Acute and Chronic Effects of Sleep

Duration on Blood Pressure

Hg) and with diastolic blood
pressure

(DBP)

prepolysomnography

in-

WHATS KNOWN ON THIS

SUBJECT: Inconsistent results have
been reported on the association
between sleep duration and blood
pressure (BP) in children, likely as a
result of inadequate adjustment for
confounders and the use of different
time frames in assessing sleep
duration.

bed periods (all b = 21 mm Hg).

WHAT THIS STUDY ADDS: Short

sleep duration and poor sleep quality
are associated with higher BP in
normal-weight adolescents. One night
of adequate sleep may partially
ameliorate the risk of high BP but
cannot completely reverse the effect

postpolysomnography (b = 20.2

of chronic sleep insufficiency.

abstract
OBJECTIVE: To evaluate the association
between ambulatory blood pressure
(ABP) and sleep duration as measured
by 7-day sleep diary and nocturnal
polysomnography
in
normal-weight
adolescents
without
significant
obstructive sleep apnea.
METHODS: Subjects aged 10 to 17.9 years with
an obstructive apnea hypo-pnea index ,5
underwent polysomnography for 9.5 hours and
24-hour ABP monitoring commencing at noon
on the same day. ABP was divided into
prepolysomnography,
in
bed
during
polysomnography, and postpoly-somnography
periods for separate analyses. Sleep duration
(SpD7) was obtained from a 7-day sleep diary,
reflecting the sleep pattern in the week before
admission. Total sleep time (TST) and sleep
efficiency
(SpE)
were
obtained
from
polysomnography.
RESULTS: A total of 143 adolescents
participated. SpD7 was inversely associated with
systolic

in
and

blood

prepolysomnography,

pressure

(SBP)

in-bed,

in
and

postpolysomnography periods (all b = 22 mm

TST was inversely associated

with

SBP

in

the

postpolysomnography period (b
= 21.5 mm Hg). SpE was
inversely associated with SBP
in in-bed period (b = 20.1 mm
Hg) and with DBP in in-bed (b =
20.1

mm

Hg)

and

mm Hg) periods. Neither TST

nor SpE was associated with
SBP

and

DBP

in

prepolysomnography period.

CONCLUSIONS: Short sleep

duration as reflected by 7-day
sleep diary was associated
with higher blood pressure in
normal-weight adolescents.
Occasional adequate sleep
may partially ameliorate the
risk of high blood pressure
but may not completely
reverse the effect of long-term
sleep insufficiency. Pediatrics
2014;133:e64e72

AUTHORS: Chun
Ting Au, MPhil,a
Crover Kwok Wah Ho,
RPSGT,b Yun Kwok
Wing, FRCPsych,
FHKAM (Psych),b
Hugh Simon Lam,
MRCPCH,
FHKAM(Paed),a and
Albert Martin Li, MDa
Departments of
a
Pediatrics and
b
Psychiatry, Prince of
Wales and Shatin
Hospital, The Chinese
University of Hong Kong,
Shatin, Hong Kong
KEY WORDS
adolescents, ambulatory
blood pressure
monitoring, obstructive
sleep apnea, obesity,
short sleep
ABBREVIATIONS
ABP
ambulator
y blood
pressure
ABPM
ambulator
y blood
pressure
monitorin
g BP
blood
pressure
DBP

diast
olic
bloo
d
pres
sure
OAH
I
obstr
uctiv
e
apne
a
hypo
pnea
inde
x
OSA

obstr
uctiv
e
slee
p
apne
a
SBP

systolic blood pressure

Accepted for publication Sep 27,

SD7average daily sleep duration obtained from a 7- 2013
day sleep diary
SEsleep efficiency

Address correspondence to Chun Ting Au,

TSTtotal sleep time

MPhil, Department of Pediatrics, Prince of

Mr Au conceptualized and designed the study, coordinated

and supervised data collection, carried out data analyses,
and drafted the initial manuscript; Dr Wing conceptualized
and designed the study and critically reviewed the
manuscript; Mr Ho performed data collection, carried out
initial analyses, and reviewed and revised the manuscript; Dr
Lam reviewed and revised the manuscript; Dr Li
conceptualized and designed the study, supervised data
collection, and critically reviewed the manuscript; and all
authors approved the final manuscript as submitted.

