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Racial/Ethnic Differences in the Prevalence of Snoring and Sleep Disordered Breathing in Young Children.

Published Online:https://doi.org/10.5664/jcsm.28104Cited by:62

ABSTRACT

Study Objective:

To determine whether there are racial/ethnic differences in the prevalence of pediatric snoring and sleep disordered breathing (SDB).

Methods:

In this cross-sectional study, parents or caretakers of 346 children, aged 2 through 6 years, attending well-child care visits at 5 general pediatric offices and clinics (3 academic, 2 private) in Brooklyn, NY completed the Sleep-Related Breathing Disorders Scale of the Pediatric Sleep Questionnaire (PSQ) along with a survey on demographics, prior treatment for SDB, and parental knowledge of pediatric SDB. The child's height and weight were recorded from the office visit.

Results:

The prevalence of snoring was 13.9% (95% CI 10.2, 17.5) and of SDB was 9.4% (95% CI 6.3, 12.6). The odds of snoring for black children was 2.5 as great as for white children, and for Hispanic children was 2.3 as great as for white children (p = 0.031). There was a higher, non–statistically significant prevalence of abnormal PSQ scores in black and Hispanic children than white children. On multivariate analysis, only black race (OR 3.1 95% CI 1.1, 8.9) and prematurity (OR 4.4 95% CI 1.6, 12.4) were associated with snoring; male gender (OR 2.9 95% CI 1.1, 8.5) was associated with SDB. Knowledge regarding SDB was low among parents and caretakers. The degree of knowledge present was not associated with parental concern about snoring and discussion of the snoring with the child's pediatrician.

Conclusions:

Black race and prematurity are independent predictors of snoring. The degree of parental knowledge regarding SDB was not associated with seeking medical treatment.

Citation:

Goldstein NA; Abramowitz T; Weedon J; Koliskor B; Turner S; Taioli E. Racial/ethnic differences in the prevalence of snoring and sleep disordered breathing in young children. J Clin Sleep Med 2011;7(2):163-171.

INTRODUCTION

Pediatric sleep disordered breathing (SDB) is viewed on a continuum of severity based on the degree of upper airway narrowing, arousal, and gas exchange abnormality, ranging from snoring to upper airway resistance syndrome to obstructive sleep apnea (OSA). While there are no published incidence studies of pediatric SDB, the prevalence of snoring and pediatric SDB has been estimated from community-based cross-sectional surveys of parental reports of snoring and difficulty breathing during sleep, with some studies utilizing selected overnight pulse oximetry or polysomnography (PSG).113 The prevalence of habitual snoring ranges from 2.4% to 15.6%, and the prevalence of SDB ranges from 0.2% to 3.8%. Most of the studies were performed in Western Europe, Australia, and Asia, and racial/ethnic differences are not reported. In contrast to the European and Asian studies, racial/ethnic differences have been suggested in several prevalence and case-control studies performed in the United States. Both non-Hispanic black race and Hispanic ethnicity have been found to be associated with SDB.3,6,911,1417 Most of the previous studies have not utilized a validated measure of SDB or have evaluated selected patient populations, thus limiting their external validity. Other potential risk factors in generally healthy children include male gender, obesity, failure to thrive, history of prematurity, allergy, asthma, and socioeconomic status.8,14,16,1821 Despite the clinical importance of SDB in children, several studies have shown that there is a low level of recognition of pediatric sleep disorders by primary care physicians and parents.2225

BRIEF SUMMARY

Current Knowledge/Study Rationale: This study was undertaken to determine risk factors for pediatric snoring and sleep disordered breathing and assess parental knowledge of sleep disordered breathing in a community-based sample.

Study Impact: Black race and prematurity are independent risk factors for snoring and male gender is an independent risk factor for sleep disordered breathing. Accurate epidemiologic data are necessary for targeted screening and timely diagnosis and treatment. Parental educational efforts may not necessarily lead to earlier evaluation of potentially affected children.

The objective of this study was to compare the prevalence of snoring and SDB among 3 racial/ethnic groups in children aged 2 through 6 years attending well-child care pediatric office visits in Brooklyn, NY, using the Pediatric Sleep Questionnaire (PSQ). Gender, age, body mass index (BMI), prematurity, history of asthma, history of allergy, and socioeconomic status were also evaluated as potential risk factors for pediatric SDB, as well as parental knowledge of SDB in the Brooklyn community.

METHODS

Selection of Subjects

Parents or caretakers of 346 children, aged 2 through 6 years, attending well-child care visits at 5 participating pediatric offices and clinics (3 academic, 2 private) from 4 Brooklyn community districts self-completed the Sleep-Related Breathing Disorders (SRBD) Scale of the PSQ along with a survey form regarding demographics, prior treatment for SDB, parental knowledge of pediatric SDB, and socioeconomic status. The child's height and weight were recorded from the office visit. BMI was calculated by dividing the child's weight in kilograms by the square of the height in meters and compared to standard percentiles for age and sex. Specific exclusion criteria were: (1) mental or physical impairment severe enough to preclude interpretation of the behavioral information, (2) craniofacial syndromes, (3) Down syndrome, (4) cerebral palsy, (5) neuromuscular disorders, (6) mucopolysaccharide storage disease, (7) immunodeficiency, (8) sickle cell disease, (9) and inability of the parent to read or understand English. The objective of this study was to evaluate risk factors for SDB in generally healthy children, so children with chronic conditions that are well-established risk factors for SDB were excluded. Children who have previously undergone treatment for SDB were included, as this was a point prevalence study, but a note was made of prior treatment.

