As with much of medicine, racial health disparities exist in the care of patients with obstructive sleep apnea (OSA). These disparities impact all aspects of care from screening and diagnosis to treatment and long-term management. Substantial barriers exist for Black and other historically marginalized racial groups in the US to obtain evaluation for OSA, exacerbated by knowledge deficits about OSA. These barriers result in disease severity being much greater at the time of clinical diagnosis. Many screening and diagnostic tools used in OSA care were adopted based on their utility in White populations without consideration of their performance in other racial groups. For example, the reduced sensitivity of pulse oximetry in detecting desaturations in people with darker skin pigmentation has been heretofore ignored in defining hypopnea. In terms of treatment, outcomes from common therapies are worse in many racial minority groups. Adherence to continuous positive airway pressure (CPAP) is substantially lower and adenotonsillectomy is less effective in resolving OSA and more likely to produce respiratory complications in Black compared to White patients. Many coverage policies further exacerbate racial disparities in OSA care. Interventions such as greater utilization of home sleep apnea testing and automated feedback messaging of CPAP use exist that can help reduce disparities. However, the development of a more diverse workforce and prioritization of health equity in developing every step of OSA care will be necessary to eliminate racial disparities ultimately.

Persistent obstructive sleep apnea (OSA) following adenotonsillectomy is a frequently encountered challenge for clinicians including pediatricians, neurologists, otolaryngologists and sleep specialists, and if untreated poses severe health risks to children.

This article evaluates the etiology and pathophysiology of persistent pediatric OSA. It also discusses the conditions that predispose some children to persistent OSA following adenotonsillectomy and reviews the different diagnostic modalities and various options for management of persistent pediatric OSA. A PubMed search was performed using the following terms in various combinations: persistent obstructive sleep apnea, pediatric obstructive sleep apnea, positive airway pressure, hypoglossal nerve stimulator, myofunctional therapy, nasal surgery, CPAP tolerance, obesity, Down syndrome, montelukast, frenulectomy, bariatric surgery, drug induced sleep endoscopy, cine MRI.

Persistent OSA following adenotonsillectomy is commonly seen in children. Understanding the anatomic and physiologic mechanisms at play is important to formulate specific management strategies. It is important to have a higher degree of suspicion for persistent OSA after an adenotonsillectomy in children with neurological comorbidities and obesity.

Sleep deficiencies, such as sleep disordered breathing (SDB) and insufficient sleep, are linked to adverse health outcomes. These sleep deficiencies are more common in racial and ethnic minoritised children and have significant negative impacts on neurobehavioural and social-emotional development. Non-Latine Black/African American children are 4-6 times more likely than non-Latine White children to experience both SDB and short sleep duration. Although SDB and insufficient sleep often co-occur in young children, there is a paucity of research considering the potential unique and additive impacts of SDB and insufficient sleep on child outcomes, as well as racial disparities in these outcomes, thus hindering comprehensive interventions. Our study objectives are to (1) examine racial disparities in the neurobehavioural and social-emotional impacts of early childhood SDB and/or insufficient sleep and (2) identify proximal and distal socioecological factors linked to these sleep disparities and outcomes.

A cross-sectional observational study comparing neurobehavioural (executive functioning, attention, vigilance) and social-emotional functioning (social skills, emotion regulation) in 400 dyads consisting of caregivers and their otherwise healthy Black and White 3-5 year-old children and divided into four groups: (A) preschoolers with SDB; (B) preschoolers with insufficient sleep; (C) preschoolers with both SDB and insufficient sleep and (D) matched controls. Child SDB, insufficient sleep, neurobehavioural skills and social-emotional functioning are measured using validated objective and subjective assessment tools, with a subset of caregivers completing qualitative interviews. Primary outcomes include individual differences in neurobehavioural and social-emotional functioning in these groups of Black and White preschoolers, and multilevel socioecological factors associated with variation in outcomes. Quantitative data will be analysed using descriptive analyses, linear regression and comparison of model coefficients. Qualitative data will be coded using thematic analysis and a joint display to stratify qualitative themes by child race and sleep deficiencies.

The study protocol has been approved by the institutional review board of the Children's Hospital of Philadelphia and the University of Oregon. Results will be disseminated through peer-reviewed publications and conferences.

The goal of this study was to evaluate the association between a polygenic risk score (PRS) for QT prolongation (QTc-PRS), corrected QT intervals (QTc) and sudden cardiac death (SCD) in participants enrolled in the UK Biobank with and without sleep-disordered breathing (SDB).

The QTc-PRS was calculated using allele copy number and previously reported effect estimates for each single nuclear polymorphism. Competing-risk regression models adjusting for age, sex, body mass index, QT prolonging medication, race, and comorbid cardiovascular conditions were used for SCD analyses.

A total of 500,584 participants were evaluated (56.5 ± 8 years, 54% female, 1.4% diagnosed with sleep apnea). A higher QTc-PRS was independently associated with the increased QTc interval duration (P < .0001). The mean QTc for the top QTc-PRS quintile was 15 msec longer than the bottom quintile (P < .001). SDB was found to be an effect modifier in the relationship between QTc-PRS and SCD. The adjusted hazard ratio per 5-unit change in QTc-PRS for SCD was 1.64 (95% confidence interval 1.16-2.31, P = .005) among those with SDB and 1.04 (95% confidence interval 0.95-1.14, P = .44) among those without SDB (P for interaction = .01). Black participants with SDB had significantly elevated adjusted risk of SCD (hazard ratio = 9.6, 95% confidence interval 1.24-74, P = .03).

In the UK Biobank population, the QTc-PRS was associated with SCD among participants with SDB but not among those without SDB, indicating that SDB is a significant modifier of the genetic risk. Black participants with SDB had a particularly high risk of SCD.

Arora A, Zareba W, Woosley RL, et al. Genetic QT score as a predictor of sudden cardiac death in participants with sleep-disordered breathing in the UK Biobank. J Clin Sleep Med. 2025;21(3):549-557.

Obstructive sleep apnea syndrome (OSAS) in children is indeed a significant and often underdiagnosed condition. The risk factors for OSAS vary across different stages of life.

Identifying risk factors early can help in taking preventive measures to reduce the likelihood of developing OSAS, and different life stages may require different interventions.

During pregnancy, maternal factors such as obesity, smoking, and genetic predispositions can increase the risk of OSAS, while breastfeeding serves as a protective factor. For children aged 2 to 12, adenotonsillar hypertrophy is the primary cause of airway narrowing, with other contributing factors including obesity, craniofacial abnormalities, and increased nasal resistance. In adolescence, obesity and craniofacial abnormalities remain the main risk factors.

By reviewing and understanding these risk factors, healthcare providers can offer more personalized and effective care, ultimately leading to better health outcomes for individuals at all stages of life.

