cultural and asthma-related risk and protective factors associated with resilient asthma outcomes in urban children and families.
        J Pediatr Psychol. 2012; 37: 424-437
        • Spilsbury J.C.
        • Storfer-Isser A.
        • Drotar D.
        • et al.
        Sleep behavior in an urban U.S. sample of school-aged children.
        Arch Pediatr Adolesc Med. 2004; 158: 988-994
        • National Heart Lung and Blood Institute
        Guidelines for the Diagnosis and Management of Asthma.
        National Institutes of Health, Bethesda, MD2007
        • Lara M.
        • Duan N.
        • Sherbourne C.
        • et al.
        Differences between child and parent reports of symptoms among Latino children with asthma.
        Pediatrics. 1998; 102: e68
        • Akinbami L.J.
        • Schoendorf K.C.
        Trends in childhood asthma: prevalence, health care utilization, and mortality.
        Pediatrics. 2002; 110: 315-322
        • Akinbami L.J.
        • Moorman J.E.
        • Bailey C.
        • et al.
        Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010.
        NCHS Data Brief. 2012; 94: 1-8
        • Akinbami L.J.
        • Moorman J.E.
        • Liu X.
        Asthma prevalence, health care use, and mortality: United States, 2005-2009.
        Natl Health Stat Report. 2011; : 1-14
        • Reddel H.K.
        • Taylor D.R.
        • Bateman E.D.
        • et al.
        An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice.
        Am J Respir Crit Care Med. 2009; 180: 59-99
        • Calhoun W.J.
        • Sutton L.B.
        • Emmett A.
        • Dorinsky P.M.
        Asthma variability in patients previously treated with beta2-agonists alone.
        J Allergy Clin Immunol. 2003; 112: 1088-1094
        • National Heart Lung and Blood Institute
        Asthma statistics, data fact sheet.
        National Heart Lung and Blood Institute, Bethesda, MD1997
        • Brouwer A.F.J.
        • Roorda R.J.
        • Duiverman E.J.
        • Brand P.L.P.
        Reference values for peak flow and FEV1 variation in healthy schoolchildren using home spirometry.
        Eur Respir J. 2008; 32: 1262-1268
        • Redline S.
        • Tishler P.V.
        • Hans M.G.
        • Tosteson T.D.
        • Strohl K.P.
        • Spry K.
        Racial differences in sleep-disordered breathing in African-Americans and Caucasians.
        Am J Respir Crit Care Med. 1997; 155: 186-192
        • Fritz G.K.
        • McQuaid E.L.
        • Kopel S.J.
        • et al.
        Ethnic differences in perception of lung function: a factor in pediatric asthma disparities?.
        Am J Respir Crit Care Med. 2010; 182: 12-18
        • Canino G.
        • Bravo M.
        The adaptation and testing of diagnostic and outcome measures for cross-cultural research.
        Int Rev Psychiatry. 1994; 6: 281-286
        • U.S. Department of Health and Human Services
        The 2005 HHS Poverty Guidelines.
        U.S. Department of Health and Human Services, Washington, DC2005
        • Esteban C.A.
        • Klein R.B.
        • Kopel S.J.
        • et al.
        Underdiagnosed and undertreated allergic rhinitis in urban school-aged children with asthma.
        Pediatr Allergy Immunol Pulmonol. 2014; 27: 75-81
        • American Thoracic Society
        European thoracic society: ATS/ERS recommendations for standardized procedures for online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide.
        Am J Respir Crit Care Med. 2005; 171: 912-930
        • Centers for Disease Control and Prevention
        Body mass index: about BMI for children and teens.
        • Bousquet J.
        • Khaltaev N.
        • Cruz A.A.
        • et al.
        Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen).
        Allergy. 2008; 63: 8-160
        • Bender B.
        • Milgrom H.
        Comparison of the effects of fluticasone propionate aqueous nasal spary and loratadine on daytime altertness and performance in children with seasonal allergic rhinitis.
        Ann Allergy Asthma Immunol. 2004; 92: 344-349
        • Van Hoecke H.
        • Vastesaeger N.
        • Dewulf L.
        • De Bacquer D.
        • Van Cauwenberge P.
        Is the allergic rhinitis and its impact on asthma classification useful in daily primary care practice?.
        J Allergy Clin Immunol Pract. 2006; 118: 758-759
        • Schatz M.
        • Sorkness C.A.
        • Li J.T.
        • et al.
        Asthma control test: reliability, validity, and responsiveness in patients not previously followed by asthma specialists.
        J Allergy Clin Immunol. 2006; 117: 549-556
        • Nathan R.A.
        • Sorkness C.A.
        • Kosinski M.
        • et al.
        Development of the asthma control test: a survey for assessing asthma control.
