Abstract
We investigated the associations of dental occlusion, other craniofacial features and body fat with paediatric sleep-disordered breathing (SDB) in a representative population sample of 491 Finnish children 6–8 years of age. Overweight and obesity were defined using age- and sex-specific body mass index cutoffs by International Obesity Task Force (IOTF) criteria. Body fat percentage was assessed by dual-energy X-ray absorptiometry. Facial proportions, dental occlusion and soft tissue structures were evaluated by an orthodontist. Sleep was assessed by a sleep questionnaire administered by the parents. SDB was defined as apnoeas, frequent or loud snoring or nocturnal mouth breathing observed by the parents. The prevalence of SDB was 9.9 % with no difference between boys and girls. The median (interquartile range) of body fat percentage was 20.6 (17.4–27.1) in girls and 15.0 (11.4–21.6) in boys. Altogether 11.4 % of boys and 15.6 % of girls were classified as having overweight or obesity according to the IOTF criteria. There was no difference in the prevalence of overweight, obesity or body fat percentage between children with SDB and those without it. Children with tonsillar hypertrophy had a 3.7 times higher risk of suffering SDB than those with normal size tonsils after adjustment for age, sex and body fat percentage. Furthermore, children with cross bite had a 3.3 times higher risk of having SDB than those without cross bite, and children with a convex facial profile had a 2.6 times higher risk of having SDB than those with a normal facial profile. Conclusion: Abnormal craniofacial morphology, but not excess body fat, is associated with an increased risk of having SDB in 6–8-year-old children. A simple model of necessary clinical examinations (i.e. facial profile, dental occlusion and tonsils) is recommended to recognize children with an increased risk of SDB.
Similar content being viewed by others
References
Ali NJ, Pitson D, Stradling JR (1993) Snoring, sleep disturbance, and behaviour in 4–5 year olds. Arch Dis Child 68:360–366
Ali NJ, Pitson DJ, Stradling JR (1994) Natural history of snoring and related behaviour problems between ages of 4 and 7 years. Arch Dis Child 71:74–76
Anuntaseree W, Rookkapan K, Kuasirikul S, Thongsuksai P (2001) Snoring and obstructive sleep apnea in Thai school-age children: prevalence and predisposing factors. Pediatr Pulmonol 32:222–227
Aurora RN, Zak RS, Karippot A, Lamm CI, Morgenthale TI, Auerbach SH, Bista SR, Casey KR, Chowdhuri S, Kristo DA, Ramar K (2011) Practice parameters for the respiratory indications for polysomnography in children. Sleep 34:379–388
Berger G, Berger R, Oksenberg A (2009) Progression of snoring and obstructive apnoea: the role of increasing weight and time. Eur Respir J 33:338–345
Björk A, Krebs B, Solow B (1964) A method for epidemiological registration of malocclusion. Acta Odontol Scand 22:27–41
Brodsky L (1989) Modern assessment of tonsils and adenoids. Pediatr Clin North Am 36:1551–1569
Cole TJ, Bellizzi MC, Flegal KM, Dietz WH (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320:1240–1243
Cole TJ, Freeman JV, Preece MA (1995) Body mass index reference curves for the UK, 1990. Arch Dis Child 73:25–29
Ferreira AM, Clemente V, Gozal D, Gomes A, Pissarra C, Cesar H, Coelho I, Silva CF, Azevedo HH (2000) Snoring in Portuguese primary school children. Pediatrics 106:E64
Foster GD, Borradaile KE, Vander Veur SS, Leh Shantz K, Dilks RJ, Goldbacher EM, Oliver TL, Lagrotte CA, Homko C, Satz W (2009) The effects of a commercially weight loss program among obese patients with type 2 diabetes: a randomized study. Postgrad Med 121:113–118
Gozal D (2007) Morbidity of sleep disordered breathing in children: facts and theory. Sleep Breath 5:35–42
Hultcranz E, Löfstrand-Tideström B (2009) The development of sleep disordered breathing from 4 to 12 years and dental arch morphology. Int J Pediatr Otorhinolaryngol 73:1234–1241
Kapuniai LE, Andrew DJ, Crowell DH, Pierce JW (1988) Identifying sleep apnea from self-reports. Sleep 11:430–436
Kipping RR, Jago R, Lawlor DA (2008) Obesity in children. Part 1: epidemiology, measurement, risk factors, and screening. BMJ 337:922–927
Kohler MJ, van den Heuvel CJ (2008) Is there a clear link between overweight/obesity and sleep disordered breathing in children? Sleep Med Rev 12:347–364
Leinum CJ, Dopp JM, Morgan BJ (2009) Sleep-disordered breathing and obesity: pathophysiology, complications and treatment. Nutr Clin Pract 24:675–687