Sleep is an important and potentially modifiable determinant of many severe health outcomes. Sleep health disparities exist and are exemplified by reported differential rates of prevalence, severity, and outcomes among minority groups and low-socioeconomic-status backgrounds. In this review we highlight the concept of sleep health, review the evidence for disparities in sleep health, examine risk factors and consequences of poor sleep health, and discuss policy implications.

Obstructive Sleep Apnea (OSA) is a common sleep-related breathing disorder characterized by airway obstruction during sleep. Diagnosing pediatric OSA is challenging, particularly in underrepresented populations, leading to disparities in treatment and long-term negative health outcomes. Our study aimed to identify alternative diagnostic tools by investigating genome-wide epigenetic changes and associated transcriptomic alterations in Black female, pediatric patients with OSA. Whole-genome bisulfite sequencing and RNA sequencing were performed on saliva samples from healthy controls and children with OSA. Analysis of differential methylation and gene expression patterns revealed dysregulated inflammation and metabolism pathways in children with OSA. Chromosomes 19 and 22 exhibited elevated methylation signatures in this patient population. Integration of methylation and gene expression data identified specific molecular markers, including NAP1L4, CCR1, and LIF. The study emphasizes the need to consider both genetic and environmental factors in pediatric OSA, and the identified markers may offer avenues for further research.

Although asthma is common in children with sleep-disordered breathing (SDB), it is unclear whether and to what extent asthma is associated with SDB-related outcomes. Our objectives are to describe risk factors for asthma among children with mild SDB (mSDB) and assess the association between asthma and the severity of sleep-related outcomes.

Cross-sectional analyses were conducted for children aged 3-12.9 years with mSDB enrolled in Pediatric Adenotonsillectomy for Snoring Children Study. Sleep-related outcomes included SDB symptoms (Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder scale (PSQ-SRBD)), SDB-specific quality of life (OSA-18), sleepiness (modified Epworth Sleepiness Score) and polysomnographic and actigraphic measures. Asthma was defined by caregiver-reported diagnosis with current asthma symptoms and medication use, or a Composite Asthma Severity Index (CASI) score ≥ 4. Asthma was further categorized into mild (CASI < 4) and moderate-to-severe (CASI ≥ 4). Regression analyses were conducted to identify asthma risk factors and estimate the associations between mild and moderate-to-severe asthma with sleep-related outcomes.

The sample included 425 children (20.3%-Black, 17.4%-Hispanic; 51.7%-female). The prevalence of asthma was 19.1% (7.1% moderate-to-severe, 12.0% mild). Environmental tobacco smoke exposure and markers of atopy were associated with asthma in multivariable-adjusted analyses. Moderate-to-severe asthma was associated with increased OSA symptoms measured by PSQ-SRBD (adjusted effect estimate for moderate-to-severe vs. no asthma ( β ^ adj; 95%CI): 0.08; 0.01, 0.15)) and decreased quality of life measured by OSA-18 ( β ^ adj; 95%CI: 7.5; 1.20, 13.82)), and a small increase in the arousal index ( β ^ adj; 95%CI: 0.80; 0.09, 1.51)).

Moderate-to-severe asthma was associated with worse QoL and greater SDB symptoms among children with mSDB. The co-occurrence of common risk factors for mSDB and asthma and worse symptoms and quality of life in children with both conditions support coordinated strategies for prevention and co-management of both disorders.

Pediatric Adenotonsillectomy for Snoring (PATS), NCT02562040, https://clinicaltrials.gov/study/NCT02562040.

Pediatric obstructive sleep apnea (OSA) is common; however, inclusion of adolescents and especially those of ethnic/racial minorities in research is scarce. We hypothesized that ethnic/racial minority adolescents undergoing polysomnography have higher prevalence and more severe OSA compared to those who are non-Hispanic (NH) White.

Retrospective review of 1,745 adolescents undergoing diagnostic polysomnography. Demographic characteristics, age, body mass index percentile, and polysomnography parameters were obtained. Descriptive statistics comparing race/ethnicity were analyzed. Linear regression of log-transformed obstructive apnea-hypopnea index, and logistic regression of moderate-severe OSA (obstructive apnea-hypopnea index ≥ 5 events/h) adjusting for covariates were analyzed.

A total of 58.2% adolescents were Hispanic, 24.1% NH-White, 4.3% NH-Asian/Pacific Islander, 4.2% NH-Black/African American, and 6.6% NH-other. Compared to the NH-White group, the Hispanic group had higher obstructive apnea-hypopnea index and any level of OSA severity, the Black/African American group had higher any level of OSA, and the NH-Asian group had higher moderate-severe OSA. Multiple linear regression of log-obstructive apnea-hypopnea index identified a positive association with Hispanic ethnicity (β: 0.25, P value < .05). Compared to the NH-White group, the Hispanic and the Asian/Pacific Islander groups were 1.45 (95% confidence interval: 1.10, 1.93) and 1.81 (95% confidence interval: 1.05, 3.10) times more likely to have moderate-severe OSA, respectively, after adjusting for relevant covariates. Stratified analysis by sex identified an association only among males between Hispanic ethnicity (odds ratio: 1.85, 95% confidence interval: 1.27, 2.70) and Asian/Pacific Islander ethnicity (odds ratio: 2.62, 95% confidence interval: 1.35, 5.11) and moderate-severe OSA, compared to the NH-White group.

Among adolescents undergoing polysomnography evaluation, we identified OSA racial/ethnic and sex disparities in Hispanic and NH-Asian adolescents. Community level studies with adequate representation of these minority groups are needed to identify factors associated with the reported increased susceptibility.

Landeo-Gutierrez J, Ryu J, Tantisira K, Bhattacharjee R. Ethnic/racial and sex disparities in obstructive sleep apnea among adolescents in southern California. J Clin Sleep Med. 2024;20(10):1637-1645.

The treatment of children with Obstructive Sleep Apnea Syndrome (OSAS) remains a point of debate among otorhinolaryngologists worldwide. This study aims to comparatively assess the clinical outcomes of adenotonsillectomy (ATE) and watchful waiting in children with OSAS. We searched the databases of PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL), until the 1st of October 2023. Comparative trials assessing the efficacy of adenotonsillectomy and watchful waiting in children with OSAS were considered. The primary outcome measure was the apnea-hypopnea index (AHI), and secondary outcomes included quality of life as measured by OSA-18 score, and mean SpO2 levels. A subgroup analysis evaluating the changes in AHI depending on the severity of the initial disease was also executed. We conducted a random-effects pairwise meta-analysis of change scores to include randomized and non-randomized controlled trials. The quality assessment was carried out by using the Cochrane risk of bias tool for randomized and the ROBINS-I tool for non-randomized trials, respectively. Two randomized and five non-randomized trials were included. There was a statistically significant difference regarding AHI in favor of the ATE group compared to the watchful waiting group (Standardized mean difference [SMD] was - 0.60, 95%CI -0.79 to -0.41, p < 0.001). Likewise, a statistically significant decrease in change scores for OSA-18 between ATE and watchful waiting was noted (SMD was - 0.79, 95%CI -0.97 to -0.61, p < 0.001). On the other hand, there was no significant difference when ATE and watchful waiting groups were compared for SpO2 levels between each other (SMD was 0.52, 95%CI -1.53 to 2.56, p < 0.62). In the subgroup analysis assessing mild OSAS, there was a significant difference in favor of ATE compared to watchful waiting (SMD was -0.91, 95%CI -1.35 to -0.47, p < 0.0001). For mild to moderate OSAS, similar results were noted favoring ATE as well (SMD was - 0.53, 95%CI -0.87 to -0.19, p < 0.003). This study provides evidence of moderate strength supporting the superiority of ATE over the watchful waiting approach in terms of AHI and OSA-18. This also appears to be the case for AHI in children with mild and mild to moderate OSAS.

