Persistent snoring in preschool children: predictors and behavioral and developmental correlates

Secondhand Smoke Exposure Measured in Urinary Cotinine Levels and Severity of Pediatric Sleep Apnea

Importance

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.

Objectives

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

Design, Setting, and Participants

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.

Exposure

OSA and secondhand smoke.

Main Outcome and Measures

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).

Results

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).

Conclusions and Relevance

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.

Impact of Breastfeeding Duration on Adenoid Hypertrophy, Snoring and Acute Otitis Media: A Case-Control Study in Preschool Children

BACKGROUND

The aim of this study was to analyze the relationship between breastfeeding duration and adenoid size, snoring and acute otitis media (AOM).

METHODS

We analyzed the medical history of children admitted to the ENT outpatient clinic in 2022 and 2023, reported symptoms, ear, nose and throat (ENT) examination, and flexible nasopharyngoscopy examination of 145 children aged 3-5 years.

RESULTS

Breastfeeding duration of 3 and 6 months or more had a significant effect on the reduction of snoring (p = 0.021; p = 0.039). However, it had no effect on the adenoid size, mucus coverage and sleeping with an open mouth. Snoring was correlated with open mouth sleeping (p < 0.001), adenoid size with a 75% A/C ratio or more (p < 0.001), and adenoid mucus coverage in the Mucus of Adenoid Scale by Nasopharyngoscopy Assessment-MASNA scale (p = 0.009). Children who were breastfed for less than 3 months had more than a four-fold greater risk of snoring. There was a statistically significant correlation between AOM and gender (p = 0.033), breastfeeding duration in groups fed 1, 3 or 6 months or more (p = 0.018; p = 0.004; p = 0.004) and those fed with mother's breast milk 3 or 6 months or more (p = 0.009; p = 0.010). Moreover, a correlation was found between adenoid size and mucus coverage, tympanogram, and open-mouth sleeping (p < 0.001). Independent factors of snoring in 3- to 5-year-old children were breastfeeding duration of less than 3 months (p = 0.032), adenoid size with an A/C ratio of 75% or more (p = 0.023) and open mouth sleeping (p = 0.001).

CONCLUSIONS

Children breastfed for 3 and 6 months or more exhibited reduced rates of snoring. There was no effect of breastfeeding duration on adenoid size in children aged 3 to 5 years, suggesting that the link between breastfeeding duration and snoring is primarily associated with craniofacial development and muscle tone stimulation. A breastfeeding duration of 1 month or more plays a key role in reducing the rate of AOM. The mother's milk plays a protective role against AOM. The presence of mucus might be responsible for snoring in preschool children. A medical history of breastfeeding should be taken into consideration when snoring children are suspected of adenoid hypertrophy.

Diagnosis and Treatment of Sleep Apnea in Children: A Future Perspective Is Needed

Obstructive sleep apnea (OSA) in children is a prevalent, but still, today, underdiagnosed illness, which consists of repetitive episodes of upper airway obstruction during sleep with important repercussions for sleep quality. OSA has relevant consequences in the pediatric population, mainly in the metabolic, cardiovascular (CV), and neurological spheres. However, contrary to adults, advances in diagnostic and therapeutic management have been scarce in the last few years despite the increasing scientific evidence of the deleterious consequences of pediatric OSA. The problem of underdiagnosis and the lack of response to treatment in some groups make an update to the management of OSA in children necessary. Probably, the heterogeneity of OSA is not well represented by the classical clinical presentation and severity parameters (apnea/hypopnea index (AHI)), and new strategies are required. A specific and consensus definition should be established. Additionally, the role of simplified methods in the diagnosis algorithm should be considered. Finally, the search for new biomarkers for risk stratification is needed in this population. In conclusion, new paradigms based on personalized medicine should be implemented in this population.

Polysomnography findings in preschool children with obstructive sleep apnea are affected by growth and developmental level

OBJECTIVE

We investigated the effect of growth and development level on polysomnography results in preschool children with obstructive sleep apnea (OSA).

METHODS

Preschool children (ages 3-6) with symptoms of snoring and were diagnosed with OSA by polysomnography in the sleep center were selected as the research object. They were split into three groups based on their growth rates: restricted, normal, and excessive. Sleep structure, respiratory events, and oxygenation index were compared between the three groups.

RESULTS

A total of 183 (111 boys and 72 girls) preschool children were enrolled. There were 26 cases in the growth restricted group, 112 cases in the normal growth group, and 45 cases in the overgrowth group. The weight and Body Mass Index (BMI) of children in the growth restricted and overgrowth groups were significantly different from those in the normal group. In terms of sleep structure, the sleep efficiency of the growth restricted group was poorer than that of the normal group. For sleep breathing events, the growth restricted group showed a greater apnea-hypopnea index (AHI), obstructive apnea hypopnea index (OAHI), hypoventilation index, and more hypoventilation than the normal group. In terms of oxygenation, the difference in degree of hypoxia between the three groups was statistically significant, and the overgrowth group had lower minimum oxygen saturation during the rapid eye movement phase than the normal group, as well as a quicker mean heart rate.

CONCLUSIONS

OSA is more likely in preschool-aged children with stunted or overgrown growth than in children with OSA alone, and the more severe the disorder, especially when accompanied with stunted growth.

Exposure to second-hand smoke during early life and subsequent sleep problems in children: a population-based cross-sectional study

BACKGROUND

Previous studies have revealed that current secondhand smoke exposure showed highly suggestive evidence for increased risk of simultaneous sleep problems in children. Data on the associations between early-life exposure to SHS with subsequent sleep problems in children were scarce. We aimed to evaluate the associations of early-life SHS exposure with sleep problems in children.

METHODS

In this cross-sectional study, children were recruited from elementary and middle schools in Liaoning Province, China between April 2012 and January 2013. We assessed early-life SHS exposure (pregnancy and the first 2 years of life) via questionnaires. Sleep problems and different types of sleep-related symptoms were measured based on the validated tool of the Sleep Disturbance Scale for Children (SDSC). Generalized linear mixed models were applied to estimate the associations of early-life SHS exposure with sleep problems.

RESULTS

We included a total of 45,562 children (22,657 [49.7%] males; mean [SD] age, 11.0 [2.6] years) and 6167 of them (13.5%) were exposed to early-life SHS during both pregnancy and the first 2 years of life. Compared with unexposed counterparts, children exposed to early-life SHS had higher total T-scores of SDSC (β = 4.32; 95%CI: 4.06, 4.58) and higher odds of increased sleep problems (OR = 2.14; 95%CI: 1.89, 2.42). When considering different sleep-related symptoms, the associations between early-life SHS exposure and symptom of sleep-wake transition disorders (i.e., bruxism) were the strongest in all analyses.

