Sleep Disturbance in Preschool Children with Allergic diseases

Sleep Disturbance in Preschool Children with Allergic diseases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sleep Disturbance in Preschool Children with Allergic diseases Yung-Sen Chang, Bor-Luen Chiang, Ya-Chuan Huang, Chih-Chen Tsai, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8998979/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Sleep problems are very common in children with asthma, allergic rhinitis (AR), and atopic dermatitis (AD). This study investigates sleep disturbances in preschool children with atopy and evaluates the impact on their emotion and behavior. Methods Questionnaires were distributed to 19,086 preschool children 2 to 6 years old taking the public annual health examination. Symptoms of atopy, sleep problems, and behavior were assessed by the ISAAC questionnaire, the Child’s Sleep Habits Questionnaire, and the Strengths and Difficulties Questionnaire, respectively. Results Of the 10,830 participants, symptoms of asthma, AR, and AD were reported in up to 25.9%, 52.9%, and 37.6%, respectively. Those with asthma, AR, and AD symptoms all had significantly higher scores in sleep onset delay, sleep anxiety, night waking, parasomnia, sleep-disordered breathing, and daytime sleepiness. Sleep problems were related to disease control. Children with asthma, AR, and AD also had significantly higher scores in hyperactivity, emotional symptoms, conduct problems, and peer problems. However, in children with AD without sleep problems, emotional symptoms score and conduct problems score were lower than those with sleep problems (p < 0.01), and were not significantly different from those without AD. Similarly, the emotional symptoms score in children with asthma without sleep problems was lower (p < 0.01) and not significantly different from those without asthma. Conclusion Preschool children with asthma, AR, and AD have more sleep problems and higher emotional and conduct problems scores which are related to their sleep problems. Therefore, evaluation and management of sleep disturbance in children with atopy is very important. asthma atopic dermatitis preschool children sleep emotion Figures Figure 1 Figure 2 Figure 3 Introduction Allergic diseases such as asthma, allergic rhinitis (AR), and atopic dermatitis (AD) are some of the most common chronic diseases in childhood. The prevalence of allergic diseases in children in Taiwan has greatly increased over time. From the year 1985 to 2011, the prevalence of asthma in children has increased from 5.08% to 17%; the prevalence of allergic rhinitis has increased from 7.84% to 47.8%; and the prevalence of atopic dermatitis has increased from 1.23% to 21%. 1, 2 Sleep disturbance is often reported in children with atopy. Nocturnal asthmatic symptoms such as cough and wheezing cause sleep disruptions and were associated with increased number of school absences and poorer school performance. 3, 4 Allergic rhinitis symptoms such as nasal congestion, sneezing, itchy eyes and nose, and rhinorrhea also contribute to sleep disturbances. The Pediatric Allergies in America Survey 5 found that 40% of AR patients reported that allergies affected their sleep. Studies have also found that nighttime symptoms of rhinitis were associated with chronic excessive daytime sleepiness and poor quality of life. 6 Moreover, patients with asthma or AR have increased risk of sleep-disordered breathing. 7 Sleep disturbance is also common in children with atopic dermatitis, including reduced sleep efficiency, longer sleep onset latency, and more sleep fragmentation, 8, 9 and the sleep disorders might also affect disease severity. 10 Sleep is very important for both physical and mental health. In children, sleep disturbance can have many negative consequences, including impaired neurocognitive function, higher rates of behavioral problems, and changes in mood. 11, 12 While sleep disturbance is common in children with atopy, it has seldom been studied whether the sleep disturbance affect their emotion and behavior. It has been suggested that AD is associated with attention deficit hyperactivity disorder (ADHD) and emotional and conduct problems only when accompanied with sleep problems. 13, 14 This study aims to investigate sleep problems in children with atopy and whether it is associated with emotional and behavioral problems. Methods This is a cross-sectional study. The Taipei City Hospital Research Ethics Committee approved the study protocol. This study conformed to the principles of the Declaration of Helsinki. 15 Participants Questionnaires were sent to the parents of a random sample of children 2 to 6 years old who were taking the children’s annual health examination provided by the Department of Health, Taipei City Government. We randomly selected 2 districts of Taipei City (Da’an and Songshan Districs) and distributed the questionnaires to the preschools and health centers where the health examinations were held. The questionnaires (including informed consent) were completed by caregivers and collected during the health examination. Questionnaires Demographic data was obtained, including age, sex, body weight and body height, number of siblings, maternal age, and maternal education level. Sleep was examined by a modified Children’s Sleep Habits Questionnaire (CSHQ) 16 , 17 , which includes questions about sleep habits, sleep duration, and evaluation for sleep problems including bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night waking, parasomnia, sleep-disordered breathing, and daytime sleepiness 18 . To screen for allergic diseases, core symptoms of asthma, allergic rhinitis, and atopic dermatitis were evaluated by the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire 19 , 20 . Physician-diagnosed asthma/ allergic rhinitis/ atopic dermatitis were defined as those who answered “yes” to the question “Has your child ever been diagnosed by a doctor to have asthma/ allergic rhinitis/ atopic dermatitis?”. Children with symptoms of asthma was defined as those who answered “yes” to “Has your child ever had wheezing or whistling in the chest at any time in the past?”. Children with symptoms of allergic rhinitis was defined as those who answered “yes” to “Has your child ever had a problem with sneezing, or a runny, or blocked nose when she/he DID NOT have a cold or the flu?”. Children with symptoms of atopic dermatitis was defined as those who answered “yes” to “Has your child ever had an itchy rash, which was coming and going for at least six months?”. Of those who answered “yes” to “Has your child had wheezing or whistling in the chest in the past 12 months?”, those who answered “Never woken with wheezing” to the question “In the past 12 months, how often, on average, has your child’s sleep been disturbed due to wheezing?” were defined as “Asthma with no sleep problems related to symptoms”, and those who answered “Less than one night per week” and “One or more nights per week” to this question were defined as “Asthma with sleep problems related to symptoms.” Of those who answered “yes” to “ Has your child had this itchy rash at any time in the past 12 months?”, those who answered “Never in the past 12 months” to the question “In the past 12 months, how often, on average, has your child been kept awake at night by this itchy rash?” were defined as “Eczema with no sleep problems related to symptoms,” and those who answered “Less than one night per week” or “One or more nights per week” to this question were defined as “eczema with sleep problems related to symptoms.” Behavioral evaluation was conducted by using the Strengths and Difficulties Questionnaire (SDQ) 21 , which includes screening for emotional symptoms, conduct problems, hyperactivity, peer relationship problems, and prosocial behavior. Statistical Analysis The χ 2 test or the Student’s t test was used to compare the data between the patients with allergic symptoms and those without allergic symptoms or between the patient subgroups. Missing data were excluded from the analysis. All statistical analyses were performed by using SPSS software (SPSS version 25, IBM Corp.). P < 0.05 defines statistical significance. Results We distributed 19,086 questionnaires, and 10,830 questionnaires were collected. Return rate of the questionnaires was 56.7%. A total of 10,464 questionnaires were valid for analysis, of which 48.6% were girls and 51.4% were boys. Mean age was 4.9 ± 1.1 years old. Prevalence of Allergic Diseases In our study population, 11.7% had physician-diagnosed asthma, 35.9% had physician-diagnosed allergic rhinitis, 21.9% had physician-diagnosed atopic dermatitis, and 14.7% had at least 2 overlapping diagnoses. (Fig. 1 ) Symptoms of allergic diseases was even more prevalent: Wheezing was