The online version contains supplementary material available at 10.1007/s12070-024-04738-0.

Sleep Disordered Breathing (SDB) is both prevalent and under-recognized in pediatric minority populations. Recognition of SDB is often triggered by symptoms of caregiver-reported snoring. However, the validity and utility of caregiver reports likely vary across populations. Our objective is to assess the association between caregiver-reported snoring and objectively recorded snoring in a low-income urban community and explore factors associated with agreement between objective and subjective snoring.

169 6 to 12 year old participants underwent at-home sleep studies with a WatchPAT device as part of the Environmental Assessment of Sleep in Youth (EASY) cohort study. Differences in subjective snoring, objective snoring, and concordance between subjective and objective snoring based on socioeconomic and clinical characteristics were assessed.

The sample had a high proportion of non-white (78.9 %) and low income (39.6 %) children. Caregivers reported snoring for 20.7 % of the children and snoring was measured objectively for 21.9 %. Of those with objective snoring, only 29.7 % were identified as snorers by caregiver report (sensitivity: 0.30; specificity: 0.82). Primary Spanish language and co-sleeping were associated with increased caregiver reported snoring, and allergy was associated with increased objective snoring. Older child age and normal range BMI percentile were associated with higher concordance between caregiver and objective snoring.

Among a community-based, predominantly minority sample, caregiver-reported snoring resulted in under-estimation of prevalence of objectively assessed snoring. Reliance on caregiver report may poorly identify children with snoring or SDB in clinical practice.

Rationale: Neighborhood disadvantage (ND) has been associated with sleep-disordered breathing (SDB) in children. However, the association between ND and SDB symptom burden and quality of life (QOL) has not yet been studied.Objectives: To evaluate associations between ND with SDB symptom burden and QOL.Methods: Cross-sectional analyses were performed on 453 children, ages 3-12.9 years, with mild SDB (habitual snoring and apnea-hypopnea index < 3/h) enrolled in the PATS (Pediatric Adenotonsillectomy Trial for Snoring) multicenter study. The primary exposure, neighborhood disadvantage, was characterized by the Child Opportunity Index (COI) (range, 0-100), in which lower values (specifically COI ⩽ 40) signify less advantageous neighborhoods. The primary outcomes were QOL assessed by the obstructive sleep apnea (OSA)-18 questionnaire (range, 18-126) and SDB symptom burden assessed by the Pediatric Sleep Questionnaire-Sleep-related Breathing Disorder (PSQ-SRBD) scale (range, 0-1). The primary model was adjusted for age, sex, race, ethnicity, maternal education, recruitment site, and season. In addition, we explored the role of body mass index (BMI) percentile, environmental tobacco smoke (ETS), and asthma in these associations.Results: The sample included 453 children (16% Hispanic, 26% Black or African American, 52% White, and 6% other). COI mean (standard deviation [SD]) was 50.3 (29.4), and 37% (n = 169) of participants lived in disadvantaged neighborhoods. Poor SDB-related QOL (OSA-18 ⩾ 60) and high symptom burden (PSQ-SRBD ⩾ 0.33) were found in 30% (n = 134) and 75% (n = 341) of participants, respectively. In adjusted models, a COI increase by 1 SD (i.e., more advantageous neighborhood) was associated with an improvement in OSA-18 score by 2.5 points (95% confidence interval [CI], -4.34 to -0.62) and in PSQ-SRBD score by 0.03 points (95% CI, -0.05 to -0.01). These associations remained significant after adjusting for BMI percentile, ETS, or asthma; however, associations between COI and SDB-related QOL attenuated by 23% and 10% after adjusting for ETS or asthma, respectively.Conclusions: Neighborhood disadvantage was associated with poorer SDB-related QOL and greater SDB symptoms. Associations were partially attenuated after considering the effects of ETS or asthma. The findings support efforts to reduce ETS and neighborhood-level asthma-related risk factors and identify other neighborhood-level factors that contribute to SDB symptom burden as strategies to address sleep-health disparities.Clinical trial registered with www.clinicaltrials.gov (NCT02562040).

Exposure to secondhand smoke has been associated with numerous health problems in children, including obstructive sleep apnea. Secondhand smoke exposure may be a risk factor for increased pediatric sleep apnea severity.

To assess the association of secondhand smoke exposure (SHSe), quantified by urinary cotinine levels, with severity of obstructive sleep apnea (OSA) in children.

This was a prospective cohort trial including pediatric patients from 3 to 16 years of age with sleep-disordered breathing who underwent a polysomnogram at a tertiary-level children's hospital in the US in either March 2014 to October 2016 or March 2020 to March 2021. Urine specimens were analyzed for cotinine, an important metabolite of nicotine. Each child's caregiver completed a validated SHSe questionnaire. Data were analyzed from February to June 2023.

OSA and secondhand smoke.

SHSe and severity of pediatric OSA, quantified by urinary cotinine levels and obstructive apnea hypopnea index (AHI) scores. Secondary outcomes were association of urinary cotinine levels with nadir oxygen saturation, sleep-related quality of life measured by the OSA-18 questionnaire, and caregiver-reported smoking habits (collected through a questionnaire).

The study included 116 patients with a median (IQR) age of 6 (5-9) years, among whom 51 (45%) had obesity. The median (IQR) AHI was 3.0 (1.2-8.0), with 28 children (30.0%) having severe disease (AHI >10). Thirty-four children (29.0%) were found to have a positive result for urine cotinine screening, with a mean (SD) level of 11.7 (9.4) ng/mL. The percentage of children with SHSe was less than anticipated. There was no association identified between urinary cotinine levels and either AHI (ρ = -0.04; 95% CI, -0.22 to 0.15) or nadir oxygen saturation (ρ = -0.07; 95% CI, -0.26 to 0.11). Furthermore, SHSe was not associated with the presence of severe OSA (odds ratio, 0.70; 95% CI, 0.26 to 1.90). Children whose caregivers reported indoor SHSe were more likely to have a detectable urinary cotinine level (odds ratio, 20.3; 95% CI, 6.67 to 61.8).

