Racial and ethnic disparities in pediatric obstructive sleep apnea: insights from a large study on adolescents in southern California

The American Thoracic Society and the American Academy of Pediatrics describe obstructive sleep apnea (OSA) in children as a sleep-related breathing disorder characterized by intermittent obstruction of the upper airway, which disrupts normal sleep patterns.¹ Misdiagnosed and untreated pediatric OSA has been associated with increased behavioral issues, such as inattentive, hyperactive, aggressive behavior and poor academic performance.^2,3,4 Whereas prompt diagnosis and appropriate treatment are essential, it is well-established that racial/ethnic, and socioeconomic disparities exist in the prevalence of pediatric OSA.⁵

Notably, Goodwin et al found that Black or Hispanic children were more likely to develop OSA and their parents observed more symptoms of sleep-disordered breathing and daytime sleepiness in their children.⁶ Apnea-hypopnea index (AHI) was also found to be higher in Black pediatric populations, and it was assumed that Black children would have more severe OSA.⁷ Prevalence of OSA was observed to be higher among children from lower-income families^8,9 and those whose mothers had lower levels of education.^10,11 The majority of studies focused on prepubertal children, so whether there are racial disparities among non-Hispanic Asian or Pacific Islander children and adolescents, and within the adolescent population in general, is still less evident and largely remains unknown.

In this issue of the Journal of Clinical Sleep Medicine, Landeo-Gutierrez et al present a retrospective study examining racial disparities in adolescents aged 11–18 years who underwent diagnostic polysomnography at Rady Children’s Hospital San Diego between October 2016 and April 2022.¹² In this study, clinical and demographic data, including past medical history and body mass index percentile, were obtained from electronic health records, and polysomnography data were recorded with Polysmith software (Nihon Koden, Irvine, California). Their study excluded children with conditions such as cerebral palsy, genetic syndromes, developmental delays, craniofacial anomalies, or those on medications affecting sleep. Socioeconomic factors were assessed using median income by zip code and the Child Opportunity Index 2.0, which generates a global Z-score based on education, health, and socioeconomic indicators. Lower Child Opportunity Index social and economic Z-scores indicate less-favorable socioeconomic conditions. The results are impressive with a large data set including 1,745 adolescents, of whom 58.2% were Hispanic, 24.1% non-Hispanic White, 4.3% non-Hispanic Asian/Pacific Islander, 4.2% non-Hispanic Black/African American (NH-Black/AA), and 6.6% were of other or unknown ethnicities. They found that Hispanic and NH-Black/AA adolescents had higher obstructive AHI (OAHI) scores compared with non-Hispanic White peers, and Hispanic males showed a significant increase in OAHI. Univariate and multivariate analysis revealed that Hispanic ethnicity was associated with a 28.4% increase in OAHI, with a more pronounced effect in males. Additionally, non-Hispanic Asian adolescents had higher odds of moderate-to-severe OSA, but this was not significant in females, and interactions between body mass index and race/ethnicity were noted, particularly for non-Hispanic Asian individuals. Finally, lower socioeconomic conditions, as indicated by a lower Child Opportunity Index social and economic Z-score, were linked to a higher likelihood of moderate-to-severe OSA among non-Hispanic Asian/Pacific Islander adolescents, but not in other groups (non-Hispanic White, Hispanic, or NH-Black/AA).

Disparities in OSA among ethnic minority children in the United States have often been reported with a focus on NH-Black/AA populations.^13,14 Previous studies, including the Cleveland Family Study¹² and Childhood Adenotonsillectomy Trial,¹⁴ demonstrated a strong association between NH-Black/AA ethnicity and increased AHI, although this link was not significant when adjusting for socioeconomic status. These studies also did not find a significant relationship between Hispanic ethnicity and OSA severity.¹⁴ Until the present time, this study led by Landeo-Gutierrez et al is the largest pediatric study to examine racial and ethnic disparities in adolescents with OSA using in-laboratory polysomnography with a notable inclusion of Hispanic children. Their novel findings are that Hispanic ethnicity was associated with a 28.4% increase in OAHI, non-Hispanic Asian adolescents had higher odds of moderate-to-severe OSA, and lower socioeconomic status was linked to a higher likelihood of moderate-to-severe OSA among non-Hispanic Asian/Pacific Islander adolescents. These findings are groundbreaking, because prior research had not identified such associations after adjusting for age, sex, body mass index percentile, and socioeconomic factors, partly due to the small representation of Hispanic participants in earlier studies (1.2–7.8%).^2,13,14 Contrary to previous knowledge, Landeo-Gutierrez et al did not find an association between NH-Black/AA ethnicity and higher OAHI, which probably cannot exclude that possibility due to the study’s demographic composition, which was heavily Hispanic given the higher Hispanic population in San Diego. The study highlights the importance of timely diagnosis and treatment for minority groups, such as Hispanic males and non-Hispanic Asian/Pacific Islander adolescents, to prevent complications related to OSA. They also proposed that future research should focus on better representation of minority groups, include assessments of upper airway anatomy and function, and consider comprehensive social determinants of health.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. This was not an industry-supported article. The authors report no conflicts of interest.