present in 18.3%, dry cough at night apart from infection in 25.9%, allergic rhinitis symptoms apart from infection in 52.9%, and eczema ever in 37.6%. Sleep Problems in Children with Allergic Diseases In children with symptoms of asthma, allergic rhinitis, or atopic dermatitis, parents reported that the child’s sleep was problematic in 55.2%, 54.1%, and 55.7%, respectively. The total sleep duration at nighttime was not significantly different in those with symptoms of asthma (wheezing ever) compared with those without symptoms of asthma (587.2 ± 45.1 vs 586.5 ± 45.8 minutes, p = 0.54). Nor was the total sleep duration at nighttime significantly different between those with and without allergic rhinitis symptoms (586.7 ± 44.7 vs 586.1 ± 46.5 minutes, p = 0.58) or between those with and without atopic dermatitis symptoms (587.5 ± 44.9 vs 586.4 ± 45.5 minutes, p = 0.92). However, results from the CSHQ showed that in children with symptoms of asthma, allergic rhinitis or atopic dermatitis all had significantly higher scores in sleep onset delay, sleep duration, sleep anxiety, night waking, parasomnia, sleep-disordered breathing, daytime sleepiness, and total sleep disturbance score. Children with symptoms of allergic rhinitis and atopic dermatitis also had significantly higher scores on bedtime resistance. (Table 1 ) Table 1 CSHQ scores in children with and without symptoms of asthma, allergic rhinitis, and atopic dermatitis Asthma No Asthma P -value Allergic rhinitis No allergic rhinitis P -value Atopic dermatitis No atopic dermatitis P -value (n = 1760) (n = 7873) (n = 5152) (n = 4584) (n = 1564) (n = 8104) Bedtime resistance 11.71 ± 2.78 11.60 ± 2.75 0.14 11.71 ± 2.75 11.53 ± 2.77 < 0.01 11.85 ± 2.74 11.58 ± 2.76 < 0.001 Sleep onset delay 1.61 ± 0.68 1.57 ± 0.67 0.02 1.60 ± 0.68 1.54 ± 0.66 < 0.001 1.66 ± 0.70 1.56 ± 0.66 < 0.001 Sleep duration 4.25 ± 1.45 4.11 ± 1.38 < 0.001 4.21 ± 1.42 4.03 ± 1.35 < 0.001 4.31 ± 1.45 4.10 ± 1.38 < 0.001 Sleep anxiety 7.20 ± 2.00 7.04 ± 1.95 < 0.01 7.16 ± 1.97 6.95 ± 1.95 < 0.001 7.23 ± 1.94 7.03 ± 1.96 < 0.001 Night wakings 3.69 ± 1.05 3.60 ± 0.99 < 0.01 3.68 ± 1.04 3.54 ± 0.94 < 0.001 3.77 ± 0.11 3.58 ± 0.97 < 0.001 Parasomnias 7.59 ± 1.56 7.40 ± 1.50 < 0.001 7.59 ± 1.57 7.27 ± 1.43 < 0.001 7.59 ± 1.61 7.40 ± 1.49 < 0.001 Sleep disordered breathing 3.88 ± 1.21 3.47 ± 0.90 < 0.001 3.73 ± 1.10 3.34 ± 0.77 < 0.001 3.72 ± 1.13 3.51 ± 0.94 < 0.001 Daytime sleepiness 15.17 ± 2.84 14.88 ± 2.79 < 0.001 15.14 ± 2.81 14.72 ± 2.79 < 0.001 15.20 ± 2.84 14.89 ± 2.71 < 0.001 Total sleep disturbance score 50.48 ± 6.66 49.25 ± 6.23 < 0.001 50.31 ± 6.42 48.58 ± 6.10 < 0.001 50.70 ± 6.54 49.25 ± 6.26 < 0.001 In children with asthma, those with more than 4 wheezing attacks in the past 12 months had significantly higher scores in sleep anxiety, night waking, parasomnias, sleep disordered breathing, and daytime sleepiness compared with those who had 0–3 wheezing attacks in the past 12 months. (Table 2 ) Children with asthma who were well-controlled with no symptoms in the past 12 months did not have significantly different scores in the CSHQ compared with children without asthma, except for a higher sleep-disordered breathing score. (Table 3 ) Similarly, children with atopic dermatitis who were well-controlled with no symptoms in the past 12 months did not have significantly different scores in the CSHQ compared with children without atopic dermatitis, except in sleep-disordered breathing and parasomnia score. (Table 3 ) Table 2 CSHQ scores in children with asthma of different severity Mild asthma † Moderate to severe asthma‡ P -value (n = 973) (n = 184) Bed time resistance 11.74 ± 2.74 12.11 ± 2.62 0.09 Sleep onset delay 1.62 ± 0.68 1.60 ± 0.69 0.71 Sleep duration 4.26 ± 1.43 4.33 ± 1.48 0.54 Sleep anxiety 7.15 ± 2.00 7.71 ± 1.91 < 0.001 Night waking 3.68 ± 1.02 3.93 ± 1.29 < 0.01 Parasomnia 7.58 ± 1.57 7.94 ± 1.76 < 0.01 Sleep disordered breathing 3.89 ± 1.23 4.28 ± 1.26 < 0.001 Daytime sleepiness 15.13 ± 2.81 15.64 ± 2.87 0.03 Total score 53.66 ± 6.03 55.79 ± 6.01 4 wheezing attacks in the past 12 months Table 3 CSHQ scores in children with asthma/atopic dermatitis who had no symptoms in the past 12 months and in children without asthma/atopic dermatitis Asthma with no symptoms in the past 12 months No asthma P -value Atopic dermatitis with no symptoms in the past 12 months No atopic dermatitis P -value (n = 487) (n = 7873) (n = 243) (n = 8104) Bed time resistance 11.48 ± 2.92 11.60 ± 2.75 0.35 11.81 ± 2.80 11.58 ± 2.76 0.21 Sleep onset delay 1.58 ± 0.67 1.56 ± 0.67 0.65 1.57 ± 0.67 1.56 ± 0.66 0.75 Sleep duration 4.17 ± 1.41 4.11 ± 1.38 0.32 4.27 ± 1.39 4.10 ± 1.38 0.08 Sleep anxiety 7.06 ± 2.03 7.04 ± 1.95 0.76 7.18 ± 1.81 7.03 ± 1.96 0.22 Night waking 3.59 ± 0.97 3.60 ± 0.99 0.84 3.59 ± 1.02 3.58 ± 0.97 0.94 Parasomnia 7.48 ± 1.47 7.40 ± 1.50 0.24 7.64 ± 1.67 7.40 ± 1.49 0.04 Sleep disordered breathing 3.68 ± 1.07 3.47 ± 0.90 < 0.001 3.69 ± 1.14 3.51 ± 0.94 0.02 Daytime sleepiness 15.10 ± 2.83 14.88 ± 2.79 0.11 15.25 ± 2.93 14.89 ± 2.80 0.05 Total score 49.46 ± 6.66 49.25 ± 6.23 0.5 50.60 ± 6.49 49.25 ± 6.26 0.003 Behavior Problems in Children with Allergic Diseases Results from the SDQ evaluation showed that children with symptoms of asthma, allergic rhinitis, and atopic dermatitis all had significantly higher scores in hyperactivity, emotional symptoms, conduct problems, peer problems, and total difficulties score. Children with symptoms of allergic rhinitis also had a significantly lower prosocial score. (Table 4 ) However, in children with asthma without sleep problems, emotional symptoms score was significantly lower than those with sleep problems, and was not significantly different from those without asthma. (Fig. 2 ) In children with atopic dermatitis without sleep problems, emotional symptoms score and conduct problems score were significantly lower than those with sleep problems, and were not significantly different from those without atopic dermatitis. (Fig. 3 ) Table 4 SDQ scores in children with and without symptoms of asthma, allergic rhinitis, and atopic dermatitis Asthma No asthma P -value Allergic rhinitis No allergic rhinitis P -value Atopic dermatitis No atopic dermatitis P -value (n = 1760) (n = 7873) (n = 5152) (n = 4584) (n = 1564) (n = 8104) Hyperactivity 3.93 ± 2.42 3.70 ± 2.35 < 0.001 3.94 ± 2.39 3.53 ± 2.33 < 0.001 3.95 ± 2.47 3.71 ± 2.35 < 0.001 Emotional symptoms 2.13 ± 1.71 1.95 ± 1.61 < 0.001 2.16 ± 1.69 1.77 ± 1.52 < 0.001 2.20 ± 1.74 1.94 ± 1.60 < 0.001 Conduct problems 1.70 ± 1.44 1.60 ± 1.37 < 0.01 1.71 ± 1.41 1.53 ± 1.35 < 0.001 1.73 ± 1.37 1.61 ± 1.38 < 0.01 Peer problems 2.12 ± 1.58 2.03 ± 1.54 0.04 2.10 ± 1.56 1.98 ± 1.53 < 0.001 2.12 ± 1.57 2.03 ± 1.54 0.03 Prosocial 7.34 ± 1.99 7.32 ± 1.98 0.71 7.26 ± 1.98 7.39 ± 1.99 0.001 7.31 ± 2.05 7.33 ± 1.97 0.77 Total difficulties score 9.87 ± 4.85 9.27 ± 4.70 < 0.001 9.89 ± 4.74 8.79 ± 4.64 < 0.001 9.99 ± 4.75 9.27 ± 4.72 < 0.001 Discussion The prevalence of allergic diseases has been rising in children worldwide. 22 , 23 Our study found that the prevalence of physician-diagnosed asthma, allergic rhinitis, and atopic dermatitis in preschool children in Taiwan were 11.7%, 35.9%, and 21.9%, respectively, and up to 14.7% had at least 2 overlapping diagnoses. Symptoms of asthma such as wheezing or dry cough at night apart from infection were reported up to 25.9%, allergic rhinitis symptoms were reported in 52.9%, and eczema ever was reported in 37.6%. Compared with the report of prevalence of childhood allergic diseases in 2011 which showed 17% for asthma, 47.8% for allergic rhinitis, and 10.8% for eczema, we can see that the prevalence of allergic diseases in children in Taiwan is still rising in the past 10 years, 1, 2 and undiagnosed rates are still high. Sleep disturbance has been reported in more than half of the children with symptoms of asthma, allergic rhinitis, or atopic dermatitis in our study. In concordance with previous studies, sleep duration was not significantly different in children with allergic diseases compared with those without allergic diseases. 8 , 24 However, children with allergic diseases had significantly more problems in almost every aspect of the CSHQ. (Table 1 ) Previous studies have also reported that sleep disturbance is common in children with allergic diseases and were mostly attributed to nocturnal symptoms. 3 , 6 , 8 , 10 However in our study we examined the type of sleep problems encountered, and we found that children with allergic diseases not only had significantly more night awakenings and daytime sleepiness, but also more problems with bedtime resistance, sleep onset delay, sleep anxiety, and parasomnias.