CONCLUSIONS

Early-life SHS exposure was associated with higher odds of global sleep problems and different sleep-related symptoms in children aged 6-18 years. Our findings highlight the importance to strengthen efforts to support the critical importance of maintaining a smoke-free environment especially in early life.

Sleep disordered breathing symptoms are associated with depressive symptoms: A longitudinal study of Chinese adolescents

BACKGROUND

Little is known about the prospective association between sleep disordered breathing (SDB) and depressive symptoms in Chinese adolescents. This study examined the independent predictive role of SDB symptoms in depressive symptoms in a large sample of adolescents.

METHODS

A total of 11831 adolescents who participated in the baseline survey of Shandong Adolescent Behavior and Health Cohort and 7072 adolescents who were resurveyed 1 year later were included for the analyses. Adolescents completed a self-administered questionnaire about demographics, mental health, sleep problems, and family environment. SDB symptoms were assessed by 3 items about loud snoring, breathing pauses, and snorting/gasping. The Chinese Youth Self-Report anxious/depressed subscale was used to assess depressive symptoms.

RESULTS

In the cross-sectional analyses, 11.8% adolescents had depressive symptoms, and elevated frequency of SDB symptoms were significantly associated with depressive symptoms. In the longitudinal study, 4.5% of adolescents had persistent depressive symptoms, the incidence rate of depressive symptoms at 1-year follow-up was 6.5%, and elevated frequency of any SDB symptoms (often: OR=2.23, 95%CI:1.50-3.32) at baseline was significantly associated with incident depressive symptoms after adjusting for potential confounders. The associations between SDB symptoms and depressive symptoms were similar for boys and girls.

LIMITATION

SDB symptoms and depressive symptoms were measured by self-report.

CONCLUSION

SDB symptoms are an independent and significant predictor of depressive symptoms in adolescents. Further research is needed to understand the biological mechanisms between SDB and mood dysregulation in adolescents.

Association between snoring and depressive symptoms in adolescents

While previous studies have suggested that snoring may be associated with depressive symptoms and suicidality in adults and preschool children, there have been no investigations in non-clinical adolescent populations. This study aimed to demonstrate the association between snoring and depressive symptoms/suicidality in adolescents. This survey study recruited 8530 students (grades 7-11) and examined depressive symptoms, suicidality, snoring frequency, daytime sleepiness, sleep duration, and presence of insomnia by questionnaires. Correlation analyses, multiple linear regression analyses and mediation analyses were performed to determine the association between snoring frequency and depressive symptoms/suicidality. The study population included 8080 students (16.73 ± 1.09 years old). Snoring frequency was positively correlated with depressive symptoms and suicidality. Snoring frequency was associated with depressive symptoms and suicidality when adjusted for age and sex, and the association remained significant after additionally adjusting for sleep duration, insomnia, and daytime sleepiness. When depressive symptoms were included as a predictor of suicidality, snoring frequency showed no significant predictive value. Mediation analysis confirmed that depressive symptoms mediate the association between snoring frequency and suicidality. Our findings suggest that self-reported complaints of snoring are associated with increased depressive symptoms and suicidality in adolescents independently of sleep duration, insomnia, and daytime sleepiness, and the connection between snoring and suicidality is mediated by depressive symptoms. These data underscore the importance of identifying snorers among adolescents and screening for depression and suicidal ideation in this population.

Association Between Habitual Snoring and Cognitive Performance Among a Large Sample of Preadolescent Children

Importance

Previous studies have identified an association between habitual snoring and lower cognitive performance in children. However, whether and to what extent this association is confounded by pertinent demographic, anthropometric, and socioeconomic characteristics is unknown.

Objective

To assess the extent to which potential confounding factors modify the association between parent-reported habitual snoring and cognitive outcomes among a large and diverse sample of typically developing preadolescent children.

Design, Setting, and Participants

This cross-sectional analysis used a baseline data set (version 2.0.1) from children enrolled in the ongoing Adolescent Brain Cognitive Development study between September 1, 2016, and October 15, 2018. Children aged 9 to 10 years without serious psychiatric or neurological comorbidities were recruited at 21 research sites in the US. Study recruitment was designed to approximate the racial and socioeconomic diversity of the US population. Data were analyzed from February 1 to March 31, 2020.

Exposures

Parent-reported habitual snoring in children that occurs 3 or more nights per week.

Main Outcomes and Measures

Associations between habitual snoring and cognitive performance were assessed using the Sleep Disturbance Scale for Children and the National Institutes of Health Toolbox Cognition Battery, which includes 7 domain-specific and 3 composite (total cognitive function, fluid cognition, and crystallized cognition) standard scores that are uncorrected for covariates. Cognitive performance was examined before and after adjustment for covariates, which included age, sex, body mass index percentile, annual household income before taxes, and highest educational level of caregiver. The extent of confounding was assessed by the effect size, represented by Cohen d, before and after inclusion of covariates using linear mixed-effects models.

Results

A total of 11 873 children aged 9 to 10 years (6187 boys [52.1%]; 6174 White [52.0%]) with available data were included in the study. Of those, habitual snoring (≥3 nights per week) was reported in 810 children (6.8%), and nonhabitual snoring (1-2 nights per week) was reported in 4058 children (34.2%). In the unadjusted models, the total cognitive function composite score among children who habitually snored was significantly lower compared with children who never snored (Cohen d, 0.35; 95% CI, 0.28-0.42). Differences were also identified in the crystallized cognition (Cohen d, 0.34; 95% CI, 0.26-0.41) and fluid cognition (Cohen d, 0.28; 95% CI, 0.21-0.35) composite scores. The association between habitual snoring and cognitive performance was substantially attenuated after adjustment for covariates (Cohen d, 0.16 [95% CI, 0.09 to 0.24] for total cognitive function, 0.14 [95% CI, 0.07 to 0.21] for crystallized cognition, and 0.13 [95% CI, 0.06 to 0.21] for fluid cognition). Similar mitigation was also observed for all domain-specific scores.

Conclusions

In this cross-sectional study, when adjusted for baseline demographic, anthropometric, and socioeconomic characteristics, the association between parent-reported habitual snoring and cognitive performance was substantially attenuated among children aged 9 to 10 years.

Prenatal and Childhood Tobacco Smoke Exposure Are Associated With Sleep-Disordered Breathing Throughout Early Childhood

OBJECTIVE

To determine whether prenatal and childhood tobacco smoke exposure (TSE) are each independently associated with mild sleep-disordered breathing (SDB) symptoms throughout early childhood, and whether the association between childhood TSE and SDB differs according to the level of prenatal exposure.

