\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Sleep and Circadian Disruptors: Unhealthy Noise and Light Levels for
Hospitalized Pediatric Stem Cell Transplant Patients}



\author[1]{Andrea L. Fidler}%
\author[2]{Julie Waitt}%
\author[2]{Leslie Lehmann}%
\author[3]{Jo M. Solet}%
\author[3]{Jeanne F. Duffy}%
\author[4]{Brian D. Gonzalez}%
\author[1]{Dean Beebe}%
\author[5]{David Fedele}%
\author[3]{Eric Zhou}%
\affil[1]{Cincinnati Children's Hospital Medical Center}%
\affil[2]{Boston Children's Hospital}%
\affil[3]{Harvard Medical School}%
\affil[4]{Moffitt Cancer Center}%
\affil[5]{University of Florida Department of Clinical and Health Psychology}%


\vspace{-1em}



  
  \date{May 04, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Noise and light levels during hospitalizations can disrupt sleep and
circadian health, resulting in worse health outcomes. This study
describes patterns of noise and light in an inpatient room of children
undergoing stem cell transplants. Objective meters tracked noise and
light levels every minute for 6 months. Median overnight sound was 55dB
(equivalent to conversational speech), which exceeded recommendations.
There were 3.4 loud noises (\textgreater{}80dB) per night on average.
Children spent 62\% of the 24-hour cycle in non-optimal lighting, with
daytime light dimmer than recommended 98\% of the time. These data
suggest improvements for hospital environment in pediatric cancer
patients.%
\end{abstract}%



\sloppy


\textbf{Sleep and Circadian Disruptors: Unhealthy Noise and Light Levels
for Hospitalized Pediatric Stem Cell Transplant Patients}

Andrea L. Fidler, PhD, MPH,\textsuperscript{1} Julie Waitt MSN, RN,
CPHON,\textsuperscript{2} Leslie E. Lehmann, MD,\textsuperscript{2} Jo
M. Solet, PhD,\textsuperscript{3,4} Jeanne F. Duffy, MBA,
PhD,\textsuperscript{3,5} Brian D. Gonzalez, PhD,\textsuperscript{6}
Dean W. Beebe, PhD, ABPP,\textsuperscript{1,7} David A. Fedele, PhD,
ABPP,\textsuperscript{8} \& Eric S. Zhou, PhD\textsuperscript{3,9-10}

\textbf{Affiliations} :

\textsuperscript{1} Division of Behavioral Medicine and Clinical
Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati OH

\textsuperscript{2} Hematopoietic Stem Cell Transplant Unit, Boston
Children's Hospital, Boston MA

\textsuperscript{3} Division of Sleep Medicine, Harvard Medical School,
Boston MA

\textsuperscript{4} Department of Medicine, Cambridge Health Alliance,
Cambridge MA

\textsuperscript{5} Division of Sleep and Circadian Disorders,
Department of Medicine, Brigham and Women's Hospital, Boston MA

\textsuperscript{6} Department of Health Outcomes and Behavior, Moffitt
Cancer Center, Tampa FL

\textsuperscript{7} Department of Pediatrics, University of Cincinnati
College of Medicine, Cincinnati OH

\textsuperscript{8} Department of Clinical and Health Psychology,
University of Florida, Gainesville FL

\textsuperscript{9} Department of Psychosocial Oncology and Palliative
Care, Dana-Farber Cancer Institute, Boston MA

\textsuperscript{10} Department of Neurology, Boston Children's
Hospital, Boston MA

\textbf{Contact info for corresponding author:} Eric Zhou,
eric\_zhou@dfci.harvard.edu, 450 Brookline Ave, Boston, MA 02215

\textbf{Abstract word count} : 100/100

\textbf{Article word count} : 1191/1200

\textbf{Running title} : Noise and Light Levels for Hospitalized
Patients

\textbf{Keywords:} sleep, circadian rhythm, light, sound, hospital,
pediatric cancer

\textbf{Abbreviations table:}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
EDI & equivalent daylight illuminance\tabularnewline
\midrule
\endhead
SCT & stem cell transplant\tabularnewline
SLCs & sound level changes\tabularnewline
WHO & World Health Organization\tabularnewline
\bottomrule
\end{longtable}

\textbf{Abstract} :

Noise and light levels during hospitalizations can disrupt sleep and
circadian health, resulting in worse health outcomes. This study
describes patterns of noise and light in an inpatient room of children
undergoing stem cell transplants. Objective meters tracked noise and
light levels every minute for 6 months. Median overnight sound was 55dB
(equivalent to conversational speech), which exceeded recommendations.
There were 3.4 loud noises (\textgreater{}80dB) per night on average.
Children spent 62\% of the 24-hour cycle in non-optimal lighting, with
daytime light dimmer than recommended 98\% of the time. These data
suggest improvements for hospital environment in pediatric cancer
patients.



