Factors Related to Sleep Disturbances Among Children with Epilepsy

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SALENDU, Max F. J. MANTIK, Stanley HARYONO This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7668996/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 Backgroundː To calculate the proportion of sleep disturbances in children with epilepsy and analyze which of the following factors are associated with sleep disturbances in children with epilepsy: age, gender, seizure type, seizure frequency, type of AED, and number of aeds. Methods : This study was conducted using an observational analytic research method with a cross-sectional approach in children with epilepsy at Prof. Dr. R.D. Kandou Hospital Manado in the time span of December 2023 to March 2024. Inclusion criteria were age 1 to 18 years, epilepsy patients, and parents agreed to participate by signing informed consent. Exclusion criteria were autism and other psychiatric disorders. Data analysis was done using SPSS version 26.0. Results : This study included 36 children with a mean age range of 8.92 years (±4.87 years). There were 3 factors that showed a significant relationship with sleep disorders, seizure type (OR = 9.231 (95% CI 1.03: 83.3); p = 0.031) and number of seizures (OR = 11 (95% CI 1.2: 99 .1); p = 0.025), number of anti-epileptic drugs (p 0.0032). It was found that the number of seizures and type of seizure were independent risk factors (p<0.05). Conclusions : In this study 64% of children with epilepsy experienced sleep disturbances, which were linked to seizure type and frequency. Future research is needed to explore additional factors like sleep hygiene, socioeconomics, and co-sleeping that could contribute to sleep disorders in these children. Pediatrics Nutrition & Dietetics Sleep disturbance Epilepsy Children Malnutrition Clinical Nutrition INTRODUCTION Sleep disorders are one of the most common problems in childhood, resulting in mood, cognitive, and behavioral disorders, as well as affecting children's physical health. 1 According to WHO (2023), epilepsy is one of the most common neurological diseases in the world. Almost 80% of people with epilepsy live in low- and middle-income countries. 2 More than 60% of epilepsy begins in childhood and is higher in children under 3 years of age. 3 , 4 In Indonesia until now there is no definitive incidence data because many people with epilepsy are not detected or do not visit health centers. 5 Some epilepsy patients experience sleep quality disorders and poor sleep. 6 Several studies related to sleep disorders in children with epilepsy have also been conducted. A cross sectional study conducted on epilepsy patients found that out of 21 epilepsy patients, 6 patients (28.6%) experienced sleep disturbances, 10% of whom experienced seizures and or involuntary movements during sleep and 28.6% snored. 6 Sleep deprivation caused by sleep disorders increases the risk of seizures in epilepsy patients and worsens seizure control. 6 Sari et al (2017) in their research on epilepsy patients found 67.7% experienced sleep disturbances, 63.2% of which were disturbances in initiating and maintaining sleep and generalized seizure type had a 5.2 times greater risk of experiencing sleep disturbances. 7 Salendu (2020) in his research found that there were 71.7% of children with epilepsy who experienced sleep disturbances, with the most types of disturbances in initiating and maintaining sleep (62%). Risk factors that were shown to independently influence the incidence of sleep disturbances in epilepsy patients were generalized seizure type, cerebral palsies, intractable epilepsy, abnormal EEG, and the use of benzodiazepine-type antiepileptic drugs. 8 The severity of epilepsy, including the number and type of seizures, the number of AEDs, and their side effects are predictors of sleep disturbances in children with epilepsy. 9 Actigraphy is an activity-based sleep monitoring system that detects and records gross body movements via an all-directional accelerometer. 10 Actigraphy is usually worn on the wrist to provide objective information on sleep-wake patterns, with the algorithm transforming the activity data detected by actigraphy into sleep-wake staging for each time (ranging from 10 seconds to 1 minute). 11 However, not many studies have used actigraphy as an objective measure of sleep disturbance in children with epilepsy. In addition, sleep disorders that occur in children with epilepsy have an impact on their quality of life, so it is important to analyze the factors that affect sleep disorders in children with epilepsy. Materials and Methods Study design and participants This study was conducted using an observational analytic research method with a cross-sectional approach in children with epilepsy at Prof. Dr. R.D. Kandou Hospital Manado in the time span of December 2023 to March 2024. Inclusion criteria were age 1 to 18 years, epilepsy patients, and parents agreed to participate by signing informed consent. Exclusion criteria were autism and other psychiatric disorders. Data synthesis Data collected were age, gender, seizure type, type of antiepileptic drugs, number of antiepileptic drugs, and sleep disturbance. Sleep disturbance was assessed with an actigraph worn on the wrist. Sleep disturbance parameters measured were as follows. Effective sleep (sleep efficiency) was the total interval between time spent sleeping and time spent on bed (cutt off <85%). Total sleep time was defined as the total time between sleep onset and wake time (hours). Wake-after-sleep onset was defined as the average time spent between waking up and going back to sleep (cutt off >40 minutes). Sleep latency is the time taken to enter sleep after lying in bed (>20 minutes). Data analysis Data analysis was conducted where categorical variables were displayed as frequencies and percentages. Meanwhile, the dispersion values of numerical variables were presented according to the results of the distribution normality assessment either through graphs such as histograms, boxplots, and density curves, or the Shapiro Wilk normality test. For those that are normally distributed, the descriptive tabulation includes the mean and standard deviation (SD) values. In contrast, numerical variables whose distribution deviated from normality were given as median and range. Bivariate analysis of each independent variable on the dependent variable used independent t test or mann whitney u test, anova test or kruskall wallis test according to the results of assumption test analysis. Multivariate analysis of all independent variables on the dependent variable used multiple logistic regression. The results of logistic regression analysis were reported as OR (odd ratio using 95% confidence interval, and p value. Data analysis was performed using SPSS version 26.0. RESULTS Subject characteristics In table 1, the study included 36 children with a mean age range of 8.92 years (±4.87 years), with a proportion of 55.6% boys and 44.4% girls. In terms of nutritional status, the majority of subjects (86.1%) were not malnourished, while 13.9% were malnourished. Most children had generalized seizures (64.9%) compared to focal seizures (30.6%). The median seizure frequency was 1 time, with most children (66.7%) having seizures only once, while 33.3% had more than one seizure. Valproate acid was the most commonly used antiepileptic drug (77.8%), with some subjects (22.2%) using a combination of valproate acid with other drugs (levetiracetam (2 respondents), carbamazepine (2 respondents), Oxcarba (1 respondent), Feniton (1 respondent). The majority of subjects (77.8%) used one type of anti-epileptic drug, while a small proportion (22.2%) used two types of drugs. A total of 63.9% of children experienced sleep disturbances, while 36.1% did not experience sleep disturbances. Table 1. Characteristics of subject Variable Total (n=36) Age ( years ), mean (SD) 8.92 (4.87) Gender , n ( %) Man Woman 20 (55.6) 16 (44.4) Status ,n (%) Malnutrition Without malnutrition 5 (13.9) 31 (86.1) Seizure Type , n( %) General Focal 25 (64.9) 11 (30.6) Frequency Seizures , median (IQR) 1 (1-2) Frequency seizures , n( %) 1 time >1 time 24 (66.7) 12 (33.3) Type of medication antiepileptic , n( %) Valproic Acid Valproic acid + combination 28 (77.8) 8 (22.2) Number of Anti- Epileptic Drugs , n( %) Monopharmaceuticals Polypharmacy 28 (77.8) 8 (22.2) Disturbance sleep , n( %) Yes No 23 (63.9) 13 (36.1) SD (standard deviation); IQR (interquartile range) Sleep disturbances profiles among epilepsy children Table 2 outlines some aspects of sleep disturbance, providing information on the median (IQR) as well as the percentage of individuals who had disturbed sleep compared to those who did not. Sleep efficiency, with a median of 0.90 and an IQR range between 0.80 to 0.94, shows that out of a total of 36 individuals, 13 had impaired sleep efficiency while 23 did not. Meanwhile, total sleep time had a median of 6.0 hours and an IQR range between 5.0 to 8.75 hours, with 55.6% of individuals having impaired total sleep time and 44.4% not. Onset of awakening after sleep, with a median of 20 minutes and an IQR range between 12.0 to 34.75 minutes, showed that 6 had impaired onset of awakening after sleep and 30 did not. On sleep latency, which had a median of 15 minutes and an IQR range between 2.50 to 28.75 minutes, with 14 individuals having impaired sleep latency and 22 not. Table 2. Profile of sleep disturbance among epilepsy children Aspect disturbance Sleep Median (IQR) Number of people who experienced it disturbance ( %) Yes No Efficiency (%) 0.90 (0.80-0.94) 13 (36.1) 23 (63.9) Total time sleep (hours) 6.0 (5.0-8.75) 20 (55.6) 16 (44.4) Awakening onset after sleep (minutes) 20 (12.0-34.75) 6 (16.7) 30 (83.3) Latency sleep (minutes) 15 (2.50-28.75) 14 (38.9) 22 (61.1) Factors related to sleep disturbances among epilepsy children In table 3, the results showed that the type of seizure was significantly correlated with sleep disturbance. Patients who experienced focal seizures tended to have a higher proportion of sleep disturbance compared to generalized seizures. Based on the OR value, it was also found that patients with focal type seizures had a 9 times risk of experiencing sleep disturbance. This finding was supported by the results of the analysis which showed statistical significance (p-value = 0.039). Furthermore, the seizure frequency category also played an important role in sleep disturbance. Patients who experienced seizures more than once tended to have an 11 times higher risk (OR: 11.000) of experiencing sleep disturbance, compared to those who only experienced seizures once. This was reinforced by the significant finding in the data analysis (p-value = 0.020). In addition, the type of antiepileptic drugs used by patients also had an impact on sleep disturbance. Patients using valproate acid in combination with other drugs had a high risk of sleep disturbance. This finding was reinforced by the results of the analysis, which showed statistical significance (p-value = 0.0032). Finally, the number of anti-epileptic drugs taken by patients also had an effect on sleep disturbance. Patients who used only one type of medication tended to have a lower risk of sleep disturbance. This finding was also supported by the data analysis which showed statistical significance (p-value = 0.032). Overall, these findings provide valuable insights into factors to consider in the management of sleep disturbances in pediatric patients with epilepsy. Table 3. Influencing factors of sleep disturbances among epilepsy children Variable Sleep Disorders OR (95%CI) P value Yes (n=23) No (n=13) Age (years), mean (SD) 9.52 (4.52) 7.85 (4.52) 1,026 (0.89: 1.82) 0.723 a Gender, n (%) Man Woman 12 (52.2) 11 (47.8) 8 (61.5) 5 (47.8) 0.897 (0.2:3.5) 0.877 b Type Seizures, n (%) Focal General (reference) 10 (43.5) 13 (56.0) 1 (7.7) 12 (92.3) 9.231 (1.03: 83.3) 0.031 c Frequency seizures, n (%) >1 time 1 time (reference) 11 (47.8) 12 (52.2) 1 (7.7) 12 (92.3) 11,000(1.2:99.1) 0.025 c Number of Anti- Epileptic Drugs, n (%) Monopharmaceuticals Polypharmacy 15 (65.2) 8 (34.8) 13 (100) 0 (0) NA 0.032 c Status, n (%) Malnutrition Without malnutrition 4 (17.4) 19 (82.6) 1 (7.7) 12 (92.3) 2.526(0.3-25.4) 0.634 c SD (standard deviation); a: simple logistic regression, b: chi square test, c: fisher exact test Furthermore, there are some observable trends related to sleep disturbances in pediatric patients with epilepsy, although the results of the statistical analysis were not significant. First, in terms of age, it can be seen that patients with sleep disorders tend to have a slightly older age, with a mean age of about 9.41 years, compared to patients without sleep disorders who have a mean age of about 7.38 years. Secondly, in terms of gender, there is a tendency that patients with sleep disorders are more often male. Third, in terms of nutritional status, although the difference was not statistically significant, there was a tendency that most patients with sleep disorders also experienced nutritional problems, with a proportion of 17.6% experiencing malnutrition, compared to patients without sleep disorders who were only about 7.7% malnourished. However, the results of statistical analysis showed that the association between age, gender and nutritional status with sleep disturbance in pediatric patients with epilepsy was not statistically significant. In table 4, based on the regression analysis results, it is known that both variables have statistical significance (p<0.05). Therefore, the variables of seizure type and seizure frequency were identified as independent predictors (p<0.05). Table 4. Odds ratio of factors influencing sleep disturbance among epilepsy children Regression Logistics β S.E Wald OR (95% CI) P value Type Seizures 2,464 1,177 4,385 11,750(1,171:117,928) 0.036 ( Focal vs General) Frequency Seizures 2,617 1,168 5,022 13,694(1,388:135,074) 0.025 (1 time Vs >1 time) Constant α -0.618 0.596 1,493 DISCUSSION Sleep disorders are common in children with epilepsy and can have a bidirectional relationship with epilepsy. Some of the most common sleep disorders in children with epilepsy include behavioral insomnia associated with poor sleep hygiene, sleep and wake transition disorders, sleep initiation and maintenance disorders, and daytime somnolence. Children with epilepsy may also exhibit sleepwalking, night terrors, confusional arousals, restless sleep, sleep fragmentation, and other sleep problems. Poor sleep habits, such as using electronic devices in bed or requiring the presence of family members to fall asleep, are also common in children with epilepsy. 12 In this study, the median sleep efficiency of children with epilepsy was 90% with an IQR range of 80–94%. This is in line with previous research which found that the average sleep efficiency in children with epilepsy was 86.86%. This value is based on a study that assessed sleep efficiency in children with epilepsy using actigraphy, which is a non-invasive method of measuring sleep and wake patterns. The study found that children with epilepsy had lower sleep efficiency compared to healthy children. Sleep efficiency in children with epilepsy can be affected by various factors, including seizure type, medication use, and sleep disturbance. 13 Furthermore, on the aspect of total sleep time, the median total sleep time of children with epilepsy in this study was 6 hours. This is lower than the previous study which stated that the total sleep time of children with epilepsy was 7.74 hours. 13 Onset of awakening after sleep (WASO) showed a median of 20 minutes. This result is lower than the previous study which found the mean duration of WASO in children with epilepsy was 55 minutes (95% CI 43;68). In terms of sleep latency, the study showed that the mean sleep latency of respondents was 15 minutes. Previous research showed a value of 18.5 minutes. 14 The results of this study showed that children who had sleep disturbances had an older mean age than children who did not have sleep disturbances, however, the analysis showed a non-significant p value. Selendu (2020) reported that as the age of a child with epilepsy increases, there is an increasing trend in the percentage of children with sleep disturbances. The findings of this study showed that in the age range of 13–18 years, 77.3% of the patients experienced sleep disturbances. Meanwhile, in the age range of 7–12 years, the percentage was 71.7%, and in the age range of 4–6 years, 67.7% of the patients also experienced sleep disturbances. Thus, it can be concluded that the older the child with epilepsy, the higher the likelihood of experiencing sleep problems. 