This cohort study did not identify any clinically meaningful association between SHSe, quantified by urinary cotinine level, and pediatric OSA severity. Future research with a larger number of children with SHSe is needed to confirm these findings and determine whether SHSe affects OSA treatment outcomes in children.

Pediatric obstructive sleep related breathing disorders (SRBD) are an important under-diagnosed health problem with associated cardiometabolic comorbidities, demonstrated with polysomnographic studies in selected samples. Our main goal was to assess the prevalence of SRBD in a population-based cohort and to analyze its association with cardiometabolic risk factors, in general and by sex.

Pediatric Sleep Questionnaire (PSQ) was applied to parents of 7-years-old children evaluated in the birth cohort, Generation XXI. Sex, anthropometrics, blood pressure (BP), lipid profile, glucose, insulin, HOMA-IR, and high-sensitivity C-reactive protein were compared among children with/without SRBD, using Chi-square, Mann-Whitney tests and logistic regression models.

A total of 1931 children (51.2 % boys) were included; 17.5 % were overweight and 15.7 % obese. The prevalence of SRBD was 13.4 %, more frequent among boys (15.7 % vs.10.9 %, p = 0.002) and in overweight/obese children (22.0 % vs.13.6 % vs.11.3 % in obese, overweight and normal weight group, respectively, p < 0.001). Children with SRBD had higher systolic BP (107 ± 8 vs.105±9 mmHg; p = 0.001) and lower HDL-cholesterol levels (54 ± 11 vs.56 ± 11 mg/dL; p = 0.04) than children without SRBD. After adjustment for sex, age, birthweight-for-gestational age and maternal age, children with SRBD had higher BMI-z-score, systolic BP, insulin and HOMA-IR levels, and lower HDL-cholesterol, when compared to those without SRBD, but these associations were lost when adjusting to BMI z-score. Analyzing obese children with the same regression model, those with SRBD presented lower HDL-cholesterol than those without SRBD.

Our results identified a male predominance of SRBD in pre-pubertal children and highlighted the potential contribution of SRBD to cardiovascular risk in obese children.

Profiles of sleep duration and timing and corresponding electroencephalographic activity reflect brain changes that support cognitive and behavioral maturation and may provide practical markers for tracking typical and atypical neurodevelopment. To build and evaluate a sleep-based, quantitative metric of brain maturation, we used whole-night polysomnography data, initially from two large National Sleep Research Resource samples, spanning childhood and adolescence (total N = 4,013, aged 2.5 to 17.5 years): the Childhood Adenotonsillectomy Trial (CHAT), a research study of children with snoring without neurodevelopmental delay, and Nationwide Children's Hospital (NCH) Sleep Databank, a pediatric sleep clinic cohort. Among children without neurodevelopmental disorders (NDD), sleep metrics derived from the electroencephalogram (EEG) displayed robust age-related changes consistently across datasets. During non-rapid eye movement (NREM) sleep, spindles and slow oscillations further exhibited characteristic developmental patterns, with respect to their rate of occurrence, temporal coupling and morphology. Based on these metrics in NCH, we constructed a model to predict an individual's chronological age. The model performed with high accuracy (r = 0.93 in the held-out NCH sample and r = 0.85 in a second independent replication sample - the Pediatric Adenotonsillectomy Trial for Snoring (PATS)). EEG-based age predictions reflected clinically meaningful neurodevelopmental differences; for example, children with NDD showed greater variability in predicted age, and children with Down syndrome or intellectual disability had significantly younger brain age predictions (respectively, 2.1 and 0.8 years less than their chronological age) compared to age-matched non-NDD children. Overall, our results indicate that sleep architectureoffers a sensitive window for characterizing brain maturation, suggesting the potential for scalable, objective sleep-based biomarkers to measure neurodevelopment.

Pediatric sleep-disordered breathing (SDB) disproportionately affects children with low socioeconomic status (SES). The multilevel risk factors that drive these associations are not well understood.

What are the associations between SDB risk factors, including individual health conditions (obesity, asthma, and allergies), household SES (maternal education), indoor exposures (environmental tobacco smoke [ETS] and pests), and neighborhood characteristics (neighborhood disadvantage), and pediatric SDB symptoms?

Cross-sectional analyses were performed on 303 children (aged 6-12 years) enrolled in the Environmental Assessment of Sleep Youth study from 2018 to 2022. Exposures were determined by caregiver reports, assays of measured settled dust from the child's bedroom, and neighborhood-level Census data (deriving the Childhood Opportunity Index to characterize neighborhood disadvantage). The primary outcome was the SDB-related symptom burden assessed by the OSA-18 questionnaire total score. Using linear regression models, we calculated associations between exposures and SDB-related symptom burden, adjusting for sociodemographic factors, then health conditions, indoor environment, and neighborhood factors.

The sample included 303 children (39% Hispanic, Latino, Latina, or Spanish origin; 30% Black or African American; 22% White; and 11% other). Increasing OSA-18 total scores were associated with low household SES after adjustment for demographic factors, and with asthma, allergies, ETS, pests (mouse, cockroach, and rodents), and an indoor environmental index (sum of the presence of pests and ETS; 0-2) after adjusting for sociodemographic factors. Even after further adjusting for asthma, allergies, and neighborhood disadvantage, ETS and pest exposure were associated with OSA-18 (ETS: β = 12.80; 95% CI, 7.07-18.53, also adjusted for pest; pest exposure: β = 3.69; 95% CI, 0.44-6.94, also adjusted for ETS).

In addition to associations with ETS, a novel association was observed for indoor pest exposure and SDB symptom burden. Strategies to reduce household exposure to ETS and indoor allergens should be tested as approaches for reducing sleep health disparities.

The goal of this study was to evaluate the association between a polygenic risk score (PRS) for QT prolongation (QTc-PRS), QTc intervals and mortality in patients enrolled in the UK Biobank with and without sleep apnea.

The QTc-PRS was calculated using allele copy number and previously reported effect estimates for each single nuclear polymorphism SNP. Competing-risk regression models adjusting for age, sex, BMI, QT prolonging medication, race, and comorbid cardiovascular conditions were used for sudden cardiac death (SCD) analyses.

500,584 participants were evaluated (56.5 ±8 years, 54% women, 1.4% diagnosed with sleep apnea). A higher QTc-PRS was independently associated with the increased QTc interval duration (p<0.0001). The mean QTc for the top QTc-PRS quintile was 15 msec longer than the bottom quintile (p<0.001). Sleep apnea was found to be an effect modifier in the relationship between QTc-PRS and SCD. The adjusted HR per 5-unit change in QTc-PRS for SCD was 1.64 (95% CI 1.16 - 2.31, p=0.005) among those with sleep apnea and 1.04 (95% CI 0.95 - 1.14, p=0.44) among those without sleep apnea (p for interaction =0.01). Black participants with sleep apnea had significantly elevated adjusted risk of SCD compared to White participants (HR=9.6, 95% CI 1.24 - 74, p=0.03).

