Children with obstructive sleep apnea (OSA) are at nearly twofold risk of developing influenza or COVID compared with children who do not have OSA, according to recent research. Adenotonsillectomy — a common treatment for OSA — did not reduce the risk.

In a retrospective cohort study of records from over 500,000 children in the TriNetX Global Collaborative Network, which aggregates de-identified electronic health record data, influenza was diagnosed in 5.1% of children with OSA vs 2.8% of control individuals (risk ratio [RR], 1.80; 95% CI, 1.765-1.836). Five-year influenza-free survival was 90.27% vs 93.04% in children with OSA and control individuals (hazard ratio [HR], 1.45; 95% CI, 1.421-1.479). COVID was diagnosed in 2.5% of those with OSA vs 1.0% of control individuals (RR, 2.496; 95% CI, 2.418-2.576); 5-year COVID-free survival was 95.02% vs 97.49% (HR, 1.986; 95% CI, 1.924-2.050).

These effects were similar across age groups. Results were published online in the Journal of Clinical Sleep Medicine. 

In a treatment sub-analysis, (n = 96,004 per group), adenotonsillectomy did not reduce the risk.

“That was super surprising,” said lead study author Alex Gileles-Hillel, MD, an associate professor at Hebrew University and director of the neonatal pulmonology service at Hadassah Medical Center, in Jerusalem, Israel. “I was reluctant to believe the result, until we looked at it from several ways.”

Tonsillectomy for OSA is not curative, Gileles-Hillel told Medscape Medical News; about 30% of children have residual sleep apnea, and fluctuations in oxygen levels can reprogram the immune system, leaving children at a risk for respiratory viruses.

Pediatric outcome data, while sparse, suggest that children with OSA hospitalized for influenza have longer lengths of stay, greater hospital costs, and higher odds of pneumonia compared with matched peers who do not have OSA, Gileles-Hillel said. Children with OSA should be vaccinated for seasonal influenza and COVID, he said.

Gileles-Hillel and colleagues reviewed records for children aged 2-18 years with incident OSA and matched control individuals. Children were assigned to the OSA cohort if they had an International Classification of Diseases, 10th Revision (ICD-10) code of G47.33 or G47.3 recorded at less than 18 years of age, or to a control cohort if they did not. Follow-up began 1 day after the index and continued for 5 years. Primary outcomes were influenza and SARS-CoV-2 infection, as documented by ICD-10 codes.

Among children at risk (508,107 with OSA and 532,045 control individuals), 25,814 and 15,018 were diagnosed with influenza across the follow-up period, respectively, with a RR for the OSA cohort of 1.800. In matched cohorts of 539,127 each, 13,134 OSA and 5372 control patients had SARS-CoV-2 infections recorded, yielding a RR of 2.496. Findings were consistent across age groups.

In a sub-analysis, researchers looked at the effect of adenotonsillectomy. Treated and untreated OSA cohorts each included 96,004 children. For influenza, untreated vs treated risks across 5 years were 4.9% (4455/90,903) and 5.6% (5005/88,638; P < .001), yielding an RR of 0.868 (95% CI, 0.834-0.903).

For COVID, untreated vs treated risks were 2.5% (2332/93,626) and 2.6% (2380/92,716; P = .173), yielding an RR of 0.970 (95% CI, 0.917-1.027).

To examine how OSA influences risk for severe viral infection, investigators reviewed cases of pneumonia due to influenza and COVID in children with OSA and control individuals (n = 506,177 each). There were 866 instances of influenza pneumonia in the OSA cohort and 322 in control individuals, yielding risks of 0.2% and 0.1%, and an RR of 2.69 (95% CI, 2.37-3.06).

Some 467 children with OSA and 18 control individuals had COVID pneumonia, with risks of 0.1% and < 0.01%, and a RR of 25.96.

“This study opens the eye that any child who has been labeled as having sleep apnea or snoring should be treated as a red flag for having respiratory infections,” said pediatric pulmonologist Umakanth Katwa, MD, director of the Sleep Center and Sleep Laboratories at Boston Children’s Center, Boston. If these children develop a cold, they should receive medical attention sooner rather than later as they have a higher likelihood of progressing to pneumonia or prolonged symptoms, he said.

OSA and snoring cause vibratory trauma to the upper airway, causing a breach in the mucosal barrier that increases susceptibility to viruses attaching there and causing inflammation, Katwa explained. Additionally, intermittent hypoxia and fragmented sleep associated with OSA can cause immune dysregulation. Children may not mount as robust a response to vaccines or may take longer to clear respiratory viruses.

Additional ways to prevent or minimize the impact of viruses in children with OSA include timely vaccinations, including for pneumonia in children with diabetes, obesity, or who are immunodeficient, he said. Timely diagnosis of sleep apnea also is critical to protect the immune system and neurocognition. Ensuring good sleep hygiene and regular sleep schedules in all children — even those without OSA or snoring — is critical so their immune system is robust and can fight viral infections, he said.