Appendix A.
Summary of published studies investigating neurocognitive performance and behavior in children with SDB
| Authors | Population | SDB/snoring measure | Neurocognitive dysfunction | Behavioral dysfunction | Note | |
|---|---|---|---|---|---|---|
| Guilleminault et al6 | 8 OSAS (5–14 y) | PSG | Academic difficulties | Emotional disturbance, hyperactive, sleepiness | Anecdotal reports only | |
| Guilleminault et al139 | 24 OSAS, 26 OSAS secondary to medical problem, 22 controls (all 1–16 y) | Esophageal pressure, PSG | Academic difficulties, language | Aggression, hyperactive, inattentive, sleepiness, withdrawn | Anecdotal reports only | |
| Brouillette et al68 | 22 OSAS (3–5 y) | Daytime PSG | Not reported | General behavior, sleepiness | Anecdotal reports and unspecified measures | |
| Guilleminault et al7 | 25 snorers, 25 controls (all 2–14 y) | Esophageal pressure, PSG | Academic difficulties | Aggressive, hyperactive, sleepiness, withdrawn | Anecdotal reports only | |
| Weissbluth et al140 | 71 behavior, academic, an development problems (6.2 ± 3.5 y); 355 controls (5.8 ± 3.1 y) | Questionnaire | Academic difficulties | Hyperactive, inattentive | No PSG, nonvalidated behavior measure | |
| Brouillette et al141 | 23 OSAS (3.8 ± 2.4 y), 46 controls (4.0 ± 2.3 y) | PSG, questionnaire | NA | Sleepiness, withdrawn | PSG in OSAS group only, nonvalidated behavior measure | |
| Stradling et al71 | 61 snorers (4.7 ± 1.7 y), 31 controls (4.7 ± 1.7 y) | Home oximetry and video, questionnaire | NA | Aggressive, hyperactive | Nonvalidated behavior measure | |
| Ali et al142 | 782 from health registrar – 66 SDB, 66 controls (all aged 4–5 y) | Home oximetry and video, questionnaire | NA | Aggressive, hyperactive, inattentive | Nonvalidated behavior measure | |
| Carskadon et al143 | 29 children with adenotonsillar hypertrophy (8.7 ± 3.0 y) | Questionnaire | NA | Disruptive | Nonvalidated behavior measure, no control group | |
| Ali et al69 | 507 from health registrar (all aged 6.5–7.5 y) – 56 snorers | Questionnaire | NA | Hyperactive, sleepiness | ||
| Rhodes et al45 | 5 patients with OSAS (12.9 ± 2.1 y), 9 clinical patients with no OSAS (13.5 ± 1.5 y) | PSG | Learning, memory | NA | All subjects were obese | |
| Ali et al70 | 12 SDB (5–12 y), 11 snorers (6–12 y), 10 controls (6–12 y) | Questionnaire, home nocturnal oximetry and video | No between-group differences (IQ, attention, response speed) | Aggressive, hyperactive, inattentive | ||
| Guilleminault et al144 | 411 sleep clinic patients (birth to 12 y) | Esophageal pressure, PSG | NA | Oppositional | Nonvalidated behavior measure | |
| Chervin et al145 | 27 ADHD patients (9.5 ± 3.7 y), 116 non-ADHD patients (8.9 ± 4.7 y) | Questionnaire | NA | Hyperactive, inattention | Groups defined by ADHD symptom, nonvalidated behavior measure | |
| Owens-lively et al146 | 23 OSAS (age not reported) | PSG | Attention | Impulsivity and inattentiveness compared with moderate/severe OSA, mild OSA more severe hyperactivity | No control group | |
| Gozal72 | 297 first grade children with poor academic performance (177 controls, 66 primary snorers, 30 nontreated SDB, and 24 treated SDB) | Home oximetry and TcCO2, questionnaire | Academic performance | NA | ||
| Owens et al147 | 100 OSAS (8.9 ± 4.7 y) vs 52 behavioral sleep problems | PSG | NA | OSAS patients displayed less problematic behavior compared with children with behavioral sleep problems | Snoring evident in the group with behavioral sleep problems | |
