Noise on Kids' Wards Might Limit Quantity and Quality of Sleep 

Becky McCall

July 24, 2018

In paediatric wards with high levels of night noise, children slept around an hour less and had poorer quality sleep, compared with sleeping at home, according to a small study from Southampton Children's Hospital. This could affect the child's behaviour, recovery and pain tolerance, the researchers suggest.

Senior author, Dr Catherine Hill, explained the results and their significance to Medscape News UK. "We've shown in the largest group to date that the general paediatric hospital setting has an adverse impact on sleep quantity and quality, and that it is noisier in hospital than at home. We know that hearing is our most attuned sense during sleep, and this is especially relevant in hospital with the high-pitched sounds of bleeps and similar."

She added that sleep was one aspect of care that could be freely delivered, and that "an hour in terms of research impact is significant with respect to cognition, behavioural regulation, pain control and recovery. Theoretically, a child's recovery could be affected too; and [in addition] they are accompanied by tired, emotionally dysregulated parents." 

The Study

Published in the July 17th edition of Archives of Disease in Childhood, the study found that children slept for an average of just under 7.5 hours in hospital, which was a mean of 62.9 minutes less than at home (p<0.001); while mothers slept for an average of 6 hours and 20 minutes in hospital, which was a mean of 72.8 minutes less than at home (p=0.004). Sleep quality was also less in hospital, with children's sleep efficiency (percentage of minutes scored as sleep from sleep onset to morning wakening) showing a mean of 77% in hospital versus 83.2% at home. 

The average median sound level recorded in hospital was 48.24 dB (decibels), with a difference of around 8 dB between open bays and single occupancy cubicles. Of note, children were exposed to significantly higher noise levels than World Health Organization (WHO) recommendations that state night noise in hospital should not exceed 30 dB, with peaks not exceeding 45 dB.

Previous research has investigated noise levels in children's oncology and intensive care wards but not general medical wards, prompting the research done here.

In this study, Hill and colleagues aimed to measure sleep quality objectively in both children and their co-sleeping parents admitted to medical wards at Southampton Children's Hospital and to compare this with their sleep at home. A secondary aim was to measure sound levels at the bedside in both environments. Sound levels were reported as weighted decibels (dBA) that represent sound levels as perceived by the human ear.

Children aged between 3-16 years, and their parents who stayed overnight, had their sleep measured objectively using wristwatch 'actigraphy', which is effectively a 'Fitbit' for sleep, explained Hill, for up to 5 consecutive nights in hospital and 5 nights at home. Sound levels were monitored overnight using a sound level meter at the patient's bedside for up to 2 nights in hospital and 2 nights at home. Sleep quantity and quality were assessed for 40 children and 16 co-sleeping mothers, and eight children had sound level monitoring. Sleep quantity at the two locations was compared for each child and parent.

Medical Education With Respect to Sleep Importance

Hill explained that they did not measure the inter-relationship between sleep quality and noise levels, but that it was reasonable to infer that noise will have affected sleep – "the sleeping brain is highly attuned to sound, an important evolutionary defence to potential threat."

She noted that the research brought the importance of sleep to the attention of paediatricians and doctors generally. "Sleep is a 'black hole' in medical education, and doctors' understanding of the function and importance of sleep is very limited. But we need to remember that sleep sub-serves nearly all physiological functions, in particular, cognitive performance, endocrine health, and growth, but somehow this has not translated to medical knowledge.

"Wards are designed by default to disrupt sleep with routines, shift times, ward rounds, and meal times running like clockwork," said the sleep specialist, explaining why sleep was often disrupted in hospital. "But how do we cater for the baby on a 24-hour cycle, the toddler who needs to sleep at 6pm, the teenager on their iPad until 10pm - how do we work around all that? A ward tends to be designed around adult sleep needs. Children's wards are very bright with pictures of clowns, therapy dogs, everything that appeals to children's minds, but we've lost sight of the fact that children also need to sleep."

Previous qualitative research by Hill found that sources of noise that disrupt sleep in hospital included timing of drugs administration, for example, at midnight whilst children would usually receive medication before bed at home; noise from mobile phones, staff chatting, as well as bleeps and crash calls. "Some noises are a necessary part of hospital functioning but there's a huge amount of avoidable noise, so this is about educating staff."

Sleep for Health in Hospital (Shh)

Given the results, Hill has put in place a multi-modal quality improvement project, called Shh (Sleep for Health in Hospital).  After being implemented for a year in Southampton, it is about to be rolled out across other hospitals in England. "It is based on staff education, with sound level monitors installed on the wards that provide feedback. We give parents information on expectations and impose sensible and considerate curfews around behaviour using the 'eight is late' strapline, asking people to turn off televisions or wear headphones, and change behaviour to support greater quiet," says Hill.

COI: Hill has declared no conflicts of interest

Sleep quality and noise: comparisons between hospital and home settings.  Published in the July 17 edition of Archives of Disease in Childhood

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