METHODS

Longitudinal cohort study, using data from the Avon Longitudinal Study of Parents and Children, a population-based birth cohort from the United Kingdom. Primary exposures were repeated measures of mother-reported prenatal and childhood TSE through age 7 years. Outcomes were mother-reported measures of mild SDB symptoms, including snoring, mouth breathing, and witnessed apnea, repeated annually through age 7 years.

RESULTS

A total of 12,030 children were followed for a median duration of 7 years. About 24.2% were exposed to prenatal tobacco smoke, 46.2% were exposed at least once in childhood, and 20.6% were exposed during both periods. Both prenatal and childhood TSE were associated with SDB symptoms throughout early childhood (adjusted OR [aOR] for any prenatal TSE 1.23; 95% confidence interval [CI] 1.08, 1.40; aOR for any childhood TSE 1.17; 95% CI 1.06, 1.29). We observed a dose-response effect between TSE and SBD symptoms, and found evidence of effect modification for those exposed during both time periods (combined high level exposure both prenatally and during childhood: aOR snoring 2.43 [95% CI 1.50, 3.93], aOR apnea 2.65 [95% CI 1.46, 4.82]).

CONCLUSIONS

Prenatal and childhood TSE were both independently associated with mild SDB symptoms throughout early childhood in a dose-dependent manner, further supporting the critical importance of maintaining a tobacco-free environment throughout gestation and childhood.

Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach

Fourteen percent of US adults use tobacco products. Because many of those who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco products often become addicted to nicotine, resulting in tobacco dependence, a chronic, relapsing disease. Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that structural forces play an important role in tobacco uptake, subsequent nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco dependence through a structural competency lens promotes recognition of the larger systemic forces perpetuating tobacco use, including deliberate targeting of groups by the tobacco industry, lack of enforcement of age-for-sale laws, inferior access to health insurance and health care, poor access to cessation resources, and economic stress. Each of these forces perpetuates tobacco initiation and use; in turn, tobacco use perpetuates the user's adverse health and economic conditions. Pediatricians are urged to view family tobacco use as a social determinant of health. In addition to screening adolescents for tobacco use and providing resources and treatment of tobacco dependence, pediatricians are encouraged to systematically screen children for secondhand smoke exposure and support family members who smoke with tobacco cessation. Additionally, pediatricians can address the structural issues perpetuating tobacco use by becoming involved in policy and advocacy initiatives.

Bedtime, body mass index and obesity risk in preschool-aged children

BACKGROUND

Although sleep duration is a risk factor for obesity in young children, less is known about other aspects of sleep health, including bedtime, on obesity risk.

OBJECTIVE

To determine whether bedtime is associated with body mass index (BMI) z-score or obesity risk in children ages 2 to 5 years, and to determine if associations are independent of sleep duration.

METHODS

Cohort analyses were undertaken using three early life obesity prevention trials (POI, INSIGHT, Healthy Beginnings) and a longitudinal cohort study (HOME). Bedtime was assessed by questionnaire and BMI through clinical measurement between 2 and 5 years in 1642 children. Adjusted regression models examined whether BMI z-score and obesity (BMI z-score ≥ 2) were associated with bedtime, nocturnal sleep time and 24-hour sleep time. A discrete mixture model categorized children into bedtime trajectory groups across time points.

RESULTS

Bedtime was inconsistently associated with BMI z-score. Although each hour later of bedtime was associated with greater odds of obesity at ages 3 (OR; 95% CI: 1.05; 1.003, 1.10) and 5 (1.35; 1.08, 1.69) years, odds were attenuated after adjustment for nocturnal or 24-hour sleep time. Longer nocturnal sleep duration at 2 years was associated with lower odds of obesity (OR 0.90; 0.86, 0.94), as was longer 24-hour sleep duration at 3 years in girls (0.70; 0.62, 0.78). BMI z-score and odds of obesity were not significantly different between 'early to bed' and 'late to bed' trajectory groups.

CONCLUSIONS

Timing of bedtime appears inconsistently related to obesity in young children, possibly via influencing overall sleep duration.

Longitudinal Assessment of Sleep Trajectories during Early Childhood and Their Association with Obesity

Introduction: To identify longitudinal sleep trajectories in early childhood and examine the influence of sleep duration on obesity risk via BMI percentile (BMIp). Methods: Sleep, physical activity, and television viewing were measured in a cohort of 301 children, starting in 2001-2002, when children were 3 years and followed them through age 6. Nighttime sleep, daytime naps, and sleep duration were calculated. A series of latent growth curve models were used to estimate predictors of rate of change in sleep duration and BMIp overtime. A parallel process latent growth model examined the longitudinal relationship between sleep duration and BMIp simultaneously. Results: Most children (>80%) slept >10 hours per night across ages 3 to 6 years, despite the majority of children (>66%) having bedtimes after 9 pm. Sleep duration decreased on average by 0.22 (95% CI 0.20-0.24) hours each year of age (p < 0.001), while BMIp increased on average by 1.76 (95% CI 1.18-2.34) each year of age (p < 0.001). Baseline sleep duration predicted the BMIp slope factor, over and above strong effects of baseline BMIp. This indicated that greater sleep duration at baseline was predictive of decreased BMIp over time (unstandardized coefficient = -1.52 (95% CI 0.34-2.71, p = 0.012). Conclusions: Longer sleep duration at age 3 predicted decreased BMIp from ages 3 to 6. These findings indicate that focusing on sleep behaviors in children before age 3 may be a priority for pediatric providers with a goal of decreasing obesity risk.

Risk factors of obstructive sleep apnea syndrome in children

Background

The known risk factors of childhood OSAS include tonsillar and adenoidhypertrophy, obesity, craniofacial anomalies, neuromuscular disorders and African-American (AA) ancestry. Whether other factors such as allergic rhinitis (AR), premature, environmental tobacco smoking (ETS) are associated with OSAS are inconsistent in different studies. Our study enrolled children of a broad age range and included potential risk factors of OSAS derived from previous studies and our own experience. Our objective is to identify risk factors of OSAS in children in a clinical setting.

Methods

Children between 2 and 15 years of age exhibiting snoring symptoms who visited the sleep center for polysomnography (PSG) were enrolled. All children completed a questionnaire, physical examination and PSG. The questionnaire included demographic data and information related to potential risk factors for sleep disorders. A physical examination included measurements of height, weight, neck circumference, waist and hip ratio, visual evaluation of the tonsils and the degree of adenoid obstruction. Children with obstructive apnea-hypopnea index (OAHI) ≥ 1 were defined as OSAS.