In the UK Biobank population, the QTc-PRS was associated with SCD among participants with sleep apnea but not among those without sleep apnea, indicating that sleep apnea is a significant modifier of the genetic risk. Black participants with sleep apnea had a particularly high risk of SCD.

Black children have a higher risk of residual obstructive sleep apnea after adenotonsillectomy than non-Black children. We analyzed Childhood Adenotonsillectomy Trial data to better understand this disparity. We hypothesized that (1) child-level factors, such as asthma, smoke exposure, obesity, sleep duration, and (2) socioeconomic factors, such as maternal education, maternal health, and neighborhood disadvantage, may confound, modify, or mediate the association between Black race and residual obstructive sleep apnea after adenotonsillectomy.

Secondary analysis of a randomized controlled trial.

Seven tertiary care centers.

We included two hundred and twenty-four 5-to-9-year-olds with mild-to-moderate obstructive sleep apnea who underwent adenotonsillectomy. The outcome was residual obstructive sleep apnea 6 months after surgery. Data were analyzed with logistic regression and mediation analysis.

Of 224 included children, 54% were Black. Compared with non-Black children, Black children had 2.7 times greater odds of residual sleep apnea (95% confidence interval [CI]: 1.2, 6.1; p = .01), adjusted for age, sex, and baseline Apnea Hypopnea Index. There was significant effect modification by obesity. Among obese children, there was no association between Black race and outcome. However, nonobese Black children were 4.9 times as likely to have residual sleep apnea than non-Black children (95% CI: 1.2, 20.0; p < 0.01). There was no significant mediation by any of the child-level or socioeconomic factors tested.

There was substantial effect modification by obesity on the association between Black race and residual sleep apnea after adenotonsillectomy for mild-to-moderate sleep apnea. Black race was associated with poorer outcome among nonobese but not obese children.

We examined (1) disparities in obstructive sleep apnea (OSA) care by insurance coverage, and by child race and ethnicity among Medicaid-insured children (MIC), and (2) healthcare utilization changes after OSA care.

IBM MarketScan insurance claims were used to index OSA care 1-year before and after initial OSA diagnosis in 2017 among 2-17-year-old children (n = 31,787, MIC: 59%). OSA care and healthcare utilization analyses adjusted for child age, sex, obesity, and complex chronic conditions.

We identified 8 OSA care pathways, including no care, which occurred in 34.4% of the overall sample. MIC had 13% higher odds of no OSA care compared to commercially-insured children (CIC). MIC had 32-48% lower odds of any treatment pathway involving specialty care, but a 13-46% higher likelihood of receiving surgical care without polysomnogram (PSG) and PSG only. In MIC, non-Latinx Black/African American (Black) and Hispanic/Latinx children were 1.3-2.2 times more likely than White children to receive treatment involving specialty care and/or PSG, while Black children were 31% less likely than White youth to undergo surgery. In the full sample, surgical care was associated with less outpatient and emergency healthcare utilization compared to those untreated or not surgically treated.

Varied OSA management by insurance coverage suggests disparities in access to and engagement in care and potentially greater disease burden among MIC. Surgical care is associated with reduced healthcare utilization. The lower odds of surgery in Black MIC should be further evaluated in the context of OSA severity, healthcare biases, and family preferences.

Children with snoring and mild sleep-disordered breathing may be at increased risk for neurocognitive deficits despite few obstructive events. We hypothesized that actigraphy-based sleep duration and continuity associate with neurobehavioral functioning and explored whether these associations vary by demographic and socioeconomic factors.

298 children enrolled in the Pediatric Adenotonsillectomy Trial, ages 3 to 12.9 years, 47.3% from racial or ethnic minority groups, with habitual snoring and an apnea-hypopnea index < 3 were studied with actigraphy (mean 7.5 ± 1.4 days) and completed a computerized vigilance task (Go-No-Go) and a test of fine motor control (9-Hole Pegboard). Caregivers completed the Behavior Rating Inventory of Executive Function. Regression analyses evaluated associations between sleep exposures (24-hour and nocturnal sleep duration, sleep fragmentation index, sleep efficiency) with the Behavior Rating Inventory of Executive Function Global Executive Composite index, pegboard completion time (fine motor control), and vigilance (d prime on the Go-No-Go), adjusting for demographic factors and study design measures.

Longer sleep duration, higher sleep efficiency, and lower sleep fragmentation were associated with better executive function; each additional hour of sleep over 24 hours associated with more than a 3-point improvement in executive function (P = .002). Longer nocturnal sleep (P = .02) and less sleep fragmentation (P = .001) were associated with better fine motor control. Stronger associations were observed for boys and children less than 6 years old.

Sleep quantity and continuity are associated with neurocognitive functioning in children with mild sleep-disordered breathing, supporting efforts to target these sleep health parameters as part of interventions for reducing neurobehavioral morbidity.

Registry: ClinicalTrials.gov; Name: Pediatric Adenotonsillectomy for Snoring (PATS); URL: https://clinicaltrials.gov/ct2/show/NCT02562040; Identifier: NCT02562040.

Robinson KA, Wei Z, Radcliffe J, et al. Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing. J Clin Sleep Med. 2023;19(9):1595-1603.

Sleep-disordered breathing (SDB) refers to a spectrum of disorders ranging from habitual snoring without frank episodes of obstructed breathing or desaturation during sleep to obstructive sleep apnea, where apneas and hypopneas repetitively occur with resultant intermittent hypoxia, arousal, and sleep disruption. Disparities in SDB reflect its overall high prevalence in children and adults from racially and ethnically minoritized or low socioeconomic status backgrounds coupled with high rates of underdiagnosis and suboptimal treatment.

To examine the relationship between neighborhood-level advantage and severe obstructive sleep apnea (OSA) in children.

A retrospective case-control study was conducted on 249 children who underwent adenotonsillectomy and had full-night polysomnography conducted within 6 months prior. Patients were divided into more or less socioeconomically disadvantaged groups using a validated measure, the area deprivation index (ADI). The primary outcomes were the relationship between the apnea-hypopnea index (AHI) and the presence of severe OSA, and the secondary outcome was residual moderate or greater OSA after tonsillectomy.

