Day-Night Activity in Hospitalized Children after Major Surgery: An Analysis of 2271 Hospital Days

Abstract

Objectives: To characterize the day-night activity patterns of children after major surgery and describe differences in children's activity patterns between the pediatric intensive care unit (PICU) and inpatient floor setting.

Study design: In this prospective observational study, we characterized the daytime activity ratio estimate (DARE; ratio between mean daytime activity [08:00-20:00] and mean 24-hour activity [00:00-24:00]) for children admitted to the hospital after major surgery. The study sample included 221 infants and children ages 1 day to 17 years admitted to the PICU at a tertiary, academic children's hospital. Subjects were monitored with continuous accelerometry from postoperative day 1 until hospital discharge. The National Health and Nutrition Examination Survey accelerometry data were utilized for normative data to compare DARE in a community sample of US children to hospitalized children.

Results: The mean DARE over 2271 hospital days was 57.8%, with a significant difference between the average DARE during PICU days and inpatient floor days (56% vs 61%, P < .0001). The average subject DARE ranged from 43% to 73%. In a covariate-adjusted mixed effects model, PICU location, lower age, orthopedic or urologic surgery, and intubation time were associated with decreased DARE. Hospitalized children had significantly lower DARE than the National Health and Nutrition Examination Survey subjects in all age groups studied, with the largest difference in the youngest PICU group analyzed (6-9 years; 59% vs 75%, P < .0001). A subset analysis of children older than 2 years (n = 144) showed that DARE was <50% on 15% of hospital days.

Conclusions: Children hospitalized after major surgery experience disruptions in day-night activity patterns during their hospital stay that may reflect disturbances in circadian rhythm.

Keywords: accelerometry; actigraphy; activity; acute rehabilitation; children; circadian rhythms; critical illness; delirium; hospital; intensive care units; sleep; surgery.

Copyright © 2019 Elsevier Inc. All rights reserved.

Figures

Figure 1 –

Histogram of DARE over all hospital days.

Figure 2 online –

Histogram of average DARE by subject.

Figure 3 –

Left: Heat map of 24-h activity arranged by DARE. Note the clear transition to consolidated rest-activity patterns above 60%. Right: Twenty-four-hour actigrams for DAREs at points A, B, and C in the left panel.

Figure 4 –

Comparison of normative, PICU and inpatient floor DARE in children ages 6-17 by age category.