Early Life Lower Respiratory Tract Infections May Increase OSA Risk in Children

Children who experience lower respiratory tract infections early in their lives were shown to be at significantly greater risk of developing obstructive sleep apnea in the first 5 years of life.

Incidence of lower respiratory tract infections (LRTIs) in early life may increase the risk of pediatric obstructive sleep apnea (OSA), with this risk potentially rising further for children with a history of severe respiratory syncytial virus (RSV) bronchiolitis during infancy. Results were published this week in Sleep.

Affecting 1% to 5% of the pediatric population, untreated OSA has been associated with several adverse health outcomes in children, including behavioral problems, impaired school performance, and greater risk of cardiovascular disease later in life.

Furthermore, the gold standard for treatment of childhood OSA, adenotonsillectomy, contributes to substantial health care utilization, which researchers note warrants a more cost-effective strategy especially for minority high-risk populations.

“However, the causative factors of nasopharyngeal obstruction leading to OSA during early childhood are unknown and understudied,” said study authors from the Children’s National Hospital. “Filling this gap is critically important to design novel interventions that prevent the initial development and progression of this common condition in children.”

With several birth cohorts having demonstrated the pivotal role of early LRTIs in the development of respiratory conditions in children, researchers sought to test the hypothesis in regards to incidence of OSA.

“Given that the nasopharynx is the entry point of respiratory viruses, it is possible that respiratory infections in infants not only contribute to the inception of wheezing and asthma, but also the development of nasopharyngeal obstruction and pediatric OSA,” they explained.

Deriving data on children enrolled between October 1998 and March 2019 (N = 3114) in the Boston Birth Cohort, a large, low-income, minority birth cohort of children followed during the first 5 years of life, participants with a LRTI during the first 2 years of life were compared with those without a LRTI during this period for risk of OSA by the age of 5 years.

Additional separate analyses assessed children with available self-reported data on infections during the first year of life (n = 2788) for incidence of severe RSV bronchiolitis episodes that required hospitalization.

Of the study cohort, 18.8% (n = 585) of children had developed a LRTI by 2 years of age and 3% reported incidence of severe RSV bronchiolitis requiring hospitalization (n = 84). A further 6.3% of preschool-aged children (n = 196) had their first LRTI episode between the ages of 2 and 5 years.

Overall, 7.6% of children developed OSA in the study (n = 238). In the investigators' findings, children with history of LRTIs in the first 2 years of life were found to be at significantly increased risk of pediatric OSA, independent of other pertinent covariates and risk factors (HR, 1.53; 95% CI, 1.15-2.05). This association was limited to LRTIs occurring in children during the first 2 years of life, with preschool-age LTRI not found to significantly increase risk of OSA.

Risk of OSA was observed to be significantly higher in children who had severe RSV bronchiolitis during infancy, with these populations indicated to be more than 2 times likely to develop the condition at 5 years compared with those without this exposure (odds ratio, 2.09; 95% CI, 1.12-3.88).

“The results suggest that RSV LRTI may contribute to the pathophysiology of OSA in children, raising concern for the possibility that primary prevention strategies can hinder the initial establishment of OSA following early viral LRTIs,” said study author Gustavo Nino, MD, director of sleep medicine at Children’s National Hospital, in a statement. “Primary prevention of OSA in children would have a dramatic effect in reducing the increasing incidence of this condition and in preventing its detrimental effects on childhood health and beyond.”


Gutierrez MJ, Nino G, Landeo-Gutierrez JS, et al. Lower respiratory tract infections in early life are associated with obstructive sleep apnea diagnosis during childhood in a large birth cohort. Sleep. Published online September 15, 2021. doi:10.1093/sleep/zsab198

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