Does Sleep Duration Influence Symptom Burden in Pediatric Concussion Recovery?

Nightly sleep duration longer than 9.9 hours is associated with increased symptom burden during the first 2 weeks of concussion recovery among adolescents, according to study results published in JAMA Network Open.

Approximately a third of children will experience persisting symptoms after concussion (PSAC; sleep, emotional, somatic, or cognitive effects) that last longer than 1 month after injury. In previous research, researchers have assessed the relationship between sleep and concussion, they are limited by small sample sizes and exclusive focus on sports-related concussions.

A team of researchers conducted a cohort study using data from the Pediatric Concussion Assessment of Rest and Exertion study (PedCARE; ClinicalTrials.gov Identifier: NCT02893969), a randomly assigned clinical trial in 3 emergency departments in Ontario, Canada between March 2017 and December 2019. The current secondary analysis was conducted from September 2022 to September 2024.

The researchers evaluated adolescents (N=291; mean age, 13.2 years; girls, 44.0%) aged 10 to 18 years who presented within 48 hours of concussion. Exclusion criteria included brain imaging abnormalities, Glasgow Coma Scale score of 13 or below, neurosurgical intervention, preexisting neurodevelopmental delay, and admission to the intensive care unit.

In this secondary analysis, burden of symptoms was evaluated at 1, 2, and 4 weeks using the Health and Behavior Inventory (HBI) in which higher scores indicated higher symptom burden. Daily motion behaviors were monitored by a waist-worn accelerometer and daily sleep logs. Reliably symptomatic was defined conservatively as a change in HBI score of 1.65 or higher and liberally as a change of 1.28 or higher.

Participants had high Predicting Persistent Postconcussive Problems in Pediatrics (5P) risk, a median of 1 (range, 1-6) previous concussion, and 16.5% lost consciousness after injury.

In the first and second weeks after concussion, the median sleep durations were 10.0 and 9.9 hours, bedtimes were 10:00 and 10:00 PM, waketimes were 8:00 and 7:45 AM, and sleep midpoints were 3:00 and 2:59 AM, respectively.

The 50^th and 90^th percentile of mean sleep duration at 1 (estimate, 2.96; 95% CI, 1.22-4.69; P <.001), 2 (estimate, 2.16; 95% CI, 0.85-3.47; P =.001), and 4 (estimate, 2.16; 95% CI, 0.85-3.47; P =.001) weeks differed significantly.

The difference between the 25^th and 75^th percentile of mean sleep duration was significant at week 1 (1.26; 95% CI, 0.25 to 2.28; P =.02), but not week 2 (0.66; 95% CI, −0.33 to 1.64; P =.19) or 4 (0.66; 95% CI, −0.33 to 1.64; P =.19).

A total of 15.4% and 10.9% of adolescents were reliably symptomatic using the liberal and conservative definitions, respectively.

Using the liberal definition of symptoms, individuals with the 90^th percentile of sleep duration were more likely to be symptomatic that those with the 50^th percentile (odds ratio [OR], 1.93; 95% CI, 1.07-3.47; P =.03) at 4 weeks.

Sleep duration over 9.5 hours a day during the first week or over 9.9 hours per day during the first 2 weeks of acute concussion were associated with higher symptom burden.

Study limitations included the use of a wait-worn accelerometer not identifying precise time of sleep onset or offset, lack of data on confounding variables (screentime, naptime, family history of sleep disorders, sleep medication use, etc), sampling bias of emergency departments only, and the use of HBI despite it not being validated in youths older than 16.99 years of age when 5.5% of participants were aged 17 years and older.

 “… [L]ong sleep duration may be associated with increased odds of being reliably symptomatic at 4 weeks, therefore a greater risk of PSAC. Clinicians should monitor youths’ sleep after concussion,” the researchers concluded.