(Table 1 ) This could probably be due to acquired sleep habits, for example, worsening cough, itch, or stuffy nose at night usually results in more parental attention, either at sleep onset or during night awakenings, and could lead to limit-setting behavioral insomnia in childhood or sleep anxiety. Disrupted sleep could lead to an irregular sleep schedule (such as sleeping-in if the child had more awakenings the previous night) and could contribute to parasomnias. Therefore, sleep hygiene education, such as having a consistent bedtime routine and keeping a fixed sleep schedule is important for children with allergic diseases and behavioral interventions should be offered if needed. 25 Parents should also be educated about awareness of behavioral insomnia in childhood in order to avoid more sleep problems than those directly caused by allergic symptoms. Sleep disordered breathing score is also significantly higher in children with either asthma, allergic rhinitis, or atopic dermatitis. (Table 1 ) In previous studies, sleep disordered breathing has been found to be associated with asthma and also asthma severity in children, but causal relationship has not been established. 26 , 27 Allergic rhinitis has been found to be one of the most important risk factors for habitual snoring in children, 28, 29 and is also associated with increased risk of obstructive sleep apnea (OSA). 24 , 30 In a study by Nosetti et al, allergic rhinitis was found in 35% of children with children with primary snoring, and 6% with OSA. It was suggested that nasal inflammation has a role in primary snoring and OSA. 31 Studies have also found that allergic rhinitis severity was significantly associated with OSA severity in children. 30 Chng et al found that habitual snoring was significantly associated with atopic dermatitis (OR 1.8; 95% CI 1.28–2.54), 28 and a large population based cohort study found that after adjusting for age, sex, urbanization level, and comorbidities, children with atopic dermatitis had a higher risk of OSA (OR 1.86). Atopic dermatitis and OSA are both chronic systemic inflammatory diseases and it was postulated that they share similar immunopathologic pathways. 32 It is important to evaluate for the presence of habitual snoring or OSA symptoms in children with allergic diseases in order to offer prompt diagnosis and management of possible sleep disordered breathing. Our study found that in children with well-controlled asthma who had no symptoms in the past 12 months, the CSHQ score for problems with bedtime resistance, sleep onset delay, sleep anxiety, night waking, and daytime sleepiness were not significantly different from those without asthma. However, the score for sleep disordered breathing was still significantly higher than those without asthma. (Table 3 ) Similar results were found in children with atopic dermatitis who had no symptoms in the past 12 months. Most CSHQ scores became not significantly different from those without atopic dermatitis, except for the score for sleep-disordered breathing. (Table 3 ) This indicates that control of allergic symptoms is crucial for improving sleep in children with allergic diseases, and has benefit on both symptom-related sleep disturbance and also sleep problems which might be induced by acquired sleep habits. However, association with sleep disordered breathing might be more related to the pathogenesis of allergic diseases and does not seem to improve with symptom control. From the results of the SDQ questionnaire, we found that children with either asthma, allergic rhinitis, or atopic dermatitis all had significantly higher scores for hyperactivity, emotional symptoms, conduct problems, peer problems, and total difficulties score than those without asthma, allergic rhinitis, or atopic dermatitis. (Table 4 ) In previous literature, behavioral problems were also found to be more pronounced in children and adolescents with asthma, including conduct disorder, attention deficit hyperactivity disorder (ADHD), and having internalizing symptoms such as being withdrawn or depressed. 33–35 Allergic rhinitis symptoms in children were found to be associated with conduct problems and emotional symptoms. 36 Association of atopic dermatitis and behavior problems was also demonstrated in previous literature, including higher internal behavior scale scores and anxiety/depression scale scores, more emotional and conduct problems, and more symptoms of hyperactivity/inattention. 37, 38 A meta-analysis showed that children with ADHD were more likely to have asthma (OR 1.8, 95% CI 1.57–2.07), allergic rhinitis (OR 1.59, 95% CI 1.13–2.23), and atopic dermatitis (OR 1.43, 95% CI 1.09–1.88). 39 Wu et al. found that the risk of having psychosocial problems were increasingly higher in children with one, two, and more than two allergic diseases. 40 The reason for the association between allergic diseases and behavioral problems is unclear and could be multifactorial. In previous literature, it was postulated that behavioral difficulties in children with allergic diseases were due to social implications, side effects of allergy medication, or negatively affected brain development. 37 Some studies have also suggested that disturbed sleep might play a role. Manjunath et al. found that sleep disturbance was a predictor of behavioral problems in children and adolescents with AD. 41 Schmitt et al. found that infant eczema with concurrent sleep problems predicted emotional problems (OR 2.63, 95%CI 1.20–5.76) and conduct problems (OR 3.03, 95%CI 1.01–9.12) at 10 years old. 13 In our study, we have shown that sleep problems are highly prevalent in children with allergic diseases. Further analysis showed that children with asthma who had sleep problems had significantly higher emotional symptoms score than children without asthma, but emotional symptoms score in children with asthma who had no sleep problems were significantly lower than those with sleep problems, and was not significantly different from those without asthma. (Fig. 2 ) Similarly, children with atopic dermatitis who had sleep problems had significantly higher emotional symptoms score and conduct problems score than children without atopic dermatitis, but emotional symptoms score and conduct problems score in children with atopic dermatitis who had no sleep problems were significantly lower than those with sleep problems, and was not significantly different from those without atopic dermatitis. (Fig. 3 ) Our study results suggest that sleep disturbance might play an important role in the behavioral problems in children with allergic diseases. Therefore, it is important to recognize sleep problems in children with allergy and offer timely management. We suggest assessing for presence of sleep disturbance when evaluating children with asthma, allergic rhinitis, and atopic dermatitis. For children with allergic disease who have sleep disturbance, we suggest that it is crucial to achieve optimal control of nighttime symptoms and it is also important to offer sleep hygiene education. This is a cross-sectional study and therefore could only demonstrate association between factors rather than causal relationship. This is also a questionnaire-based study and therefore could be prone to have recall bias. Further prospective studies with objective measurements of sleep are needed to clarify the relationship between sleep disturbance and emotional or conduct problems in children with asthma, allergic rhinitis, or atopic dermatitis. Sleep problems are highly prevalent in preschool children with asthma, allergic rhinitis, and atopic dermatitis, including more night awakenings, daytime sleepiness, bedtime resistance, sleep onset delay, sleep anxiety, parasomnias, and sleep disordered breathing. Children with allergic diseases also have significantly higher emotional and conduct problems scores, which might be related to their sleep problems. We suggest routine evaluation of sleep disturbance and symptoms of sleep disordered breathing in children with asthma, allergic rhinitis, and atopic dermatitis, and we stress the importance of optimal control of nighttime symptoms and offering sleep hygiene education and avoiding acquired problematic sleep habits in those with sleep problems. Abbreviations AD, atopic dermatitis; ADHD, attention deficit hyperactivity disorder; AR, allergic rhinitis; CSHQ, Children’s Sleep Habits Questionnaire; ISAAC, International Study of Asthma and Allergies in Childhood; SDQ, Strengths and Difficulties Questionnaire Declarations Conflict of Interest The authors have no relevant conflicts of interest. Consent to Participate Declaration : not applicable Acknowledgements This research was funded by the Department of Health, Taipei City Government, Taiwan. Grant Number: 10701-62-006; 11201-62-011. We would also like to acknowledge the help from the Department of Health and the Department of Education, Taipei City Government, for distributing questionnaires. Funding This research was funded by the Department of Health, Taipei City Government, Taiwan. Grant Number: 10701-62-006; 11201-62-011. Competing Interests The authors have no relevant financial or non-financial interests to disclose. 