Wales Hospital, The Chinese University of

Hong Kong, Shatin, Hong Kong. E-mail:
junau@cuhk.edu.hk
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275).

Copyright 2014 by the American

Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors
have indicated they have no financial

www.pediatrics.org/cgi/doi/10.1542/peds.2013-1379

relationships relevant to this article to

doi:10.1542/peds.2013-1379

disclose.

Downloadedfrom

pediatrics.aappublications
.orgatIndonesia:AAP

Sponsoredon
June10,2015

FUNDING: Supported by the

Research Grants Council of
the Hong Kong Special
Administrative Region, China
(CUHK470108).

POTENTIAL CONFLICT
OF INTEREST: Mr Ho
received honorarium for
lecturing on Sleep and
Neurologic Tests at a
meeting hosted by
Compumedics Limited in
Seoul, South Korea, on
August 30, 2012; the other
authors have indicated they
have no potential conflicts
of interest to disclose.
e64
AU et al

ARTICLE

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TABLE 2 Sleep Patterns of Different Sleep Duration Groups

Mean Sleep Duration Over the Past 7 Days
#7 Hours (n = 18)

P (for linear
trend)

7.018 Hours (n = 37) 8.019 Hours (n = 49) 9.0110 Hours (n = 26)

7-Day sleep diary period

Mean sleep duration
6:21 6 1:00
(SD7), h:min
Mean bedtime, h:min
24:38 6 1:18
Mean get-up time, h:min 7:16 6 1:12
Nap durationa, min
8.1 6 17.6
Mean sleep latencya, min
22.7 6 19.7
Any caffeine use in the
4 (22.2)
7-day period, n (%)
Any caffeine use
2 (11.1)
on the day before the
laboratory visit, n (%)
Polysomnography
TST, min
515 6 50
Sleep latencya, min
9.2 6 9.5
SE, %
90.7 6 8.5
Wake after sleep
43.4 6 44.8
onseta, min
Arousal index, /h
6.7 6 2.8
REM latency, min
91.2 6 40.7
REM, % of TST
24.0 6 4.6
Slow wave sleep,
18.6 6 5.7
% of TST
OAHIa, /h
1.3 6 1.5
ODIa, /h
0.3 6 0.4
SpO2 nadir, %
93 6 2

.10 Hours (n = 13)

7:36 6 0:13

8:29 6 0:18

9:25 6 0:15

10:22 6 0:24

,.001

23:58 6 0:58
7:41 6 1:01
9.8 6 12.9
18.2 6 17.4
12 (32.4)

23:19 6 0:59
7:57 6 0:53
6.4 6 12.0
15.3 6 9.9
14 (28.6)

23:40 6 1:21
9:13 6 1:21
7.7 6 16.2
15.8 6 10.4
6 (23.1)

23:34 6 0:42
10:03 6 0:58
8.7 6 17.4
15.3 6 16.5
5 (38.5)

.004
,.001
.98
.30
.74

3 (8.1)

5 (10.2)

3 (11.5)

1 (7.7)

.99

484
16.0
88.7
48.0

6 72
6 11.6
6 9.3
6 50.8

495
15.1
87.1
57.3

6 55
6 12.5
6 9.2
6 48.7

483
15.8
84.7
69.3

6 65
6 13.0
6 9.0
6 48.1

465
25.5
86.8
49.0

6 64
6 16.8
6 8.1
6 31.8

.04
,.001
.09
.08

6.1
114.7
22.9
22.4

6 2.0
6 68.5
6 4.2
6 5.8

7.4
107.8
22.2
21.6

6 2.8
6 46.6
6 4.3
6 5.7

7.8
117.0
22.1
20.5

6 3.1
6 47.1
6 5.6
6 7.5

7.0
102.5
24.2
22.4

6 3.0
6 41.7
6 4.8
6 6.7

.25
.54
.89
.23

1.0 6 1.2
0.4 6 0.7
92 6 2

0.9 6 1.1
0.4 6 0.6
93 6 2

1.1 6 1.2
0.4 6 0.6
92 6 2

0.4 6 0.6
0.2 6 0.3
94 6 2

.33
.42
.50

Data are presented as means 6 SDs unless otherwise indicated. P values were obtained from linear contrast tests. ODI, oxygen desaturation index; REM,
rapid eye movement sleep; SpO2, pulse oxygen saturation.
a

Data were log-transformed to satisfy the assumption of normality before linear contrast tests. Nap duration, OAHI, and ODI were transformed into log (x + 0.1)
because of the presence of zero in some subjects. Original data are presented.

revealed that a

in

DBP.