| Harvey et al80 | 56 SDB (2.9 ± 1.3 y) | PSG | Not reported | Not reported | 28%neurologicallyabnormal | |
| Blunden et al31 | 16 snorers (7.2, 5–10 y), 16 controls (7.7, 5–10 y) | PSG (n = 26), questionnaire | Attention, IQ, memory | No differences between groups | Groups not matched for SES | |
| Ferreira et al148 | 976 children (8.1 ± 1.5 y) from community (8.8% habitual snorers) | Questionnaire | NA | Irritability, sleepiness | ||
| Goldstein et al85 | 36 snorers (4.6, 2–10 y) | Questionnaire, physical examination | NA | externalizing | No control group | |
| Kelmanson149 | 200 infants—71 snorers/noisy breathing (3.0 ± 1.0 mo) | Questionnaire | NA | Negative mood | Nonvalidated sleep measure | |
| Owens et al46 | 18 OSAS (7.3 ± 2.0 y) | PSG | No difference between mild and moderate OSAS | Learning problems, somatic complaints, no difference between mild and moderate OSAS | No control group | |
| Richards and Ferdman73 | 45 OSAS post-AT (2.5–15.5 y) | PSG, questionnaire | School performance | Sleepiness | Retrospective review, no control group | |
| Brunetti et al150 | 895 school students(7.3 y, 3–11 y) – 44 habitual snorers (4.9%) | Questionnaire, limited home PSG (n = 34), laboratory PSG (n = 12) | Academic performance | Hyperactive | ||
| Chervin and Archbold151 | 113 sleep clinical patients (9.9 ± 4.0 y) – 59 SDB, 54 non-SDB | PSG | NA | No reported associations | Non-SDB group included primary snorers | |
| Gozal and Pope152 | 797 low-performing students, 791 high-performing students (all 13–14 y) | Questionnaire | Snoring more likely amongst low-performing students | NA | ||
| Hansen and Vandenberg47 | 7 OSAS (7.3 ± 2.0 y), 7 narcoleptics (7.3 ± 2.0 y) | PSG | Attention | NA | No control group | |
| Smedje et al153 | 635 children (84 ± 5 mo) from community (9.3% habitual snorers) | Questionnaire | NA | No reported associations | ||
| Stein et al154 | 472 children (4–12 y) from pediatric clinic (23% snored >1 night/wk) | Questionnaire | NA | Social problems, somatic complaints | ||
| Chervin and Archbold151 | 866 children attending clinics (6.8 ± 3.2 y), 139 habitual snorers | Questionnaire | NA | Snoring associated with hyperactivity | ||
| Goldstein et al84 | 64 children awaiting AT (7.3 ± 2.0 y) | Questionnaire, physical examination | NA | All behaviors within clinical range | No control group | |
| Lewin et al19 | 12 severe OSAS (6.6 ± 1.5 y), 16 mild OSAS (7.6 ± 3.0 y), 10 controls (6.9 ± 1.1 y) | PSG (OSAS only), questionnaire | Information processing, verbal IQ (associations and group differences reported for severe OSAS group and controls only) | Internalizing problems, somatic complaints, externalizing problems, anxiety/depression, social problems in mild OSAS group only | No PSG in control group | |
| Castronovo et al156 | 447 children (4.1 ± 0.9 y) from community, 154 habitual snorers | Questionnaire, limited home PSG (n = 241) | NA | Irritable | Nonvalidated behavior measure | |
| Chervin et al22 | 146 school children (9.3 ± 0.4 y) | Questionnaire | Teacher reports of performance but not objective test scores | NA | ||
| Chervin et al157 | 872 children attending clinics (6.7 ± 3.2 y) | Questionnaire | NA | Aggression, conduct problems | ||
| Freidman et al16 | 39 OSAS (6.8 ± 0.2 y), 20 controls (7.4 ± 1.4 y) | PSG (OSAS only), questionnaire | Analytic thinking, auditory-visual integration, general intelligence, memory | NA | No PSG in control group | |
| Gottlieb et al60 | 3,019 children (all 5 y, 362 habitual snorers) | Questionnaire | NA | Aggression, hyperactive, inattentive, sleepiness | ||