Of the 249 children included in the study, 175 (70.3%) were socially disadvantaged (ADI > 50). The median (interquartile range [IQR]) age was 9.4 (7.3-12.3) years, 129 (51.8%) were male, and the majority were White (151, 60.9%), Black (51, 20.6%), and/or of Hispanic (155, 62.5%) ethnicity. A total of 140 (56.2%) children were obese. The median (IQR) AHI was 8.9 (3.9-20.2). There was no significant difference in the median AHI or the presence of severe OSA between the more and less disadvantaged groups. Severe OSA was found to be associated with obesity (odds ratio [OR] = 3.13, 95% confidence interval [CI] = 1.83-5.34), and residual moderate or greater OSA was associated with older age (OR = 1.20, 95% CI = 1.05-1.38).

The ADI was not significantly associated with severe OSA or residual OSA in this cohort of children. Although more neighborhood-level disadvantage may increase the risk of comorbidities associated with OSA, it was not an independent risk factor in this study.

Level 4.

This article reviews disparities in pediatric sleep health and sleep disorders from early childhood through adolescence (birth to age 18 years). Sleep health is a multidimensional construct including sleep duration, consolidation, and other domains, whereas sleep disorders reflect both behaviorally (eg, insomnia) and medically based (eg, sleep disordered breathing) sleep diagnoses. Using a socioecological framework, we review multilevel (ie, child, family, school, health-care system, neighborhood, and sociocultural) factors linked to sleep health disparities. Mechanistic research and studies using an intersectional lens to understand overlapping marginalized identities are needed to inform multilevel interventions to promote sleep health equity in pediatrics.

To synthesize the existing literature regarding the complex interplay between sleep disturbance, obesity, and diabetes. The review emphasizes the three pillars of health being diet, exercise, and sleep, with the notion that if one is ignored, then the other two could suffer.

Sleep deprivation is associated with incident obesity, perhaps mediated by dysregulation in leptin and ghrelin - hormones important in regulation of appetite. Sleep apnea is very common particularly among obese people with type 2 diabetes mellitus. Treatment of sleep apnea has clear symptomatic benefits although its impact on long-term cardiometabolic health is less clear. Sleep disturbance may be an important modifiable risk for patients at risk of cardiometabolic disease. An assessment of sleep health may be an important component of the comprehensive care of patients with obesity and diabetes mellitus.

The association between obstructive sleep apnea (OSA) and lifestyle habits in children with obesity is largely unknown. This study aimed to determine whether there was an association between lifestyle patterns (sleep quality, physical activity, recreational screen time, and substance use) and OSA presence and severity in children with obesity.

This cross-sectional study recruited children with obesity, aged 8-17 years, who were referred to undergo polysomnography. Children completed questionnaires on sleep quality, physical activity, recreational screen time, and substance use. Children also had a diagnostic polysomnography. The association between questionnaire scores and OSA severity, after adjusting for body mass index z-score, age, and sex, was evaluated using negative binomial multiple regression. Correlations were conducted between sleep quality, physical activity, screen time, substance use, and OSA severity.

A total of 100 children were included in the analysis (mean age: 14.3 ± 2.6 years; 44% female; mean body mass index z-score: 2.5 ± 0.4; 65% with OSA). In the adjusted regression analysis, each additional substance-use behavior was associated with a 17% (95% confidence interval: 1%, 36%) increase in OSA severity. Correlations were identified between poorer sleep quality and lower physical activity (r = -.42), poorer sleep quality and more substance-use behaviors (r = .40), and greater physical activity and less substance-use behaviors (r = -.26).

In children with obesity, more substance-use behaviors were independently associated with greater OSA severity. As there are complex, bidirectional relationships between lifestyle behaviors and OSA severity, interventions need to be comprehensive and multifactorial to ensure successful treatment of OSA and its sequelae in children.

Blinder H, Narang I, Chaput J-P, Katz SL; on behalf of the Canadian Sleep and Circadian Network. Sleep quality, physical activity, screen time, and substance use in children with obesity: associations with obstructive sleep apnea. J Clin Sleep Med. 2023;19(3):511-518.

Sleep-disordered breathing reflects a continuum of overnight breathing difficulties, ranging from mild snoring to obstructive sleep apnea syndrome. Sleep-disordered breathing in childhood is associated with significant adverse outcomes in multiple domains of functioning. This review summarizes the evidence of well-described ethnic, racial, and socioeconomic disparities in pediatric sleep-disordered breathing, from its prevalence to its treatment-related outcomes. Research on potential socio-ecological contributors to these disparities is also reviewed. Critical future research directions include the development of interventions that address the modifiable social and environmental determinants of these health disparities.

Unresolved obstructive sleep apnoea (OSA) after an adenotonsillectomy, henceforth referred to as persistent OSA, is increasingly recognised in children (2-18 years). Although associated with obesity, underlying medical complexity, and craniofacial disorders, persistent OSA also occurs in otherwise healthy children. Inadequate treatment of persistent OSA can lead to long-term adverse health outcomes beyond childhood. Positive airway pressure, used as a one-size-fits-all primary management strategy for persistent childhood OSA, is highly efficacious but has unacceptably low adherence rates. A pressing need exists for a broader, more effective management approach for persistent OSA in children. In this Personal View, we discuss the use and the need for evaluation of current and novel therapeutics, the role of shared decision-making models that consider patient preferences, and the importance of considering the social determinants of health in research and clinical practice. A multipronged, comprehensive approach to persistent OSA might achieve better clinical outcomes in childhood and promote health equity for all children.

This study examined differences in sleep patterns by race, ethnicity, and socioeconomic status (SES) among children with Obstructive Sleep Apnea Syndrome (OSAS), and linkages between sleep patterns and neurobehavioral functioning.

We used baseline data from the Childhood Adenotonsillectomy Study (CHAT), a multicenter, single-blind, randomized controlled trial designed to evaluate the efficacy of early adenotonsillectomy versus watchful waiting with supportive care for children with OSAS. Participants included children with OSAS (ages 5.0-9.9 years). SES indicators were obtained via questionnaire and geocoding (ArcGIS version 10.1). Caregivers and teachers reported on child inattention/impulsivity and executive functioning. Nighttime sleep duration and variability were measured using five-night sleep diaries.

Black children experienced shorter nighttime sleep duration than White children, by about 25 min, as well as greater sleep duration variability, while sleep duration was more variable in children of "other" racial and ethnic backgrounds versus White children. Of the socioeconomic correlates, only lower family income was associated with sleep duration variability. A short and more variable nighttime sleep duration were each associated with caregiver-rated child inattention and impulsivity. Greater sleep duration variability was linked to greater teacher-rated, but not caregiver-rated, executive functioning impairments.

Compared to White children with OSAS, Black children with OSAS experience a shorter and more variable nighttime sleep duration. Having a short and/or variable sleep duration may increase risk for neurobehavioral impairments in youth with OSAS, underscoring the potential benefits of sleep health promotion in the context of OSAS care.

1) To determine the prevalence polysomnogram (PSG) and continuous positive airway pressure (CPAP) therapy use in children who received adenotonsillectomy (AT) for sleep symptoms. 2) To identify health care disparities in these regards.