\textbf{Introduction}

Pediatric patients undergoing stem cell transplant (SCT) are
hospitalized for extended periods and are at high risk for sleep
disturbances due to noise and light disruptions.\textsuperscript{1} Poor
sleep can lead to adverse health effects, including immune system
dysregulation.\textsuperscript{2--4} As pediatric SCT patients are
immunocompromised and at risk for comorbidities, it is important to
optimize their environment for sleep and circadian health.

Noise and light are frequent disruptors of sleep and circadian health in
pediatric hospital rooms.\textsuperscript{5} Noise often spikes during
the night on pediatric oncology units as a result of staff room entries,
medication administrations, and alarms.\textsuperscript{6--8} Irregular
and ``unnatural'' light-dark cycles can cause circadian
disruptions.\textsuperscript{9,10} Noise and light disruptions are
independently associated with less sleep among children with
cancer.\textsuperscript{8}

Within inpatient rooms of children with cancer, noise and light
disruptions have been tracked only for brief periods (e.g., three
days)\textsuperscript{11} and primarily focused on nighttime light
levels.\textsuperscript{11--13} This study expands findings by
characterizing noise and light patterns across full 24-hour periods over
several months in an inpatient pediatric SCT room.

\textbf{Methods}

\textbf{Procedures}

Over 6 months, we recorded sound and light levels at one-minute
intervals within a patient room on the inpatient SCT unit at a
children's hospital in the northeast United States using the Extech
SDL600 (noise) and Extech SDL400 (light). Meters were wall-mounted near
the head of the bed to approximate the patients' experience (Figure
1).\textsuperscript{14} We recorded admission/discharge dates and
patient demographics. The study was deemed exempt by the hospital's IRB.

\textbf{Analytic Plan}

\emph{Data Processing}

Analyses were restricted to the dates that rooms were occupied,
excluding admission/discharge days. Due to device malfunction, light
data were not captured from 03/03/2022 to 05/22/2022, sound data were
not captured from 07/07/2022 to 08/13/2022, and \textless{}1\% of all
sound data was corrupted. We manually scanned for and agreed via
consensus to remove corrupted data along with the five datapoints
preceding and following the affected ones.

\emph{Data Analyses}

We examined patterns of sound and light across three times of day:
overnight (8:00pm-7:59am), daytime (8:00am-3:59pm), and evening
(4:00pm-7:59pm). For noise, we evaluated whether median levels at night
exceeded 40 dB, the World Health Organization's (WHO) recommended
maximum for nighttime noise spikes in inpatient hospital
rooms.\textsuperscript{15} For light, we determined the percent of time
that patients were exposed to inappropriate light levels. Recent
consensus-based recommendations for optimal light conditions include
exposure to a melanopic equivalent daylight illuminance (EDI) of [?]250
lux during daytime hours, [?]10 lux during the evening, and [?]1 lux
overnight.\textsuperscript{16} Because our meter was wall mounted, we
converted melanopic EDI to vertically measured illuminance by
multiplying the recommended melanopic EDI by a correction factor of 1.79
based on a melanopic daylight efficiency ratio of 0.56 for 4000K
fluorescent lights.\textsuperscript{17,18} Therefore, the vertically
measured illuminance thresholds are 448 lux during the daytime, 18 lux
during the evening, and 2 lux overnight. For the nighttime hours, we
also measured the frequency of noise spikes \textgreater{}80 dB, sound
level changes (SLCs, the difference between two consecutive sound
measurements) \textgreater{}17.5 dB, and light spikes \textgreater{}150
lux -- all of which are associated with night
wakings.\textsuperscript{12,14,19} Data were analyzed using RStudio.

\textbf{Results}

\textbf{Patient Characteristics}

Six pediatric SCT patients aged 1-17 years (M\textsubscript{age} = 8.4 \selectlanguage{ngerman}±
6.6) occupied the observed room from February to August 2022. Four
patients were male, one was female, and one did not have their sex
recorded. Their average length of stay was 31.5 days (range = 13-61).
Five had their primary caregiver stay overnight.