| Kaemingk et al48 | 149 school children (8.4 ± 1.7 y), 77 API ≥ 5 | PSG | Memory | None found | ||
| Kohyama et al61 | 32 SDB (5.6, 4–9 y), | PSG (SDB only) | NA | Anxiety, inattention, | No sleep | |
| 137 controls (5.3, 4–6 y) | social problems, somatic complaints, thought problems, withdrawn | assessment for controls | ||||
| Montgomery-Downs et al23 | 746 developmentally or financially disadvantaged children (4.2 ± 0.53 y) | Questionnaire | School performance | Hyperactivity, sleepiness | High percentage on nonresponders | |
| O’Brien et al13 | 71 children with ADHD symptoms, 39 controls (all 5–7 y) | PSG, questionnaire | No reported effects | OSAS and snoring are more prevalent when ADHD symptoms are mild | Groups defined by ADHD symptoms, limited analysis of contribution of OSAS | |
| Shin et al158 | 3,871 high-school students (16.8 y), 433 habitual snorers | Questionnaire | School grades | Sleepiness | Nonvalidated sleep and behavior measure | |
| Urschitz et al159, 160 | 1,144 school children (9.6 ± 0.7 y), 114 habitual snorers | Questionnaire, home nocturnal oximetry | Mathematical, science, and spelling performance | Attention, hyperactive, sleepiness | ||
| Archbold et al49 | 12 children scheduled for AT (9.0 ± 0.85 y) | PSG | Sustained attention, vigilance | NA | No control group | |
| Avior et al79 | 19 OSAS (8.0 y, range 5–14 y) | Questionnaire, adenotonsillar hypertrophy | Attention | Attention | No control group | |
| Beebe et al24 | 32 SDB (6.7 ± 0.5 y), 17 controls (6.7 ± 0.5 y) | PSG (SDB only), questionnaire | Verbal fluency | Aggression, conduct problems, hyperactive | Psychostimulants use amongst controls, no PSG for control | |
| Crabtree et al62 | 85 SDB (10.1 ± 1.5 y), 35 controls (9.6 ± 0.9 y) | PSG, questionnaire | NA | Depression, social problems | ||
| Ersu et al161 | 2,147 school students (8.5 ± 1.3 y), 151 habitual snorers | Questionnaire | NA | Hyperactive, sleepiness | ||
| Gottlieb et al17 | 61 SDB, 144 controls (all 5 y) | Questionnaire, PSG (n = 180) | Attention, executive function, hand–eye coordination, IQ, memory | ADHD symptoms, inattention | ||
| Huang et al162 | 88 ADHD (8.5 ± 1.9 y, 50 with OSA), 27 controls (9.0 ± 2.0 y) | PSG, questionnaire | Response time | Hyperactive | ||
| Kaditis et al163 | 3,680 school students (1–18 y, median age 9.8 y), 154 habitual snorers | PSG (n = 70), questionnaire | NA | Sleepiness | ||
| Kennedy et al50 | 13 snorers (7.0 ± 4.0 y), 13 controls (7.0 ± 4.0 y) | PSG | Attention, IQ, memory, verbal | NA | ||
| Melendres et al41 | 108 SDB (7.0 ± 4.0 y), 72 controls (8.0 ± 4.0 y) | PSG (SDB only), questionnaire | NA | Hyperactive, sleepiness | ||
| O’Brien et al27 | 35 SDB (6.7 ± 0.6 y), 35 controls (6.7 ± 0.5 y) | PSG, questionnaire | Executive function, phonological processing, visual attention | No differences between groups | Testing on morning after PSG | |
| O’Brien et al51 | 49 high sleep pressure score (SPS) (6.7 ± 0.5 y), 150 low SPS (6.7 ± 0.5 y) | PSG, questionnaire | Language, verbal IQ, visuospatial, memory | Inattention | Low SPS also displayed significant obstruction | |
| O’Brien et al26 | 87 snorers (6.6 ± 0.5 y), 31 controls (6.8 ± 0.4 y) | PSG, questionnaire | Language, visual attention, visuospatial | Anxiety, delinquency, depression, hyperactive, inattention, social problems, withdrawn | ||
