ReviewCopySleep Disordered Breathing in a Population-Based Cohort: Behavioral Effects at 4 and 7 YearsJournal: PediatricsManuscript ID: 2011-1402 Article Type: Regular Article Date Submitted by the Author: 10-May-2011 Complete List of Authors: Bonuck, Karen; Albert Einstein College of Medicine, Family and Social Medicine Chervin, Ronald; University of Michigan, Neurology Freeman, Katherine; Albert Einstein College of Medicine, Department of Epidemiology and Population Health Xu, Linzhi; Albert Einstein College of Medicine, Family and Social Medicine Keyword/Category: Behavior disorders/problems, Sleep-disordered breathing, Sleep Apnea The American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007 Confidential - Not for Circulation
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Sleep Disordered Breathing in a Population-Based Cohort: Behavioral Effects at 4 and 7 Years
Karen Bonuck, PhD (corresponding author)Professor, Department of Family Medicine
Albert Einstein College of Medicine1300 Morris Park AvenueBronx, NY [email protected] phone 718 430 4085
Katherine Freeman, Dr.P.H.Professor, Department of Epidemiology and Population HealthMontefiore Medical Center/Albert Einstein College of Medicine111East 210 th StreetBronx, NY 10467
Ronald D. Chervin, MD, MSProfessor, Department of Neurology and Director, Sleep Disorders CenterUniversity of MichiganC728 Med Inn Bldg1500 E. Medical Center Dr.Ann Arbor, MI [email protected] phone 734-647-9064
Linzhi Xu, PhDResearch Associate, Department of Family and Social MedicineAlbert Einstein College of Medicine1300 Morris Park AvenueBronx, NY [email protected]
All authors meet the criteria for authorship. Dr. Bonuck conceptualized and designed the study, drafted theinitial manuscript, reviewed and modified the analyses in collaboration with Drs. Freeman and Xu, andincorporated co-author feedback into the final manuscript. Dr. Freeman worked to develop the methods, carriedout initial analyses, supervised final analyses of Dr. Xu, and reviewed and revised the final manuscript. Dr.Chervin advised on study design and analyses, and carefully reviewed and revised multiple versions of themanuscript. Dr. Xu collaborated on statistical design issues, completed final analyses, and reviewed and revised
the final version of the paper.
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Objectives: Examine statistical effects of sleep-disordered breathing (SDB) symptom trajectories from 6months to 7 years on subsequent behavior.
Patients and Methods: Parents in the Avon Longitudinal Study of Parents and Children (ALSPAC) reported onchildren’s snoring, mouth breathing, and witnessed apnea at >2 surveys at 6, 18, 30, 42, 57, and 69 months, andcompleted the Strengths and Difficulties Questionnaire (SDQ) at 4 (n=9,206) and 7 (n=8,342) years. Clusteranalysis produced 5 “Early” (6-42 months) and “Late” (6-69 months) symptom trajectories (“clusters”).Adverse behavioral outcomes were defined by top 10 th percentiles on SDQ total and subscales, at 4 and 7 years,
in multivariable logistic regression models.
Results: The SDB clusters predicted ≈ 20%-90% increased odds of subsequent problematic behavior,controlling for 16 potential confounders. Early clusters predicted problematic behavior at 7 years equally wellas at 4 years. The “Worst Case” cluster, with peak symptoms at 2.5 years that subsequently resolved,nonetheless at 7 years predicted hyperactivity (OR=1.96, 95% CI [1.52 to 2.53]), conduct (1.61, [1.39 to 2.19]),and peer difficulties (1.69, [1.39 to 2.06]), whereas a “Later Symptom” cluster predicted emotional difficulties(1.69, [1.39 to 2.06]). In two clusters, all SDB symptoms peaked before 1.5 years and abated by 2.5 years, butstill predicted 40%-50% increased odds of behavior problems at 7 years.
Conclusions: In this large, population-based, longitudinal study, early-life SDB symptoms had strong,
persistent statistical effects on subsequent behavior in childhood. Findings suggest that SDB symptoms mayrequire attention as early as the first year of life.
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What is Known on This Subject● Sleep disordered breathing (SDB) is associated with neurobehavioral morbidity in children.● Prior related research has generally been cross-sectional or short (i.e. 1-2 years) follow-up studies of a singlesymptom (i.e. snoring, obstructive sleep apnea, mouth-breathing), with limited control for confounders.
What This Study Adds● SDB was assessed as a trajectory of combined symptoms from 6 months to 6.75 years, in over 11,000
children.● SDB was associated with 40% and 60% more behavioral difficulties at 4 and 7 years, respectively.
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HOME Score, mean (range: 0-8) 5.75(1.66) 5.61 (1.76) † 5.81 (1.62) 5.48 (1.75) † 5.84 (1.61)
Parity, >=1 55.4% 52.0% 54.5% 50.7%‡ 54.5%
*These n=13,810 constitute the base sample used to derive the clusters and SDQ outcomes.†p<.01 for difference between top 10% vs. lower 90%‡p<.05 for difference between top 10% vs. lower 90%§“Lower” defined as “O” level education or less (equivalent to school leaving certificate at 16 in the UK), from 5 original groupings.
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1Adjusted for fish intake, FAI, Mother and home score, smoke during pregnancy, alcohol during pregnancy, race, breast feeding ever,housing inadequency, parity, gestation age, paternal social, maternal education, birth weight, maternal age, gender.2 Additional adjusted for Tonsils or adenoids removed.3 Covariates shown are only those that were significant (p<.05) in reduced models with each of the four symptomatic modelsincorporated as a separate variable (vs. combined clusters 1,2,3, & 4).
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1Adjusted for fish intake, FAI, Mother and home score, smoke during pregnancy, alcohol during pregnancy, race, breastfeeding ever, housing inadequacy, parity, gestation age, paternal social, maternal education, birth weight, maternal age,gender.2Additional adjusted for Tonsils or adenoids removed ever.
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