The protocol was approved by the Institutional Review Board of the Long Island College Hospital and was exempted from IRB review at the State University of New York (SUNY) Downstate Medical Center, since anonymous surveys were collected without identifiable data. A convenience sample was recruited based on the availability of the research assistants to attend office hours and collect questionnaires. The parents/caretakers of all eligible children were approached at each office visit. A total of 385 parents were approached, and 32 (8%) refused to participate. No information is available regarding the children whose parents did not participate.

Completion of Surveys

The SRBD Scale consists of 22 closed response question-items, extracted from the PSQ, and validated against PSG.26 In a sample of 54 children with PSG-confirmed SDB and 108 children attending appointments at one of 2 general pediatric clinics, the SRBD scale of the PSQ showed a sensitivity of 81% and a specificity of 87% in comparison to PSG. In a follow-up study of 5- to 12-year old children, high baseline score (1 SD above the mean) predicted a 3-fold risk of OSA on PSG.27 The items ask about snoring frequency, loud snoring, observed apneas, difficulty breathing during sleep, daytime sleepiness, inattentive or hyperactive behavior, and other features of pediatric SDB. The survey scores range from 0.0 to 1.0. Scores > 0.33 are considered positive and suggestive of high risk for pediatric SDB. Children whose parents reported a positive response to the item “Does your child snore more than half the time?” were considered to be snorers, as this item has the strongest association of all the questions regarding the frequency and severity of snoring with positive PSG.26

The parental survey form consisted of questions regarding patient demographics, history of the following: (1) prematurity; (2) asthma; (3) allergies; (4) prior sleep study; (5) treatment for sleep apnea; and (6) tonsillectomy and/or adenoidectomy, highest grade of school or year of college completed by the parent, insurance status, annual household income, parental/caretaker knowledge of sleep apnea quantified as “a lot,” “some,” “a little,” or “nothing,” any history of parental concern about their child's snoring, and discussion of the snoring with the child's pediatrician or other medical professional (Table 1). Racial/ethnic classification was determined using the categories defined by the National Institute of Health. Hispanic children were considered Hispanic regardless of their racial category.

Table 1 Sociodemographic factors, medical history, snoring, sleep disordered breathing (SDB), and parental awareness of SDB in 346 Children in Brooklyn, NY

FactorNo. (%)
    Respondent's relationship to child
        n338
        Mother267 (79.0)
        Father53 (15.7)
        Adoptive parent1 (0.3)
        Grandparent9 (2.7)
        Other8 (2.4)
        Unknown8
    Gender
        n334 (100)
        Male162 (48.5)
        Female172 (51.5)
        Unknown12
    Race/Ethnicity
        n346 (100)
        White133 (38.4)
        Black/African American155 (44.8)
        Hispanic41 (11.8)
        Other17 (4.9)
    Birth History
        n342 (100)
        Full-term285 (83.3)
        Prematurity57 (16.7)
        Unknown4
    Asthma
        n341 (100)
        Present38 (11.1)
        Absent303 (88.9)
        Unknown5
    Allergies
        n328
        Present69 (21.0)
        Absent259 (79.0)
        Unknown18
    BMI
        n311
        Underweight, < 5th percentile25 (8.0)
        Healthy, ≥ 5th & < 85th percentile197 (63.3)
        Overweight, ≥ 85th & < 95th percentile40 (12.9)
        Obese, ≥ 95th percentile49 (15.8)
        Unknown35
    Insurance
        n333
        None4 (1.2)
        Medicaid23 (6.9)
        Medicaid-HMO108 (32.4)
        Commercial196 (58.9)
        Military2 (0.6)
        Unknown13
    Caretaker's highest grade of school completed
        n331
        None or grades 1-89 (2.7)
        High school incomplete (grades 9-11)26 (7.9)
        High school complete (grade 12 or GED)44 (13.3)
        Business or technical/vocational after high school18 (5.4)
        Some college; no 4 year degree96 (29.0)
        College graduate (BS, BA, or 4-year degree)72 (21.8)
        Post-college graduate (Masters/Ph.D./Medical/Law)66 (19.9)
        Unknown15
    Annual household income
        n303
        < $20K45 (14.9)
        $20K to < $35K48 (15.8)
        $35K to < $50K42 (13.9)
        $50K to < $75K61 (20.1)
        $75K to < $100K33 (10.9)
        $100K to < $150K35 (11.6)
        $150K to < $250K16 (5.3)
        ≥ $250K23 (7.6)
        Unknown43
    Snoring more than half the time
        n339
        Yes47 (13.9)
        No292 (86.1)
        Unknown7
    SDB – Mean PSQ score > 0.33
        n339
        Yes32 (9.4)
        No307 (90.6)
        Unknown7
    Parental knowledge about obstructive sleep apnea
        n341
        A lot37 (10.9)
        Some85 (24.9)
        A little99 (29.0)
        None120 (35.2)
        Unknown5
    Concerned about snoring
        n211
        Yes52 (24.6)
        No159 (75.4)
        N/A135
    Discussed snoring with pediatrician/medical professional
        n200
        Yes49 (24.5)
        No151 (75.5)
        N/A146

BMI, body mass index; HMO, health maintenance organization; PSQ, Pediatric Sleep Questionnaire.