8 This could be due to the fact that the older the child, the greater the likelihood of experiencing sleep disturbances, as there are more factors that affect sleep patterns. The findings from our study show that although there is a tendency for older children to experience sleep disturbances, the difference is not statistically significant. This could be because individual characteristics of each child such as sleep habits and daily activity patterns may also contribute to the variability in the results of this study. In addition, disease severity and environmental factors also influence sleep disturbances in children with epilepsy. The proportion of sleep disturbances in children who experience focal seizures is more common than generalized seizures. The results of the analysis showed a significant relationship between seizure type and sleep disturbance with an OR (95%CI) value of 9. (0.086 :0.358). Seizures in children with epilepsy in a state of sleep occur in one third of patients. This is in line with research by Chen et al (2011) on pediatric patients with epilepsy where they found that the prevalence of poor sleep quality was significantly higher in the partial seizure group (p < 0.05). 15 However, Sari et al (2017) in their research on epilepsy patients at the Child Neurology Polyclinic of Dr. Sardjito Hospital found that the type of seizure was significantly higher in the partial seizure group. 7 Sardjito found that the generalized seizure type was at risk for sleep disturbances (OR = 5.2, 95% CI 1.356–19.96, p = 0.024).20 This study is in line with other studies in children with epilepsy which state that the generalized seizure type has more sleep disturbances than the partial seizure type. 16 Ong et al (2010) in their study found that the severity of epilepsy contributed to sleep disturbances. 9 The sleep phase changes the morphology of epileptiform discharges in a number of childhood epilepsy syndromes. There are two main phases during sleep: non-rapid eye movement (NREM) and rapid eye movement (REM), both of which are caused by activity in different parts of the brain. During deep sleep, there is little body movement and regular breathing. Most seizures, especially generalized seizures, are likely to occur in this phase. Whereas deep sleep is characterized by eye movements, hypnic jerks (face, arms and legs), and rapid irregular breathing. This phase is known as active sleep and mostly occurs during dreaming. Deep sleep can last from a few minutes to after hours. Most partial seizures occur in this phase. 9 Patients with night time seizures show decreased sleep efficiency, increased time to the first REM period, and increased sleepiness on the maintenance of wakefulness test (MWT). 17 When there is a decrease in GABA, it will trigger epilepsy. The pathophysiology of impaired GABA release or increased acetylcholine and norepinephrine is responsible for changes in sleep stages in children with epilepsy. 7 In this study, children who had more than 1 seizure were more at risk of sleep disturbance compared to children who had 1 seizure. Seizure activity is strongly influenced by changes in the excitability of nerve cells and the relationship between these cells. The more the frequency of seizures, the more anxiety during sleep. 18 Triono and Herini (2016) stated that the frequency of seizures more than 10 times before therapy is suspected of failure of pediatric epilepsy monotherapy through the mechanism of forming new epileptogenic foci. 19 This study is not in line with Salendu et al (2020) who reported that there was no significant relationship between seizure frequency and sleep disturbance in children with epilepsy. Patients with seizure frequency < 5 times per month experienced the most sleep disturbances (82.1%). 8 This difference in results could be due to differences in seizure frequency categories. Patients who received more than 1 type of drug (valproic acid combined with other AEDs experienced sleep disturbances more often than those who only received 1 type of drug (valporic acid). Previous studies have reported that antiepileptic drugs affect sleep quality, daytime alertness, and neurocognitive function. 20 Sleep disturbance such as somnolence is one of the most common side effects of antiepileptic drug treatment, as it can alter the sleep-wake cycle and sleep architecture. 21 In this study, carbazepine phenytonin, levetiracetam and Oxcarbamazepine were the drugs combined with valporic acid. The side effects of phenytonin on sleep disturbance are decreased sleep efficiency and decreased REM sleep. Levetiracetam has the side effect of slow sleep waves which will affect sleep efficiency and total sleep time. Karmazepine has effects mainly on decreasing REM sleep causing an increase in WASO duration. While Oxcarba can cause insomnia. 22 This study makes an important contribution to understanding the need for a holistic intervention approach for children with epilepsy, given the complexity of this condition and the multiple factors that have been shown to influence sleep disturbance in epilepsy patients. Efforts to develop intervention strategies should not only focus on seizure control but also address aspects of the patient's holistic well-being, including sleep disturbances. However, while this study provides valuable insights, there are some limitations that need to be noted. One significant limitation is the relatively small sample size. As such, more in-depth multivariate analysis or further research to confirm the findings may not be possible. In addition, it should be noted that some factors that may also have an influence on sleep disorders, such as the patient's psychological state, sleeping environment, or even hormonal changes in adolescence, were not examined in detail in this study. CONCLUSIONS Based on this study, it can be concluded that more than half of children with epilepsy experience sleep disturbances. Focal seizures, seizure frequency more than 1, polytherapy (valproate acid and other OAE combinations) increase the proportion of sleep disorders in children with epilepsy. This study did not find an association between age, gender and sleep disturbance in children with epilepsy. Declarations Conflict of interest None declared Funding The authors received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors Acknowledgements The authors have nothing to declare Ethics Statement The study protocol was reviewed and approved by the Ethics Committee of RSUP Prof. Dr. R. D. Kandou, Manado, Indonesia. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Informed Consent Written informed consent was obtained from all participants prior to their inclusion in the study. Participants were fully informed about the objectives, procedures, potential risks, and benefits of the research, and their right to withdraw at any time without consequences. References Dehghani M, Fayyazi A, Cheraghi F, Hakimi H, Mosazadeh S, Almasi S. The relationship between severity of epilepsy and sleep disorder in epileptic children. Iran J Child Neurol. 2019;13(2). World Health Organization. Epilepsy. World Health Organization. 2023. Singhi P, Gupta A. Epilepsy in Children—Important Facets. Vol. 88, Indian Journal of Pediatrics. 2021. Jagadeesan P, Malai Arasu R. Clinical profile of children with epilepsy: a cross-sectional study. Int J Contemp Pediatrics. 2020;7(11). Aaberg KM, Gunnes N, Bakken IJ, Soraas CL, Berntsen A, Magnus P, et al. Incidence and prevalence of childhood epilepsy: A nationwide cohort study. Pediatrics. 2017;139(5). Utami DKI, Suryapraba A. SLEEP QUALITY AND SLEEP DISORDERS PROFILE OF EPILEPSY PATIENTS IN NEUROLOGY POLYCLINIC SANGLAH GENERAL HOSPITAL DENPASAR BALI. 2018;1–10. Sari R, Triono A, Sutomo R. Gangguan Tidur pada Anak dengan Epilepsi dan Faktor yang Memengaruhi. Sari Pediatri. 2017;19(1). Salendu, Margareth P, Widodo DP. Gangguan tidur pada anak dengan epilepsi dan faktor-faktor yang memengaruhinya. Ilmu Kesehatan Anak Universitas Indonesia. 