Association of Snoring With Behavior and Cognition in Adolescents

Source: Isaiah A, Uddin S, Ernst T, et al. Cognitive and behavioral outcomes of snoring among adolescents. JAMA Netw Open. 2024;7(11):e2444057; doi: 10.1001/jamanetworkopen.2024.44057.Investigators from the University of Maryland, Baltimore, MD, and Harvard Medical School, Boston, MA, conducted a retrospective study to evaluate the association between snoring and both cognitive and behavioral problems in adolescents. For the study, they reviewed data from the Adolescent Brain Cognitive Development (ABCD) study. ABCD is a prospective cohort study of children enrolled at 21 sites in the US. Participants were enrolled when they were 9–10 years old and followed for up to 5 years. For the current study, information on snoring was obtained as part of the Sleep Disturbance Scale for Children and recoded as no snoring, nonhabitual snoring, and habitual snoring, based on parental report of the number of nights of snoring per week. Participants completed 10 cognitive assessments that are included in the National Institutes of Health Tool Box (NIH-TB) for Assessment of Neurological and Behavioral Function Cognitive Battery at years 1, 3, and 5 of the study. Behavioral problems were assessed using the Child Behavior Checklist (CBCL), which was administered annually to children enrolled in ABCD. For the current study, scores from various domains in the CBCL were aggregated as internalizing problems, external problems and total problems. Mixed effects regression analyses were used to assess the association between snoring and NIH-TB scores or CBCL scores. Multiple demographic characteristics were included in the models, and participants were classified as obese or non-obese based on BMI percentile for age.Data on 11,862 children with a mean age of 9.9 years were included in year 1 analyses, decreasing to 4,668 participants by year 5. At baseline, 34.2% of children were nonhabitual snorers, and 6.8% had habitual snoring. The rate of snoring decreased over the study period, with 29.5% having nonhabitual snoring and 3.2% habitual snoring by year 5. In the multivariate models, scores on the NIH-TB assessments were similar among habitual snorers compared to those with nonhabitual or no snoring, even after stratifying by obesity status. However, scores on the CBCL indicated that snoring was associated with a significantly increased risk for behavior problems. Among both non-obese and obese participants, internalizing behaviors, externalizing behaviors, and total scores were significantly associated with snoring (P <0.001 for all comparisons).The authors conclude that snoring in adolescents was associated with an increased risk of problem behaviors.Dr Raphael has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The American Academy of Pediatrics recommends screening for habitual snoring in all children and adolescents and subsequent further evaluation if identified.1 Yet, prior studies of pediatric practices have noted that screening rates for sleep disordered breathing (SDB) are low.2,3 The current study highlights the negative effect of habitual snoring on behavioral outcomes among adolescents. While the majority of participants in the current study were not obese (~20% had a BMI >95th percentile), findings were similar in obese and non-obese patients. Thus, the study findings reiterate the importance of recognizing habitual snoring in adolescents, regardless of BMI.The current investigators did not provide information about whether participants with habitual snoring underwent surgical or medical interventions during the 5-year study period. This limits the interpretability of the nearly 53% decline in the prevalence of habitual snoring, as it is not clear if this represents self-resolution of snoring over time or provider interventions. Additionally, while CBCL scores were higher among participants with habitual snoring, reassuringly, even in this group CBCL scores were within normal ranges and did not worsen with time.The current investigators did not distinguish between adolescents with primary snoring and those with sleep apnea. In a prior meta-analysis of 77 studies (age range, 0–18 years), other investigators found that despite the absence of sleep apnea, neurocognitive effects were present amongst primary snorers. However, similar to the findings in the current study, the results of the prior meta-analysis revealed an age-dependent effect on cognitive outcomes. The minimal effect of habitual snoring on cognition in adolescents suggests that they may be better able to compensate for neurocognitive deficits compared with younger children.4Overall, the findings of the current study further support the role of shared decision-making, particularly when considering surgical interventions for habitual snoring. In a previous study in young children (age 3–13 years) with mild SDB, though improvements in behaviors were noted post-surgery, adenotonsillectomy did not significantly improve cognitive outcomes as compared to watchful waiting. (See AAP Grand Rounds. 2024;51[4]:40.)5Adolescents with habitual snoring do not appear to differ from non-snorers or infrequent snorers with regards to cognition, although they are at greater risk for problematic behaviors.