And behavioural problems persisted even as the prevalence of snoring declined.

Snoring in children and adolescents, usually caused by obstructive sleep apnoea (OSA) due to adenotonsillar hypertrophy or obesity, causes great concern among parents, including frequent questions about the relation between snoring and cognitive difficulties or behavioural problems. In this secondary analysis of a prospective cohort study, researchers followed about 4700 children for five years from a baseline age of 9 to 10 years. Validated measures were used to make annual assessments of snoring, cognitive function and caregiver­-reported behavioural problems, including mood disorders, thought problems, attention problems and rule-­breaking and aggressive behaviour. The authors did not identify and account for adolescents who underwent adeno­tonsillectomy or other sleep-related interventions during the study period. During the five­-year follow up, the following outcomes were noted:

• the prevalence of habitual snoring (three or more nights per week) declined from 6.8% to 3.2% (nonhabitual snoring [snoring one to two nights per week] prevalence was roughly stable at about 30%)
• snoring frequency was not associated with cognitive performance, apart from usual increases in cognitive function with age
• snoring frequency was associated significantly with parent­-reported behavioural problems across all domains, with the strongest association in adolescents with obesity
• behavioural problems did not worsen over time with persistent snoring, and the prevalence of behavioural problems persisted even as the prevalence of snoring declined.

Comment: The lack of association between snoring frequency and cognitive dysfunction should be reassuring to parents. Interpreting the finding that snoring is associated with behavioural problems is more difficult. Parents of adolescents who snore might over-­report behavioural problems because of a belief that snoring (either by itself or as a marker for OSA) causes such problems; thus, an aggressive push for adenotonsillectomy might be inappropriate. And behavioural problems could persist following adenotonsillectomy, because other causes might be the culprits. Screening for both snoring and behavioural problems is recommended, but decisions about treatment, including use of continuous positive airway pressure and surgery, require careful shared decision making.

Thomas L. Schwenk, MD, Dean Emeritus, University of Nevada, Reno School of Medicine, Reno; Professor Emeritus, University of Michigan Medical School, Ann Arbor, USA, and

James A. Feinstein, MD, MPH, Associate Professor of Pediatrics, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, USA.

Isaiah A, et al. Cognitive and behavioral outcomes of snoring among adolescents. JAMA Netw Open 2024; 7: e2444057.

This summary is taken from the following Journal Watch titles: Pediatrics and Adolescent Medicine, Neurology.