2020; Ong LC, Yang WW, Wong SW, Alsiddiq F, Khu YS. Sleep habits and disturbances in Malaysian children with epilepsy. J Paediatr Child Health. 2010;46(3). Tsai SY, Lee WT, Lee CC, Jeng SF, Weng WC. Agreement Between Actigraphy and Diary-Recorded Measures of Sleep in Children With Epilepsy. Journal of Nursing Scholarship. 2018;50(2). Xue B, Licis A, Boyd J, Hoyt CR, Ju YES. Validation of actigraphy for sleep measurement in children with cerebral palsy. Sleep Med. 2022;90. Furones García M, García Peñas JJ, González Alguacil E, Moreno Cantero T, Ruiz Falcó ML, Cantarín Extremera V, et al. Sleep disorders in children with epilepsy. Neurologia. 2024;39(3). Tsai SY, Tsai HY, Lin YY, Chen SR, Kuo SY, Lou MF. Sleep and Its Disturbance in Parents of Children and Adolescents with Epilepsy: A Systematic Review and Meta-Analysis. Vol. 15, Nature and Science of Sleep. 2023. Turaga S, Soanpet P, Manikinda J, Kohat AK, Davidi SR. Observational study of prevalence of sleep disorder in patients with epilepsy. Int J Epilepsy. 2016;3(1). Chen NC, Tsai MH, Chang CC, Lu CH, Chang WN, Lai SL, et al. Sleep quality and daytime sleepiness in patients with epilepsy. Acta Neurol Taiwan. 2011;20(4). Batista BHB, Nunes ML. Evaluation of sleep habits in children with epilepsy. Epilepsy and Behavior. 2007;11(1). St. Louis EK. Sleep and epilepsy: Strange bedfellows no more. Vol. 50, Minerva Pneumologica. 2011. Stores G, Wiggs L, Campling G. Sleep disorders and their relationship to psychological disturbance in children with epilepsy. Child Care Health Dev. 1998;24(1). Triono A, Herini ES. Faktor Prognostik Kegagalan Terapi Epilepsi pada Anak dengan Monoterapi. Sari Pediatri. 2016;16(4). Kotagal P. The relationship between sleep and epilepsy. Semin Pediatr Neurol. 2001;8(4). Placidi F, Scalise A, Marciani MG, Romigi A, Diomedi M, Gigli GL. Effect of antiepileptic drugs on sleep. Clinical Neurophysiology. 2000;111(SUPPL. 2). Al-Biltagi MA. Childhood epilepsy and sleep. World J Clin Pediatr. 2014;3(3). Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7668996","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":518420503,"identity":"b21d62aa-c57c-43d9-8161-20c5a5e60f35","order_by":0,"name":"Praevilia M. 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J.","lastName":"MANTIK","suffix":""},{"id":518420505,"identity":"10664cd6-1758-4655-b974-fe3aedbaae63","order_by":2,"name":"Stanley HARYONO","email":"","orcid":"","institution":"Sam Ratulangi University","correspondingAuthor":false,"prefix":"","firstName":"Stanley","middleName":"","lastName":"HARYONO","suffix":""}],"badges":[],"createdAt":"2025-09-22 03:09:11","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7668996/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7668996/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92062855,"identity":"f859126f-9e23-4246-aa88-dcea87f9129d","added_by":"auto","created_at":"2025-09-24 08:31:52","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":131934,"visible":true,"origin":"","legend":"","description":"","filename":"Paperdr.Stanley.docx","url":"https://assets-eu.researchsquare.com/files/rs-7668996/v1/795be3cf293a0650bb185cca.docx"},{"id":92064575,"identity":"9626fea6-2944-4ed9-b0e2-eab6f32ae1c7","added_by":"auto","created_at":"2025-09-24 08:39:52","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs7668996.json","url":"https://assets-eu.researchsquare.com/files/rs-7668996/v1/868768bd01e5b2d1e71fc154.json"},{"id":92062854,"identity":"e4730738-0925-4f69-ba63-92b9a0beedb6","added_by":"auto","created_at":"2025-09-24 08:31:52","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":65867,"visible":true,"origin":"","legend":"","description":"","filename":"rs76689960enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7668996/v1/67094220e3544bed6a65d57d.xml"},{"id":92062856,"identity":"1d988ec3-e240-49be-b1cb-3793d4d2f3dd","added_by":"auto","created_at":"2025-09-24 08:31:52","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":63551,"visible":true,"origin":"","legend":"","description":"","filename":"rs76689960structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7668996/v1/e5f217f7443d9180c5f01107.xml"},{"id":92064977,"identity":"a684d04d-545c-4dd0-b299-df6caaa169b1","added_by":"auto","created_at":"2025-09-24 08:47:52","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69721,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7668996/v1/c9fe7e16bfa6926508b5c7fe.html"},{"id":92064978,"identity":"d441c3fe-8c5f-473b-9c12-34a931f47646","added_by":"auto","created_at":"2025-09-24 08:47:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":600985,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7668996/v1/36a1a81f-c497-4a98-b988-e44e1e2d1e4c.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eFactors Related to Sleep Disturbances Among Children with Epilepsy\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSleep disorders are one of the most common problems in childhood, resulting in mood, cognitive, and behavioral disorders, as well as affecting children's physical health.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e According to WHO (2023), epilepsy is one of the most common neurological diseases in the world. Almost 80% of people with epilepsy live in low- and middle-income countries.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e More than 60% of epilepsy begins in childhood and is higher in children under 3 years of age.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e In Indonesia until now there is no definitive incidence data because many people with epilepsy are not detected or do not visit health centers.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Some epilepsy patients experience sleep quality disorders and poor sleep.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eSeveral studies related to sleep disorders in children with epilepsy have also been conducted. A cross sectional study conducted on epilepsy patients found that out of 21 epilepsy patients, 6 patients (28.6%) experienced sleep disturbances, 10% of whom experienced seizures and or involuntary movements during sleep and 28.6% snored.\u003csup\u003e6\u003c/sup\u003e Sleep deprivation caused by sleep disorders increases the risk of seizures in epilepsy patients and worsens seizure control.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Sari et al (2017) in their research on epilepsy patients found 67.7% experienced sleep disturbances, 63.2% of which were disturbances in initiating and maintaining sleep and generalized seizure type had a 5.2 times greater risk of experiencing sleep disturbances.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Salendu (2020) in his research found that there were 71.7% of children with epilepsy who experienced sleep disturbances, with the most types of disturbances in initiating and maintaining sleep (62%). Risk factors that were shown to independently influence the incidence of sleep disturbances in epilepsy patients were generalized seizure type, cerebral palsies, intractable epilepsy, abnormal EEG, and the use of benzodiazepine-type antiepileptic drugs.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The severity of epilepsy, including the number and type of seizures, the number of AEDs, and their side effects are predictors of sleep disturbances in children with epilepsy.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eActigraphy is an activity-based sleep monitoring system that detects and records gross body movements via an all-directional accelerometer.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Actigraphy is usually worn on the wrist to provide objective information on sleep-wake patterns, with the algorithm transforming the activity data detected by actigraphy into sleep-wake staging for each time (ranging from 10 seconds to 1 minute).\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e However, not many studies have used actigraphy as an objective measure of sleep disturbance in children with epilepsy. In addition, sleep disorders that occur in children with epilepsy have an impact on their quality of life, so it is important to analyze the factors that affect sleep disorders in children with epilepsy.