Jon Quach

Outcomes of Child Sleep Problems Over the School-Transition Period: Australian Population Longitudinal Study

BACKGROUND. Adequate sleep optimizes childrens learning and behavior. However, the natural history and impact of sleep problems during school transition is unknown. OBJECTIVES. To determine (1) the natural history of sleep problems over the 2-year period spanning school entry and (2) associations of childrens health-related quality of life, language, behavior, learning, and cognition at ages 6.5 to 7.5 years with (a) timing and (b) severity of sleep problems. METHODS. Data were drawn from the Longitudinal Study of Australian Children. Children were aged 4 to 5 years at wave 1 and 6 to 7 years at wave 2. Parent-reported predictors included (1) timing (none, persistent, resolved, incident) of moderate/severe sleep problems over the 2 waves and (2) severity (none, mild, moderate/severe) of sleep problems at wave 2. Outcomes included parent-reported health-related quality of life and language, parent- and teacher-reported behavior, teacher-reported learning, and directly assessed nonverbal (matrix reasoning) and verbal (receptive vocabulary) cognition. Linear regression, adjusted for child age, gender, and social demographic variables, was used to quantify associations of outcomes with sleep-problem timing and severity. RESULTS. Sleep data were available at both waves for 4460 (89.5%) children, of whom 22.6% (17.0% mild, 5.7% moderate/severe) had sleep problems at wave 2. From wave 1, 2.9% persisted and 2.8% developed a moderate/severe problem, whereas 10.1% resolved. Compared with no sleep problems, persistent and incident sleep problems predicted poorest health-related quality of life, behavior, language, and learning scores, whereas resolving problems showed intermediate outcomes. These outcomes also showed a dose-response relationship with severity at wave 2, with effect sizes for moderate/severe sleep problems ranging from −0.25 to −1.04 SDs. Cognitive outcomes were unaffected. CONCLUSIONS. Sleep problems during school transition are common and associated with poorer child outcomes. Randomized, controlled trials could determine if population-based sleep interventions can reduce the prevalence and impact of sleep problems.

Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias.

Objective: To describe the characteristics and outcomes of patients receiving a medical emergency team (MET) review for the MET syndromes of acute change in conscious state or arrhythmia and to assess the effect of delayed MET activation on their outcomes. Design: Retrospective analysis of medical records. Setting: University teaching hospital. Patients: Two cohorts of 100 patients for each of the MET syndromes of acute change in conscious state or arrhythmia. Interventions: None. Measurements and Main Results: We collected information on patient demographics, comorbidities, and presence of sepsis, hypovolemia, cardiogenic shock, and patient outcome. We also documented the presence and duration of delayed MET activation. The median age for both syndromes was >70 yrs, and major comorbidities were present in >10% of patients. A history of ischemic heart disease (p < .001) and congestive cardiac failure (p = .007) was more common in patients with arrhythmias. Cardiogenic shock and sepsis were common underlying causes of the MET calls for the two groups. However, cardiogenic shock was more common in patients with arrhythmias (p < .001). Hospital mortality was 35% for patients with an acute change in conscious state, compared with 18% for patients with arrhythmias (p = .01). Delayed MET activation occurred in 35% of acute change in conscious state patients and in 24% of arrhythmia patients (p = .09) with a median duration of delay of 16 and 13 hrs, respectively. Delayed MET activation was associated with increased mortality (odds ratio 3.1, 95% confidence interval 1.4–6.6, p = .005). Conclusions: An acute change in conscious state leading to a MET call carried a greater risk of death than activation due to arrhythmias. Delayed activation was common for both syndromes and was independently associated with an increased risk of death.

