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Clinical Characteristics of Primary Snoring vs Mild Obstructive Sleep Apnea in Children: Analysis of the Pediatric
Ron B Mitchell1, Kaitlyn Cook2,3,4, Susan Garetz5
1Children's Medical Center of Dallas and University of Texas Southwestern Medical Center, Dallas.
Insights
Distinguishing primary snoring from mild obstructive sleep apnea (OSA) in children is challenging without polysomnography. Clinical factors like Black race, obesity, and high cotinine levels showed some association with mild OSA.
Area of Science:
- Pediatric Sleep Medicine
- Respiratory Medicine
- Clinical Trials
Background:
- Primary snoring and mild obstructive sleep apnea (OSA) in children are often managed similarly, with an apnea-hypopnea index (AHI) of 1 or greater frequently used to define OSA and guide treatment decisions like adenotonsillectomy (AT).
- However, it remains unclear if these two conditions represent distinct clinical populations in children.
Purpose of the Study:
- To determine if a combination of clinical characteristics can differentiate children with primary snoring from those with mild OSA.
Main Methods:
- Analysis of baseline data from the multicenter Pediatric Adenotonsillectomy Trial for Snoring (PATS) study.
- Included children aged 3.0-12.9 years with polysomnography-diagnosed mild obstructive sleep-disordered breathing (AHI 1-3) or primary snoring (AHI <1).
- Logistic regression models were used to identify distinguishing demographic, clinical, and caregiver report factors.
Main Results:
- Black race, obesity, and high urinary cotinine levels were associated with a higher likelihood of mild OSA compared to primary snoring.
- Other demographic factors, clinical findings, and questionnaire results did not significantly differentiate between the two groups.
- A combined model of significant predictors showed limited ability to distinguish between mild OSA and primary snoring.
Conclusions:
- Primary snoring and mild OSA in children are difficult to differentiate based on clinical characteristics alone; polysomnography is essential for accurate diagnosis.
- Mild OSA, as defined by an AHI of 1-3, did not identify a distinct clinical subgroup of children who would clearly benefit from adenotonsillectomy for obstructive sleep-disordered breathing.
Importance:
It is unknown whether children with primary snoring and children with mild obstructive sleep apnea (OSA) represent populations with substantially different clinical characteristics. Nonetheless, an obstructive apnea-hypopnea index (AHI) of 1 or greater is often used to define OSA and plan for adenotonsillectomy (AT).
Objective:
To assess whether a combination of clinical characteristics differentiates children with primary snoring from children with mild OSA.
Design, Setting, And Participants:
Baseline data from the Pediatric Adenotonsillectomy Trial for Snoring (PATS) study, a multicenter, single-blind, randomized clinical trial conducted at 6 academic sleep centers from June 2016 to January 2021, were analyzed. Children aged 3.0 to 12.9 years with polysomnography-diagnosed (AHI <3) mild obstructive sleep-disordered breathing who were considered candidates for AT were included. Data analysis was performed from July 2022 to October 2023.
Main Outcomes And Measures:
Logistic regression models were fitted to identify which demographic, clinical, and caregiver reports distinguished children with primary snoring (AHI <1; 311 patients [67.8%]) from children with mild OSA (AHI 1-3; 148 patients [32.2%]).
Results:
A total of 459 children were included. The median (IQR) age was 6.0 (4.0-7.5) years, 230 (50.1%) were female, and 88 (19.2%) had obesity. A total of 121 (26.4%) were Black, 75 (16.4%) were Hispanic, 236 (51.5%) were White, and 26 (5.7%) were other race and ethnicity. Black race (odds ratio [OR], 2.08; 95% CI, 1.32-3.30), obesity (OR, 1.80; 95% CI, 1.12-2.91), and high urinary cotinine levels (>5 µg/L) (OR, 1.88; 95% CI, 1.15-3.06) were associated with greater odds of mild OSA rather than primary snoring. Other demographic characteristics, clinical examination findings, and questionnaire reports did not distinguish between primary snoring and mild OSA. A weighted combination of the statistically significant clinical predictors had limited ability to differentiate children with mild OSA from children with primary snoring.
Conclusions And Relevance:
In this analysis of baseline data from the PATS randomized clinical trial, primary snoring and mild OSA were difficult to distinguish without polysomnography. Mild OSA vs snoring alone did not identify a clinical group of children who may stand to benefit from AT for obstructive sleep-disordered breathing.
Trial Registration:
ClinicalTrials.gov Identifier: NCT02562040.
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