Risk of influenza and COVID-19 illness and pediatric obstructive sleep apnea: a TriNetX cohort with 5-year follow-up

Obstructive sleep apnea (OSA) is associated with impaired immune responses. Prior small-scale investigations suggested that pediatric OSA leads to a more severe clinical course of common childhood viruses. Whether OSA increases the risk of infection remains unknown.

To examine whether children with OSA are at increased risk of influenza or COVID-19, and to assess the effect of adenotonsillectomy.

Using TriNetX, we compared children aged 2-18 years with incident OSA and matched controls without OSA. Outcomes were ICD-10-coded influenza and COVID-19 over a five-year follow-up. We estimated risk ratios (RRs) and Kaplan-Meier hazard ratios (HRs).

Matched cohorts included 539,127 children each (mean age 5.6 ± 3.6 years). Influenza was diagnosed in 5.1% of OSA vs. 2.8% of controls (RR 1.80; 95% CI, 1.765-1.836); five-year influenza-free survival was 90.27% vs. 93.04% (HR 1.45; 95% CI, 1.421-1.479). COVID-19 was diagnosed in 2.5% vs. 1.0% (RR 2.496; 95% CI, 2.418-2.576); five-year COVID-19-free survival was 95.02% vs. 97.49% (HR 1.986; 95% CI, 1.924-2.050). Effects were similar across age groups. In the treatment sub-analysis (n = 96,004 per group), adenotonsillectomy did not reduce risk. In secondary analyses, OSA was also associated with a higher risk of pneumonia due to influenza or COVID-19.

In a period spanning 5 years after OSA diagnosis, children of all ages have a significantly higher risk of influenza and COVID-19 diagnoses. Although absolute risks are low, adenotonsillectomy does not lessen susceptibility, suggesting persistent immune dysregulation and supporting prioritization of seasonal vaccination in children with OSA.