Statistical Analysis

The sample size estimation for the prevalence of snoring among the 3 racial/ethnic groups was performed using the power analysis software NCSS/PASS 2008. Based on the prior literature, the odds of snoring for black children was assumed to be 3 times the odds for white children, and the odds of snoring for Hispanic children was assumed to be twice the odds for white children.6,11,16 Assuming a prevalence of snoring of 10% for whites, 30% for blacks, and 20% for Hispanics, using the χ2 statistic for a 3 × 2 table and assuming a power of 80%, 232 total children were needed equally divided between racial/ethnic groups. The effect size as measured by Cohen's w was 0.37. The sample size was increased to > 300 in order to take into account incomplete surveys and children who could not be classified as black, white, or Hispanic.

The prevalence of snoring and SDB (PSQ score > 0.33) along with the corresponding 95% confidence intervals (CIs) was determined for each of the 3 racial/ethnic groups. CIs were based on logistic regression-derived Wald statistics. Comparison of the prevalence of snoring and SDB among the groups was performed using the generalized Fisher exact test and simple logistic regression with likelihood ratio tests. Likelihood profile CIs are reported for odds ratio estimates. A multiple logistic regression model was used to determine if any of the following were significant predictors of snoring and SDB: race/ethnicity, gender, age, percentile BMI, prematurity, history of asthma, history of allergy and socioeconomic status as determined by caretaker education, yearly household income, and insurance status. Chi-square analyses were performed to compare the children with complete data included in the multiple regression analysis to those not included with respect to the outcomes of snoring and SDB, as well as all the predictors. For the sample of snoring children, Spearman correlation and the Fisher exact test were used to determine if there was a relationship between parental knowledge about sleep apnea and concern about their children's snoring and between parental knowledge of sleep apnea and discussion with the child's pediatrician or other medical professional. SAS Release 9.2 (SAS Institute, Cary NC) statistical software was used. A p-value less than 0.05 was considered statistically significant.

RESULTS

Surveys were completed by 353 parents or caretakers. Seven surveys (2.0%) were discarded due to incomplete racial/ethnic data or failure to complete the PSQ, so the final data set consisted of 346 patients. Very few Hispanic patients were seen in the participating offices; because of time and budgetary constraints, the study was terminated prior to enrollment of the required number of Hispanic children based on the power analysis. Virtually all the surveys were completed by the child's mother (79.0%) or father (15.7%) (Table 1). The mean (SD) age was 4.9 (1.4) years, and there was a fairly equal distribution of boys and girls. The racial/ethnic distribution was 38.4% white, 44.8% black/African American, 11.8% Hispanic, and 4.9% other. The distribution is similar to that of Brooklyn whose population is 35% white, 34% black, 20% Hispanic, and 11% other.28 A history of prematurity was present in 16.7%, asthma in 11.1%, and allergies in 21.0%. Eight percent of the patients were underweight, 12.9% were overweight, and 15.8% were obese. Virtually all of the patients had commercial (58.9%) or public insurance (39.3%). The vast majority of caretakers had at least a high school education (89.4%), while 41.7% had a college degree or post-graduate degree. Annual household income varied widely, with 56.5% earning between $35K and $150K per year, and 30.7% earning < $35K per year.

The PSQ responses showed that 47 (13.9 %) children snored more than half the time (95% CI 10.2, 17.5, n = 339). The mean (SD) PSQ score was 0.13 (0.14). A mean PSQ score > 0.33 was found for 32 (9.4%) patients (95% CI 6.3, 12.6, n = 339). Twelve of 342 (3.5%) patients had a prior sleep study, 11/339 (3.2%) had prior treatment for sleep apnea, 10/344 (2.9%) had a prior tonsillectomy, and 14/335 (4.2%) had a prior adenoidectomy.

Snoring was found in 18.7% (95% CI 13.2, 25.7) of black children, 17.5% (95% CI 8.6, 32.4) of Hispanic children and 8.3% (95% CI 4.7, 14.4) of white children (Table 2). A mean PSQ score > 0.33 (SDB) was found in 11.6% (95% CI 7.4, 17.7) of black children, 9.8% (95% CI 3.7, 23.3) of Hispanic children, and 6.8% (95% CI 3.6, 12.5) of white children. The difference between blacks and whites was statistically significant for snoring but not for SDB. On unadjusted analysis, black children had 2.5 times the odds of snoring as white children, and Hispanic children had 2.3 times the odds of snoring as white children.

Table 2 Racial/ethnic distribution of snoring and sleep disordered breathing (SDB) in Children in Brooklyn, NY

Race/EthnicityNNo. Snoring (%)Snoring 95% CISnoring OR (95% CI for OR)*NNo. SDB (%)SDB 95% CISDB OR (95% CI for OR)*
    White13211 (8.3)4.7, 14.4Ref.1339 (6.8)3.6, 12.5Ref.
    Black15028 (18.7)13.2, 25.72.5 (1.2, 5.5)15518 (11.6)7.4, 17.71.8 (0.8, 4.4)
    Hispanic407 (17.5)8.6, 32.42.3 (0.8, 6.4)414 (9.8)3.7, 23.31.5 (0.4, 4.9)
    Significance0.0310.0320.3600.362

*Simple logistic regression,

Generalized Fisher exact test,

Type 3 Likelihood Ratio, Referent (ref.) = white.

