48 Chapter 2 only one high quality paper on well-defined sleep parameters. Older children might have a higher risk of impaired sleep duration during steroid use, but age as risk factor for impaired circadian parameters is not found. Replication studies are needed to confirm which age group is particularly at risk for specific sleep problems. Sex as risk factor was investigated in four studies (two cohorts) of which three of high quality13,54,56 and one of lower quality.48 Two studies in the same cohort13,56 reported no sex difference on most actigraphic sleep parameters, but boys did experience more nocturnal awakenings, whereas girls napped more in univariate analyses.13 In a multivariable analysis, only the parameter wake time after sleep onset (WASO) was decreased in girls and increased in boys during dexamethasone treatment.55 In the same cohort, Rogers et al. also did not find significant sex differences in the circadian rhythm parameters.54 Drigan et al. described that parents reported girls to have an increased risk for steroid-induced sleep disturbance.48 However, their 1-item parent reported question to assess sleep is not a validated questionnaire, making this evidence of lower quality. The quality of evidence investigating sex as a risk factor is overall low. It suggests that sex does not impact most sleep parameters (e.g., sleep quality), however some parameters (nocturnal awakenings, napping, WASO) may be impacted differently for boys and girls. Treatment factors (type of steroid and steroid dose) Only one study compared type of steroid as a risk factor for sleep problems. Using multivariate analyses, it was found that children receiving prednisone experienced better sleep quality and fewer night awakenings during steroid treatment in comparison with dexamethasone.12 Although this single study is of higher quality, evidence regarding type of steroid as a risk factor is scarce and therefore rated as very low quality in the GRADE. Four studies (two cohorts) compared the effect of steroid dose on sleep problems. Three of the studies in the same cohort drew the conclusion that a higher steroid dose gave rise to more sleep problems.13,54,56 Only one other study with a different cohort evaluated steroid dose and found that steroid dose was not related to sleep disturbance.48 However, this study is of lower quality partly due to methodological problems with the validity of the measurement method. Overall, the review suggests, without clear evidence, that steroid type and dose might have an impact on sleep problems, but this is only based on one cohort of patients and therefore of low to very low quality. Parental factors We did not find any studies describing steroid-induced sleeping problems and parental factors with our search.
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