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted using an observational analytic research method with a cross-sectional approach in children with epilepsy at Prof. Dr. R.D. Kandou Hospital Manado in the time span of December 2023 to March 2024. Inclusion criteria were age 1 to 18 years, epilepsy patients, and parents agreed to participate by signing informed consent. Exclusion criteria were autism and other psychiatric disorders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collected were age, gender, seizure type, type of antiepileptic drugs, number of antiepileptic drugs, and sleep disturbance. Sleep disturbance was assessed with an actigraph worn on the wrist. Sleep disturbance parameters measured were as follows. Effective sleep (sleep efficiency) was the total interval between time spent sleeping and time spent on bed (cutt off \u0026lt;85%). Total sleep time was defined as the total time between sleep onset and wake time (hours). Wake-after-sleep onset was defined as the average time spent between waking up and going back to sleep (cutt off \u0026gt;40 minutes). Sleep latency is the time taken to enter sleep after lying in bed (\u0026gt;20 minutes).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was conducted where categorical variables were displayed as frequencies and percentages. Meanwhile, the dispersion values of numerical variables were presented according to the results of the distribution normality assessment either through graphs such as histograms, boxplots, and density curves, or the Shapiro Wilk normality test. For those that are normally distributed, the descriptive tabulation includes the mean and standard deviation (SD) values. In contrast, numerical variables whose distribution deviated from normality were given as median and range. Bivariate analysis of each independent variable on the dependent variable used independent t test or mann whitney u test, anova test or kruskall wallis test according to the results of assumption test analysis. Multivariate analysis of all independent variables on the dependent variable used multiple logistic regression. The results of logistic regression analysis were reported as OR (odd ratio using 95% confidence interval, and p value. Data analysis was performed using SPSS version 26.0.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eSubject characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn table 1, the study included 36 children with a mean age range of 8.92 years (\u0026plusmn;4.87 years), with a proportion of 55.6% boys and 44.4% girls. In terms of nutritional status, the majority of subjects (86.1%) were not malnourished, while 13.9% were malnourished. Most children had generalized seizures (64.9%) compared to focal seizures (30.6%). The median seizure frequency was 1 time, with most children (66.7%) having seizures only once, while 33.3% had more than one seizure. Valproate acid was the most commonly used antiepileptic drug (77.8%), with some subjects (22.2%) using a combination of valproate acid with other drugs (levetiracetam (2 respondents), carbamazepine (2 respondents), Oxcarba (1 respondent), Feniton (1 respondent). The majority of subjects (77.8%) used one type of anti-epileptic drug, while a small proportion (22.2%) used two types of drugs. A total of 63.9% of children experienced sleep disturbances, while 36.1% did not experience sleep disturbances.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eCharacteristics of subject\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n=36)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eAge ( years ), mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e8.92 (4.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eGender , n ( %)\u003c/p\u003e\n \u003cp\u003eMan\u003c/p\u003e\n \u003cp\u003eWoman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (55.6)\u003c/p\u003e\n \u003cp\u003e16 (44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eStatus ,n (%)\u003c/p\u003e\n \u003cp\u003eMalnutrition\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Without malnutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (13.9)\u003c/p\u003e\n \u003cp\u003e31 (86.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eSeizure Type , n( %)\u003c/p\u003e\n \u003cp\u003eGeneral\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Focal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25 (64.9)\u003c/p\u003e\n \u003cp\u003e11 (30.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eFrequency Seizures , median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e1 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eFrequency seizures , n( %)\u003c/p\u003e\n \u003cp\u003e1 time\u003c/p\u003e\n \u003cp\u003e\u0026gt;1 time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24 (66.7)\u003c/p\u003e\n \u003cp\u003e12 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eType of medication antiepileptic , n( %)\u003c/p\u003e\n \u003cp\u003eValproic Acid\u003c/p\u003e\n \u003cp\u003eValproic acid + combination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (77.8)\u003c/p\u003e\n \u003cp\u003e8 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eNumber of Anti- Epileptic Drugs , n( %)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Monopharmaceuticals\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Polypharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (77.8)\u003c/p\u003e\n \u003cp\u003e8 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eDisturbance sleep , n( %)\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23 (63.9)\u003c/p\u003e\n \u003cp\u003e13 (36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD (standard deviation); IQR (interquartile range)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSleep disturbances profiles among epilepsy children\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 outlines some aspects of sleep disturbance, providing information on the median (IQR) as well as the percentage of individuals who had disturbed sleep compared to those who did not. Sleep efficiency, with a median of 0.90 and an IQR range between 0.80 to 0.94, shows that out of a total of 36 individuals, 13 had impaired sleep efficiency while 23 did not. Meanwhile, total sleep time had a median of 6.0 hours and an IQR range between 5.0 to 8.75 hours, with 55.6% of individuals having impaired total sleep time and 44.4% not. Onset of awakening after sleep, with a median of 20 minutes and an IQR range between 12.0 to 34.75 minutes, showed that 6 had impaired onset of awakening after sleep and 30 did not. On sleep latency, which had a median of 15 minutes and an IQR range between 2.50 to 28.75 minutes, with 14 individuals having impaired sleep latency and 22 not.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eProfile of sleep disturbance among epilepsy children\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"551\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAspect disturbance Sleep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of people who experienced it disturbance ( %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eEfficiency (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e0.90 (0.80-0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e13 (36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e23 (63.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eTotal time sleep (hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e6.0 (5.0-8.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e20 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e16 (44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eAwakening onset after sleep (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e20 (12.0-34.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e6 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e30 (83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eLatency sleep (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e15 (2.50-28.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e14 (38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e22 (61.