Results

A total of 1578 children were enrolled and1009 children exhibited OSAS. Univariate analyses showed that snoring occurring for ≥ 3 months, male gender, preterm birth, breastfeeding, obesity, neck circumference ≥ 30 cm, waist/hip ratio ≥ 0.95, tonsillar hypertrophy, and adenoid hypertrophy were associated with OSAS. The proportion of low educational level was higher in parents who breastfed their babies than those who didn’t. Multivariate analysis showed that snoring for ≥ 3 months, male gender, obesity, breastfeeding, tonsillar hypertrophy, and adenoid hypertrophy were associated with OSAS. Confounders such as socioeconomic status, parental occupation, and health-related behaviors should be explored further to investigate the relationship between breastfeeding and OSAS.

Conclusion

The independent risk factors for OSAS in children included snoring ≥ 3 months, male gender, obesity, breastfeeding, tonsillar and adenoid hypertrophy.

The study was registered on Clinical Trials government (NCT02447614). The name of the trial is “Follow-up Studies of Primary Snoring (PS) and Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) in Chinese Children” and the URL is https://clinicaltrials.gov/.

Risk Factors for Obstructive Sleep Apnea Syndrome in Children: State of the Art

The obstructive sleep apnea syndrome (OSAS) represents only part of a large group of pathologies of variable entity called respiratory sleep disorders (RSD) which include simple snoring and increased upper airway resistance syndrome (UARS). Although the etiopathogenesis of adult OSAS is well known, many aspects of this syndrome in children are still debated. Its prevalence is about 2% in children from 2 to 8 years of age, mostly related to the size of the upper airways adenoid tissue. Several risk factors linked to the development of OSAS are typical of the pediatric age. The object of this paper is to analyze the state of the art on this specific topic, discussing its implications in terms of diagnosis and management.

Secondhand Smoke Exposure and Sleep-Related Breathing Problems in Toddlers

BACKGROUND

Adequate sleep during childhood is an important component of overall health and wellbeing for children. Secondhand smoke (SHS) exposure has been linked to a greater risk of sleep-disordered breathing.

OBJECTIVE

Our objective was to investigate relationships between SHS exposure and sleep-related breathing problems in healthy toddlers aged 2 to 5 years. We hypothesized that there is an independent relationship between objectively measured SHS exposure and presence of sleep-related breathing problems by parental report.

METHODS

A convenience sample of 149 healthy children ages 2 to 5 years was recruited from an academic pediatric primary care center for this cross-sectional study; 138 had complete data that were analyzed. Current SHS exposure was determined by hair nicotine level. Presence of sleep-related breathing problems was assessed by 1 survey item. Inflammation was determined by serum C-reactive protein (CRP) level. Analysis in Stata 15 included a series of multivariate logistic regression models, controlling for individual-level demographics and body mass index z scores according to mediation analysis procedures for dichotomous outcomes.

RESULTS

Approximately 24% of parents reported their child snored, gasped, or had difficulty breathing at night sometimes, most of the time, or almost always. Regression models with mediation analysis indicate that SHS exposure significantly increased the odds of reporting the child had sleep-related breathing problems, and 18% of this relationship is explained by log serum CRP levels.

CONCLUSIONS

Although the cross-sectional nature of this study limits causality, evidence suggests a relationship exists between SHS exposure, as measured by log hair nicotine and sleep-related breathing problems at night.

Parent report of children's sleep disordered breathing symptoms and limited academic progress in reading, writing, and math

OBJECTIVES

To estimate via questionnaire within a population sample of New Zealand (NZ) children aged 6-to-10 years, the prevalence of sleep disordered breathing (SDB) and those struggling academically, and to identify individual and shared risk factors (health and demographic) for parent-reported SDB symptoms and academic difficulties.

METHODS

In this cross-sectional study, parents/caregivers of children were recruited through schools and social media to complete an online questionnaire covering health and demographic factors, their children's SDB symptoms (Pediatric Sleep Questionnaire; PSQ) and parental ratings of academic performance based on teacher feedback relative to expected progress in the national curriculum (well below/below/at/above) in reading, writing, and math.

RESULTS

A total of 1205 children (53% male) aged (mean) eight years two months were included, comprising 79.4% NZ European/other and 15.0% Māori. The survey-weighted prevalence of SDB (based on the PSQ) was 17.5%. This was higher amongst those with academic difficulties rated 'below/well below' expected progress for reading, writing and math (estimated at 24.0%, 31.0% and 27.5% respectively), with increased odds (adjusted odds ratios) for poor progress of 1.9 (95% CI: 1.2, 3.0), 1.8 (95% CI: 1.2, 2.7) and 2.4 (95% CI: 1.6, 3.7) respectively. There were no shared risk factors common to both SDB and academic difficulties identified from multivariate analyses.

CONCLUSIONS

The findings suggest that children with parent-reported SDB symptoms may be at high risk for poor progress in reading, writing, and math. Future research could examine whether treatment of SDB reduces barriers to learning and offsets educational risk.

Effect of maternal smoking in pregnancy and childhood on child and adolescent sleep outcomes to 21 years: a birth cohort study

BACKGROUND

The effects of prenatal maternal smoking have been studied extensively, however little research has examined the effects of prenatal exposure to maternal smoking on offspring sleep, particularly over several developmental periods. We examined the effects of prenatal maternal smoking and postnatal smoking from birth to 14 years, on offspring sleep at 6 months, 5, 14 and 21 years.

METHODS

This was a prospective, community-based birth cohort study involving 7223 women who delivered a singleton child in Brisbane, Australia between 1981 and 1983. Women were recruited at the first antenatal visit. Offspring sleep problems were reported by mothers at 6 months, 5 and 14 years, and by youth at 14 and 21 years. 3738 mothers prospectively reported their smoking status from pregnancy to 14 years postpartum. Youth snoring was reported by mothers at 14 years and by youth at 21 years. Multinomial logistic regression analyses were performed.

RESULTS AND DISCUSSION

Prenatal maternal smoking was independently associated with an increased risk of offspring adolescent parasomnias including walking and talking in sleep and nightmares, and an increased likelihood of being in the highest quintile for maternal and youth reported sleep problems at 14 years. Maternal postnatal smoking was associated with increased likelihood of offspring snoring at 14 years.