| Rosen et al164 | 162 SDB (9.5 ± 0.9 y), 667 controls (9.5 ± 0.8 y) | Limited PSG, questionnaire | NA | Aggressive, emotionally labile, hyperactive, oppositional, social problems, somatic complaints | Inclusion in SDB group could be based on parental report only | |
| Arman et al165 | 96 habitual snorers (9.3 ± 1.4 y), 190 controls (9.4 ± 1.2 y) | Questionnaire | NA | ADHD symptoms, conduct problems, inattention, oppositional, sleepiness | ||
| Blunden et al166 | 11 snorers (9.4 ± 1.2 y), 9 snorers + behavioral sleep problems (9.4 ± 1.2 y), 13 behavioral sleep problems (9.4 ± 1.2 y), 31 controls (9.4 ± 1.2 y) | Questionnaire | Attention, verbal IQ | Externalizing, internalizing | ||
| Carvalho et al167 | 79 SDB (9.4 ± 1.2 y), 468 nonrespiratory sleep disorders (9.4 ± 1.2 y), 633 controls (9.4 ± 1.2 y) | Questionnaire | Visual–motor ability | NA | ||
| Chervin168 | 229 children from clinics (10.6 ± 3.1 y), 28 habitual snorers | Questionnaire | NA | Hyperactive | ||
| Goodwin et al169 | 480 school students (9.4 ± 1.2 y), 115 SDB (RDI ≥ 1) | Unattended home PSG | Learning problems | Sleepiness | Nonvalidated behavior measure | |
| Montgomery-Downs et al15 | 19 OSAS (4.2 ± 0.8 y), 19 controls (4.3 ± 0.7 y) | PSG, questionnaire | IQ, verbal fluency | NA | ||
| Mulvaney et al63 | 403 school students (9.4 ± 1.2 y), 63 SDB, 340 controls | Unattended home PSG | NA | ADHD symptoms, aggressive, emotional lability, inattention, oppositional, social problems, thought problems | Controls displayed significant respiratory disturbance | |
| Sogut et al170 | 1,198 school children (8.1 ± 1.9 y), 39 habitual snorers | PSG (28 snorers), questionnaire | School grades | Sleepiness | Nonvalidated behavior measure | |
| Tran et al78 | 42 children scheduled for AT (5.8 ± 2.5 y), 41 children scheduled for unrelated surgery (7.3 ± 3.8 y) | PSG (AT group only) | NA | Presurgery comparisons not made, but all mean scores within normal range for both groups | No PSG for control | |
| Urschitz et al171 | 995 school students (9.6 ± 0.7 y, 99 habitual snorers) | Questionnaire, home nocturnal oximetry | Mathematical ability | NA | ||
| Chervin et al43 | 78 children scheduled for adenotonsillectomy (8.1 ± 1.8 y), 27 controls (9.3 ± 2.0 y) | esophageal pressure, PSG, questionnaire | Attention | ADHD symptoms, hyperactive, sleepiness | Some controls demonstrated SDB | |
| Emancipator et al172 | 164 SDB (9.4 ± 0.8 y), 671 non-SDB (9.4 ± 0.8 y), all children from community sample | Limited PSG, questionnaire | Executive function, information processing, language comprehension, verbal problem solving | NA | ||
| Galland et al32 | 61 children scheduled for adenotonsillectomy (7.0 ± 2.0 y) | Limited PSG, questionnaire | Attention, impulsivity | Aggression, depression, hyperactive, inattention, somatic complaints | No control group | |
| Halbower et al52 | 19 OSAS (10.0 ± 2.5 y), 12 controls (9.8 ± 2.6 y) | PSG | Executive function, IQ | NA | 5/19 OSAS children had ADHD diagnosis | |
| Hill et al33 | 21 scheduled for adenotonsillectomy (5.5 ± 1.3 y), 17 controls (5.5 ± 1.4 y) | PSG (SDB only), questionnaire | Attention, processing speed | NA | No PSG for control | |
| Kurnatowski et al34 | 117 SDB (9.4 ± 1.2 y), 104 controls (9.4 ± 1.2 y) | PSG | Attention, executive function, memory, verbal comprehension, visuospatial | NA | 30% controls demonstrated snoring | |
| Li et al53 | 40 referred for adenotonsillar hypertrophy (8.4 ± 1.6 y) | PSG | Attention | No association with SDB severity | No control group | |
| Mitchell and Kelly64 | 23 OSAS (9.4 ± 1.2 y) | PSG | NA | Somatic complaints | No control group | |