Löfstrand-Tideström B, Thilander B, Ahlqvist-Rastad J, Jakobsson O, Hultcrantz E (1999) Breathing obstruction in relation to craniofacial and dental arch morphology in 4-year-old children. Eur J Orthod 21:323–332
Mallampati S, Gatt S, Gugino L, Desai S, Waraksa B, Freiberger D, Liu P (1985) A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 32:429–434
Marcus CL, Loughlin GL (1996) Obstructive sleep apnea in children. Semin Pediatr Neurol 3:23–28
Marino A, Malagnini I, Ranieri R, Villa MP, Malagola C (2009) Craniofacial morphology in preschool children with obstructive sleep apnea syndrome. Eur J Paediatr Dent 10:181–184
Ng DK, Chow PY, Chan CH, Kwok KL, Cheung JM, Kong FY (2006) An update of childhood snoring. Acta Paediatr 95:1029–1035
Ng DK, Lam YY, Kwok KL, Chow PY (2004) Obstructive sleep apnea syndrome and obesity in children. Hong Kong Med J 10:44–48
Pahkala R, Puustinen R, Tuomilehto H, Ahlberg J, Seppä J (2011) Risk factors for sleep disordered breathing: the role or craniofacial structure. Acta Odontol Scand 69:137–143
Partinen M, Gislason T (1995) Basic Nordic Sleep Questionnaire (BNSQ): a quantitated measure of subjective sleep complaints. J Sleep Res 4:150–155
Peltomäki T (2007) The effect of mode of breathing on craniofacial growth—revisited. Eur J Orthod 29:426–429
Pirilä-Parkkinen K, Pirttiniemi P, Nieminen P, Tolonen U, Pelttari U, Löppönen H (2009) Dental arch morphology in children with sleep-disordered breathing. Eur J Orthod 31:160–167
Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham K (1999) Risk factors for sleep-disordered breathing in children. Associations with obesity, race and respiratory problems. Am J Respir Crit Care Med 159:1527–1532
Rosen CL, Storfer-Isser A, Taylor HG, Kirchner HL, Emancipator JL, Redline S (2004) Increased behavioural morbidity in school-aged children with sleep-disordered breathing. Pediatrics 114:1640–1648
Sahlman J, Pukkila M, Seppä J, Tuomilehto H (2007) Evolution of mild obstructive sleep apnoea after different treatments. Laryngoscope 117:1107–1111
Tauman R, Gozal D (2006) Obesity and obstructive sleep apnea in children. Pediatr Respir Rev 7:247–259
Tuomilehto H, Peltonen M, Partinen M, Lavigne G, Eriksson JG, Herder C, Aunola S, Keinänen-Kiukaanniemi S, Ilanne-Parikka P, Uusitupa M, Tuomilehto J, Lindström J, Finnish Diabetes Prevention Study Group (2009) Sleep duration, lifestyle intervention, and incidence of type 2 diabetes in impaired glucose tolerance: The Finnish Diabetes Prevention Study. Diabetes Care 32:1965–1971
Verhulst SL, Franckx H, Van Gaal L, De Backer W, Desager K (2009) The effect of weight loss on sleep-disordered breathing in obese teenagers. Obesity 17:1178–1183
Verhulst SL, Van Gaal L, De Backer W, Desager K (2008) The prevalence, anatomical correlates and treatment of sleep-disordered breathing in obese children and adolescents. Sleep Med Rev 12:339–346
Vuorela N, Saha MT, Salo M (2009) Prevalence of overweight and obesity in 5- and 12-year-old Finnish children in 1986 and 2006. Acta Paediatr 98:507–512
Wei JL, Mayo MS, Smith HJ, Reese M, Weatherly RA (2007) Improved behavior and sleep after adenotonsillectomy in children with sleep disordered breathing. Arch Otolaryngol Head Neck Surg 133(10):974–979
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. New Engl J Med 328:1230–1235
Acknowledgments
We thank the voluntary children and their parents who participated in the present study. We are also most indebted to the PANIC Study researchers for their skillful contribution in performing the study. This work has been financially supported by grants from the Ministry of Social Affairs and Health of Finland, the Ministry of Education and Culture of Finland the Finnish Innovation Fund Sitra, the Social Insurance Institution of Finland, the Finnish Cultural Foundation, the Juho Vainio Foundation, the Foundation for Paediatric Research, the Paavo Nurmi Foundation and the Kuopio University Hospital (EVO-funding number 5031343).
Conflict of interest
The authors declare that there is no conflict of interests.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Ikävalko, T., Tuomilehto, H., Pahkala, R. et al. Craniofacial morphology but not excess body fat is associated with risk of having sleep-disordered breathing—The PANIC Study (a questionnaire-based inquiry in 6–8-year-olds). Eur J Pediatr 171, 1747–1752 (2012). https://doi.org/10.1007/s00431-012-1757-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00431-012-1757-x