The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes—A follow-up study

OBJECTIVE To evaluate the impact of Rapid Response System (RRS) maturation on delayed Medical Emergency Team (MET) activation and patient characteristics and outcomes. DESIGN Observational study. SETTING Tertiary hospital. PATIENTS Recent cohort of 200 patients receiving a MET review and early control cohort of 400 patients receiving a MET review five years earlier at the start of RRS implementation. MEASUREMENTS AND RESULTS We obtained information including demographics, clinical triggers for and timing of MET activation in relation to the first documented MET review criterion (activation delay) and patient outcomes. We found that patients in the recent cohort were older, more likely to be surgical and to have Not For Resuscitation (NFR) orders before MET review. Furthermore, fewer patients (22.0% vs. 40.3%, p<0.001) had delayed MET activation. When delayed activation occurred, there was a non-significant difference in its duration (early cohort: 12.0 [IQR 23.0]h vs. recent cohort: 9.0 [IQR 20.5]h, p=0.554). Similarly, unplanned ICU admissions decreased from 31.3% to 17.3% (p<0.001). Delayed MET activation was independently associated with greater risk of unplanned ICU admission and hospital mortality (O.R. 1.79, 95% C.I. 1.33.-2.93, p=0.003 and O.R. 2.18, 95% C.I. 1.42-3.33, p<0.001, respectively). Being part of the recent cohort was independently associated with a decreased risk of delayed activation (O.R. 0.45, 95% C.I. 0.30-0.67, p<0.001) and unplanned ICU admission (O.R. 0.5, 95% C.I. 0.32-0.78, p=0.003). CONCLUSIONS Maturation of a RRS is associated with a decrease in the incidence of unplanned ICU admissions and MET activation delay. Assessment of a RRS early in the course of its implementation may underestimate its efficacy.

Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension

PURPOSE To describe the characteristics and outcomes of patients receiving a medical emergency team (MET) review for the MET syndromes of respiratory distress or hypotension and to assess the effect of delayed MET activation on their outcomes. MATERIALS AND METHODS We retrospectively analyzed the medical records of 2 cohorts of 100 patients for each of the MET syndromes of respiratory distress and hypotension. We collected information on patient demographics, comorbidities, presence of sepsis, and patient outcome. We documented the presence and duration of delayed MET activation. RESULTS Patients with respiratory distress were more likely to be postoperative (40% vs 28%, P = .07), but less likely to have a history of congestive cardiac failure (12% vs 22%, P = .06). Sepsis was present in 58% of cases. The hospital mortality for MET calls due to respiratory distress and hypotension was 38% and 35%, respectively (P = .77). Delayed MET calls occurred in 50% of patients with the MET syndrome of respiratory distress and in 39% of those with hypotension (P = .11). The median duration of delay was 12 hours in patients with respiratory distress compared to 5 hours for patients with hypotension (P = .016). A delay in making a MET call was associated with an increase in mortality (odds ratio, 2.10; 95% confidence interval, 1.01-4.34; P = .045). CONCLUSIONS Patients receiving MET calls for respiratory distress or hypotension were elderly and had a mortality greater than 35%. In many cases, MET activation was delayed. This delay was associated with increased mortality.

A Brief Sleep Intervention Improves Outcomes in the School Entry Year: A Randomized Controlled Trial

OBJECTIVE: To determine the feasibility of screening for child sleep problems and the efficacy of a behavioral sleep intervention in improving child and parent outcomes in the first year of schooling. METHODS: A randomized controlled trial was nested in a population survey performed at 22 elementary schools in Melbourne, Australia. Intervention involved 2 to 3 consultations that covered behavioral sleep strategies for children whose screening results were positive for a moderate/severe sleep problem. Outcomes were parent-reported child sleep problem (primary outcome), sleep habits, psychosocial health-related quality of life, behavior, and parent mental health (all at 3, 6, and 12 months) and blinded, face-to-face learning assessment (at 6 months). RESULTS: The screening survey was completed by 1512 parents; 161 (10.8%) reported a moderate/severe child sleep problem, and 108 of 136 (79.2% of those eligible) entered the trial. Sleep problems tended to resolve more rapidly in intervention children. Sleep problems affected 33% of 54 intervention children versus 43% of 54 control children at 3 months (P = .3), 25.5% vs 46.8% at 6 months (P = .03), and 32% vs 33% at 12 months (P = .8). Sustained sleep-habit improvements were evident at 3, 6, and 12 months (effect sizes: 0.33 [P = .03]; 0.51 [P = .003]; and 0.40 [P = .02]; respectively), and there were initial marked improvements in psychosocial scores that diminished over time (effect sizes: 0.47 [P = .02]; 0.41 [P = .09]; and 0.26 [P = .3]; respectively). Better prosocial behavior was evident at 12 months (effect size: 0.35; P = .03), and learning and parent outcomes were similar between groups. CONCLUSIONS: School-based screening for sleep problems followed by a targeted, brief behavioral sleep intervention is feasible and has benefits relevant to school transition.

Children’s sleep patterns from 0 to 9 years: Australian population longitudinal study.

