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Sleep. 2014 Feb 1;37(2):261-9. doi: 10.5665/sleep.3394.

Predictors of obstructive sleep apnea severity in adenotonsillectomy candidates.

Author information

  • 1Department of Medicine, Brigham and Women's Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
  • 2Department of Pediatrics, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH.
  • 3Sleep Center, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA.
  • 4Department of Otolaryngology, University of Michigan Medical Center, Ann Arbor, MI.
  • 5University of Texas Southwestern Medical Center, Dallas, TX.
  • 6Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
  • 7Department of Pediatrics, Cardinal Glennon Children's Hospital, Saint Louis University, St Louis, MO.
  • 8Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.
  • 9Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY.
  • 10Sleep Disorders Center and Department of Neurology, University of Michigan, Ann Arbor, MI.
  • 11Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA.



There is uncertainty over which characteristics increase obstructive sleep apnea syndrome (OSAS) severity in children. In candidates for adenotonsillectomy (AT), we evaluated the relationship of OSAS severity and age, sex, race, body mass index (BMI), environmental tobacco smoke (ETS), prematurity, socioeconomic variables, and comorbidities.


Cross-sectional screening and baseline data were analyzed from the Childhood Adenotonsillectomy Trial, a randomized, controlled, multicenter study evaluating AT versus medical management. Regression analysis assessed the relationship between the apnea hypopnea index (AHI) and risk factors obtained by direct measurement or questionnaire.


Clinical referral setting.


Children, ages 5 to 9.9 y with OSAS.


Of the 1,244 children undergoing screening polysomnography, 464 (37%) were eligible (2 ≤ AHI < 30 or 1 ≤ obstructive apnea index [OAI] < 20 and without severe oxygen desaturation) and randomized; 129 (10%) were eligible but were not randomized; 608 (49%) had AHI/OAI levels below entry criteria; and 43 (3%) had levels of OSAS that exceeded entry criteria. Among the randomized children, univariate analyses showed significant associations of AHI with race, BMI z score, environmental tobacco smoke (ETS), family income, and referral source, but not with other variables. After adjusting for potential confounders, African American race (P = 0.003) and ETS (P = 0.026) were each associated with an approximately 20% increase in AHI. After adjusting for these factors, obesity and other factors were not significant.


Apnea hypopnea index level was significantly associated with race and environmental tobacco smoke, highlighting the potential effect of environmental factors, and possibly genetic factors, on pediatric obstructive sleep apnea syndrome severity. Efforts to reduce environmental tobacco smoke exposure may help reduce obstructive sleep apnea syndrome severity.



Adenotonsillectomy; apnea hypopnea index; disparities; obstructive sleep apnea syndrome; polysomnography; tobacco

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