Multiple logistic regression was performed for the 232 children with complete data for all potential predictors of snoring and SDB. Covariates stratified by the predictor of primary interest (race/ethnicity) are presented in Table 3. Comparison of the 232 subjects included in the model to the 114 subjects not included with respect to the outcomes of snoring and SDB and all the multiple regression predictors demonstrated that only caretaker's education proved statistically significant (p = 0.001). Those who completed some college or business/technical/vocational training after high school were more likely to have completed the entire questionnaire than caretakers from any other group.

Table 3 Covariates analyzed in multiple logistic regression model stratified by race/ethnicity (n = 232)

FactorBlack, No. (%)*Hispanic, No. (%)*White, No. (%)*Total
    Gender
        Male58 (53.7)11 (42.3)43 (43.9)112
        Female50 (46.3)15 (57.7)55 (56.1)120
    Age, y
        231 (28.7)8 (30.8)20 (20.4)59
        326 (24.1)5 (19.2)20 (20.4)51
        421 (19.4)5 (19.2)27 (27.6)53
        514 (13.0)3 (11.5)17 (17.4)34
        616 (14.8)5 (19.2)14 (14.3)35
    BMI Percentile
        Underweight9 (8.3)2 (7.7)7 (7.1)18
        Healthy69 (63.9)15 (57.7)65 (66.3)149
        Overweight12 (11.1)2 (7.7)17 (17.4)31
        Obese18 (16.7)7 (26.9)9 (9.2)34
    Birth History
        Premature22 (20.4)9 (34.6)10 (10.2)41
        Full-term86 (79.6)17 (65.4)88 (89.8)191
    Asthma
        Present22 (20.4)3 (11.5)4 (4.1)29
        Absent86 (79.6)23 (88.5)94 (95.9)203
    Allergies
        Present20 (18.5)5 (19.2)17 (17.4)42
        Absent88 (81.5)21 (80.8)81 (82.7)190
    Caretaker Education
        ≤ High school37 (34.3)4 (15.4)6 (6.1)47
        Some college42 (38.9)12 (46.2)43 (43.9)97
        College degree or post-graduate29 (26.9)10 (38.5)49 (50.0)88
    Annual income
        < $35K50 (46.3)11 (42.3)10 (10.2)71
        $35-$75K36 (33.3)7 (26.9)36 (36.7)79
        > $75K22 (20.4)8 (30.8)52 (53.1)82
    Insurance
        Public or none56 (51.9)6 (23.1)29 (30.0)91
        Commercial or military52 (48.2)20 (76.9)69 (70.4)141
    Snoring
        Yes20 (18.7)2 (7.7)8 (8.2)30
        No87 (81.3)24 (92.3)90 (91.8)201
    SDB
        Yes11 (10.2)3 (11.5)9 (9.2)23
        No97 (89.8)23 (88.5)89 (90.8)209

*% of race/ethnicity.

BMI, body mass index; SDB, sleep disordered breathing.

The results of the multiple regression analysis are presented in Table 4. Only race/ethnicity and a history of prematurity were significantly associated with snoring (p = 0.029 and p = 0.004, respectively), and only gender (p = 0.034) was significantly associated with SDB. Black children had 3.1 times the odds of snoring as white children; children with a history of prematurity had 4.4 times the odds of snoring as full-term children. Boys had 2.9 times the odds of SDB as girls. Although the odds ratio (95% CI) for SDB for children aged 6 compared to children aged 2 was 6.2 (1.2, 47.6), the likelihood ratio χ2 for age was not significant (p = 0.218) and the CI was very wide. This apparent paradox in our statistical testing does not allow a definitive conclusion regarding age as a predictor. The relatively low prevalence of snoring and SDB may account for the lack of additional statistically significant results from the models.

Table 4 Potential predictors of snoring and sleep disordered breathing (SDB) in 232 children in Brooklyn, NY

VariableSnoring
SDB
OR Estimate95% CI for OROR Estimate95% CI for OR
    Race/ethnicity: black vs. white3.1*1.1, 8.90.80.2, 2.7
    Race/ethnicity: Hispanic vs. white0.7*0.1, 3.71.00.2, 5.1
    Gender: male vs. female1.20.5, 2.92.9*1.1, 8.5
    Age, y: 3 vs. 21.70.5, 5.84.40.8, 33.7
    Age, y: 4 vs. 20.60.1, 2.42.90.5, 21.7
    Age, y: 5 vs. 22.50.7, 9.24.80.8, 38.7
    Age, y: 6 vs. 21.70.4, 6.36.21.2, 47.6
    BMI percentile: underweight vs. healthy0.60.1, 3.02.70.5, 11.9
    BMI percentile: overweight vs. healthy0.70.1, 2.50.80.1, 3.3
    BMI percentile: obese vs. healthy1.00.3, 3.60.60.1, 2.7
    Birth history: premature vs. full-term4.4*1.6, 12.41.40.4, 4.4
    Asthma0.60.1, 2.31.60.4, 6.3
    Allergies1.00.3, 3.01.40.4, 4.8
    Caretaker education: college degree or post-graduate vs. ≤ high school0.80.2, 3.61.30.3, 6.5
    Caretaker education: some college vs. ≤ high school1.40.4, 5.21.10.3, 4.5
    Annual income < $35K vs. $35K- $75K0.80.2, 2.83.40.9, 14.0
    Annual income: > $75K vs. $35K-$75K1.60.5, 5.60.80.2, 3.4
    Insurance: public or none vs. commercial or military0.80.3, 2.70.40.1, 1.3

Multiple logistic regression for the 232 subjects with complete data.