Retrospective database analysis.

This study used data from Optum (Health Services Innovation Company) to identify 92,490 children who received AT for sleep symptoms between 2004 and 2018. Prevalence of preoperative PSG and postoperative PSG and CPAP were described. Clinical and demographic characteristics were compared between children who had preoperative PSG and those who did not. Characteristics of children with trisomy 21 (T21) were compared to assess PSG and CPAP use in a high-risk cohort. Predictive modeling was used to identify patient characteristics associated with postoperative PSG and CPAP use.

Preoperative PSG was obtained in 5.5% of children overall and 33.2% of children with T21. Male sex, obesity, other medical comorbidities, non-White race/ethnicity, and higher parent education were associated with preoperative PSG. Fewer than 3% of children received postoperative PSGs and approximately 3% went on to receive CPAP therapy postoperatively. Multiple logistic regression showed that age at surgery, male sex, obesity, other medical comorbidities, non-White race/ethnicity, and higher parent education were associated with postoperative PSG and CPAP use.

This study described the prevalence pre-AT PSG use and post-AT PSG and CPAP use for persistent symptoms and identified sleep health care disparities in these regards. These results show that increased, equitable access to PSG is needed in children, particularly in the workup and treatment persistent symptoms after AT.

4 Laryngoscope, 133:184-188, 2023.

Obstructive sleep apnea syndrome (OSAS) treatment has been shown to improve cardiac behavioral and cognitive functions in typically developing children. Early OSAS diagnosis in children with Down syndrome (DS) would be important to prevent its complications, especially cognitive ones, but remains overlooked. The main objective of our study was to assess the cognitive function of children with DS, with and without OSAS. The second objective was to determine the impact of the therapeutic intervention on the cognitive function of children with OSAS. This study included 41 children with DS who underwent polysomnography for OSAS diagnosis and a cognitive evaluation. They were aged between 3.4 and 17.3 years and 24 (59%) were boys. Their median OAHI was 2.6 (0-31)/h of sleep, 30 (73%) were diagnosed with OSAS (15 had mild OSAS, and 15 had moderate/severe OSAS). Some scores of the Raven's colored progressive matrices were negatively correlated with the respiratory arousal index, OAHI tended to be positively correlated with Reiss behavioral problems. 24 (59%) patients received a treatment. Even if we were unable to demonstrate this formally due that only 16 children (39%) accepted a follow-up visit, some displayed improvement in their neuropsychological scores, especially those with moderate/severe OSAS after treatment. Children with DS have low intellectual abilities and more risk of developing OSAS compared to the general population, which may lead to further neurocognitive impairment. Early screening and management are important in this population to prevent any further neurocognitive delay in their development.

Children with apnea-predominant obstructive sleep apnea (OSA) are hypothesized to have a more severe form of the disease. However, research is lacking as to whether there is a significant difference in outcomes between children with apnea-predominant vs hypopnea-predominant OSA.

To assess the association between baseline apnea-predominant or hypopnea-predominant OSA on polysomnography and quality of life (QOL) outcomes in children with obstructive sleep apnea managed by watchful waiting with supportive care (WWSC) or adenotonsillectomy (AT).

This case-control study is a secondary analysis of a randomized clinical trial, the Childhood Adenotonsillectomy Trial, which was conducted at multiple tertiary children's hospitals from October 2007 to June 2012. Children aged 5.0 to 9.9 years with OSA were randomized to WWSC or AT and underwent polysomnography and completed validated QOL and symptom assessments at baseline and 7 months. The current data analysis was performed from October 2020 to February 2022.

Apnea-predominant OSA was defined as an apnea hypopnea index (AHI) greater than 2 with more than 50% of the obstructive events being apneas. Patients were considered to have hypopnea-predominant OSA if they had an AHI greater than 2 and more than 50% of the obstructive events were hypopneas.

A total of 386 children (185 boys [48%]; mean [SD] age, 6.56 [1.4] years) were analyzed. The mean (SD) obstructive AHI for patients was 6.98 (5.62), with 198 patients (51%) having mild disease. Thirty-seven children (10%) had apnea-predominant OSA at baseline. Black children were at increased risk for apnea-predominant OSA vs White children (odds ratio [OR], 13.40; 95% CI, 5.70-33.90). Children with apnea predominance were more likely to have severe OSA (AHI >10) compared with children with hypopnea predominance (OR, 2.30; 95% CI, 1.03-5.03); baseline Pediatric Sleep Questionnaire and OSA-18 QOL scores were similar between the 2 groups. Among children undergoing AT, those with baseline apnea predominance were more likely to have a Pediatric Sleep Questionnaire score greater than 0.33 at follow-up (OR, 3.30; 95% CI, 1.01-10.80). Rates of OSA resolution and improvements in QOL scores following AT or WWSC were similar between the apnea-predominant and hypopnea-predominant groups.

In children with OSA, apnea-predominant disease is uncommon. Apnea predominance was not associated with symptom resolution and cure rates in children undergoing AT or WWSC for OSA. Further research is needed to assess how apnea predominance affects AT outcomes in children with more severe disease.

To review, critically analyze and synthesize knowledge from the international literature regarding the association between allergic rhinitis (AR) and sleep disorders, the impact of AR treatment on children's sleep, and lay the foundation for future research on this topic.

A literature search using PubMed database including original and review articles, systematic reviews and meta-analyses using keywords related to AR, sleep disorders and sleep-disordered breathing.

Sleep is fundamental to health, and its assessment and control of conditions that trigger or aggravate disturbances are of the uttermost importance. Allergic rhinitis (AR) is common in children and may interfere with both their quality of life and quality of sleep. It has emerged as one of the most important risk factors for habitual snoring in children and appeared to increase the risk of Obstructive Sleep Apnea (OSA), with AR severity exhibiting a significant and independent association with pediatric OSA severity. However, in some studies, those associations between AR and OSA in children are not very consistent.

A substantial level of controversy exists regarding the interactions between AR and OSA in children. Notwithstanding, identifying and treating AR in clinical settings is probably an important step toward improving symptoms and preventing deterioration of sleep quality in children and may improve the severity of underlying OSA. Considering the high prevalence, morbidity, economic and social implications of both AR and sleep problems, it is crucial that healthcare providers improve their understanding of the relationships between those conditions among children.

The present study was developed to explore risk factors related to the incidence and severity of obstructive sleep apnea syndrome (OSAS) in children.

The present study enrolled pediatric patients who admitted to our department for snoring and/or open-mouth breathing. All children completed a questionnaire and underwent physical examination and polysomnography (PSG). The cases were separated into OSAS and primary snoring (PS) groups. Factors associated with these two groups were analyzed, with risk factors significantly associated with OSAS then being identified through logistic regression analyses. OSAS was further subdivided into mild, moderate, and severe subgroups, with correlations between risk factors and OSAS severity then being analyzed.