Objective To provide accurate population normative data documenting cross-sectional, age-specific sleep patterns in Australian children aged 0–9 years. Design and setting The first three waves of the nationally representative Longitudinal Study of Australian Children, comprising two cohorts recruited in 2004 at ages 0–1 years (n=5107) and 4–5 years (n=4983), and assessed biennially. Participants Children with analysable sleep data for at least one wave. Measures At every wave, parents prospectively completed 24-h time-use diaries for a randomly selected week or weekend day. ‘Sleeping, napping’ was one of the 26 precoded activities recorded in 15-min time intervals. Results From 0 to 9 years of age, 24-h sleep duration fell from a mean peak of 14 (SD 2.2) h at 4–6 months to 10 (SD 1.9) h at 9 years, mainly due to progressively later mean sleep onset time from 20:00 (SD 75 min) to 21:00 (SD 60 min) and declining length of day sleep from 3.0 (SD 1.7) h to 0.03 (SD 0.2) h. Number and duration of night wakings also fell. By primary school, wake and sleep onset times were markedly later on weekend days. The most striking feature of the centile charts is the huge variation at all ages in sleep duration, sleep onset time and, especially, wake time in this normal population. Conclusions Parents and professionals can use these new centile charts to judge normalcy of childrens sleep. In future research, these population parameters will now be used to empirically determine optimal child sleep patterns for child and parent outcomes like mental and physical health.

Outcomes of a universal shared reading intervention by 2 years of age: the Let's Read trial.

BACKGROUND: Early shared reading and literacy promotion benefits have stimulated international interest in the development of early-years literacy-promotion programs despite limited evidence of effectiveness at a broader population level. OBJECTIVE: To determine whether a population-based primary care literacy promotion intervention during the first 2 years of life improves early markers of subsequent literacy by 2 years of age. DESIGN AND METHODS: This cluster randomized controlled trial took place in 5 relatively disadvantaged areas in Melbourne, Australia. Infants attending their maternal and child health centers were recruited at age 1–2 months. The intervention (4–8, 12, and 18 months) comprised maternal and child health nurses modelling shared reading activities to parents, supported by parent information and free books. Outcomes (at 2 years) included expressive vocabulary (MacArthur Bates Communicative Development Inventory), communication (Communication and Symbolic Behavior Scales), and home literacy environment (StimQ-Toddler). We analyzed the outcomes using random-effects (linear regression) models allowing for clustering. RESULTS: A total of 552 families (87.6%; 324 intervention and 228 control families) of 630 recruited families (66.5% response) were retained to outcome. A total of 97.3% of intervention parents received some (93.7% to all) of the intervention. At 2 years, the trial arms had similar vocabulary (adjusted mean difference: −2.0 [95% confidence interval: −6.2 to 2.2]; P = .36), communication (adjusted mean difference: 0.2 [95% confidence interval: −2.3 to 2.7]; P = .87), and home literacy (adjusted mean difference: −0.4 [95% confidence interval: −1.0 to 0.2]; P = .21). CONCLUSIONS: This universal literacy-promotion program was not beneficial in relatively disadvantaged communities by the age of 2 years and may be ineffective. Alternative interpretations may relate to program intensity, reach and/or sleeper effects. Definitive outcomes at 4 years are awaited.

Primary healthcare costs associated with sleep problems up to age 7 years: Australian population-based study

Objectives In Australian 0–7-year olds with and without sleep problems, to compare (1) type and costs to government of non-hospital healthcare services and prescription medication in each year of age and (2) the cumulative costs according to persistence of the sleep problem. Design Cross-sectional and longitudinal data from a longitudinal population study. Setting Data from two cohorts participating in the first two waves of the nationally representative Longitudinal Study of Australian Children. Participants Baby cohort at ages 0–1 and 2–3 (n=5107, 4606) and Kindergarten cohort at ages 4–5 and 6–7 (n=4983, 4460). Measurements Federal Government expenditure on healthcare attendances and prescription medication from birth to 8 years, calculated via linkage to Australian Medicare data, were compared according to parent report of child sleep problems at each of the surveys. Results At both waves and in both cohorts, over 92% of children had both sleep and Medicare data. The average additional healthcare costs for children with sleep problems ranged from

Schooling duration rather than chronological age predicts working memory between 6 and 7 years: memory maestros study

141 (age 5) to

Four-Year-Old Outcomes of a Universal Infant-Toddler Shared Reading Intervention The Let's Read Trial

43 (age 7), falling to