*statistically significant at α = 0.05;

BMI, body mass index.

Only 10.9% parents reported knowing “a lot” about sleep apnea, while 35.2% knew nothing about sleep apnea. Only 24.6% of the parents of children who snored were concerned about the snoring, and only 24.5% discussed the snoring with the child's pediatrician or other medical professional. For the 46 children who snored and had complete parental knowledge data, there was weak and nonsignificant correlation between knowledge of sleep apnea and parental concern about snoring (r = −0.08, p = 0.578) and weak and nonsignificant correlation between parental knowledge of sleep apnea and discussion of snoring with the child's pediatrician or other medical professional (r = −0.22, p = 0.141). When comparing parents who reported to know “a lot” about sleep apnea compared to parents who reported their knowledge to be from “none” to “some,” there was no significant difference between groups in the number of parents concerned about their child's snoring (p = 0.362) and the number of parents who discussed their child's snoring with their pediatrician (p > 0.99).

Of the parents of the 24 children who had a prior sleep study, prior treatment for sleep apnea, or a history of tonsillectomy and/or adenoidectomy, 7 (29.2%) reported knowing “ a lot” about sleep apnea, 9 (37.5%) knew “some” about sleep apnea, 5 (20.8%) knew “a little” about sleep apnea, and 3 (12.5%) knew nothing about sleep apnea. Of the 20 with complete knowledge data, 11 (55.0%) were at some point concerned about their child's snoring and 15 (75.0%) had discussed their child's snoring with the child's pediatrician or other medical professional.

DISCUSSION

The overall prevalence of snoring in children attending well-child care visits in Brooklyn was 13.9%, and the prevalence of SDB based on an abnormal PSQ score was 9.4%. An additional 3.2% had prior treatment for SDB. The snoring prevalence agrees with the epidemiologic studies of healthy children reporting values between 2.4% and 15.6%, but the prevalence of SDB was higher than reported in the epidemiologic studies (0.2 to 3.8%) that are generally based on questionnaire data and relatively insensitive recording techniques. Archbold et al., also using the PSQ, found the overall prevalence of snoring to be 17.1% and the prevalence of abnormal SDB scores to be 11% in children attending two general pediatric clinics.29

Our results demonstrate that the prevalence of snoring was significantly higher in black (18.7%) and Hispanic (17.5%) children than white (8.3%) children. Although PSQ scores suggestive of SDB were found in a greater percentage of black (11.6%) and Hispanic (9.8%) children than white (6.8%) children, the results were not significant, plausibly due to the small numbers of SDB cases. The small number of Hispanic children accounts for the large confidence intervals for snoring and SDB for this group and precludes forming useful conclusions regarding the association of Hispanic ethnicity and snoring and SDB in the logistic regression model. Black race was an independent predictor of snoring but not SDB in the model. The study was not powered to detect differences in the prevalence of SDB, as the sample size required would have been prohibitively large and beyond the scope of our resources.

Previous studies examining race/ethnicity as a risk factor for pediatric SDB suffer from either the use of selected patient populations—thus limiting the generalizability of the study results—and/or lack of a validated measure of SDB. Rosen et al.11 performed overnight home cardiorespiratory recordings on 850 children (41% non-Hispanic black, 46% preterm) aged 8 to 11 years recruited from the Low Birth Weight-Maternal Employment Study in Cleveland, Ohio. Depending on the definition used, SDB was 4 to 6 times more likely in black children compared with white children and 3 to 5 times as likely in former preterm infants as children born at full term. The children in this study were older than those considered to be most at risk for SDB. The complex recruitment scheme enrolled children who were former preterm low birth weight infants with neonatal intensive unit stays of > 1 week in addition to an approximately equal number of healthy children who were born full-term during the same birth years. Supplemental recruitment of both former preterm and full-term children was performed to enhance minority representation. The socioeconomic status of the cohort was not described.

Montgomery-Downs et al.9 surveyed the parents of 1,010 disadvantaged preschoolers in Jefferson County, Kentucky. They found that 22% were at risk for SDB, based on questionnaire responses regarding sleep, school performance, and behavior. Black children were found to be at higher risk for SDB (OR = 1.76) than white children. This study only included children of low socioeconomic status, and although the survey was previously validated against PSG, the sensitivity and specificity compared to PSG was only 0.92 and 0.21. Chervin et al.14 administered the PSQ to 146 parents of second and fifth grade children and evaluated school performance by teacher ratings and year-end math and reading assignments in an urban community west of Detroit. On bivariate analysis, risk for SDB was associated with black race, low socioeconomic status, and poor teacher ratings. In this cohort, 43% were considered to be of low socioeconomic status, based on participation in the school lunch assistance program.