\textbf{Noise}

Across all overnight data points, the minimum noise level was 51.4 dB,
with a median of 55.0 dB. Overnight noise peaked at 98.4 dB. At least
one noise disruption (spike \textgreater{}80 dB or SLCs
\textgreater{}17.5 dB) occurred on 96.5\% of nights. On an average
night, the patients were exposed to 3.4 noise spikes \textgreater{}80dB
and 5.6 SLCs \textgreater{}17.5 dB. See Figures 2a-b.

\textbf{Light}

Across a 24-hour day, 61.9\% of time was spent in non-optimal light
conditions. During the daytime, light was \textless{}448 lux 97.5\% of
the time, with a median of 73.0 lux (range = 0-1454 lux). Light was
\textgreater{}18 lux for 58.6\% of the evening, with a median of 29.0
lux (range = 0-2370 lux). Overnight, children spent 30.2\% of their time
in light \textgreater{}2 lux. Light spiked to a maximum of 513 lux at
night, with children being exposed to light spikes \textgreater{}150 lux
on 4.9\% of nights. Notably, those light spikes occurred between
7:00-7:59am. See Figures 2b-d.

\textbf{Discussion}

Hospitalized pediatric SCT patients were consistently exposed to
disruptive noise and light. Nighttime noise levels always exceeded WHO
recommendations for sleep,\textsuperscript{15} with patients exposed to
multiple noise spikes associated with night
wakings.\textsuperscript{12,14,19} While light levels were frequently
dim enough to be conducive to sleep at night, patients were rarely
exposed to light bright enough to preserve a healthy circadian rhythm
during the day. Furthermore, the afternoon timing of the brightest
daytime light exposure was also not ideal for maintaining circadian
entrainment.\textsuperscript{16}

The high noise levels are consistent with a recent review and are a
well-known issue for inpatients.\textsuperscript{5} Humans can become
accustomed to a persistently noisy environment so long as it is constant
-- variability may drive night wakings.\textsuperscript{12,14,19} By two
different metrics, children in our study were exposed to exceedingly
disruptive noise: 3.4 noise spikes \textgreater{}80 dB (roughly
equivalent to a gas-powered lawnmower\textsuperscript{20}) and 5.6 SLCs
\textgreater{}17.5 dB per night. It may be important to focus
intervention efforts on minimizing brief, but problematic, bursts of
sound.

Patients were exposed to insufficient light for \textgreater{}97\% of
the daytime, consistent with prior research among
adults.\textsuperscript{14,16} They were also exposed to brighter than
recommended light for \textgreater{}50\% of the evening and 30\% of the
night. As children likely benefit from even lower levels of evening
light than adult recommendations, we may be underestimating the
potential for circadian disruption.\textsuperscript{16} The relatively
low and afternoon-skewed daytime light, combined with the brighter than
recommended light during the evening and early night, is thought to lead
to circadian rhythm disruption, longer hospitalizations, and higher
morbidity.\textsuperscript{21} Improving circadian health should be an
area of growing interest among pediatric researchers and
clinicians.\textsuperscript{22} Future studies should include objective
assessments of patients, including sleep disruptions, circadian rhythm
timing,\textsuperscript{23,24} and outcomes (e.g., length of stay).

Findings should be considered within the context of study limitations.
We did not measure light/sound directly at eye/ear level or assess
direct patient outcomes. Furthermore, these results may not be
generalizable to all hospitals, inpatient populations, and rooms. For
example, room layout and location impact light
exposure.\textsuperscript{21}

Our findings suggest considerable room for improvement of the inpatient
environment to better support sleep and circadian
health.\textsuperscript{21,25,26} Although environmental factors are
known to be the most common sleep disruptors, the majority of
sleep-promoting interventions target individuals' behaviors, not their
environments.\textsuperscript{5} Due to the known challenges with
sustaining interventions targeting patients or providers, institutions
should make systematic changes that prioritize sleep and circadian
function (e.g., reducing overnight noise or consolidating
procedures\textsuperscript{7,27,28}).\textsuperscript{29} Almost all
section chiefs of hospital medicine rate patient sleep as important, but
fewer than half of their hospitals have adopted sleep friendly
practices.\textsuperscript{30} This speaks to the need for the
establishment of sleep/circadian health standards that institutions are
incentivized to implement.\textsuperscript{31}



\textbf{Conflict of Interest Statement}

Eric S. Zhou has received grant funding from Jazz Pharmaceuticals and
Harmony Biosciences, and he has received consulting fees from Samsung
and MindUP. Brian D. Gonzalez reports fees unrelated to this work from
Sure Med Compliance and Elly Health. Jo M. Solet owns stock in and is an
advisor to Kunason and Dream Zzzz; she is also an advisor to Lark. The
remaining authors have no known conflicts of interest to disclose.

