Patient-Reported Outcomes for Measuring Sleep Disturbance in Pediatric Atopic Dermatitis: Cross-Sectional Study of the Patient Reported Outcomes Measurement Information System Pediatric Sleep Measures and Actigraphy

Atopic dermatitis (AD) is a common, chronic, relapsing inflammatory skin disorder affecting up to 13% of children in the United States. Children with AD are particularly vulnerable to poor sleep, including difficulty falling asleep, awakenings during the night, difficulty awakening in the morning, and daytime sleepiness. This study sought to test the PROMIS (Patient Reported Outcomes Management Information System) questionnaire in pediatric patients with AD and develop an algorithm to screen for sleep disturbance in this patient population.

Sixty-one children aged 5 to 17 years with mild, moderate, and severe AD. The diagnosis of AD was made via Hanifin and Rajka criteria and severity was assessed via use of the Patient Oriented Eczema Measure (POEM).

Participants aged 8 years and above and one parent filled out multiple questionnaires focused on sleep, itch, quality of life and disease severity. Questionnaires include PROMIS pediatric sleep disturbance, PROMIS sleep impairment, itch numerical scale, the Children’s Dermatology Life Quality Index (CDLQI), the Pediatric Sleep Questionnaire, and the Epworth Sleepiness Scale. Both the POEM and CDLQI have a question that asks about sleep disturbance and these questions were reviewed to act as a screening tool. Additionally, pediatric participants wore an Actiwatch for one week to collect actigraphy data and filled out sleep diaries to track sleep timing, wake time, and medication use. Data obtained include sleep onset latency, bed time, wake time, minutes awake after sleep onset, sleep efficiency, and total sleep time.

Sixty-one children with AD with mild (n = 17), moderate (n = 23), and severe (n = 21) disease. Allergic comorbidities were similar between groups. Both parent-proxy-reported PROMIS sleep disturbance (mild versus moderate versus severe was 55.7±7.5 vs 59.8±10.8 vs 67.1±9.5, respectively; P < .01), and patient reported PROMIS sleep disturbance (51.2±9.3 vs 55.5±7.3 vs 61.1±10.3, respectively, P = .02, n = 45) was significantly different between disease severity groups. Those patients (n = 12) who continued on sedating antihistamine during the study tended to have more severe AD, poorer sleep by parent-proxy-PROMIS sleep disturbance, and more minutes of wake after sleep onset. There was a mild to moderate correlation between parent-proxy and child reported PROMIS sleep disturbance with objective sleep disturbance measures (r = 0.28, P = .03 and 0.34, P = .02, respectively). The sleep question on the POEM performed well as a screen for significant sleep disturbance on PROMIS parent-proxy sleep disturbance measure (T-score ≥60), with high sensitivity (94.9%) but low specificity (37.2%). The sleep question on the POEM performed better than the sleep question on the CDLQI.

Sleep disturbance in children with AD can be measured via patient or parent-proxy-report utilizing the PROMIS Pediatric or Parent-Proxy Sleep Disturbance tool. However, utilizing the POEM as an initial screening tool first, followed by the PROMIS if the sleep question is positive, is a prospective approach to diagnose sleep disorders in children with AD.

Pediatric patients with AD are vulnerable to poor sleep. Objective measures including actigraphy and polysomnography provide valuable information on sleep disturbance; however, these methods are not readily available to most practitioners and may be cumbersome to patients. The information provided by the PROMIS can inform processes to improve sleep hygiene in children with AD.