Goodwin et al.6 surveyed the parents of 1,494 schoolchildren aged 4 to 11 years in Tucson, Arizona. The parents of Hispanic children reported snoring and witnessed apnea more frequently than the parents of non-Hispanic white children (11.4% vs. 7.4%, p < 0.02 and 4.7% vs. 1.9%; p < 0.007, respectively). This study also relied on non-validated questionnaire data and although the cohort is community-based, no socioeconomic data were presented. In a follow-up study of 480 children from the initial cohort at ages 6 to 11 using home unattended PSG, Hispanic ethnicity was not a predictor of positive PSG in either the unadjusted or adjusted analyses.30

Bixler et al.3 surveyed the parents of 5,740 children in local elementary schools (grades K-5) in Dauphin County, PA and subsequently performed overnight PSG on 700 randomly selected children. The prevalence of moderate SDB (AHI ≥ 5) was 1.2% (95% CI 0.6, 2.2); 13.8% of the sample was black and 6.3% was Hispanic. Minority designation (black or Hispanic) was an independent risk factor for snoring (snoring but AHI < 1) and mild SDB (AHI ≥ 1 but < 5) but not moderate SDB, although only 8 children had studies with an AHI ≥ 5. As a population study, this study eliminated some of the selection bias of the other studies, but black and Hispanic children were grouped together, and the children were older than those evaluated in the present study. Socioeconomic data regarding the sample were not presented. The strength of the present study was the use of a community-based essentially middle-class, insured cohort of young children whose parents had generally high levels of education, thus eliminating the selection bias that detracts from most of the previous studies.

Our multivariate analysis demonstrated that only race/ethnicity and prematurity were significantly associated with snoring, and male sex was significantly associated with SDB. Our rate of prematurity (16.7%) was somewhat higher than the 2006 national average of 12.8%.31 Although it is generally accepted that SDB is most common in children aged 2 through 6, the prevalence rates of snoring and SDB are fairly constant throughout these ages. Most prior studies report gender differences in snoring and SDB with boys affected at a rate 50% to 100% higher than girls.8 Our prevalence of obesity (15.8%) and overweight (12.9%) are higher than the 2007-2008 national rates for 2- to 5-year-olds of 10.4% and 10.8%.32 Although obesity is a well-established risk factor for SDB in adults, its association with SDB in children is less clear. Of 15 studies evaluating the association of weight status with SDB, 9 reported positive findings and 6 reported negative findings.3,8 Similarly, several prior studies have demonstrated an association of SDB with failure to thrive, although other studies have not found a significant association.33

Our prevalence of asthma (11.1%) was similar to the 2008 national rate for children of 9.5%, although our prevalence of allergies (21.0%) was higher than the national rate for respiratory allergies (11.3%) and other allergies (14.2%).34 We did not find an association between asthma and allergies with snoring and SDB. Although a few preliminary studies have shown an association between wheezing, lower respiratory symptoms, and exercise-induced asthma with SDB, larger confirmatory studies are needed.16,18 There have been conflicting results regarding the association of allergy and SDB. McColley et al.19 reported a higher prevalence (36%) of allergic sensitization by multi-antigen radioallergosorbent testing (RAST) in 39 children with habitual snoring referred to the sleep laboratory (as compared to the expected rate in the general population), and OSA was more commonly diagnosed in the allergic children than the non-allergic children (57% vs. 40%; p < 0.01). In contrast, Carr et al.20 found that RAST testing results to common airborne allergens in 117 children < 16 years undergoing adenotonsillectomy for treatment of OSA correlated with the expected results in the general population.

We did not find an association of snoring and SDB with socioeconomic status. The environment in which the children live should have been adequately captured by measurement of three separate socioeconomic variables. Spilsbury et al.21 evaluated residence in a neighborhood of severe socioeconomic disadvantage as a risk factor for SDB in 843 children from the Cleveland Children's Sleep and Health Study. The authors found that residence in a neighborhood of severe socioeconomic disadvantage was significantly associated with OSA after adjusting for effects of prematurity, obesity, and African American race (OR = 3.44; 95% CI 1.53, 7.75). Chervin et al.14 in the study described above found that the risk for SDB was also associated with low socioeconomic status. On multivariate analysis, low socioeconomic status retained its association when including asthma history, black race, and hours in bed in the model, but showed no association when BMI was included. In the present study, we did not find an association of BMI with SDB.

Factors that may account for differences in the development of SDB amongst different racial/ethnic groups include differences in craniofacial anatomy, adenotonsillar hyperplasia, regional fat distribution, neuromotor tone, and systemic inflammation. There is mounting evidence that there is a familial predisposition to the development of SDB, as genetic-epidemiologic surveys of families of index patients with OSA have demonstrated a higher prevalence of SDB in family members as compared to the general population.3537 It is likely that multiple genetic factors interact to produce the OSA phenotype, and many candidate genes are currently being studied.

Knowledge regarding pediatric SDB was low among parents and caretakers. Several studies have shown also shown that there is a low level of recognition of pediatric sleep disorders by primary care physicians and parents. In a survey of 600 community-based pediatricians, only one quarter of the respondents reported screening toddlers and school-aged children for snoring.22 Parents of 830 children attending 2 community-based general pediatrics clinics completed the PSQ; 86 were symptomatic for SDB or other sleep disorders.23 Of these 86 children, only 15% had current chart notes that mentioned the PSQ-defined sleep problems. In a cross-sectional online survey of 584 parents conducted by the Harris Interactive Group, only 15% considered themselves “knowledgeable” about pediatric SDB, and less than 20% knew that pediatric SDB could be treated by adenotonsillectomy.24 As expected, knowledge about SDB was higher amongst parents whose children had undergone a work-up for SDB or had undergone tonsillectomy and/or adenoidectomy.

Surprisingly, there was no association between parental knowledge of sleep apnea and concern about snoring and discussion of snoring with a medical professional. There is a large body of health promotion research that has shown that health education may be a useful first step but is often insufficient to promote behavior change.3840 Our preliminary findings also suggest that parental educational efforts regarding snoring and pediatric SDB may not necessarily lead to earlier evaluation of potentially affected children. Targeted, collaborative interventions involving the physician's office, school, and community will most likely be required to achieve the best outcomes.