CONCLUSIONS

Exposure to maternal prenatal smoking has different effects on offspring sleep compared to exposure to postnatal smoking. Prenatal smoking exposure may be associated with changes in neurodevelopment whereas postnatal smoking is more likely to affect the respiratory system. These findings highlight the long lasting and potentially serious clinical effects of exposure to pre and postnatal maternal smoking on offspring, the mechanisms by which warrant further investigation.

Breastfeeding and risk of habitual snoring in children: A meta-analysis

Research regarding the effects of breastfeeding on habitual snoring in children has yielded conflicting results. Therefore, a meta-analysis was carried out to evaluate the effect of breastfeeding on the risk of habitual snoring in children. Relevant studies published in English or Chinese were identified by a search of PubMed, Embase, Web of Science, Chinese National Knowledge Infrastructure, China Biology Medical literature, and Wanfang databases up to October 2018. Random effects model was used to pool the findings, and results were expressed as odds ratios (OR) with 95% CIs. Eleven studies with 71,622 participants were included in the present meta-analysis. The pooled OR of habitual snoring for more versus less breastfeeding (duration) was 0.74 (95% CI [0.62, 0.90]), and the result remained significant in cohort studies (OR, 0.74; 95%CI [0.66, 0.84]). We found no evidence of publication bias. This meta-analysis of observational studies indicates that breastfeeding for a long time is associated with reduced risk of habitual snoring in children. The finding needs to be investigated in well-designed prospective studies.

Dysbiosis in Snoring Children: An Interlink to Comorbidities?

BACKGROUND AND OBJECTIVES

Early microbial colonization has a key impact on infant health through nutritional, immunological, and metabolic programming. The origin of child snoring is multifactorial and complex, and may thereby also generate long-term health problems. The link between child snoring and gut microbes remains unclear, although indirect evidence exists regarding this relationship. This study aimed to characterize the connection between gut microbiota and child snoring.

METHODS

In a prospective, observational CHILD-SLEEP birth cohort study, gut microbiota in a subcohort of 43 of these children at 2 years of life was profiled with 16S ribosomal RNA gene amplicon sequencing.

RESULTS

A higher abundance of the Proteobacteria phylum, the Enterobacteriaceae family, and Erysipelotrichaceae family, as well as a higher ratio of Firmicutes to Bacteroidetes were detected in snorers as compared to controls. Furthermore, snorers showed significantly lower microbial diversity and richness than non-snorers.

CONCLUSIONS

The snoring children manifest different gut microbiota as compared with healthy children. Considering that snoring and sleep disorders can be a source of long-term consequences, including cardiovascular, metabolic, immunological, neurocognitive and behavioral consequences, our results proposes early microbiota as a new treatment target.

Prenatal and Neonatal Factors Predicting Sleep Problems in Children Born Extremely Preterm or With Extremely Low Birthweight

Objective: Prematurely born children have been reported to have more sleep problems throughout childhood than children born at term. The aim of this study was to explore if prenatal or neonatal factors can predict sleep problems at age 11 years in children born extremely preterm (EPT). Method: A prospective observational study of all infants who were born EPT in Norway in 1999 and 2000. Prenatal and neonatal data were collected by all Norwegian obstetric and pediatric departments. Parental questionnaire mapped sleep problems and sleep habits at the age of 11 years. Results: Of the 372 eligible children, 221 participated. Of those, 28.1% snored, 27.5% had difficulty falling asleep or frequent awakenings and 17.2% suffered from daytime sleepiness. The mean sleep duration was 9.4 h (range 4.3-11.0 h). Smoking in pregnancy predicted snoring (odds ratio 4.3). Neonatal cerebral hemorrhage and being born small for gestational age predicted difficulty falling asleep or frequent awakenings (odds ratio 2.2 and 2.3). Other morbidities during pregnancy or the newborn period, gestational age or the burden of treatment in the neonatal intensive care unit did not predict sleep problems. None of the studied prenatal or neonatal factors predicted daytime sleepiness or sleep duration <9 h. Conclusion: Of numerous prenatal and neonatal factors, only smoking during pregnancy, being born small for gestational age and cerebral hemorrhage predicted sleep problems at 11 years of age among these children born EPT.

Salivary cotinine levels in children with otolaryngological disorders

OBJECTIVE

To determine if salivary cotinine, a biomarker for tobacco smoke exposure, is elevated more often or to a higher degree in children meeting criteria for tonsillectomy or tympanostomy tube insertion.

METHODS

Saliva samples were obtained from 3 groups of children for salivary cotinine measurement. Group 1 served as healthy controls. Group 2 consisted of subjects meeting tympanostomy tube criteria. Group 3 consisted of patients meeting tonsillectomy criteria. Environmental tobacco smoke (ETS) exposure was defined as a salivary cotinine concentration ≥1.0 ng/mL. Demographic data, smoke exposure history, and co-morbidities were also determined.

RESULTS

331 patients were included, with 112 in Group 1, 111 in Group 2, and 108 in Group 3. No differences were encountered for smoke exposure by history or smoker's identity, salivary cotinine level, or frequency of positive cotinine results. 42.6% of Group 1 had positive salivary cotinine compared to 51.8% of Group 2 and 47.7% of Group 3. Group 1 had a mean salivary cotinine level of 2.42 ng/mL compared to 2.54 ng/mL in Group 2 and 2.60 ng/mL in Group 3. The frequency of positive cotinine levels was higher than expected based on parental history. Among subjects with positive cotinine levels, 93 had no ETS exposure, and 64 had ETS exposure by history.

CONCLUSION

Approximately 50% of children who undergo tonsillectomy and tympanostomy tube insertion have objective evidence of ETS exposure. Parental history underestimates passive smoke exposure, which can impact perioperative care.

Association between Breast Feeding and Paediatric Sleep Disordered Breathing: a Systematic Review

BACKGROUND

Breast feeding has been suggested as a potential protective factor against childhood snoring and sleep disordered breathing (SDB). SDB can have major health consequences. The objective of this systematic review is to synthesise the available literature concerning any potential association between infant feeding methods and SDB in young children.

METHODS

Five electronic databases were searched. All searches were inclusive until August 5, 2016. Two authors independently reviewed potentially relevant articles for eligibility. Any prospective or retrospective study, case-control study, cohort study, clinical trial, and cross-sectional study that evaluated the association between infant feeding methods and SDB were included. Data on study design, aim of study, sample size, study population, assessment tool, infant feeding methods, and outcome measures were extracted.

RESULTS

Nine studies fulfilled the criteria to be finally included in this review, only cohorts and cross-sectional studies were identified. While seven of the selected studies reported a statistically significant association between breast feeding and reduced risk of SDB, the remaining two studies did not report any association. The main methodological limitation was high heterogeneity in the diagnostic criteria and assessment tools to identify SDB and limited data collection on infant feeding methods.