\textbf{Acknowledgements}

This research was generously supported by grant funding from Pedals for
Pediatrics (PI: Zhou) and an institutional research training grant
(T32DK063929).

\textbf{Legends}

Figure 1: Room layout and meter placement.

Figure 2a: Mean noise levels per hour with 95\% confidence intervals.

Figure 2b: Frequency of noise spikes \textgreater{}80 dB, SLCs
\textgreater{}17.5 dB, and light spikes \textgreater{}150 lux per week

Figure 2c: Mean light levels per hour with 95\% confidence intervals.

Figure 2d: Average percent of time spent in inappropriate light
conditions across the 24-hour day.

\textbf{References}

1. Dandoy CE, Beebe DW, Crosby LE, et al. Sleep: An Unrecognized
Casualty of Stem Cell Transplant. \emph{Biology of Blood and Marrow
Transplantation} . 2017;23(3):S229-S230. doi:10.1016/j.bbmt.2016.12.453

2. Dechnik A, Traube C. Delirium in hospitalised children. \emph{The
Lancet Child \& Adolescent Health} . 2020;4(4):312-321.
doi:10.1016/S2352-4642(19)30377-3

3. Park H, Chiang JJ, Bower JE, et al. Sleep and Inflammation During
Adolescents' Transition to Young Adulthood. \emph{Journal of Adolescent
Health} . 2020;67(6):821-828. doi:10.1016/j.jadohealth.2020.04.015

4. Garbarino S, Lanteri P, Bragazzi NL, Magnavita N, Scoditti E. Role of
sleep deprivation in immune-related disease risk and
outcomes.\emph{Commun Biol} . 2021;4(1):1304.
doi:10.1038/s42003-021-02825-4

5. Fidler AL, Voorhees S, Zhou ES, Stacciarini JM, Fedele DA. A
systematic review and proposed conceptual model of sleep disturbances
during pediatric hospitalizations. \emph{Sleep} . 2022;2022:1-17.
doi:10.1093/SLEEP/ZSAC038

6. Hinds PS, Hockenberry M, Rai SN, et al. Nocturnal awakenings, sleep
environment interruptions, and fatigue in hospitalized children with
cancer. \emph{Oncology Nursing Forum} . 2007;34(2):397-402.
doi:10.1188/07.ONF.393-402

7. Badia P, Hickey V, Flesch L, et al. Quality improvement initiative to
reduce nighttime noise in a transplantation and cellular therapy
unit.\emph{Biology of Blood and Marrow Transplantation} .
2019;25(9):1844-1850. doi:10.1016/j.bbmt.2019.05.001

8. Linder LA, Christian BJ. Nighttime sleep disruptions, the hospital
care environment, and symptoms in elementary school-age children with
cancer. \emph{Oncol Nurs Forum} . 2012;39(6):553-561.
doi:10.1038/jid.2014.371

9. Cain SW, Phillips AJK. Do no harm: the beginning of the age of
healthy hospital lighting. \emph{Sleep} . 2021;44(3):zsab016.
doi:10.1093/sleep/zsab016

10. Stickland A, Clayton E, Sankey R, Hill CM. A qualitative study of
sleep quality in children and their resident parents when in
hospital.\emph{Archives of disease in childhood} . 2016;101(6):546-551.
doi:10.1136/archdischild-2015-309458

11. Linder LA, Christian BJ. Characteristics of the nighttime hospital
bedside care environment (sound, light, and temperature) for children
with cancer. \emph{Cancer nursing} . 2011;34(3):176-184.
doi:10.1097/NCC.0b013e3181fc52d0

12. Stremler R, Micsinszki S, Adams S, Parshuram C, Pullenayegum E,
Weiss SK. Objective sleep characteristics and factors associated with
sleep duration and waking during pediatric hospitalization. \emph{JAMA
Network Open} . 2021;4(4):e213924-e213924.
doi:10.1001/JAMANETWORKOPEN.2021.3924

13. Bevan R, Grantham-Hill S, Bowen R, et al. Sleep quality and noise:
Comparisons between hospital and home settings. \emph{Archives of
Disease in Childhood} . 2019;104(2):147-151.
doi:10.1136/archdischild-2018-315168

14. Jaiswal S, Garcia S, Owens R. Sound and Light Levels Are Similarly
Disruptive in ICU and non-ICU Wards. \emph{J Hosp Med} .
2017;12(10):798-804. doi:10.12788/jhm.2826

15. Birgitta Berglund, Lindvall T, Dietrich H Schwela, World Health
Organization Occupational and Environmental Health Team.\emph{Guidelines
for Community Noise} . World Health Organization; 1999.

