Preserving sleep in paediatric peri‐operative care

Good quality sleep is essential for maintaining physical and psychological health, as it allows the body to repair tissues, support immune function and regulate hormones. Sleep quality during hospitalisation or post-surgery is especially important, as sleep deprivation may affect recovery and prolong hospital stay. Although well-studied in adults, studies investigating the sleep quality of young children after surgery are rare. The prospective study by Meewisse et al. on the effects of anaesthesia and surgery on sleep–wake timing and subjective sleep quality focuses on children (age 1–11 y) [1], a group often underrepresented in peri-operative sleep research. There has been one study in a similar age-group (age 3–12 y) that reported the views of parents on the sleep quality of their child during hospitalisation [2]. This retrospective study found that light, noise and daily schedules were the main factors affecting the child's sleep quality; however, children who had undergone surgery were not included [2]. As reports of sleep quality are often subjective, a major strength of this study by Meewisse et al. is its prospective nature, where parents/caregivers were given sleep diaries and questionnaires around the time of the child's surgery or procedure. The investigators also did not study children whose sleep may have been confounded by other factors (e.g. severe sleep disorders, ICU admissions), so that specific anaesthesia/surgery effects can be studied, providing valuable insights into how anaesthesia and minor surgical procedures affect sleep–wake rhythms. The study by Meewisse et al. was well-conducted and challenges previous assumptions about the impact of anaesthesia on sleep in children. The prevailing assumption that surgery, anaesthesia and pain disrupt sleep architecture is based primarily on studies of major procedures in adults [3]. However, the absence of such disturbance following day surgery in children shows that procedures, especially minor ones conducted during the day, directly challenge this existing belief. The results of the study by Meewisse et al. suggest that there is a fundamentally different response in children, which may be due to their inherent physiological resilience or because of the low-stress context of day surgery. Studies have shown that children have a more robust sleep homeostasis [4] and heightened neuroplasticity in the developing brain when compared with adults [5]. This study by Meewisse et al. should be applauded for its minimally invasive nature; children were not disturbed during sleep nor involved in filling in questionnaires, but it is noted that future work should incorporate objective sleep assessments, such as the use of polysomnography, which has been proven to be successful in paediatrics [6]. Future studies should also explore high-stress surgical contexts and children undergoing major surgery to determine if more significant sleep disruptions might result in those settings. Meewisse et al. also highlighted critical knowledge gaps in our understanding of paediatric peri-operative sleep physiology. Given the potential vulnerability of the developing brains and circadian systems of young children, and the increase in paediatric surgical procedures in current practice, there is a need for more rigorous research, including the use of EEG-based sleep studies and hormonal assays to determine the true impact of surgery and anaesthesia on paediatric sleep architecture and circadian regulation. The issue of sleep disturbance during hospital stays or surgery is often perceived by anaesthetists as a minor and self-limiting problem; however, even transient sleep disturbances may have serious sequelae for patients. Instead of being a simple state of rest, sleep is an active, dynamic process and a function critical for physiological restoration, cognitive function and emotional regulation [7]. The brain utilises sleep to perform essential maintenance, as shown by the discovery of the glymphatic system, which increases the clearance of neurotoxic waste during sleep [8]. The role of the glymphatic system may be magnified peri-operatively due to the increased inflammation which may be seen post-surgery; therefore, the provision of optimal recovery conditions, including sleep, is paramount. Preserving sleep may be crucial for mitigating known risks such as immune depression and increased susceptibility to infection [3]. It has been shown in older patient populations that anaesthesia may modify the melatonin circadian secretion and disturb postoperative sleep, which may relate to postoperative delirium [9]. Melatonin has been studied in children, and is an interesting and pertinent area of peri-operative research, considering the relatively high incidence (around 30%) of emergence delirium in children aged < 6 y [10]. A study of adult patients by van Zuylen et al. [11] showed that the midpoint of sleep on the night before surgery was already disturbed (i.e. occurred earlier) compared with three nights before surgery. The authors concluded that the phase advance before surgery may be due to a shorter sleep duration, earlier wake up time and alarm clock use, with other factors such as pre-operative fasting and stress playing a role. Results from this study also showed that sleep phase was advanced in the nights immediately post-surgery, which was associated with longer sleep latency and inertia, along with increased sleep duration. Interestingly, the changes in sleep variables seen immediately after surgery were independent of whether a patient had