The Journal of Pediatrics
Volume 155, Issue 3 , Pages 306-307, September 2009

Primary Snoring in Children—No Longer Benign

  • Gerald M. Loughlin, MD

      Affiliations

    • Corresponding Author InformationReprint requests: Gerald M. Loughlin, MD, Pediatrician-in-Chief, Phyllis and David Komansky Center for Children's Health, New York-Presbyterian Hospital, 525 East 68th St, Rm M-622, New York, NY 10021.

Nancy C. Paduano Professor and Chairman, Department of Pediatrics, Weill Cornell Medical College, Pediatrician-in-Chief, Phyllis and David Komansky Center for Children's Health, New York-Presbyterian Hospital, New York, New York

Article Outline

ATS, American Thoracic Society, UPPP, Uvulopalatopharyngoplasty

 

See related article, p 362

In this issue of The Journal, Li et al report on a link between the development of systemic hypertension in children and snoring without obstructive apnea, hypoventilation, hypoxia, or sleep disturbance, a condition previously referred to as “primary snoring.”1 Although the alterations in blood pressure found in these children may be minor, the finding that primary snoring could result in blood pressure changes during childhood suggests that this population may be at risk for the development of clinically significant hypertension later in life, if this snoring were to persist for an extended period (“as the twig is bent, the tree's inclined”).2, 3 This is a well-designed study that corrects deficiencies of earlier efforts to define this relationship. It included an objectively defined normal control population, ambulatory blood pressure monitoring, and confirmed the presence of isolated snoring with polysomnography, the purported gold standard. More important, these data add to a growing body of information supporting the notion that snoring, even without alterations in gas exchange, can no longer be considered benign. The results strongly suggest that snoring, even without apnea, must now be thought of in the same way that we consider other respiratory noises, such as stridor and wheeze, as signs of airway obstruction. This observation complements findings by Blunden et al in 5- to 10-year-old children who snore,4 Urschitz et al, whose work established a link between snoring without blood gas abnormalities and diminished academic performance in primary school children,5 and work by O'Brien et al on the relationship between neurobehavioral abnormalities and primary snoring.6

These provocative observations will have profound effects on the approach to diagnosis and management of snoring in children. In 1996, a consensus conference sponsored by the Pediatric Assembly of the American Thoracic Society (ATS) concluded “a history of loud snoring alone has not been shown consistently to have sufficient diagnostic sensitivity upon which to base a recommendation for surgery—whether adenotonsillectomy, uvulopalatopharyngoplasty (UPPP), or.”7 Even an updated version of these clinical practice guidelines from the American Academy of Pediatrics dealing with the diagnosis and management of obstructive sleep apnea in children recommends nocturnal polysomnography as the gold standard for quantifying the degree of breathing or sleep disturbance in a child with snoring to determine who is a candidate for therapy, such as surgery.8 On the basis of these guidelines, when the results of the polysomnography study are normal, defined primarily by the number of apnea events or alterations in gas exchange, no further therapy is indicated. However, on the basis of the work by Li et al, coupled with the others aforementioned, a new approach to the snoring child appears to be in order.

Unfortunately at this time, although we may consider snoring without apnea or blood gas disturbance that occurs frequently as abnormal, there is no consensus on how much snoring is too much. Considering that commonly habitual primary snoring has been reported in children (prevalence estimates between 10% and 12%), it is essential that we learn more about snoring without apnea or hypoxia. Because parental reporting is unreliable and polysomnography is both expensive and of limited availability, improved approaches to confirming the presence of habitual snoring that do not require a night in a polysomnography laboratory is an important first step.9

In addition, we have to determine whether it is sufficient to simply confirm that a child is snoring to initiate therapy. Is treatment indicated in all children found with this condition? What other factors influence the development of long-term consequences of isolated snoring? Is age of onset of snoring important for the development of adverse consequences? How does the duration of snoring during a night's sleep or its frequency either on a nightly or weekly basis influence the development of complications? Are the consequences of snoring the same in an infant as in a toddler or adolescent? These are essential questions that will likely require longitudinal and multicenter studies. Answers to these questions will be important, especially to primary care physicians and parents. Regardless, it seems clear that once a diagnosis of habitual snoring is established, these children must be considered to be an at-risk population. They must be screened routinely, at a minimum for hypertension, and close attention needs to be paid to assessing academic performance and behavior in the older child.

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References 

  1. Li AM, Chun TA, Crover H, Fok TK, Wing YK. Blood pressure is increased in children with primary snoring. J Pediatr. 2009;155:362–368
  2. Pope A. Epistles to several persons, epistle 1 to Lord Cobham. 1734. Line 149.
  3. Franklin KA, Janson C, Gislason T, Gulsvik A, Gunnbjornsdottir M, Laerum BN, et al. Early life environment and snoring in adulthood. Respir Res. 2008;9:63
  4. Blunden S, Lushington K, Kennedy D, Martin J, Dawson D. Behavior and neurocognitive performance in children 5-10 years who snore compared to controls. J Clin Exp Neuropsychol. 2000;22:554–568
  5. Urschitz MS, Guenther A, Eggebrecht E, Wolff J, Urschitz-Duprat PM, Schlaud M, et al. Snoring, intermittent hypoxia and academic performance in primary school children. Am J Respir Crit Care Med. 2003;168:464–468
  6. O'Brien LM, Mervis CB, Holbrook CR, Bruner JL, Klaus CJ, Rutherford J, et al. Neurobehavioral implications of habitual snoring in children. Pediatrics. 2004;114:44–49
  7. American Thoracic Society . Standards and Indications for cardiopulmonary sleep studies in children. Am J Resp Crit Care Med. 1996;153:866–878
  8. American Academy of Pediatrics Policy Statement . Clinical practice guidelines: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109:704–712
  9. Carroll JL, McColley SA, Marcus CL, Curtis S, Loughlin GM. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest. 1995;108:610–618

PII: S0022-3476(09)00493-4

doi:10.1016/j.jpeds.2009.05.013

Refers to article:

  • Blood Pressure is Elevated in Children with Primary Snoring , 22 June 2009

    Albert M. Li, Chun T. Au, Crover Ho, Tai F. Fok, Yun K. Wing
    The Journal of Pediatrics September 2009 (Vol. 155, Issue 3, Pages 362-368.e1)

The Journal of Pediatrics
Volume 155, Issue 3 , Pages 306-307, September 2009

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