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eFactors related to sleep disturbances among epilepsy children\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn table 3, the results showed that the type of seizure was significantly correlated with sleep disturbance. Patients who experienced focal seizures tended to have a higher proportion of sleep disturbance compared to generalized seizures. Based on the OR value, it was also found that patients with focal type seizures had a 9 times risk of experiencing sleep disturbance. \u0026nbsp;This finding was supported by the results of the analysis which showed statistical significance (p-value = 0.039). Furthermore, the seizure frequency category also played an important role in sleep disturbance. Patients who experienced seizures more than once tended to have an 11 times higher risk (OR: 11.000) of experiencing sleep disturbance, compared to those who only experienced seizures once. This was reinforced by the significant finding in the data analysis (p-value = 0.020). In addition, the type of antiepileptic drugs used by patients also had an impact on sleep disturbance. Patients using valproate acid in combination with other drugs had a high risk of sleep disturbance. This finding was reinforced by the results of the analysis, which showed statistical significance (p-value = 0.0032). Finally, the number of anti-epileptic drugs taken by patients also had an effect on sleep disturbance. Patients who used only one type of medication tended to have a lower risk of sleep disturbance. This finding was also supported by the data analysis which showed statistical significance (p-value = 0.032). Overall, these findings provide valuable insights into factors to consider in the management of sleep disturbances in pediatric patients with epilepsy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eInfluencing factors of sleep disturbances among epilepsy children\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"597\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSleep Disorders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (n=23)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (n=13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003eAge (years), mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e9.52 (4.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e7.85 (4.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1,026 (0.89: 1.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0.723 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003eGender, n (%)\u003c/p\u003e\n \u003cp\u003eMan\u003c/p\u003e\n \u003cp\u003eWoman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (52.2)\u003c/p\u003e\n \u003cp\u003e11 (47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (61.5)\u003c/p\u003e\n \u003cp\u003e5 (47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.897 (0.2:3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.877 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003eType Seizures, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Focal\u003c/p\u003e\n \u003cp\u003eGeneral (reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (43.5)\u003c/p\u003e\n \u003cp\u003e13 (56.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003cp\u003e12 (92.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.231 (1.03: 83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.031 \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003eFrequency seizures, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026gt;1 time\u003c/p\u003e\n \u003cp\u003e1 time (reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (47.8)\u003c/p\u003e\n \u003cp\u003e12 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003cp\u003e12 (92.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11,000(1.2:99.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.025 \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003eNumber of Anti- Epileptic Drugs, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Monopharmaceuticals\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Polypharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (65.2)\u003c/p\u003e\n \u003cp\u003e8 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (100)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.032 \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003eStatus, n (%)\u003c/p\u003e\n \u003cp\u003eMalnutrition\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Without malnutrition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003cp\u003e19 (82.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003cp\u003e12 (92.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e2.526(0.3-25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.634 \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD (standard deviation); a: simple logistic regression, b: chi square test, c: fisher exact test\u003c/p\u003e\n\u003cp\u003eFurthermore, there are some observable trends related to sleep disturbances in pediatric patients with epilepsy, although the results of the statistical analysis were not significant. First, in terms of age, it can be seen that patients with sleep disorders tend to have a slightly older age, with a mean age of about 9.41 years, compared to patients without sleep disorders who have a mean age of about 7.38 years. Secondly, in terms of gender, there is a tendency that patients with sleep disorders are more often male. Third, in terms of nutritional status, although the difference was not statistically significant, there was a tendency that most patients with sleep disorders also experienced nutritional problems, with a proportion of 17.6% experiencing malnutrition, compared to patients without sleep disorders who were only about 7.7% malnourished. However, the results of statistical analysis showed that the association between age, gender and nutritional status with sleep disturbance in pediatric patients with epilepsy was not statistically significant.\u003c/p\u003e\n\u003cp\u003eIn table 4, based on the regression analysis results, it is known that both variables have statistical significance (p\u0026lt;0.05). Therefore, the variables of seizure type and seizure frequency were identified as independent predictors (p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eOdds ratio of factors influencing sleep disturbance among epilepsy children\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegression Logistics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS.E\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWald\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003eType Seizures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e2,464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e1,177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e4,385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e11,750(1,171:117,928)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 579px;\"\u003e\n \u003cp\u003e( Focal vs General)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003eFrequency Seizures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e2,617\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e1,168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e5,022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e13,694(1,388:135,074)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 579px;\"\u003e\n \u003cp\u003e(1 time Vs \u0026gt;1 time)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003eConstant\u0026nbsp;\u0026alpha;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e-0.618\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.596\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e1,493\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSleep disorders are common in children with epilepsy and can have a bidirectional relationship with epilepsy. Some of the most common sleep disorders in children with epilepsy include behavioral insomnia associated with poor sleep hygiene, sleep and wake transition disorders, sleep initiation and maintenance disorders, and daytime somnolence. Children with epilepsy may also exhibit sleepwalking, night terrors, confusional arousals, restless sleep, sleep fragmentation, and other sleep problems. Poor sleep habits, such as using electronic devices in bed or requiring the presence of family members to fall asleep, are also common in children with epilepsy.