undergone day surgery or had been in hospital overnight. Sleep is especially important in the developing brains of young children which rely heavily on high-quality sleep to support synaptic plasticity, memory consolidation and emotional regulation [12, 13]; these are processes that are fundamental to long-term cognitive and behavioural health. The impact of sleep deprivation on cognitive function is well-recognised [14]. Preserving sleep and circadian integrity in young patients should be a priority in paediatric anaesthesia, just as we prioritise pain management and early mobilisation. Therefore, it is crucial to preserve the natural sleep architecture and circadian rhythms during the peri-operative period, as this may play a protective role, underscoring the importance of strategies that minimise sleep disruption [15]. One such strategy is the prioritisation of day surgery models, which allow children to recover in the comfort of their homes whenever possible. While a meta-analysis provided compelling evidence that successfully improving postoperative sleep can significantly reduce the risk of postoperative delirium in adults [16], qualitative studies reveal that little has been done to achieve this [17, 18]. Although many modifiable factors such as lighting, noise and fragmented care routines have been identified, hospital environments remain notoriously disruptive to sleep, leading to decreased restorative sleep cycles that children (and adults) need [19]. In contrast, recovery at home enables children to rest in familiar surroundings, maintaining their natural sleep–wake rhythms and reducing stress for both child and parent. Furthermore, the emotional benefits of home recovery cannot be overstated, as reduced anxiety and the ability to follow familiar sleep rituals contribute to smoother postoperative recovery and better long-term outcomes. The day surgery model aligns seamlessly with the principles of sleep hygiene, emphasising the need for stable, predictable sleep environments, especially during periods of physiological stress, such as postoperative healing [20]. By avoiding unnecessary overnight hospital stays, clinicians can mitigate the risks of sleep fragmentation and circadian misalignment, which may exacerbate pain sensitivity, delay recovery and potentially impair neurodevelopmental trajectories. Of course, day surgery is not suitable for all procedures or patients, but for low-to-moderate-risk surgeries, it represents a cost-effective strategy for healthcare systems and is gentler on the developing brains of children. While clinical practice should continue to embrace family-centred pathways, there are clinical scenarios, including major surgeries or complex medical needs, that necessitate hospitalisation. For these children, proactive strategies to protect sleep and circadian rhythms are essential to mitigate the known risks of sleep disruption on recovery and neurodevelopment [21]. However, this area remains understudied, leaving significant gaps in evidence-based practice. Key research areas should include quantifying the impact of anaesthesia, surgical stress and postoperative pain on sleep architecture and circadian rhythm; developing targeted interventions; and evaluating long-term outcomes. Interventions may include environment and behavioural-based strategies as well as pharmacological therapies. Child-friendly hospital environments should employ noise-reduction protocols; circadian-aligned lighting; and parental co-sleeping options to promote sleep. Drugs that promote natural sleep should be explored and investigated. For example, melatonin may be an effective drug for the treatment of circadian sleep–wakefulness disorder [22]. Dexmedetomidine may be another promising drug to improve sleep in hospital settings as it induces natural stage 2 sleep with a reduction in the incidence of agitation and delirium [23]. Evaluating long-term outcomes linking sleep preservation to recovery and neurocognitive development is important for clinicians to understand the impact of anaesthesia and major surgery on sleep, as well as the effectiveness of intervention. Previous research has shown a link between sleep deprivation and DNA damage [24], a precursor in cancer development if unchecked. The use of advanced tests at the molecular level may assist clinicians in understanding the impact of hospitalisation and intervention on sleep in children. A systemic review emphasised that the perceptions of ‘good sleep’ and responses to sleep disruptions are deeply personal and culturally influenced [25]. Effective peri-operative sleep management must extend beyond a one-size-fits-all intervention. This requires a holistic, patient-centred approach that promotes a restorative sleep environment actively; acknowledges individual and cultural perspectives on sleep; and integrates sleep hygiene as a core component of peri-operative care to optimise clinical outcomes and patient experiences. By addressing these gaps, we strive to transform postoperative care for children who are hospitalised, ensuring that sleep, a pillar of healing, is safeguarded even in high-acuity settings. While the study by Meewisse et al. is reassuring in that it suggests that minor procedures under anaesthesia may not drastically alter sleep–wake rhythms in children, we must not assume this applies to all paediatric surgical scenarios. This finding is not the final word but the essential first step in a much larger conversation of how to optimise sleep pre- and post-surgery in children. SW is the Statistical Editor of Anaesthesia. No other competing interests declared.