16. Brown TM, Brainard GC, Cajochen C, et al. Recommendations for
daytime, evening, and nighttime indoor light exposure to best support
physiology, sleep, and wakefulness in healthy adults. \emph{PLoS Biol} .
2022;20(3):e3001571. doi:10.1371/journal.pbio.3001571

17. Kenneth Wright Jr., PhD \& Timothy Brown, PhD. Email communication.
November 2022.

18. International Commission on Illumination. CIE S 026 a-opic Toolbox.
Published 2020. Accessed December 7, 2022.
http://cie.co.at/news/launch-cie-s-026-toolbox-and-user-guide

19. Stanchina ML, Abu-Hijleh M, Chaudhry BK, Carlisle CC, Millman RP.
The influence of white noise on sleep in subjects exposed to ICU
noise.\emph{Sleep Medicine} . 2005;6(5):423-428.
doi:10.1016/j.sleep.2004.12.004

20. National Center for Environmental Health. What Noises Cause Hearing
Loss? Center for Disease Control and Prevention. Published October 7,
2019. Accessed October 24, 2022.
https://www.cdc.gov/nceh/hearing\_loss/what\_noises\_cause\_hearing\_loss.html

21. Tan X, van Egmond L, Partinen M, Lange T, Benedict C. A narrative
review of interventions for improving sleep and reducing circadian
disruption in medical inpatients. \emph{Sleep Medicine} . 2019;59:42-50.
doi:10.1016/j.sleep.2018.08.007

22. Roenneberg T, Merrow M. The Circadian Clock and Human
Health.\emph{Current Biology} . 2016;26(10):R432-R443.
doi:10.1016/j.cub.2016.04.011

23. Wittenbrink N, Ananthasubramaniam B, Münch M, et al. High-accuracy
determination of internal circadian time from a single blood
sample.\emph{J Clin Invest} . 2018;128(9):3826-3839.
doi:10.1172/jci120874

24. Benloucif S, Burgess HJ, Klerman EB, et al. Measuring melatonin in
humans. \emph{J Clin Sleep Med} . 2008;4(1):66-69.

25. de Lima Andrade E, da Cunha e Silva DC, de Lima EA, de Oliveira RA,
Zannin PHT, Martins ACG. Environmental noise in hospitals: a systematic
review. \emph{Environ Sci Pollut Res} . 2021;28(16):19629-19642.
doi:10.1007/s11356-021-13211-2

26. DuBose JR, Hadi K. Improving inpatient environments to support
patient sleep. \emph{International Journal for Quality in Health Care} .
2016;28(5):540-553. doi:10.1093/intqhc/mzw079

27. Cook DJ, Arora VM, Chamberlain M, et al. Improving hospitalized
children's sleep by reducing excessive overnight blood pressure
monitoring. \emph{Pediatrics} . 2020;146(3). doi:10.1542/peds.2019-2217

28. Bartick MC, Thai X, Schmidt T, Altaye A, Solet JM. Decrease in
as-needed sedative use by limiting nighttime sleep disruptions from
hospital staff. \emph{J Hosp Med} . 2010;5(3):E20-24.
doi:10.1002/jhm.549

29. Buxton OM, Ellenbogen JM, Wang W, et al. Sleep disruption due to
hospital noises: a prospective evaluation. \emph{Ann Intern Med} .
2012;157(3):170-179. doi:10.7326/0003-4819-157-3-201208070-00472

30. Affini MI, Arora VM, Gulati J, et al. Defining existing practices to
support the sleep of hospitalized patients: A mixed-methods study of
top-ranked hospitals. \emph{J Hosp Med} . 2022;17(8):633-638.
doi:10.1002/jhm.12917

31. Orlov NM, Arora VM. A call for a ``Sleep-Friendly'' designation in
hospitals. \emph{Sleep} . 2022;45(5). doi:10.1093/SLEEP/ZSAC066\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure1/Figure1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure2/Figure2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