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn this study, the median sleep efficiency of children with epilepsy was 90% with an IQR range of 80\u0026ndash;94%. This is in line with previous research which found that the average sleep efficiency in children with epilepsy was 86.86%. This value is based on a study that assessed sleep efficiency in children with epilepsy using actigraphy, which is a non-invasive method of measuring sleep and wake patterns. The study found that children with epilepsy had lower sleep efficiency compared to healthy children. Sleep efficiency in children with epilepsy can be affected by various factors, including seizure type, medication use, and sleep disturbance.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFurthermore, on the aspect of total sleep time, the median total sleep time of children with epilepsy in this study was 6 hours. This is lower than the previous study which stated that the total sleep time of children with epilepsy was 7.74 hours.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Onset of awakening after sleep (WASO) showed a median of 20 minutes. This result is lower than the previous study which found the mean duration of WASO in children with epilepsy was 55 minutes (95% CI 43;68). In terms of sleep latency, the study showed that the mean sleep latency of respondents was 15 minutes. Previous research showed a value of 18.5 minutes.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe results of this study showed that children who had sleep disturbances had an older mean age than children who did not have sleep disturbances, however, the analysis showed a non-significant p value. Selendu (2020) reported that as the age of a child with epilepsy increases, there is an increasing trend in the percentage of children with sleep disturbances. The findings of this study showed that in the age range of 13\u0026ndash;18 years, 77.3% of the patients experienced sleep disturbances. Meanwhile, in the age range of 7\u0026ndash;12 years, the percentage was 71.7%, and in the age range of 4\u0026ndash;6 years, 67.7% of the patients also experienced sleep disturbances. Thus, it can be concluded that the older the child with epilepsy, the higher the likelihood of experiencing sleep problems.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e This could be due to the fact that the older the child, the greater the likelihood of experiencing sleep disturbances, as there are more factors that affect sleep patterns. The findings from our study show that although there is a tendency for older children to experience sleep disturbances, the difference is not statistically significant. This could be because individual characteristics of each child such as sleep habits and daily activity patterns may also contribute to the variability in the results of this study. In addition, disease severity and environmental factors also influence sleep disturbances in children with epilepsy.\u003c/p\u003e\u003cp\u003eThe proportion of sleep disturbances in children who experience focal seizures is more common than generalized seizures. The results of the analysis showed a significant relationship between seizure type and sleep disturbance with an OR (95%CI) value of 9. (0.086 :0.358). Seizures in children with epilepsy in a state of sleep occur in one third of patients. This is in line with research by Chen et al (2011) on pediatric patients with epilepsy where they found that the prevalence of poor sleep quality was significantly higher in the partial seizure group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003csup\u003e15\u003c/sup\u003e However, Sari et al (2017) in their research on epilepsy patients at the Child Neurology Polyclinic of Dr. Sardjito Hospital found that the type of seizure was significantly higher in the partial seizure group.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Sardjito found that the generalized seizure type was at risk for sleep disturbances (OR\u0026thinsp;=\u0026thinsp;5.2, 95% CI 1.356\u0026ndash;19.96, p\u0026thinsp;=\u0026thinsp;0.024).20 This study is in line with other studies in children with epilepsy which state that the generalized seizure type has more sleep disturbances than the partial seizure type.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eOng et al (2010) in their study found that the severity of epilepsy contributed to sleep disturbances.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The sleep phase changes the morphology of epileptiform discharges in a number of childhood epilepsy syndromes. There are two main phases during sleep: non-rapid eye movement (NREM) and rapid eye movement (REM), both of which are caused by activity in different parts of the brain. During deep sleep, there is little body movement and regular breathing. Most seizures, especially generalized seizures, are likely to occur in this phase. Whereas deep sleep is characterized by eye movements, hypnic jerks (face, arms and legs), and rapid irregular breathing. This phase is known as active sleep and mostly occurs during dreaming. Deep sleep can last from a few minutes to after hours. Most partial seizures occur in this phase.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Patients with night time seizures show decreased sleep efficiency, increased time to the first REM period, and increased sleepiness on the maintenance of wakefulness test (MWT).\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e When there is a decrease in GABA, it will trigger epilepsy. The pathophysiology of impaired GABA release or increased acetylcholine and norepinephrine is responsible for changes in sleep stages in children with epilepsy.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn this study, children who had more than 1 seizure were more at risk of sleep disturbance compared to children who had 1 seizure. Seizure activity is strongly influenced by changes in the excitability of nerve cells and the relationship between these cells. The more the frequency of seizures, the more anxiety during sleep.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Triono and Herini (2016) stated that the frequency of seizures more than 10 times before therapy is suspected of failure of pediatric epilepsy monotherapy through the mechanism of forming new epileptogenic foci.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e This study is not in line with Salendu et al (2020) who reported that there was no significant relationship between seizure frequency and sleep disturbance in children with epilepsy. Patients with seizure frequency\u0026thinsp;\u0026lt;\u0026thinsp;5 times per month experienced the most sleep disturbances (82.1%).\u003csup\u003e8\u003c/sup\u003e This difference in results could be due to differences in seizure frequency categories.\u003c/p\u003e\u003cp\u003ePatients who received more than 1 type of drug (valproic acid combined with other AEDs experienced sleep disturbances more often than those who only received 1 type of drug (valporic acid). Previous studies have reported that antiepileptic drugs affect sleep quality, daytime alertness, and neurocognitive function.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Sleep disturbance such as somnolence is one of the most common side effects of antiepileptic drug treatment, as it can alter the sleep-wake cycle and sleep architecture.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn this study, carbazepine phenytonin, levetiracetam and Oxcarbamazepine were the drugs combined with valporic acid. The side effects of phenytonin on sleep disturbance are decreased sleep efficiency and decreased REM sleep. Levetiracetam has the side effect of slow sleep waves which will affect sleep efficiency and total sleep time. Karmazepine has effects mainly on decreasing REM sleep causing an increase in WASO duration. While Oxcarba can cause insomnia.