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Lancet 398(10311):1569–1580 Silverberg JI, Barbarot S, Gadkari A, Simpson EL, Weidinger S, Mina-Osorio P et al (2021) Atopic dermatitis in the pediatric population: A cross-sectional, international epidemiologic study. Ann Allergy Asthma Immunol ; 126(4): 417 – 28 e2. Liu J, Zhang X, Zhao Y, Wang Y (2020) The association between allergic rhinitis and sleep: A systematic review and meta-analysis of observational studies. PLoS ONE 15(2):e0228533 Vriend J, Corkum P (2011) Clinical management of behavioral insomnia of childhood. Psychol Res Behav Manag 4:69–79 Castro-Rodriguez JA, Brockmann PE, Marcus CL (2017) Relation between asthma and sleep disordered breathing in children: is the association causal? Paediatr Respir Rev 22:72–75 Capanoglu M, Ginis T, Buyuktiryaki B, Guvenir H, Vezir E, Misirlioglu ED et al (2024) The frequency of sleep-disordered breathing in preschool children with asthma and its effects on control of asthma. Allergol Immunopathol (Madr) 52(1):38–43 Chng SY, Goh DY, Wang XS, Tan TN, Ong NB (2004) Snoring and atopic disease: a strong association. Pediatr Pulmonol 38(3):210–216 Tafur A, Cherrez-Ojeda I, Patino C, Gozal D, Rand C, Ronnie M et al (2009) Rhinitis symptoms and habitual snoring in Ecuadorian children. Sleep Med 10(9):1035–1039 D'Elia C, Gozal D, Bruni O, Goudouris E, Meira ECM (2022) Allergic rhinitis and sleep disorders in children - coexistence and reciprocal interactions. J Pediatr (Rio J) 98(5):444–454 Nosetti L, Piacentini G, Macchi A, De Bernardi F, Simoncini D, Nicoloso M et al (2019) Nasal cytology in children with primary snoring and obstructive sleep apnoea syndrome. Int J Pediatr Otorhinolaryngol 122:133–137 Hu JM, Lin CS, Chen SJ, Chen CY, Lin CL, Kao CH (2018) Association between obstructive sleep apnea and atopic dermatitis in children: A nationwide, population-based cohort study. Pediatr Allergy Immunol 29(3):260–266 Rajhans P, Sagar R, Patra BN, Bhargava R, Kabra SK (2021) Psychiatric Morbidity and Behavioral Problems in Children and Adolescents with Bronchial Asthma. Indian J Pediatr 88(10):968–973 Verkleij M, van de Griendt EJ, Kaptein AA, van Essen-Zandvliet L, Duiverman E, Geenen R (2011) Behavioral problems in children and adolescents with difficult-to-treat asthma. J Asthma 48(1):18–24 Calam R, Gregg L, Simpson B, Morris J, Woodcock A, Custovic A (2003) Childhood asthma, behavior problems, and family functioning. J Allergy Clin Immunol 112(3):499–504 Yamaguchi C, Ebara T, Futamura M, Ohya Y, Asano M (2021) Do allergic clinical manifestations increase the risk of behavioral problems in children? A cross-sectional study. Pediatr Allergy Immunol 32(8):1646–1653 Keller W, Vogel M, Prenzel F, Genuneit J, Jurkutat A, Hilbert C et al (2021) Atopic diseases in children and adolescents are associated with behavioural difficulties. BMC Pediatr 21(1):197 Kisieliene I, Aukstuolyte B, Mainelis A, Rudzeviciene O, Bylaite-Bucinskiene M, Wolenberg A (2024) Associations between Atopic Dermatitis and Behavior Difficulties in Children. Med (Kaunas) ; 60(3) Miyazaki C, Koyama M, Ota E, Swa T, Mlunde LB, Amiya RM et al (2017) Allergic diseases in children with attention deficit hyperactivity disorder: a systematic review and meta-analysis. BMC Psychiatry 17(1):120 Wu WC, Chang HY, Kuo KN, Chen CY, Tu YC, Yang YH (2011) Psychosocial problems in children with allergic diseases: a population study in Taiwan. Child Care Health Dev 37(5):662–670 Manjunath J, Silverberg JI (2022) Atopic Dermatitis Is Associated With Multiple Behavioral Problems in US Children and Adolescents. Dermatitis 33(6S):S52–S60 Additional Declarations No competing interests reported. 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Chang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYHACNhDBw8bMfPABiMFHrBYZfna2ZAOwXmK12Ej285hJwLn4gMH5w88e/NxRy2NwmC2t8muOnQwbA/PDRzfwabmRZm7Ye+Y4UAvzsduy25KBDmMzNs7Bq4WHTYK37RjYltuS25iBWnjYpPFqOX+GTfIvWAuPWbHktnoitBzIYZPmbavhkWzmMWP8uO0wYS2SN9LMpGXbDvDwM7MlSzNuOw6MIAJ+4QOGmOTbtjp7Nv7DBz/+3FZtz8/e/PAxPi0KB8DUYTDJzAMm8SgHAfkGMFUHJhl/EFA9CkbBKBgFIxMAAG4uQ+FWB+GlAAAAAElFTkSuQmCC","orcid":"","institution":"Taipei City Hospital Renai Branch","correspondingAuthor":true,"prefix":"","firstName":"Yung-Sen","middleName":"","lastName":"Chang","suffix":""},{"id":605713713,"identity":"e65f215d-5024-4c9f-b1bd-f53b672048cf","order_by":1,"name":"Bor-Luen Chiang","email":"","orcid":"","institution":"National Taiwan University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bor-Luen","middleName":"","lastName":"Chiang","suffix":""},{"id":605713714,"identity":"c540c5c1-c919-4c53-b095-3c10c572614f","order_by":2,"name":"Ya-Chuan Huang","email":"","orcid":"","institution":"National Cheng-Chi University","correspondingAuthor":false,"prefix":"","firstName":"Ya-Chuan","middleName":"","lastName":"Huang","suffix":""},{"id":605713715,"identity":"c0a7f3e4-2761-459e-a688-d2c5698e2848","order_by":3,"name":"Chih-Chen Tsai","email":"","orcid":"","institution":"Taipei City Hospital Renai Branch","correspondingAuthor":false,"prefix":"","firstName":"Chih-Chen","middleName":"","lastName":"Tsai","suffix":""},{"id":605713716,"identity":"2c4e783f-f534-425a-9638-5bdb73b62a07","order_by":4,"name":"Yu-Ting Wu","email":"","orcid":"","institution":"National Cheng-Chi University","correspondingAuthor":false,"prefix":"","firstName":"Yu-Ting","middleName":"","lastName":"Wu","suffix":""},{"id":605713718,"identity":"25db67f6-186d-42b4-90cf-6c3637a0fbdf","order_by":5,"name":"Chien-Ming Yang","email":"","orcid":"","institution":"National Cheng-Chi University","correspondingAuthor":false,"prefix":"","firstName":"Chien-Ming","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2026-03-01 03:38:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8998979/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8998979/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104708017,"identity":"e3e8926e-c312-461e-883c-1b1ad0e19768","added_by":"auto","created_at":"2026-03-16 09:45:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1817981,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8998979/v1/2036d90b33b4220dc5dad301.jpg"},{"id":104708020,"identity":"7acd8b80-f1a1-4bc5-bbe7-abbe36d7a379","added_by":"auto","created_at":"2026-03-16 09:45:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1933165,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8998979/v1/5d77e5a7411c27f1b6fe28d9.jpg"},{"id":104708019,"identity":"46a04d39-7343-418a-a994-3f001a8ecf4c","added_by":"auto","created_at":"2026-03-16 09:45:01","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2318652,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8998979/v1/acaeccda3010367900742e7d.jpg"},{"id":107869562,"identity":"bb3f6b3d-87d7-47af-af5d-d40a777755fd","added_by":"auto","created_at":"2026-04-27 07:37:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6467199,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8998979/v1/7639880c-ea80-4292-bd88-9b16fd8bfa47.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sleep Disturbance in Preschool Children with Allergic diseases","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAllergic diseases such as asthma, allergic rhinitis (AR), and atopic dermatitis (AD) are some of the most common chronic diseases in childhood. The prevalence of allergic diseases in children in Taiwan has greatly increased over time. From the year 1985 to 2011, the prevalence of asthma in children has increased from 5.08% to 17%; the prevalence of allergic rhinitis has increased from 7.84% to 47.8%; and the prevalence of atopic dermatitis has increased from 1.23% to 21%. \u003csup\u003e1, 2\u003c/sup\u003e Sleep disturbance is often reported in children with atopy. Nocturnal asthmatic symptoms such as cough and wheezing cause sleep disruptions and were associated with increased number of school absences and poorer school performance. \u003csup\u003e3, 4\u003c/sup\u003e Allergic rhinitis symptoms such as nasal congestion, sneezing, itchy eyes and nose, and rhinorrhea also contribute to sleep disturbances. The Pediatric Allergies in America Survey \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e found that 40% of AR patients reported that allergies affected their sleep. Studies have also found that nighttime symptoms of rhinitis were associated with chronic excessive daytime sleepiness and poor quality of life. \u003csup\u003e6\u003c/sup\u003e Moreover, patients with asthma or AR have increased risk of sleep-disordered breathing. \u003csup\u003e7\u003c/sup\u003e Sleep disturbance is also common in children with atopic dermatitis, including reduced sleep efficiency, longer sleep onset latency, and more sleep fragmentation, \u003csup\u003e8, 9\u003c/sup\u003e and the sleep disorders might also affect disease severity.