CONCLUSIONS

The current evidence may point to a protective association, however, as uncertainty is moderate, any suggestion that breast feeding may or may not decrease the risk of SDB is currently unwarranted. More research on the topic is required to resolve some of the contradictions between included studies.

Auditory behavior and auditory temporal resolution in children with sleep-disordered breathing

OBJECTIVE

Intermittent hypoxia caused by obstructive sleep apnea syndrome (OSAS) may lead to damage in brain areas associated to auditory processing. The aim of this study was to compare children with OSAS or primary snoring (PS) to children without sleep-disordered breathing with regard to their performance on the Gaps-in-Noise (GIN) test and the Scale of Auditory Behaviors (SAB) questionnaire.

METHODS

Thirty-seven children (6-12 years old) were submitted to sleep anamnesis and in-lab night-long polysomnography. Three groups were organized according to clinical criteria: OSAS group (13 children), PS group (13 children), and control group (11 children). They were submitted to the GIN test and parents answered SAB questionnaire. The Kruskal-Wallis statistical test was used to compare the groups; p < 0.05 was considered statistically significant.

RESULTS

The OSAS group performed significantly worse than PS (p = 0.011) and Control (p = 0.029) groups on gap detection percentage, while PS and Control groups showed no significant differences. The three groups showed similar gap detection thresholds. Regarding SAB questionnaire, PS group had significantly worse scores when compared to Control (p = 0.011), but not to OSAS (p = 0.101) groups. No statistical difference between OSAS and Control groups were found.

CONCLUSION

Children with OSAS showed worse performance on GIN test in comparison to children with PS and children without sleep-disordered breathing. PS negatively affected auditory behavior in children. These findings suggest that sleep-disordered breathing may lead to auditory behavior impairment.

Prospective longitudinal associations between household smoke exposure in early childhood and antisocial behavior at age 12

Young children exert little control over household tobacco smoke exposure, which is considered a developmental neurotoxicant. Using the Quebec Longitudinal Study birth cohort, we examine prospective associations between early childhood smoke exposure and later antisocial behavior. Parents of 1035 children reported on the presence of household smokers at seven follow-ups from ages 1.5 to 7.5. At age 12, children self-reported on five aspects of early antisocial dispositions. After adjusting for confounders, every standard deviation increase in household smoke exposure was prospectively associated with a 19% standard deviation unit increase in conduct problems (β=0.07; 95% confidence interval [CI] from 0.04 to 0.09), a 11% standard deviation unit increase in proactive aggression (β=0.04; 95% CI from 0.01 to 0.07), a 13% standard deviation unit increase in reactive aggression (β=0.07; 95% CI from 0.03 to 0.12), a 14% standard deviation unit increase in school indiscipline (β=0.13; 95% CI from 0.05 to 0.20), and a 10% standard deviation unit increase in dropout risk (β=0.07; 95% CI from 0.01 to 0.12). These long-term findings warrant fostering parental awareness of developmental risks by policy-makers/health practitioners. School curricula can equally integrate these ideas into their curriculum.

Parental Snoring and Environmental Pollutants, but Not Aeroallergen Sensitization, Are Associated with Childhood Snoring in a Birth Cohort

The objective of this study was to determine whether atopy and other clinical and environmental variables predict the risk of childhood habitual snoring (HS) in a birth cohort born to atopic parents. Participants completed clinical evaluations and questionnaires at ages 1-4 and age 7. HS was defined as snoring ≥3 nights/week. Traffic-related air pollution (TRAP) exposure was estimated using land-use regression. The association between early (≤age 4) and current (age 7) allergic disease, environmental exposures, and snoring at age 7 was examined using adjusted logistic regression. Of the 609 children analyzed the prevalence of HS at age 7 was 21%. Early tobacco smoke exposure [environmental tobacco smoke (ETS)] [odds ratio (OR) 1.79, 95% CI (confidence interval) 1.12-2.84], rhinitis (OR 1.74, 95% CI 1.06-2.92), wheezing (OR 1.63, 95% CI 1.05-2.53), maternal HS (OR 2.08, 95% CI 1.36-3.18), and paternal HS (OR 1.83, 95% CI 1.14-3.00) were significantly associated with HS at age 7. Current TRAP (OR 1.93, 95% CI 1.13-3.26), respiratory infections (OR 1.16, 95% 1.03-1.35), maternal HS (OR 2.86, 95% CI 1.69-4.84), and paternal HS (OR 3.01, 95% CI 1.82-5.09) were significantly associated with HS at age 7. To our knowledge, this is the largest birth cohort examining longitudinal predictors of snoring in children born to atopic parents. Parental HS was the only variable consistently associated with childhood HS from ages 1 to 7. Early rhinitis, early ETS exposure, and concurrent traffic pollution exposure increased the risk of HS at age 7, while aeroallergen sensitization did not. Children with these characteristics should be considered for screening of sleep disorders.

Pediatric Sleep Apnea Syndrome: An Update

Obstructive sleep apnea syndrome (OSAS) may be central neurologic (<5%) or obstructive (>95%) in origin and is a relatively prevalent condition in children. It affects 1%-5% of children aged 2-8 years and is caused by a variety of different pathophysiologic abnormalities. Cardiovascular, metabolic, and neurocognitive comorbidities can occur in both children and adults when left untreated. It also can cause severe behavioral problems in children. The American Academy of Pediatrics recommends that all children be screened with an appropriate history and physical examination for symptoms and signs suggestive of OSAS. The diagnosis is primarily made clinically and confirmed by polysomnographic findings. Treatment depends on the child's age, underlying medical problems, polysomnography findings, and whether or not there is upper airway obstruction usually secondary to enlarged adenoids and/or tonsils, allergic and nonallergic rhinitis, acute and chronic sinusitis, and other upper airway pathology. If enlarged adenoid or tonsils or both conditions exist, an adenoidectomy, tonsillectomy, or adenotonsillectomy remains the treatment of choice. Pharmacotherapy of OSAS has shown some effect in children with mild symptoms. This paper reviews the prevalence, pathophysiology, clinical presentation, diagnosis, and treatment of OSAS.