In

with elevated ABP in normal-weight adolescents, especially in the addition,

sleep
pre-polysomnography and in-bed periods. An average of 1 hour of duration and SE
reduced sleep duration was associated with an in-crease of 2 mm Hg as recorded on
in SBP and 1 mm Hg

polysomnography
were
independently
associated
BP

in

with
the

postpolysomnogra
phy

period.

Although the effect

size was modest,
a previous study

TABLE 3 ABP of Different Sleep Duration

Groups

Downloadedfrom

small

difference in BP
was
associated
with significant left
ventricular
abnormali-ties,21
which
are
important markers
of
future
cardiovascular
adverse events.32
Thus, our findings
could
have
important
longterm
health
implications.

values
Hg were obtained from linear contrast tests.
SBP z score Morning surge,Pmm
SBP
DBP z score
DBP
24-Hour average Nocturnal dipping, %
SBP
SBP, mm Hg
Data are
DBP
DBP, mm Hg
presented as
e68
AU et al
means 6 SDs.

pediatrics

.aappub

lications. orgatIndonesia:AAPSponsoredon June10,2015

ARTICLE

FIGU
RE 2
Scatter
plot of
24-hour
ABP z
scores
against
7-day
sleep
duration
.

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TABLE 4 Association Between ABP and Sleep Quantity and Quality

Model 1a

Dependent Variable
SD7 (hours)
SBP (mm Hg)
Prepolysomnography period
In-bed period
Postpolysomnography period
Nocturnal dipping, %
Morning surge
DBP (mm Hg)
Prepolysomnography period
In-bed period
Postpolysomnography period
Nocturnal dipping, %
Morning surge
Data
1

Model 2b
SD7 (hours)

TST (hours)

21.6 (22.7 to 20.5)

.005
22.0 (23.1 to 21.0) ,.001
21.6 (22.7 to 20.4)
.007
0.7 (20.1 to 1.4)
.07
0.5 (20.7 to 1.8)
.39

21.0 (22.3 to 0.3)

20.9 (22.1 to 0.3)
21.5 (23.0 to 20.02)
0.1 (20.8 to 1.0)
20.1 (21.6 to 1.4)

.14
.15
.05
.86
.92

21.6 (22.8 to 20.5)

22.2 (23.2 to 21.1)
21.7 (22.8 to 20.5)
0.8 (0.02 to 1.5)
0.4 (20.9 to 1.6)

20.8 (21.6 to 0.04)

21.1 (22.0 to 20.2)
20.2 (21.1 to 0.8)
0.8 (20.3 to 1.9)
1.0 (20.2 to 2.2)

20.3 (21.2 to 0.7)

20.6 (21.6 to 0.5)
21.0 (22.2 to 0.2)
0.6 (20.7 to 1.9)
20.4 (21.8 to 1.0)

.57
.29
.11
.38
.56

20.8 (21.6 to 20.04)

21.2 (22.1 to 20.4)
20.3 (21.3 to 0.6)
0.9 (20.2 to 2.0)
0.8 (20.4 to 2.0)

.06
.02
.76
.14
.10

SE (%)

.005
,.001
.005
.04
.57

20.1 (20.2 to 0.1)

20.1 (20.3 to 20.01)
20.2 (20.3 to 0.0)
0.1 (20.04 to 0.2)
20.1 (20.3 to 0.04)

.20
.04
.06
.21
.15

.04
.007
.48
.09
.19

20.1 (20.2 to 0.03)

20.1 (20.3 to -0.02)
20.2 (20.3 to 20.1)
0.1 (20.02 to 0.3)
20.2 (20.3 to 20.01)

.17
.02
.006
.10
.04

are presented as b (95% confidence interval).

Independent variables included age, gender, BMI z score, OAHI, parental history of hypertension, TST measured on polysomnography, and sleep duration recorded by sleep diary.

2diary.

