Sleep-Disordered Breathing as a Mediator Between Premature Birth and Behavior Problems in School-Aged Children: A Cross-Sectional Study of 6–10 Year Olds in Shanghai, China

Yuli Hu,1,2,* Siqiong Jiang,1,* Shiyin Yang,3 Chunsheng Wang,4 Jianyin Zou,5 Jian Guan,5 Yupu Liu,5 Qunfeng Lu1,2 1Nursing Department of Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Xuhui, Shanghai, 200233, People’s Republic of China; 2School of Nursing, Shanghai Jiaotong University, Shanghai, 200025, People’s Republic of China; 3Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, People’s Republic of China; 4School of Medicine, Huzhou University, Zhejiang, 310000, People’s Republic of China; 5Department of Otolaryngology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, People’s Republic of China*These authors contributed equally to this workCorrespondence: Yupu Liu, Email [email protected] Qunfeng Lu, Email [email protected]: Premature birth poses a major challenge in global obstetric clinical practice. The relationship between preterm infants and behavioral problems in school-aged children remains debatable, and the mediating role of sleep-disordered breathing (SDB) in this connection has not been investigated. This study aimed to address these gaps through a large-scale cross-sectional survey.Methods: We recruited 18,138 children aged 6– 10 from schools. Data on demographics, prematurity, SDB, and childhood behavioral problems were collected. The Paediatric Sleep Questionnaire (PSQ), a validated screening tool, assessed SDB symptoms, and the Conners’ Parent Rating Scale (CPRS) evaluated behavioral problems. Path analysis with bootstrap methods was used for statistical analysis.Results: Among 18,138 participants, 8% (n = 1,450) were premature. After adjusting for age, gender, BMI z-score, maternal age, and maternal education level, prematurity showed a positive association with total PSQ score (B = 0.411, p < 0.01). Higher total PSQ scores were significantly associated with all six CPRS dimensions (all p < 0.05). While prematurity was not directly associated with Conduct, Psychosomatic, Impulsive-hyperactive, or Hyperactivity scores in CPRS (all p > 0.05), it demonstrated significant associations with Learning problems (β = 0.063, p = 0.005) and Anxiety scores (β = 0.076, p = 0.003). Mediation analysis showed PSQ accounted for a large proportion of associations between prematurity and Conduct, Psychosomatic, Impulsive – hyperactive, and Hyperactivity problems (95% Bootstrap CI excluded 0).Conclusion: Premature infants may exhibit behavioral problems significantly associated with SDB, though our cross-sectional design precludes causal inference and parent-reported SDB severity may bias true associations. Future studies should utilize longitudinal cohorts to explore whether SDB is involved in the relationship between prematurity and behavioral problems (eg, anxiety). Additionally, they should conduct pilot randomized controlled trials of SDB interventions in preterm infants to assess neurodevelopmental benefits. Final conclusions require subsequent causal validation.Keywords: premature birth, behavioral problems, sleep-disordered breathing