Sleep problems and suicide attempts among adolescents: a case-control study

This study used a case-control design to compare sleep disturbances in 40 adolescents who attempted suicide with 40 never-suicidal adolescents. Using hierarchical logistic regression analyses, we found that self-reported nighttime awakenings were significantly associated with attempted suicide, after controlling for antidepressant use, antipsychotic use, affective problems, and being bullied. In a separate regression analysis, the parent-reported total sleep problems score also predicted suicide attempt status, controlling for key covariates. No associations were found between suicide attempts and other distinct sleep problems, including falling asleep at bedtime, sleeping a lot during the day, trouble waking up in the morning, sleep duration, and parent-reported nightmares. Clinicians should be aware of sleep problems as potential risk factors for suicide attempts for adolescents.

Pediatric Sleep Pharmacology: A Primer

"What will you give my child to help him sleep?" is a common question parents ask and some health care providers abhor hearing. Entire families may suffer when one member does not sleep well. Poor sleep may complicate the management of other comorbid conditions. Health care providers may have received only limited education on sleep disorders and are frequently forced to choose between treatment options that are poorly studied in children. Fortunately, when addressed correctly, many children with chronic sleep disorders may improve their sleep and daytime behavior in a relatively short time. This review provides a framework to help understand the causes of poor sleep in children and the potential pharmacologic options.

Mandibular movements identify respiratory effort in pediatric obstructive sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea-hypopnea (OAH) diagnosis in children is based on the quantification of flow and respiratory effort (RE). Pulse transit time (PTT) is one validated tool to recognize RE. Pattern analysis of mandibular movements (MM) might be an alternative method to detect RE. We compared several patterns of MM to concomittant changes in PTT during OAH in children with adenotonsillar hypertrophy.

METHODS

PARTICIPANTS

33 consecutive children with snoring and symptoms/signs of OAH.

MEASUREMENTS

MMs were measured during polysomnography with a magnetometer device (Brizzy Nomics, Liege, Belgium) placed on the chin and forehead. Patterns of MM were evaluated representing peak to peak fluctuations > 0.3 mm in mandibular excursion (MML), mandibular opening (MMO), and sharp MM (MMS), which closed the mouth on cortical arousal (CAr).

RESULTS

The median (95% CI) hourly rate of at least 1 MM (MML, or MMO, or MMS) was 18.1 (13.2-36.3) and strongly correlated with OAHI (p = 0.003) but not with central apnea-hypopnea index (CAHI; p = 0.292). The durations when the MM amplitude was > 0.4 mm and PTT > 15 ms were strongly correlated (p < 0.001). The mean (SD) of MM peak to peak amplitude was larger during OAH than CAH (0.9 ± 0.7 mm and 0.2 ± 0.3 mm; p < 0.001, respectively). MMS at the termination of OAH had larger amplitude compared to MMS with CAH (1.5 ± 0.9 mm and 0.5 ± 0.7 mm, respectively, p < 0.001).

CONCLUSIONS

MM > 0.4 mm occurred frequently during periods of OAH and were frequently terminated by MMS corresponding to mouth closure on CAr. The MM findings strongly correlated with changes in PTT. MM analysis could be a simple and accurate promising tool for RE characterization and optimization of OAH diagnosis in children.

Quality measures for the care of pediatric patients with obstructive sleep apnea

ABSTRACT

The Board of Directors of the American Academy of Sleep Medicine (AASM) commissioned a Task Force to develop quality measures as part of its strategic plan to promote high quality patient-centered care. Among many potential dimensions of quality, the AASM requested Workgroups to develop outcome and process measures to aid in evaluating the quality of care of five common sleep disorders: insomnia, obstructive sleep apnea in adults, obstructive sleep apnea in children, restless legs syndrome, and narcolepsy. This paper describes the rationale, background, general methods development, and considerations in implementation of these quality measures in obstructive sleep apnea (OSA) in children. This document describes measurement methods for five desirable process measures: assessment of symptoms and risk factors of OSA, initiation of an evidence-based action plan, objective evaluation of high-risk children with OSA by obtaining a polysomnogram (PSG), reassessment of signs and symptoms of OSA within 12 months, and documentation of objective assessment of positive airway pressure adherence. When these five process measures are met, clinicians should be able to achieve the two defined outcomes: improve detection of childhood OSA and reduce signs and symptoms of OSA after initiation of a management plan. The AASM recommends the use of these measures as part of quality improvement programs that will enhance the ability to improve care for patients with childhood OSA.

Sleep-disordered breathing, sleep duration, and childhood overweight: a longitudinal cohort study

OBJECTIVES

To examine independent associations between sleep-disordered breathing (SDB), sleep duration from birth through 6.75 years, and body mass index (BMI) through 15 years of age in a population-based cohort.

STUDY DESIGN

The Avon Longitudinal Study of Parents and Children collected parent questionnaire data on child sleep duration and SDB symptoms from birth through 6.75 years and child BMI from the Avon Longitudinal Study of Parents and Children research clinics (n = 1899). For SDB, logistic regression models-minimal, confounder, and confounder + sleep duration adjusted-examined associations with BMI at 7, 10, and 15 years of age. For short sleep duration (≤10th percentile), comparable SDB-adjusted models examined associations with BMI at 15 years of age.

RESULTS

Children with the worst SDB symptoms vs asymptomatic children, had increased odds of overweight at 7 (OR = 2.08, 95% CI = 1.04-4.17), 10 (OR = 1.79, 95% CI = 1.02-3.16), and 15 years of age (OR = 2.25, 95% CI = 1.27-3.97) in models adjusted for sleep duration. Similarly, short sleep duration at ≈5-6 years was associated with overweight at 15 years, independent of SDB. Children with short sleep duration at 4.75 years were more likely to be overweight at 15 years in minimally (OR = 2.21, 95% CI = 1.52-3.20), confounder (OR = 1.99, 95% CI = 1.34-2.96), and SDB-adjusted (OR = 2.04, 95% CI = 1.36-3.04) models.

CONCLUSIONS

Both SDB and short sleep duration significantly and independently increase children's odds of becoming overweight. Findings underscore the potential importance of early identification and remediation of SDB, along with insufficient sleep, as strategies for reducing childhood obesity.

Prenatal exposure to polybrominated diphenyl ethers and polyfluoroalkyl chemicals and infant neurobehavior

OBJECTIVE

To assess the impact of prenatal exposure to polybrominated diphenyl ethers (PBDEs) and polyfluoroalkyl chemicals (PFCs) on early infant neurobehavior.

STUDY DESIGN

In a cohort of 349 mother/infant pairs, we measured maternal serum concentrations during pregnancy of PBDEs, including BDE-47 and other related congeners, as well as 2 common PFCs, perfluorooctanoic acid (PFOA) and perfluorooctane sulfonic acid. When the infants were 5 weeks of age, we measured their neurobehavior by using the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS).