        J Allergy Clin Immunol. 2004; 113: 59-65
        • Okupa A.Y.
        • Sorkness C.A.
        • Mauger D.T.
        • Jackson D.J.
        • Lemanske Jr., R.F.
        Daily diaries vs retrospective questionnaires to assess asthma control and therapeutic responses in asthma clinical trials: is participant burden worth the effort?.
        Chest. 2013; 143: 993-999
        • Koinis-Mitchell D.K.
        • McQuaid E.L.
        • Seifer R.
        • et al.
        Symptom perception in children with asthma: cognitive and psychological factors.
        Health Psychol. 2009; 28: 226-237
        • Wang X.
        • Dockery D.W.
        • Wypij D.
        • Fay M.E.
        • Ferris Jr., B.G.
        Pulmonary function between 6 and 18 years of age.
        Pediatr Pulmonol. 1993; 15: 75-88
        • Hankinson J.L.
        • Odencratz J.R.
        • Fedan K.B.
        Spirometric reference values from a sample of the general U.S. population.
        Am J Respir Crit Care Med. 1999; 159: 179-187
        • McQuaid E.L.
        • Walders N.
        • Kopel S.J.
        • Fritz G.K.
        • Klinnert M.D.
        Pediatric asthma management in the family context: the family asthma management System scale.
        J Pediatr Psychol. 2005; 30: 492-502
        • Meltzer L.J.
        • Walsh C.M.
        • Traylor J.
        • Westin A.M.
        Direct comparison of two new actigraphs and polysomnography in children and adolescents.
        Sleep. 2012; 35: 159-166
        • Acebo C.
        • Sadeh A.
        • Seifer R.
        • et al.
        Estimating sleep patterns with activity monitoring in children and adolescents: how many nights are necessary for reliable measures?.
        Sleep. 1999; 22: 95-103
        • Acebo C.
        • Sadeh A.
        • Seifer R.
        • Tzischinsky O.
        • Hafer A.
        • Carskadon M.A.
        Sleep/wake patterns derived from activity monitoring and maternal report for healthy 1-to 5-year-old children.
        Sleep. 2005; 28: 1568
        • Sitnick S.L.
        • Goodlin-Jones B.L.
        • Anders T.F.
        The use of actigraphy to study sleep disorders in preschoolers: some concerns about detection of nighttime awakenings.
        Sleep. 2008; 31: 395
        • LeBourgeois M.
        • Giannotti F.
        • Cortesi F.
        • Wolfson A.
        • Harsh J.
        The relationship between reported sleep quality and sleep hygiene in Italian and American adolescents.
        Am Acad Pediatr. 2005; 115: 257-265
        • Feldman J.
        • Fritz G.K.
        • McQuaid E.L.
        • et al.
        Symptom perception and asthma morbidity in pediatric asthma.
        in: Paper presented at International Society for the Advancement of Respiratory Psychophysiology. 2005 ([Hamburg, Germany])
        • Klinnert M.
        • McQuaid E.
        • Gavin L.
        Assessing the family asthma management System.
        J Asthma. 1997; 34: 77-88
        • Celano M.
        • Klinnert M.D.
        • Holsey C.N.
        • McQuaid E.L.
        Validity of the Family Asthma Management System scale with an urban African-American sample.
        J Pediatr Psychol. 2011; 36: 576-585
        • Canino G.
        • McQuaid E.L.
        • Alvarez M.
        • et al.
        Issues and methods in disparities research: the Rhode Island–Puerto Rico Asthma Center.
        Pediatr Pulmonol. 2009; 44: 899-908
        • Everhart R.S.
        • Kopel S.J.
        • McQuaid E.L.
        • et al.
        Differences in environmental control and asthma outcomes among urban Latino, African American, and non-Latino white families.
        Pediatr Allergy Immunol Pulmonol. 2011; 24: 165-169
        • Muthen B.O.
        • Muthen L.
        Mplus User's Guide.
        Muthen and Muthen, Los Angeles2004
        • Cohen S.
        • Williamson G.M.
        Perceived stress in a probability sample of the United States.
        in: Spacapan S. Oskamp S. The Social Psychology of Health: Claremont Symposium on Applied Social Psychology. Sage, Thousand Oaks, CA1998: 31-67
        • Hart C.N.
        • Carskadon M.A.
        • Considine R.V.
        • et al.
        Changes in children's sleep duration on food intake, weight, and leptin.
        Pediatrics. 2013; 132: e1473-e1480
        • Beebe D.W.
        • Simon S.
        • Summer S.
        • Hemmer S.
        • Strotman D.
        • Dolan L.M.
        Dietary intake following experimentally restricted sleep in adolescents.
        Sleep. 2013; 36: 827-834