Weaknesses of our study include the relatively low prevalence of snoring and SDB (which may have resulted in inadequate sample size and power to detect additional associations between potential risk factors and SDB); the small number of Hispanic children; the use of a convenience sample; incomplete data for one-third of the sample; and not using an objective test of snoring and SDB, such as PSG. PSG is expensive and time-consuming, and the PSQ has been validated against PSG for use in research settings when PSG is not feasible. Accurate epidemiologic data are necessary for targeted screening and timely diagnosis and treatment of pediatric SDB. Our results suggest that male gender, black race, and prematurity are risk factors for snoring and SDB, but identification of additional risk factors requires additional larger studies, preferably utilizing laboratory-based overnight PSG.

CONCLUSION

In our cross-sectional study, the prevalence of snoring and SDB was higher among black and Hispanic children than white children. On multivariate analysis, only black race and prematurity were associated with snoring, and male gender was associated with SDB. Knowledge regarding SDB was low among parents and caretakers, although the degree of knowledge present was not associated with seeking medical treatment. Future studies should determine the most appropriate educational efforts and interventions involving the parents, physician's office, school, and community that will lead to timely diagnosis and treatment.

DISCLOSURE STATEMENT

This was not an industry supported study. The authors have indicated no financial conflicts of interest.

ABBREVIATIONS

SDB

Sleep disordered breathing

OSA

Obstructive sleep apnea

PSG

Polysomnography

PSQ

Pediatric Sleep Questionnaire

BMI

Body mass index

SRBD

Sleep-Related Breathing Disorders

SUNY

State University of New York

CIs

Confidence intervals

RAST

Radioallergosorbent testing

HMO

Health maintenance organization

OR

Odds ratio

REFERENCES

  • 1 Ali NJPitson DJStradling JRSnoring, sleep disturbance, and behaviour in 4-5 year oldsArch Dis Child1993683606, 8280201

    CrossrefGoogle Scholar
  • 2 Anuntaseree WRookkapan KKuasirikul SThongsuksai PSnoring and obstructive sleep apnea in Thai school-age children: prevalence and predisposing factorsPediatr Pulmonol2001322227, 11536452

    CrossrefGoogle Scholar
  • 3 Bixler EOVgontzas ANLin H-M, et al.Sleep disordered breathing in children in a general population sample: prevalence and risk factorsSleep2009327316, 19544748

    CrossrefGoogle Scholar
  • 4 Castronovo VZucconi MNosetti L, et al.Prevalence of habitual snoring and sleep-disordered breathing in preschool-aged children in an Italian communityJ Pediatr200314237782, 12712054

    CrossrefGoogle Scholar
  • 5 Gislason TBenediktsdóttir BSnoring, apneic episodes, and nocturnal hypoxemia among children 6 months to 6 years old. An epidemiologic study of lower limit of prevalenceChest19951079636, 7705162

    CrossrefGoogle Scholar
  • 6 Goodwin JLBabar SIKaemingk KL, et al.Symptoms related to sleep-disordered breathing in white and Hispanic children: the Tucson Children's Assessment of Sleep Apnea StudyChest2003124196203, 12853523

    CrossrefGoogle Scholar
  • 7 Liu XMa YWang Y, et al.Brief report: an epidemiologic survey of the prevalence of sleep disorders among children 2 to 12 years old in Beijing, ChinaPediatrics20051151 Suppl2668, 15866861

    CrossrefGoogle Scholar
  • 8 Lumeng JCChervin RDEpidemiology of pediatric obstructive sleep apneaProc Am Thorac Soc2008524252, 18250218

    CrossrefGoogle Scholar
  • 9 Montgomery-Downs HEGozal DSleep habits and risk factors for sleep-disordered breathing in infants and young toddlers in Louisville, KentuckySleep Med200672119, 16564742

    CrossrefGoogle Scholar
  • 10 Montgomery-Downs HEJones VFMolfese VGozal DSnoring in preschoolers: associations with sleepiness, ethnicity, and learningClin Pediatr (Phila)20034271926, 14601921

    CrossrefGoogle Scholar
  • 11 Rosen CLLarkin EKKirchner HL, et al.Prevalence and risk factors for sleep- disordered breathing in 8- to 11-year old children: association with race and prematurityJ Pediatr20031423839, 12712055

    CrossrefGoogle Scholar
  • 12 Teculescu DBCaillier IPerrin PRebstock ERauch ASnoring in French preschool childrenPediatr Pulmonol19921323944, 1523035

    CrossrefGoogle Scholar
  • 13 Valery PCMasters IBChang ABSnoring and its association with asthma in Indigenous children living in the Torres Strait and Northern Peninsula AreaJ Paediatr Child Health2004404615, 15265188

    CrossrefGoogle Scholar
  • 14 Chervin RDClarke DFHuffman JL, et al.School performance, race, and other correlates of sleep-disordered breathing in childrenSleep Med20034217, 14592356

    CrossrefGoogle Scholar
  • 15 Redline STishler PVHans MGTosteson TDStrohl KPSpry KRacial differences in sleep-disordered breathing in African-Americans and CaucasiansAm J Respir Crit Care Med199715518692, 9001310

    CrossrefGoogle Scholar
  • 16 Redline STishler PVSchluchter MAylor JClark KGraham GRisk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problemsAm J Respir Crit Care Med19991595 Pt 1152732, 10228121