Independent variables included age, gender, BMI z score, OAHI, parental history of hypertension, SE measured on polysomnography, and sleep duration recorded by sleep

as obtained from
In this study, subjects with an OAHI .5 were excluded because there polysomnography
is evi-dence to support that children with more severe OSA have were more closely
with
significantly higher cardiovascular risk than healthy controls and associated
children with milder disease.20,37 Another merit of this study was thatABP

during and
after
overnight poly-somnography was performed on the same day as 24hour ABPM, both im-mediately after completion of the 7-day sleep polysomnography.
diary. This study design allowed us to separately delineate the The latter was
relatively long-term (7 days) and acute effects of sleep duration on especially true for
BP. By standardizing the start time (21:30 6 30 minutes) and end time DBP.

These

(07:00 6 30 minutes) of polysomnography recording to provide a fixed findings suggested

BP
was
time in bed of 9.5 hours 6 5 minutes for all subjects, acute changes in that
their sleep pattern could be dem-onstrated. Our results revealed that sensitive to acute
changes in sleep
subjects with shorter SD7 had shorter sleep latency and longer TST

as reflec-ted in their polysomnography results. This could be

considered as a sign of sleep rebound from sleep deprivation in the

pattern, meaning
that BP level was

influenced by the
preceding week. By analyzing the ABP data in prepolysomnography,
sleep quantity and

that there was a

carryover effect

may have some

bene-ficial effect

of short
duration

on BP, but
effect of

sleep

accumulated
in
the previous days
on SBP, and the
effect was not
totally cancelled
out by 1 night of
compensated
sleep.
This
finding
implications

has
for

weekend
sleep
compensation,
which
is
phenomenon

in-bed, and postpolysomnography peri-ods separately, it was found

commonly
adopted

before and during polysomnography, whereas TST and SE

adolescents.
Similar to our

quality
in
the
that, in general, SD7 was more closely related to ABP measured previous
night.
However, it did not
imply that 1 night
of adequate sleep
could compensate
for the ad-verse
effect
of
accumulated sleep
debt. Our results

by

previous finding
that
weekend
compensation
may
partially
ameliorate
effect of

the
short

sleep duration on

revealed that SD7

obesity,2

was

demonstrated
that similar sleep

not

only

associated
SBP
in

with
pre-

polysomnography
and in-bed periods
but also in the
postpolysomnogra
phy period. This
finding suggested

we

compensation
may modulate BP
changes. Thus,
our cur-rent study
supported
weekend
compensation

that

the

highly correlated.41

and ABPM were

polysomnography

long-term short sleep duration on BP could not be completely Our previous study
also reported good
eliminated.

per-formed only at

and ABPM on the

a single time point,

same

The major limitation of this study was that prepolysomnography sleep agreement between
was only recorded subjectively by sleep di-aries but not objectively by actigraphy-

which hindered a

affect

better

obtained from either

understanding

actigraphy. Sleep diaries may be subject to re-porting error that may measured and subreported
over- or un-derestimate sleep duration. However, several studies jectively

the

duration
revealed that actigraphy may also lead to errors by overes-timating sleep
the duration of wake after sleep onset and underestimate TST, when (intra-class
compared with polysomnography and sleep diary.3840 There is

correlation

evidence that subjective and objective sleep variables in adolescents, coefficient = 0.72).
including sleep start time, sleep end time, and sleep duration, were Polysomnography

e70

Downloadedfrom pediatrics.aappublications.org at

Indonesia:A

AP

day
the

may
results

of

as-sessment.

association

Nevertheless,

between changes

having

in sleep duration,

assessments on the

sleep architecture,

same day provided

and BP. Moreover,

us an opportunity to

performing

delineate the

AU et al

SponsoredonJune10,2015

the

ARTICLE

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AcuteandChronicEffectsofSleepDurationonBloodPressure
ChunTingAu,CroverKwokWahHo,YunKwokWing,HughSimonLamand
AlbertMartinLi
Pediatrics;originallypublishedonlineDecember16,
2013;DOI:10.1542/peds.20131379
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AcuteandChronicEffectsofSleepDurationonBloodPressure
ChunTingAu,CroverKwokWahHo,YunKwokWing,HughSimonLamand
AlbertMartinLi
Pediatrics;originallypublishedonlineDecember16,
2013;DOI:10.1542/peds.20131379

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PEDIATRICSistheofficialjournaloftheAmericanAcademyofPediatrics.Amonthly
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