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study makes an important contribution to understanding the need for a holistic intervention approach for children with epilepsy, given the complexity of this condition and the multiple factors that have been shown to influence sleep disturbance in epilepsy patients. Efforts to develop intervention strategies should not only focus on seizure control but also address aspects of the patient's holistic well-being, including sleep disturbances. However, while this study provides valuable insights, there are some limitations that need to be noted. One significant limitation is the relatively small sample size. As such, more in-depth multivariate analysis or further research to confirm the findings may not be possible. In addition, it should be noted that some factors that may also have an influence on sleep disorders, such as the patient's psychological state, sleeping environment, or even hormonal changes in adolescence, were not examined in detail in this study.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eBased on this study, it can be concluded that more than half of children with epilepsy experience sleep disturbances. Focal seizures, seizure frequency more than 1, polytherapy (valproate acid and other OAE combinations) increase the proportion of sleep disorders in children with epilepsy. This study did not find an association between age, gender and sleep disturbance in children with epilepsy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConflict of interest\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have nothing to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics Statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Ethics Committee of RSUP Prof. Dr. R. D. Kandou, Manado, Indonesia. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInformed Consent\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants prior to their inclusion in the study. Participants were fully informed about the objectives, procedures, potential risks, and benefits of the research, and their right to withdraw at any time without consequences.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDehghani M, Fayyazi A, Cheraghi F, Hakimi H, Mosazadeh S, Almasi S. The relationship between severity of epilepsy and sleep disorder in epileptic children. Iran J Child Neurol. 2019;13(2). \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Epilepsy. World Health Organization. 2023. \u003c/li\u003e\n\u003cli\u003eSinghi P, Gupta A. Epilepsy in Children\u0026mdash;Important Facets. Vol. 88, Indian Journal of Pediatrics. 2021. \u003c/li\u003e\n\u003cli\u003eJagadeesan P, Malai Arasu R. Clinical profile of children with epilepsy: a cross-sectional study. Int J Contemp Pediatrics. 2020;7(11). \u003c/li\u003e\n\u003cli\u003eAaberg KM, Gunnes N, Bakken IJ, Soraas CL, Berntsen A, Magnus P, et al. Incidence and prevalence of childhood epilepsy: A nationwide cohort study. Pediatrics. 2017;139(5). \u003c/li\u003e\n\u003cli\u003eUtami DKI, Suryapraba A. SLEEP QUALITY AND SLEEP DISORDERS PROFILE OF EPILEPSY PATIENTS IN NEUROLOGY POLYCLINIC SANGLAH GENERAL HOSPITAL DENPASAR BALI. 2018;1\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eSari R, Triono A, Sutomo R. Gangguan Tidur pada Anak dengan Epilepsi dan Faktor yang Memengaruhi. Sari Pediatri. 2017;19(1). \u003c/li\u003e\n\u003cli\u003eSalendu, Margareth P, Widodo DP. Gangguan tidur pada anak dengan epilepsi dan faktor-faktor yang memengaruhinya. Ilmu Kesehatan Anak Universitas Indonesia. 2020; \u003c/li\u003e\n\u003cli\u003eOng LC, Yang WW, Wong SW, Alsiddiq F, Khu YS. Sleep habits and disturbances in Malaysian children with epilepsy. J Paediatr Child Health. 2010;46(3). \u003c/li\u003e\n\u003cli\u003eTsai SY, Lee WT, Lee CC, Jeng SF, Weng WC. Agreement Between Actigraphy and Diary-Recorded Measures of Sleep in Children With Epilepsy. Journal of Nursing Scholarship. 2018;50(2). \u003c/li\u003e\n\u003cli\u003eXue B, Licis A, Boyd J, Hoyt CR, Ju YES. Validation of actigraphy for sleep measurement in children with cerebral palsy. Sleep Med. 2022;90. \u003c/li\u003e\n\u003cli\u003eFurones Garc\u0026iacute;a M, Garc\u0026iacute;a Pe\u0026ntilde;as JJ, Gonz\u0026aacute;lez Alguacil E, Moreno Cantero T, Ruiz Falc\u0026oacute; ML, Cantar\u0026iacute;n Extremera V, et al. Sleep disorders in children with epilepsy. Neurologia. 2024;39(3). \u003c/li\u003e\n\u003cli\u003eTsai SY, Tsai HY, Lin YY, Chen SR, Kuo SY, Lou MF. Sleep and Its Disturbance in Parents of Children and Adolescents with Epilepsy: A Systematic Review and Meta-Analysis. Vol. 15, Nature and Science of Sleep. 2023. \u003c/li\u003e\n\u003cli\u003eTuraga S, Soanpet P, Manikinda J, Kohat AK, Davidi SR. Observational study of prevalence of sleep disorder in patients with epilepsy. Int J Epilepsy. 2016;3(1). \u003c/li\u003e\n\u003cli\u003eChen NC, Tsai MH, Chang CC, Lu CH, Chang WN, Lai SL, et al. Sleep quality and daytime sleepiness in patients with epilepsy. Acta Neurol Taiwan. 2011;20(4). \u003c/li\u003e\n\u003cli\u003eBatista BHB, Nunes ML. Evaluation of sleep habits in children with epilepsy. Epilepsy and Behavior. 2007;11(1). \u003c/li\u003e\n\u003cli\u003eSt. Louis EK. Sleep and epilepsy: Strange bedfellows no more. Vol. 50, Minerva Pneumologica. 2011. \u003c/li\u003e\n\u003cli\u003eStores G, Wiggs L, Campling G. Sleep disorders and their relationship to psychological disturbance in children with epilepsy. Child Care Health Dev. 1998;24(1). \u003c/li\u003e\n\u003cli\u003eTriono A, Herini ES. Faktor Prognostik Kegagalan Terapi Epilepsi pada Anak dengan Monoterapi. Sari Pediatri. 2016;16(4). \u003c/li\u003e\n\u003cli\u003eKotagal P. The relationship between sleep and epilepsy. Semin Pediatr Neurol. 2001;8(4). \u003c/li\u003e\n\u003cli\u003ePlacidi F, Scalise A, Marciani MG, Romigi A, Diomedi M, Gigli GL. Effect of antiepileptic drugs on sleep. Clinical Neurophysiology. 2000;111(SUPPL. 2). \u003c/li\u003e\n\u003cli\u003eAl-Biltagi MA. Childhood epilepsy and sleep. World J Clin Pediatr. 2014;3(3). \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"Sleep disturbance, Epilepsy, Children, Malnutrition, Clinical Nutrition","lastPublishedDoi":"10.21203/rs.3.rs-7668996/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7668996/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackgroundː\u003c/strong\u003e To calculate the proportion of sleep disturbances in children with epilepsy and analyze which of the following factors are associated with sleep disturbances in children with epilepsy: age, gender, seizure type, seizure frequency, type of AED, and number of aeds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This study was conducted using an observational analytic research method with a cross-sectional approach in children with epilepsy at Prof. Dr. R.D. Kandou Hospital Manado in the time span of December 2023 to March 2024. Inclusion criteria were age 1 to 18 years, epilepsy patients, and parents agreed to participate by signing informed consent. Exclusion criteria were autism and other psychiatric disorders. Data analysis was done using SPSS version 26.0.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: This study included 36 children with a mean age range of 8.92 years (±4.87 years). There were 3 factors that showed a significant relationship with sleep disorders, seizure type (OR = 9.231 (95% CI 1.03: 83.3); p = 0.031) and number of seizures (OR = 11 (95% CI 1.2: 99 .1); p = 0.025), number of anti-epileptic drugs (p 0.0032). It was found that the number of seizures and type of seizure were independent risk factors (p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: In this study 64% of children with epilepsy experienced sleep disturbances, which were linked to seizure type and frequency. Future research is needed to explore additional factors like sleep hygiene, socioeconomics, and co-sleeping that could contribute to sleep disorders in these children.\u003c/p\u003e","manuscriptTitle":"Factors Related to Sleep Disturbances Among Children with Epilepsy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-24 08:31:48","doi":"10.21203/rs.3.rs-7668996/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":"629b32ef-a9b6-4f24-bd88-7e10283e704b","owner":[],"postedDate":"September 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55247121,"name":"Pediatrics"},{"id":55247122,"name":"Nutrition \u0026 Dietetics"}],"tags":[],"updatedAt":"2025-09-24T08:31:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-24 08:31:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7668996","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7668996","identity":"rs-7668996","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}