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSleep is very important for both physical and mental health. In children, sleep disturbance can have many negative consequences, including impaired neurocognitive function, higher rates of behavioral problems, and changes in mood. \u003csup\u003e11, 12\u003c/sup\u003e While sleep disturbance is common in children with atopy, it has seldom been studied whether the sleep disturbance affect their emotion and behavior. It has been suggested that AD is associated with attention deficit hyperactivity disorder (ADHD) and emotional and conduct problems only when accompanied with sleep problems. \u003csup\u003e13, 14\u003c/sup\u003e This study aims to investigate sleep problems in children with atopy and whether it is associated with emotional and behavioral problems.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a cross-sectional study. The Taipei City Hospital Research Ethics Committee approved the study protocol. This study conformed to the principles of the Declaration of Helsinki.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eQuestionnaires were sent to the parents of a random sample of children 2 to 6 years old who were taking the children\u0026rsquo;s annual health examination provided by the Department of Health, Taipei City Government. We randomly selected 2 districts of Taipei City (Da\u0026rsquo;an and Songshan Districs) and distributed the questionnaires to the preschools and health centers where the health examinations were held. The questionnaires (including informed consent) were completed by caregivers and collected during the health examination.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQuestionnaires\u003c/h3\u003e\n\u003cp\u003eDemographic data was obtained, including age, sex, body weight and body height, number of siblings, maternal age, and maternal education level. Sleep was examined by a modified Children\u0026rsquo;s Sleep Habits Questionnaire (CSHQ)\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, which includes questions about sleep habits, sleep duration, and evaluation for sleep problems including bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night waking, parasomnia, sleep-disordered breathing, and daytime sleepiness \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. To screen for allergic diseases, core symptoms of asthma, allergic rhinitis, and atopic dermatitis were evaluated by the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Physician-diagnosed asthma/ allergic rhinitis/ atopic dermatitis were defined as those who answered \u0026ldquo;yes\u0026rdquo; to the question \u0026ldquo;Has your child ever been diagnosed by a doctor to have asthma/ allergic rhinitis/ atopic dermatitis?\u0026rdquo;. Children with symptoms of asthma was defined as those who answered \u0026ldquo;yes\u0026rdquo; to \u0026ldquo;Has your child ever had wheezing or whistling in the chest at any time in the past?\u0026rdquo;. Children with symptoms of allergic rhinitis was defined as those who answered \u0026ldquo;yes\u0026rdquo; to \u0026ldquo;Has your child ever had a problem with sneezing, or a runny, or blocked nose when she/he DID NOT have a cold or the flu?\u0026rdquo;. Children with symptoms of atopic dermatitis was defined as those who answered \u0026ldquo;yes\u0026rdquo; to \u0026ldquo;Has your child ever had an itchy rash, which was coming and going for at least six months?\u0026rdquo;. Of those who answered \u0026ldquo;yes\u0026rdquo; to \u0026ldquo;Has your child had wheezing or whistling in the chest in the past 12 months?\u0026rdquo;, those who answered \u0026ldquo;Never woken with wheezing\u0026rdquo; to the question \u0026ldquo;In the past 12 months, how often, on average, has your child\u0026rsquo;s sleep been disturbed due to wheezing?\u0026rdquo; were defined as \u0026ldquo;Asthma with no sleep problems related to symptoms\u0026rdquo;, and those who answered \u0026ldquo;Less than one night per week\u0026rdquo; and \u0026ldquo;One or more nights per week\u0026rdquo; to this question were defined as \u0026ldquo;Asthma with sleep problems related to symptoms.\u0026rdquo; Of those who answered \u0026ldquo;yes\u0026rdquo; to \u0026ldquo; Has your child had this itchy rash at any time in the past 12 months?\u0026rdquo;, those who answered \u0026ldquo;Never in the past 12 months\u0026rdquo; to the question \u0026ldquo;In the past 12 months, how often, on average, has your child been kept awake at night by this itchy rash?\u0026rdquo; were defined as \u0026ldquo;Eczema with no sleep problems related to symptoms,\u0026rdquo; and those who answered \u0026ldquo;Less than one night per week\u0026rdquo; or \u0026ldquo;One or more nights per week\u0026rdquo; to this question were defined as \u0026ldquo;eczema with sleep problems related to symptoms.\u0026rdquo; Behavioral evaluation was conducted by using the Strengths and Difficulties Questionnaire (SDQ)\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, which includes screening for emotional symptoms, conduct problems, hyperactivity, peer relationship problems, and prosocial behavior.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe χ\u003csup\u003e2\u003c/sup\u003e test or the Student\u0026rsquo;s t test was used to compare the data between the patients with allergic symptoms and those without allergic symptoms or between the patient subgroups. Missing data were excluded from the analysis. All statistical analyses were performed by using SPSS software (SPSS version 25, IBM Corp.). P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 defines statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe distributed 19,086 questionnaires, and 10,830 questionnaires were collected. Return rate of the questionnaires was 56.7%. A total of 10,464 questionnaires were valid for analysis, of which 48.6% were girls and 51.4% were boys. Mean age was 4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 years old.\u003c/p\u003e\n\u003ch3\u003ePrevalence of Allergic Diseases\u003c/h3\u003e\n\u003cp\u003eIn our study population, 11.7% had physician-diagnosed asthma, 35.9% had physician-diagnosed allergic rhinitis, 21.9% had physician-diagnosed atopic dermatitis, and 14.7% had at least 2 overlapping diagnoses. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) Symptoms of allergic diseases was even more prevalent: Wheezing was present in 18.3%, dry cough at night apart from infection in 25.9%, allergic rhinitis symptoms apart from infection in 52.9%, and eczema ever in 37.6%.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSleep Problems in Children with Allergic Diseases\u003c/h2\u003e \u003cp\u003eIn children with symptoms of asthma, allergic rhinitis, or atopic dermatitis, parents reported that the child\u0026rsquo;s sleep was problematic in 55.2%, 54.1%, and 55.7%, respectively. The total sleep duration at nighttime was not significantly different in those with symptoms of asthma (wheezing ever) compared with those without symptoms of asthma (587.2\u0026thinsp;\u0026plusmn;\u0026thinsp;45.1 vs 586.5\u0026thinsp;\u0026plusmn;\u0026thinsp;45.8 minutes, p\u0026thinsp;=\u0026thinsp;0.54). Nor was the total sleep duration at nighttime significantly different between those with and without allergic rhinitis symptoms (586.7\u0026thinsp;\u0026plusmn;\u0026thinsp;44.7 vs 586.1\u0026thinsp;\u0026plusmn;\u0026thinsp;46.5 minutes, p\u0026thinsp;=\u0026thinsp;0.58) or between those with and without atopic dermatitis symptoms (587.5\u0026thinsp;\u0026plusmn;\u0026thinsp;44.9 vs 586.4\u0026thinsp;\u0026plusmn;\u0026thinsp;45.5 minutes, p\u0026thinsp;=\u0026thinsp;0.92). However, results from the CSHQ showed that in children with symptoms of asthma, allergic rhinitis or atopic dermatitis all had significantly higher scores in sleep onset delay, sleep duration, sleep anxiety, night waking, parasomnia, sleep-disordered breathing, daytime sleepiness, and total sleep disturbance score. Children with symptoms of allergic rhinitis and atopic dermatitis also had significantly higher scores on bedtime resistance. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCSHQ scores in children with and without symptoms of asthma, allergic rhinitis, and atopic dermatitis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo Asthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"10\" rowspan=\"11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAllergic rhinitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo allergic rhinitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"10\" rowspan=\"11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAtopic dermatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo atopic dermatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1760)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;7873)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;5152)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;4584)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1564)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8104)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBedtime resistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.53\u0026thinsp;\u0026plusmn;\u0026thinsp;2.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e11.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e11.58\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep onset delay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.21\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e7.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNight wakings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e3.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParasomnias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e7.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep disordered breathing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e3.51\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaytime sleepiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.17\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.88\u0026thinsp;\u0026plusmn;\u0026thinsp;2.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.14\u0026thinsp;\u0026plusmn;\u0026thinsp;2.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e15.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e14.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal sleep disturbance score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.48\u0026thinsp;\u0026plusmn;\u0026thinsp;6.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.31\u0026thinsp;\u0026plusmn;\u0026thinsp;6.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e48.58\u0026thinsp;\u0026plusmn;\u0026thinsp;6.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e50.70\u0026thinsp;\u0026plusmn;\u0026thinsp;6.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e49.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn children with asthma, those with more than 4 wheezing attacks in the past 12 months had significantly higher scores in sleep anxiety, night waking, parasomnias, sleep disordered breathing, and daytime sleepiness compared with those who had 0\u0026ndash;3 wheezing attacks in the past 12 months. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) Children with asthma who were well-controlled with no symptoms in the past 12 months did not have significantly different scores in the CSHQ compared with children without asthma, except for a higher sleep-disordered breathing score. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) Similarly, children with atopic dermatitis who were well-controlled with no symptoms in the past 12 months did not have significantly different scores in the CSHQ compared with children without atopic dermatitis, except in sleep-disordered breathing and parasomnia score. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCSHQ scores in children with asthma of different severity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild asthma\u0026nbsp;\u0026dagger;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate to severe asthma\u0026Dagger;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;973)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;184)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBed time resistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e11.74\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e12.11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep onset delay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.15\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.71\u0026thinsp;\u0026plusmn;\u0026thinsp;1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNight waking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParasomnia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e7.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep disordered breathing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaytime sleepiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e53.66\u0026thinsp;\u0026plusmn;\u0026thinsp;6.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e55.79\u0026thinsp;\u0026plusmn;\u0026thinsp;6.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026dagger;Mild asthma: 0\u0026ndash;3 wheezing attacks in the past 12 months\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026Dagger;Moderate to severe asthma: \u0026gt;4 wheezing attacks in the past 12 months\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCSHQ scores in children with asthma/atopic dermatitis who had no symptoms in the past 12 months and in children without asthma/atopic dermatitis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsthma with no symptoms in the past 12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo asthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"10\" rowspan=\"11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAtopic dermatitis with no symptoms in the past 12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo atopic dermatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;487)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;7873)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;243)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8104)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBed time resistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.81\u0026thinsp;\u0026plusmn;\u0026thinsp;2.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.58\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep onset delay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNight waking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParasomnia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep disordered breathing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.51\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaytime sleepiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.88\u0026thinsp;\u0026plusmn;\u0026thinsp;2.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.46\u0026thinsp;\u0026plusmn;\u0026thinsp;6.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.60\u0026thinsp;\u0026plusmn;\u0026thinsp;6.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e49.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBehavior Problems in Children with Allergic Diseases\u003c/h3\u003e\n\u003cp\u003eResults from the SDQ evaluation showed that children with symptoms of asthma, allergic rhinitis, and atopic dermatitis all had significantly higher scores in hyperactivity, emotional symptoms, conduct problems, peer problems, and total difficulties score. Children with symptoms of allergic rhinitis also had a significantly lower prosocial score. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) However, in children with asthma without sleep problems, emotional symptoms score was significantly lower than those with sleep problems, and was not significantly different from those without asthma. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) In children with atopic dermatitis without sleep problems, emotional symptoms score and conduct problems score were significantly lower than those with sleep problems, and were not significantly different from those without atopic dermatitis. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSDQ scores in children with and without symptoms of asthma, allergic rhinitis, and atopic dermatitis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo asthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"7\" rowspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAllergic rhinitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo allergic rhinitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"7\" rowspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAtopic dermatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo atopic dermatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1760)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;7873)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;5152)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;4584)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1564)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8104)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperactivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.94\u0026thinsp;\u0026plusmn;\u0026thinsp;2.