| Suratt et al59 | 114 with adenotonsillar hypertrophy (8.5 ± 1.9 y) | PSG, questionnaire | verbal reasoning, vocabulary | Somatic complaints | No control group | |
| Ziliotto et al54 | 10 oral breathing and SDB (7.6 y), 10 oral breathing and SDB (8.1 y), 10 controls (7.5 y) | PSG (oral breathing groups only) | Memory for sounds (auditory processing) | NA | No PSG for control | |
| Constantin et al65 | 138 sleep clinic patients (5.5 ± 3.0 y) | PSG | NA | No difference between OSAS and non-OSAS | Retrospective behavior assessment, no control group | |
| Dillon et al66 | 78 children scheduled for adenotonsillectomy (8.1 ± 1.8 y), 27 controls (9.3 ± 2.0 y) | PSG | NA | ADHD symptoms, oppositional | Some controls demonstrated SDB | |
| Gozal et al55 | 102 OSAS (6.4 ± 0.4 y), 103 snorers (6.6 ± 0.3 y), 73 controls (6.3 ± 0.3 y) | PSG, questionnaire | Global cognitive ability | NA | Specific cognitive domains not specified | |
| Hiscock et al173 | 4,983 communities (4.7 ± 0.2 y) | Questionnaire | Verbal ability | Conduct problems | ||
| Uema et al56 | 24 OSAS, 37 primary snorers, 20 controls (all 6–12 y) | PSG | Verbal memory | NA | Deficits in both OSAS and primary snorers | |
| Wei et al88 | 117 referred for adenotonsillectomy (6.5 ± 1.8 y) | Questionnaire | NA | ADHD-type behavior, inattention, oppositional | No control group, no comparison with standard norms | |
| Giordani et al25 | 40 OSAS scheduled for adenotonsillectomy (7.8 ± 1.8 y), 38 non-OSAS scheduled for adenotonsillectomy (8.4 ± 1.8 y), 26 controls (9.2 ± 2.0 y) | PSG | OSAS: attention, mathematical ability, visual memory, visuospatial; non-OSAS: mathematical ability, visual memory, visuospatial | externalizing, hyperactivity, internalizing | Controls from unrelated surgery clinic | |
| Karpinski et al174 | 39 preschool students (4.3 ± 0.6 y) | Questionnaire | Executive function | NA | Only 6 snoring children | |
| Moré et al82 | 73 snorers (4.6 ± 2.0 y) | Questionnaire, PSG (61 children) | Memory | Aggression | No control group, no comparison with standard norms | |
| Zhao et al30 | 403 communities (8.3 ± 1.6 y) | Unattended home PSG | NA | Aggression/oppositional, social problems, somatic complaints | Deficits irrespective of hypoxia severity | |
| Aronen et al175 | 43 snorers (4.9 ± 1.1 y), 46 controls (4.8 ± 1.1 y) | Questionnaire | Auditory attention, language development, verbal ability | Anxiety, emotional lability | Not all children included in analyses of language and attention | |
| Calhoun et al57 | 571 communities (413 controls, 8.7 ± 1.6 y; 158 SDB, 8.7 ± 1.7 y) | PSG | Nonverbal IQ (snoring + OSA vs nonsnoring + no OSA) | NA | ||
| Ericsson et al89 | 67 referred for tonsillar hypertrophy (all 4.5–5.5 y) | None | NA | Internalizing | No control group, no measure of SDB | |
| Gozal et al58 | 87 OSAS (6.4 ± 0.5 y), 52 controls (6.1 ± 0.4 y) | PSG | Executive function, language development, mathematical ability, verbal ability | NA | ||
| Kohler et al18 | 44 SDB (6.6 ± 2.6 y), 48 controls (7.7 ± 2.6 y) | PSG | Executive function, IQ, language development, sensorimotor, verbal memory, visuospatial | NA | ||
| Lundeborg et al83 | 67 referred for tonsillar hypertrophy (4.8 ± 0.4 y), 47 controls (4.8 ± 0.4 y) | None | Language development (phonological processing) | NA | No measure of SDB | |
Abbreviations: AT, adenotonsillectomy; SDB, sleep-disordered breathing; OSAS, obstructive sleep apnea syndrome; PSG, polysomnography; TcCO2, transcutaneous CO2 monitoring; IQ, intelligence quotient; NA, not assessed.