In total, 1,550 children were included in the present study, of which 852 and 698 were enrolled in the OSAS and PS groups. In univariate analyses, obesity, family passive smoking, a family history of snoring, allergic rhinitis, asthma, adenoid hypertrophy, and tonsil hypertrophy were all related to pediatric OSAS (P < 0.05). In a multivariate logistic regression analysis, adenoid hypertrophy (OR:1.835, 95% CI: 1.482-2.271) and tonsil hypertrophy (OR:1.283, 95% CI:1.014-1.622) were independently associated with the risk of pediatric OSAS (P < 0.05). Stratification analyses revealed that OSAS incidence increased in a stepwise manner with increases in adenoid and tonsil grading (P < 0.01). Correlation analyses revealed that adenoid hypertrophy and tonsilar hypertrophy were not significantly associated with OSAS severity (r = 0.253, 0.069, respectively, P < 0.05), and tonsil and adenoid size were no correlation with obstructive apnea-hypopnea index (OAHI) (r = 0.237,0.193, respectively, P < 0.001).

Obesity, family passive smoking, a family history of snoring, allergic rhinitis, asthma, tonsil hypertrophy, and adenoid hypertrophy may be potential risk factors for pediatric OSAS. Adenoid hypertrophy and tonsil hypertrophy were independently related to the risk of pediatric OSAS, with OSAS incidence increasing with the size of the adenoid and tonsil, while the severity of OSAS is not parallel related to the adenoid or tonsil size.

Adenotonsillectomy, performed for approximately 500 000 children annually in the US alone, is the first line of treatment of pediatric obstructive sleep apnea (OSA). The Childhood Adenotonsillectomy Trial (CHAT), the first randomized clinical trial to test the efficacy of adenotonsillectomy, compared the management of pediatric nonsevere OSA by early adenotonsillectomy (eAT) vs watchful waiting with supportive care. Since the publication of the primary article in 2013, the CHAT study data set were made available via the National Sleep Research Resource, which allowed researchers to address a range of additional clinical questions relevant to the care of children with OSA. This review focuses on secondary analyses associated with the CHAT data set as grouped by the outcome of interest.

The results of most secondary analyses suggest that children who underwent eAT experienced the greatest improvements in symptom burden, sleepiness, parent-reported behavior, and quality of life. Changes in other domains, such as cognition, cardiovascular physiology, and metabolic indicators, were modest and selective. The associations between most treatment outcomes and polysomnographic parameters were weak. Symptoms were poor predictors of OSA severity. The results from these secondary analyses benefitted from the rigor of multicenter design and centralized polysomnography interpretation in CHAT. However, the exclusion of younger preschool-aged children and children with primary snoring limited the generalizability of findings. In addition, because caregivers were not masked, some of the parent-reported outcomes may have been inflated.

The results of this narrative review suggest that CHAT provides a model for future OSA-related studies in children for design, conduct, and subsequent reuse of the study data set, and its findings have advanced our understanding of the pathophysiology and management of pediatric nonsevere OSA. Directions for future research include whether the findings from this landmark study are generalizable to younger children and children with primary snoring and severe OSA. Similar studies may help address practice variability associated with pediatric OSA and help identify children who are most likely to benefit from undergoing eAT.

Association between smoking and sleep apnea is well-known from previous studies. However, the influence of secondhand smoke (SHS), which is a potential risk factor of obstructive sleep apnea (OSA), remains unclear. Our aim was to investigate the relationship between SHS and OSA using a meta-analysis.

For the meta-analysis, searches were performed in MEDLINE, EMBASE, and Web of Science databases on January 10, 2022, by combining various keywords including "SHS exposure" and "OSA". Data were extracted using defined inclusion and exclusion criteria. Fixed-effects model meta-analyses were used to pool risk ratio (RR) estimates with their 95% confidence intervals (CI). I² was used to assess heterogeneity. Moreover, we performed subgroup meta-analyses of children-adults, and smoker fathers and mothers.

In total, 267 articles were obtained through an electronic search. Twenty-six articles were included in our analysis according to the inclusion and exclusion criteria. We found evidence of an association between SHS exposure and possible OSA (RR 1.64, 95% CI 1.44-1.88). The results of the subgroup analyses showed that children passive smokers (RR 1.84, 95% CI 1.60-2.13) were at greater risks of possible OSA than adult passive smokers (RR 1.35, 95% CI 1.21-1.50). Also, significant differences were observed in mothers with smoking exposure (RR 2.61, 95% CI 1.62-4.21, p < 0.0001), as well as in fathers with smoking exposure (RR 2.15, 95% CI 0.98-4.72, p = 0.06).

Our meta-analysis confirmed that SHS exposure is significantly associated with OSA. In the subgroup analyses, the association of SHS and possible OSA was significant in both children and adults, as well as in smoker mothers and fathers.

Obstructive sleep apnea is associated with neurobehavioral dysfunction, but the relationship between disease severity as measured by the apnea-hypopnea index and neurobehavioral morbidity is unclear. The objective of our study is to compare the neurobehavioral morbidity of mild sleep-disordered breathing versus obstructive sleep apnea.

Children 3-12 years old recruited for mild sleep-disordered breathing (snoring with obstructive apnea-hypopnea index < 3) into the Pediatric Adenotonsillectomy Trial for Snoring were compared to children 5-9 years old recruited for obstructive sleep apnea (obstructive apnea-hypopnea 2-30) into the Childhood Adenotonsillectomy Trial. Baseline demographic, polysomnographic, and neurobehavioral outcomes were compared using univariable and multivariable analysis.

The sample included 453 participants with obstructive sleep apnea (median obstructive apnea-hypopnea index 5.7) and 459 participants with mild sleep-disordered breathing (median obstructive apnea-hypopnea index 0.5). By polysomnography, participants with obstructive sleep apnea had poorer sleep efficiency and more arousals. Children with mild sleep-disordered breathing had more abnormal executive function scores (adjusted odds ratio 1.96, 95% CI 1.30-2.94) compared to children with obstructive sleep apnea. There were also elevated Conners scores for inattention (adjusted odds ratio 3.16, CI 1.98-5.02) and hyperactivity (adjusted odds ratio 2.82, CI 1.83-4.34) in children recruited for mild sleep-disordered breathing.

Abnormal executive function, inattention, and hyperactivity were more common in symptomatic children recruited into a trial for mild sleep-disordered breathing compared to children recruited into a trial for obstructive sleep apnea. Young, snoring children with only minimally elevated apnea-hypopnea levels may still be at risk for deficits in executive function and attention.

Pediatric Adenotonsillectomy for Snoring (PATS), NCT02562040; Childhood Adenotonsillectomy Trial (CHAT), NCT00560859.