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.53\u0026thinsp;\u0026plusmn;\u0026thinsp;2.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.95\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e3.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.13\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConduct problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.70\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeer problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProsocial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.34\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e7.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal difficulties score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.87\u0026thinsp;\u0026plusmn;\u0026thinsp;4.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.27\u0026thinsp;\u0026plusmn;\u0026thinsp;4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.89\u0026thinsp;\u0026plusmn;\u0026thinsp;4.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.79\u0026thinsp;\u0026plusmn;\u0026thinsp;4.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e9.99\u0026thinsp;\u0026plusmn;\u0026thinsp;4.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e9.27\u0026thinsp;\u0026plusmn;\u0026thinsp;4.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe prevalence of allergic diseases has been rising in children worldwide.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Our study found that the prevalence of physician-diagnosed asthma, allergic rhinitis, and atopic dermatitis in preschool children in Taiwan were 11.7%, 35.9%, and 21.9%, respectively, and up to 14.7% had at least 2 overlapping diagnoses. Symptoms of asthma such as wheezing or dry cough at night apart from infection were reported up to 25.9%, allergic rhinitis symptoms were reported in 52.9%, and eczema ever was reported in 37.6%. Compared with the report of prevalence of childhood allergic diseases in 2011 which showed 17% for asthma, 47.8% for allergic rhinitis, and 10.8% for eczema, we can see that the prevalence of allergic diseases in children in Taiwan is still rising in the past 10 years,\u003csup\u003e1, 2\u003c/sup\u003e and undiagnosed rates are still high.\u003c/p\u003e \u003cp\u003eSleep disturbance has been reported in more than half of the children with symptoms of asthma, allergic rhinitis, or atopic dermatitis in our study. In concordance with previous studies, sleep duration was not significantly different in children with allergic diseases compared with those without allergic diseases.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e However, children with allergic diseases had significantly more problems in almost every aspect of the CSHQ. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) Previous studies have also reported that sleep disturbance is common in children with allergic diseases and were mostly attributed to nocturnal symptoms.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e However in our study we examined the type of sleep problems encountered, and we found that children with allergic diseases not only had significantly more night awakenings and daytime sleepiness, but also more problems with bedtime resistance, sleep onset delay, sleep anxiety, and parasomnias.(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) This could probably be due to acquired sleep habits, for example, worsening cough, itch, or stuffy nose at night usually results in more parental attention, either at sleep onset or during night awakenings, and could lead to limit-setting behavioral insomnia in childhood or sleep anxiety. Disrupted sleep could lead to an irregular sleep schedule (such as sleeping-in if the child had more awakenings the previous night) and could contribute to parasomnias. Therefore, sleep hygiene education, such as having a consistent bedtime routine and keeping a fixed sleep schedule is important for children with allergic diseases and behavioral interventions should be offered if needed.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Parents should also be educated about awareness of behavioral insomnia in childhood in order to avoid more sleep problems than those directly caused by allergic symptoms.\u003c/p\u003e \u003cp\u003eSleep disordered breathing score is also significantly higher in children with either asthma, allergic rhinitis, or atopic dermatitis. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) In previous studies, sleep disordered breathing has been found to be associated with asthma and also asthma severity in children, but causal relationship has not been established.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Allergic rhinitis has been found to be one of the most important risk factors for habitual snoring in children,\u003csup\u003e28, 29\u003c/sup\u003e and is also associated with increased risk of obstructive sleep apnea (OSA).\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e In a study by Nosetti et al, allergic rhinitis was found in 35% of children with children with primary snoring, and 6% with OSA. It was suggested that nasal inflammation has a role in primary snoring and OSA.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Studies have also found that allergic rhinitis severity was significantly associated with OSA severity in children.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Chng et al found that habitual snoring was significantly associated with atopic dermatitis (OR 1.8; 95% CI 1.28\u0026ndash;2.54),\u003csup\u003e28\u003c/sup\u003e and a large population based cohort study found that after adjusting for age, sex, urbanization level, and comorbidities, children with atopic dermatitis had a higher risk of OSA (OR 1.86). Atopic dermatitis and OSA are both chronic systemic inflammatory diseases and it was postulated that they share similar immunopathologic pathways. \u003csup\u003e32\u003c/sup\u003e It is important to evaluate for the presence of habitual snoring or OSA symptoms in children with allergic diseases in order to offer prompt diagnosis and management of possible sleep disordered breathing.\u003c/p\u003e \u003cp\u003eOur study found that in children with well-controlled asthma who had no symptoms in the past 12 months, the CSHQ score for problems with bedtime resistance, sleep onset delay, sleep anxiety, night waking, and daytime sleepiness were not significantly different from those without asthma. However, the score for sleep disordered breathing was still significantly higher than those without asthma. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) Similar results were found in children with atopic dermatitis who had no symptoms in the past 12 months. Most CSHQ scores became not significantly different from those without atopic dermatitis, except for the score for sleep-disordered breathing. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) This indicates that control of allergic symptoms is crucial for improving sleep in children with allergic diseases, and has benefit on both symptom-related sleep disturbance and also sleep problems which might be induced by acquired sleep habits. However, association with sleep disordered breathing might be more related to the pathogenesis of allergic diseases and does not seem to improve with symptom control.\u003c/p\u003e \u003cp\u003eFrom the results of the SDQ questionnaire, we found that children with either asthma, allergic rhinitis, or atopic dermatitis all had significantly higher scores for hyperactivity, emotional symptoms, conduct problems, peer problems, and total difficulties score than those without asthma, allergic rhinitis, or atopic dermatitis. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) In previous literature, behavioral problems were also found to be more pronounced in children and adolescents with asthma, including conduct disorder, attention deficit hyperactivity disorder (ADHD), and having internalizing symptoms such as being withdrawn or depressed. \u003csup\u003e33\u0026ndash;35\u003c/sup\u003e Allergic rhinitis symptoms in children were found to be associated with conduct problems and emotional symptoms.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e Association of atopic dermatitis and behavior problems was also demonstrated in previous literature, including higher internal behavior scale scores and anxiety/depression scale scores, more emotional and conduct problems, and more symptoms of hyperactivity/inattention.\u003csup\u003e37, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e A meta-analysis showed that children with ADHD were more likely to have asthma (OR 1.8, 95% CI 1.57\u0026ndash;2.07), allergic rhinitis (OR 1.59, 95% CI 1.13\u0026ndash;2.23), and atopic dermatitis (OR 1.43, 95% CI 1.09\u0026ndash;1.88).