Daytime sleepiness: A hidden cause of behavioural and emotional issues in OSA children

Excessive daytime sleepiness (EDS) is a risk factor for behavioural and emotional issues in children with obstructive sleep apnoea (OSA), researchers from the Chinese University of Hong Kong (CUHK) have shown.

“OSA is a prevalent sleep disorder that affects around 3–5 percent of school-aged children in Hong Kong,” wrote the researchers. Up to half of children with OSA experienced EDS (ie, inability to stay awake and alert during the major waking episodes of the day). [Sleep Med 2024:115:93-99; PLoS One2018;13:e0204409]

Concomitant EDS and OSA is believed to be a distinct phenotype that predisposes adults to cognitive impairment and mood disturbances. “[However,] the clinical relevance of EDS in children with OSA is less studied,” noted the researchers. “Whether EDS can serve as a pointer to identify children with OSA who are at risk of neuro-behavioural consequences has not been examined.”

In a recent retrospective study, the researchers analyzed data from 391 children with sleep-related complaints (mean age, 8.6 years; male, 67 percent). Seventy children did not have OSA or EDS (non-OSA/EDS), 137 had OSA only, 50 had EDS only, and 134 had both OSA and EDS (OSA + EDS). A parent-reporting questionnaire – the Child Behavioural Checklist (CBCL) – was used to measure behavioural, emotional, and social problems in eight categories, including anxiety/depression, withdrawal, somatic complaints, social, thought, or attention problems, as well as rule-breaking or aggressive behaviours.

Of note, the total CBCL T score was significantly higher in the OSA + EDS group vs the non-OSA/EDS and the OSA-only groups (61 vs 54 and 54; both p<0.001). The association between presence of EDS and total CBCL T score remained significant even after adjusting for age, sex, body mass index, and 7-day average sleep duration.

“The presence of EDS was associated with significantly higher odds of clinically significant behavioural problems [ie, CBCL T score ≥65] for all subscales, while the presence of OSA was associated only with higher odds of rule-breaking behaviours, but not the other subscales,” reported the researchers.

These results imply that EDS is a risk factor for adverse behavioural and emotional outcomes in children with OSA. “Sleep fragmentation in children with OSA may lead to impairment of the prefrontal cortex, which is the control centre of emotional and social behaviours,” explained the reseachers.

However, EDS is often underrecognized and underdiagnosed in children as they are unable to verbalize the internal state of sleepiness. “For children with OSA presenting with complaints including hyperactivity and impulsive behaviours, it is essential to consider the possibility of EDS as a potential underlying cause,” pointed out the researchers.

Previous studies revealed persistent sleepiness in children with OSA even after surgical intervention. Additionally, there were no cognitive and behavioural changes in children after treatment of OSA. [Respirology 2021;26:690-699; PLoS One 2015;10:e0139142] “Future studies should examine whether interventions to alleviate EDS in children with OSA could improve their behavioural and emotional outcomes,” suggested the researchers.