RESULTS

Neither PBDE nor PFC exposures during gestation were associated with the 11 individual NNNS outcomes included in our study; however, when we used latent profile analysis to categorize infants into neurobehavioral profiles based on performance on the NNNS (social/easygoing, high arousal/difficult, or hypotonic), a 10-fold increase in prenatal PFOA concentrations significantly increased the odds of being categorized as hypotonic compared with social/easygoing (aOR 3.79; 95% CI 1.1-12.8).

CONCLUSIONS

Infants of mothers with greater serum concentrations of PFOA during pregnancy were more likely to be categorized as hypotonic. No association between PBDE concentrations and hypotonia was found. Additional studies should further investigate possible associations of prenatal PFC exposure and muscle tone in infants and children.

The possible long-term effects of early-life circadian rhythm disturbance on social behavior

Sleep loss impairs brain function. As late sleep onset can reduce sleep, this sleep/circadian rhythm disturbance may cause brain impairment. Specific data on the long-term effects of sleep/circadian rhythm disturbance on subsequent brain function are lacking. Japan, a sleep-deprived society from infancy to adulthood, provides an ideal platform to investigate the association of these disturbances in early life with subsequent functioning. In this article, several current problematic behaviors among youth in Japan (dropping out from high school, school absenteeism, early resignation from employment, and suicide) are discussed in relation to early life sleep/circadian rhythm patterns. We hypothesize that daily habits of modern society during early stages of life produce unfavorable effects on brain function resulting in problematic behaviors in subsequent years.

Breastfeeding and snoring: a birth cohort study

OBJECTIVE

To investigate the relationship between breastfeeding and snoring in childhood.

METHODS

In a cohort of children with a family history of asthma who were recruited antenatally we prospectively recorded data on infant feeding practices throughout the first year of life. Snoring status and witnessed sleep apnea were measured at age 8 years by parent-completed questionnaire. Associations were estimated by logistic regression with, and without, adjustment for sets of confounders designed to exclude biasing effects.

RESULTS

Habitual snoring was reported in 18.8% of the sample, and witnessed apnea in 2.7%. Any breastfeeding for longer than one month was associated with a reduced risk of habitual snoring at age 8 (adjusted OR 0.48, 95% CI 0.29 to 0.81) and duration of breastfeeding was inversely associated with the prevalence of habitual snoring (adjusted OR 0.79, 95% CI 0.62 to 1.00). Any breastfeeding for longer than 1 month was associated with a lower risk of witnessed sleep apnea (adjusted OR 0.17, 95% CI 0.04 to 0.71). The protective associations were not mediated by BMI, current asthma, atopy or rhinitis at age 8 years.

CONCLUSIONS

Breastfeeding for longer than one month decreases the risk of habitual snoring and witnessed apneas in this cohort of children with a family history of asthma. The underlying mechanism remains unclear but the finding would be consistent with a beneficial effect of the breast in the mouth on oropharyngeal development with consequent protection against upper airway dysfunction causing sleep-disordered breathing.

Effects of passive smoking on snoring in preschool children

OBJECTIVE

To examine the association between passive smoking and snoring in preschool children using parent-reported questionnaires and urine cotinine levels.

STUDY DESIGN

This was a population-based cross-sectional survey of 2954 children aged 2-6 years in Hong Kong. Parent-reported questionnaires provided information on snoring and household smoking. One-third of children randomly chosen from the cohort provided urine samples for cotinine analysis. Increased urine cotinine was defined as urinary cotinine concentration ≥ 30 ng/mg creatinine. Using multivariate logistic regression analysis, we analyzed the association between snoring and passive smoking, controlling for potential confounders including age, sex, body mass index z-score, atopic diseases, recent upper respiratory tract infection, parental allergy, parental education, family income, and bedroom-sharing.

RESULTS

A total of 2187 completed questionnaires were included in the final analysis, and 724 children provided urine samples for cotinine measurement. After adjustment for confounding factors, questionnaire-based household smoking (>10 cigarettes/d: OR = 2.22, 95% CI = 1.02-4.81) and increased urine cotinine (OR = 4.37, 95% CI = 1.13-16.95) were significant risk factors for habitual snoring (snoring ≥ 3 nights per week). For occasional snoring (snoring 1-2 nights per week), reported household smoking (1-10 cigarettes/d: OR = 1.41, 95% CI = 1.14-1.76; >10 cigarettes/d: OR = 1.56, 95% CI = 1.05-2.31), and increased urine cotinine (OR = 1.82, 95% CI = 1.03-3.20) were also identified as significant risk factors. A dose-effect relationship was found for snoring frequency and adjusted natural logarithms of urinary cotinine concentrations (P < .001).

CONCLUSIONS

Environmental tobacco smoke exposure is an independent risk factor for snoring in preschool children. Parents' smoking cessation should be encouraged in management of childhood snoring.

Lower health related quality of life and psychosocial difficulties in children with monosymptomatic nocturnal enuresis--is snoring a marker of severity?

PURPOSE

Sleep disordered breathing in children is linked to numerous negative psychosocial consequences, including lower health related quality of life, increased behavioral problems and impaired neuropsychological functioning. We examined whether snoring, which is the least severe form of sleep disordered breathing, or health related quality of life could account for the increased rate of psychosocial difficulty in children with monosymptomatic nocturnal enuresis.

MATERIALS AND METHODS

Patients diagnosed with monosymptomatic nocturnal enuresis seen at an outpatient pediatric urology clinic completed measures of health related quality of life (Obstructive Sleep Apnea Syndrome-18-Item Questionnaire), sleep disordered breathing (Pediatric Sleep Questionnaire) and psychosocial difficulty (Pediatric Symptom Checklist). Patients were categorized into 2 groups (snoring vs no snoring) based on the Pediatric Symptom Checklist snoring subscale score.

RESULTS

Included in the study were 62 males and 45 females with a mean ± SD age of 9.09 ± 2.58 years and a mean body mass index of 21.00 ± 6.93 kg/m(2) (range 13 to 49). The sample was evenly split between 56 snorers (52.3%) and 51 nonsnorers (47.7%). Compared to children with monosymptomatic nocturnal enuresis who did not snore, MANCOVA results revealed that patients with monosymptomatic nocturnal enuresis who snored had significantly more externalizing problems and total psychosocial problems, in addition to significantly more impairment in all areas of health related quality of life.

CONCLUSIONS

Snoring in children with monosymptomatic nocturnal enuresis puts them at increased risk for behavioral and psychosocial problems, in addition to impaired health related quality of life. These findings support the need for future studies of the neurological links between sleep disordered breathing and monosymptomatic nocturnal enuresis.