\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Wu et al. found that the risk of having psychosocial problems were increasingly higher in children with one, two, and more than two allergic diseases.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe reason for the association between allergic diseases and behavioral problems is unclear and could be multifactorial. In previous literature, it was postulated that behavioral difficulties in children with allergic diseases were due to social implications, side effects of allergy medication, or negatively affected brain development.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e Some studies have also suggested that disturbed sleep might play a role. Manjunath et al. found that sleep disturbance was a predictor of behavioral problems in children and adolescents with AD.\u003csup\u003e41\u003c/sup\u003e Schmitt et al. found that infant eczema with concurrent sleep problems predicted emotional problems (OR 2.63, 95%CI 1.20\u0026ndash;5.76) and conduct problems (OR 3.03, 95%CI 1.01\u0026ndash;9.12) at 10 years old.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e In our study, we have shown that sleep problems are highly prevalent in children with allergic diseases. Further analysis showed that children with asthma who had sleep problems had significantly higher emotional symptoms score than children without asthma, but emotional symptoms score in children with asthma who had no sleep problems were significantly lower than those with sleep problems, and was not significantly different from those without asthma. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) Similarly, children with atopic dermatitis who had sleep problems had significantly higher emotional symptoms score and conduct problems score than children without atopic dermatitis, but emotional symptoms score and conduct problems score in children with atopic dermatitis who had no sleep problems were significantly lower than those with sleep problems, and was not significantly different from those without atopic dermatitis. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) Our study results suggest that sleep disturbance might play an important role in the behavioral problems in children with allergic diseases. Therefore, it is important to recognize sleep problems in children with allergy and offer timely management. We suggest assessing for presence of sleep disturbance when evaluating children with asthma, allergic rhinitis, and atopic dermatitis. For children with allergic disease who have sleep disturbance, we suggest that it is crucial to achieve optimal control of nighttime symptoms and it is also important to offer sleep hygiene education.\u003c/p\u003e \u003cp\u003eThis is a cross-sectional study and therefore could only demonstrate association between factors rather than causal relationship. This is also a questionnaire-based study and therefore could be prone to have recall bias. Further prospective studies with objective measurements of sleep are needed to clarify the relationship between sleep disturbance and emotional or conduct problems in children with asthma, allergic rhinitis, or atopic dermatitis.\u003c/p\u003e \u003cp\u003eSleep problems are highly prevalent in preschool children with asthma, allergic rhinitis, and atopic dermatitis, including more night awakenings, daytime sleepiness, bedtime resistance, sleep onset delay, sleep anxiety, parasomnias, and sleep disordered breathing. Children with allergic diseases also have significantly higher emotional and conduct problems scores, which might be related to their sleep problems. We suggest routine evaluation of sleep disturbance and symptoms of sleep disordered breathing in children with asthma, allergic rhinitis, and atopic dermatitis, and we stress the importance of optimal control of nighttime symptoms and offering sleep hygiene education and avoiding acquired problematic sleep habits in those with sleep problems.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAD, atopic dermatitis; ADHD,\u0026nbsp;attention deficit hyperactivity disorder; AR, allergic rhinitis; CSHQ, Children\u0026rsquo;s Sleep Habits Questionnaire; ISAAC, International Study of Asthma and Allergies in Childhood; SDQ,\u0026nbsp;Strengths and Difficulties Questionnaire\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant conflicts of interest.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent to Participate Declaration\u003c/strong\u003e: not applicable\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the Department of Health, Taipei City Government, Taiwan. Grant Number:\u0026nbsp;10701-62-006; 11201-62-011. We would also like to acknowledge the help from the Department of Health and the Department of Education, Taipei City Government, for distributing questionnaires.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the Department of Health, Taipei City Government, Taiwan. Grant Number: 10701-62-006; 11201-62-011.\u0026nbsp;\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. The Taipei City Hospital Research Ethics Committee approved the study protocol.\u0026nbsp;\u003c/p\u003e\n\n\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYan DC, Ou LS, Tsai TL, Wu WF, Huang JL (2005) Prevalence and severity of symptoms of asthma, rhinitis, and eczema in 13-to 14-year-old children in Taipei, Taiwan. Annals Allergy Asthma Immunol 95(6):579\u0026ndash;585\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYao TC, Ou LS, Yeh KW, Lee WI, Chen LC, Huang JL et al (2011) Associations of Age, Gender, and BMI with Prevalence of Allergic Diseases in Children: PATCH Study. J Asthma 48(5):503\u0026ndash;510\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHorner CC, Mauger D, Strunk RC, Graber NJ, Lemanske RF Jr., Sorkness CA et al (2011) Most nocturnal asthma symptoms occur outside of exacerbations and associate with morbidity. 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Dermatitis 33(6S):S52\u0026ndash;S60\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"asthma, atopic dermatitis, preschool children, sleep, emotion","lastPublishedDoi":"10.21203/rs.3.rs-8998979/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8998979/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eSleep problems are very common in children with asthma, allergic rhinitis (AR), and atopic dermatitis (AD). This study investigates sleep disturbances in preschool children with atopy and evaluates the impact on their emotion and behavior.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eQuestionnaires were distributed to 19,086 preschool children 2 to 6 years old taking the public annual health examination. Symptoms of atopy, sleep problems, and behavior were assessed by the ISAAC questionnaire, the Child\u0026rsquo;s Sleep Habits Questionnaire, and the Strengths and Difficulties Questionnaire, respectively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 10,830 participants, symptoms of asthma, AR, and AD were reported in up to 25.9%, 52.9%, and 37.6%, respectively. Those with asthma, AR, and AD symptoms all had significantly higher scores in sleep onset delay, sleep anxiety, night waking, parasomnia, sleep-disordered breathing, and daytime sleepiness. Sleep problems were related to disease control. Children with asthma, AR, and AD also had significantly higher scores in hyperactivity, emotional symptoms, conduct problems, and peer problems. However, in children with AD without sleep problems, emotional symptoms score and conduct problems score were lower than those with sleep problems (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and were not significantly different from those without AD. Similarly, the emotional symptoms score in children with asthma without sleep problems was lower (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and not significantly different from those without asthma.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePreschool children with asthma, AR, and AD have more sleep problems and higher emotional and conduct problems scores which are related to their sleep problems. Therefore, evaluation and management of sleep disturbance in children with atopy is very important.\u003c/p\u003e","manuscriptTitle":"Sleep Disturbance in Preschool Children with Allergic diseases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-16 09:44:55","doi":"10.21203/rs.3.rs-8998979/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c7327099-6790-4cc6-b97e-b1ecd5b41f07","owner":[],"postedDate":"March 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-25T11:55:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-16 09:44:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8998979","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8998979","identity":"rs-8998979","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}