    CrossrefGoogle Scholar
  • 17 Stepanski EZayyad ANigro CLopata MBasner RSleep-disordered breathing in a predominantly African-American pediatric populationJ Sleep Res199986570, 10188138

    CrossrefGoogle Scholar
  • 18 Sulit LGStorfer-Isser ARosen CLKirchner HLRedline SAssociations of obesity, sleep-disordered breathing, and wheezing in childrenAm J Respir Crit Care Med200517165964, 15591475

    CrossrefGoogle Scholar
  • 19 McColley SACarroll JLCurtis SLoughlin GMSampson HAHigh prevalence of allergic sensitization in children with habitual snoring and obstructive sleep apneaChest19971111703, 8996012

    CrossrefGoogle Scholar
  • 20 Carr EObholzer RCaulfield HA prospective study to determine the incidence of atopy in children undergoing adenotonsillectomy for obstructive sleep apneaInt J Pediatr Otorhinolaryngol2007711922, 16979762

    CrossrefGoogle Scholar
  • 21 Spilsbury JCStorfer-Isser AKirchner L, et al.Neighborhood disadvantage as a risk factor for pediatric obstructive sleep apneaJ Pediatr20061493427, 16939744

    CrossrefGoogle Scholar
  • 22 Owens JAThe practice of pediatric sleep medicine: results of a community surveyPediatrics2001108E51, 11533369

    CrossrefGoogle Scholar
  • 23 Chervin RDHedger Archbold KPanahi PPituch KJSleep problems seldom addressed at two general pediatric clinicsPediatrics2001107137580, 11389260

    CrossrefGoogle Scholar
  • 24 Strocker AMShapiro NLParental understanding and attitudes of pediatric obstructive sleep apnea and adenotonsillectomyInt J Pediatr Otorhinolaryngol200771170915, 17850886

    CrossrefGoogle Scholar
  • 25 Tamay ZAkcay AKilic GSuleyman AOnes UGuler NAre physicians aware of obstructive sleep apnea in children?Sleep Med200675804, 16996307

    CrossrefGoogle Scholar
  • 26 Chervin RDHedger KDillon JEPituch KPediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problemsSleep Med20001213, 10733617

    CrossrefGoogle Scholar
  • 27 Chervin RDWeatherly RAGaretz SL, et al.Pediatric sleep questionnaire: prediction of sleep apnea and outcomesArch Otolaryngol Head Neck Surg200713321622, 17372077

    CrossrefGoogle Scholar
  • 28 Brooklyn Community Health.2007Brooklyn, NYOffice of Institutional Advancement and Office of Planning, SUNY Downstate Medical Center

    Google Scholar
  • 29 Archbold KHPituch KJPanabi PChervin RDSymptoms of sleep disturbances among children at two general pediatric clinicsJ Pediatr200214097102, 11815771

    CrossrefGoogle Scholar
  • 30 Goodwin JLKaemingk KLMulvaney SAMorgan WJQuan SFClinical screening of school children for polysomnography to detect sleep-disordered breathing–the Tucson Children's Assessment of Sleep Apnea Study (TuCASA)J Clin Sleep Med2005124754, 16429591

    LinkGoogle Scholar
  • 31 Martin JAHamilton BESutton PD, et al.Births: Final data for 2006. National vital statistics reports; vol 57 no. 72009Hyattsville, MDNational Center for Health Statistics

    Google Scholar
  • 32 Ogden CLCarroll MDCurtin LRLamb MMFlegal KMPrevalence of high body mass index in US children and adolescents, 2007-2008JAMA20103032429, 20071470

    CrossrefGoogle Scholar
  • 33 Stone RSSpeigel JHPrevalence of obstructive sleep disturbance in children with failure to thriveJ Otolaryngol Head Neck Surg200985739, 19769829

    Google Scholar
  • 34 Bloom BCohen RAFreeman GSummary health statistics for U.S. children: National Health Interview Survey, 2008National Center for Health Statistics. Vital Heath Stat200910244

    Google Scholar
  • 35 Friberg DSundquist JLi XHemminki KSundquist KSibling risk of obstructive sleep apnea and adenotonsillar hypertrophySleep200932107783, 19725259

    CrossrefGoogle Scholar
  • 36 Ovchinsky ARao MLotwin IGoldstein NAThe familial aggregation of pediatric obstructive sleep apneaArch Otolaryngol Head Neck Surg20021288158, 12117342

    CrossrefGoogle Scholar
  • 37 Redline STishler PVTosteson TD, et al.The familial aggregation of obstructive sleep apneaAm J Respir Crit Care Med19951516827, 7881656

    CrossrefGoogle Scholar
  • 38 Bazata DDRobinson JGFox KMGrandy SAffecting behavior change in individuals with diabetes: findings from the Study to Help Improve Early Evaluation and Management of Risk Factors Leading to Diabetes (SHIELD)Diabetes Educ200834102536, 19075084

    CrossrefGoogle Scholar
  • 39 Edwards TCumberland PHailu GTodd JImpact of health education on active trachoma in hyperendemic rural communities in EthiopiaOphthalmology200611354855, 16581416

    CrossrefGoogle Scholar
  • 40 Shepherd JPeersman GWeston RNapuli ICervical cancer and sexual lifestyle: a systematic review of health education interventions targeted at womenHealth Educ Res20001568194, 11142076

    CrossrefGoogle Scholar