Obesity and anthropometric measurements predict more severe sleep-disordered breathing (SDB) in children, and are associated with cardiovascular risk factors in children without SDB. We aimed to investigate whether anthropometric measurements predicted autonomic control in children with SDB. We hypothesised that anthropometric measures would be significant predictors of decreased heart rate variability.
Children (3–17 years) with SDB (n = 298) and non-snoring controls (n = 126) underwent polysomnography. BMI z-score, neck, waist and hip circumference were recorded. Heart rate variability, indicating autonomic control, was analysed during wake, non-rapid eye movement stages N1, N2 and N3, and rapid eye movement (REM) sleep. The determinants of heart rate variability (low-frequency power [LF], high-frequency power [HF] and LF/HF ratio) were analysed using multiple stepwise linear regression. Independent variables were age, neck, waist and hip circumference, neck-to-waist ratio, waist-to-hip ratio and waist-to-height ratio, obstructive apnoea hypopnoea index, arousal index and SpO2 nadir.
Waist and hip circumference, and waist-to-height ratio were significant negative determinants of both HF and LF power during wake, reflecting dampened autonomic control (LF: waist/height ratio, B = −1917 (95% CI: −3640, −194), p = 0.03; HF: hip circumference, B = −27, (−48, −7), p = 0.01), N1&2 (LF/HF: hip circumference, B = 0.01 (0.004, 0.024), p = 0.005) and N3 (LF: waist/height ratio, B = −2495, (−4005, −986), p = 0.001; HF, hip circumference, B = −54, (−102, −6), p = 0.03; LF/HF, waist circumference, B = 0.01, (0.004, 0.015), p = 0.002). Age was the strongest determinant of heart rate variability during wake and sleep.
This study suggests that while age is a determinant of autonomic control in children with SDB, the strongest modifiable factor determining dampened autonomic control is increased central adiposity, as reflected in the waist and hip circumference and the waist-to-height ratio.
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Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:242–52.
Nisbet LC, Yiallourou SR, Nixon GM, Biggs SN, Davey MJ, Trinder J, et al. Characterization of the acute pulse transit time response to obstructive apneas and hypopneas in preschool children with sleep-disordered breathing. Sleep Med. 2013;14:1123–31.
Penzel T, Kantelhardt JW, Lo CC, Voigt K, Vogelmeier C. Dynamics of heart rate and sleep stages in normals and patients with sleep apnea. Neuropsychopharmacology. 2003;28:S48–S53.
O’Driscoll D, Foster AM, Ng ML, Yang JSC, Bashir F, Nixon GM, et al. Acute cardiovascular changes with obstructive events in children with sleep-disordered breathing. Sleep. 2009;32:1265–71.
Walter LM, Nixon GM, Davey MJ, Anderson V, Walker AM, Horne RS. Autonomic dysfunction in children with sleep disordered breathing. Sleep Breath. 2012. https://doi.org/10.1007/s11325-11012-10727-x.
Muzumdar HV, Sin S, Nikova M, Gates G, Kim D, Arens R. Changes in heart rate variability after adenotonsillectomy in children with obstructive sleep apnea. Chest. 2011;139:1050–9.
Horne R. Cardiovascular consequences of sleep disordered breathing in children. Sleep Biol Rhythms. 2009;7:A6.
Nisbet LC, Yiallourou SR, Biggs SN, Nixon GM, Davey MJ, Trinder JA, et al. Preschool children with obstructive sleep apnea: the beginnings of elevated blood pressure? Sleep. 2013;36:1219–26.
Nisbet LC, Yiallourou SR, Nixon GM, Biggs SN, Davey MJ, Trinder J, et al. Nocturnal autonomic function in preschool children with sleep-disordered breathing. Sleep Med. 2013;14:1310–6.
Amin RS, Carroll JL, Jeffries JL, Grone C, Bean JA, Chini B, et al. Twenty-four-hour ambulatory blood pressure in children with sleep-disordered breathing. Am J Respir Crit Care Med. 2004;169:950–6.
Amin RS, Kimball TR, Bean JA, Jeffries JL, Willging JP, Cotton RT, et al. Left ventricular hypertrophy and abnormal ventricular geometry in children and adolescents with obstructive sleep apnea. Am J Respir Crit Care Med. 2002;165:1395–9.
Montesano M, Miano S, Paolino MC, Massolo AC, Ianniello F, Forlani M, et al. Autonomic cardiovascular tests in children with obstructive sleep apnea syndrome. Sleep. 2010;33:1349–55.
Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130:e714–755.
Mathew JL, Narang I. Sleeping too close together: obesity and obstructive sleep apnea in childhood and adolescence. Paediatr Respir Rev. 2014;15:211–8.
Juonala M, Magnussen CG, Berenson GS, Venn A, Burns TL, Sabin MA, et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med. 2011;365:1876–85.
Kwok KL, Ng DK, Cheung YF. BP and arterial distensibility in children with primary snoring. Chest. 2003;123:1561–6.
Xu Z, Li B, Shen K. Ambulatory blood pressure monitoring in Chinese children with obstructive sleep apnea/hypopnea syndrome. Pediatr Pulmonol. 2013;48:274–9.
Horne RSC, Shandler G, Tamanyan K, Weichard A, Odoi A, Biggs SN, et al. The impact of sleep disordered breathing on cardiovascular health in overweight children. Sleep Med. 2018;41:58–68.
Li AM, Au CT, Sung RY, Ho C, Ng PC, Fok TF, et al. Ambulatory blood pressure in children with obstructive sleep apnoea: a community based study. Thorax. 2008;63:803–9.
Androutsos O, Grammatikaki E, Moschonis G, Roma-Giannikou E, Chrousos GP, Manios Y, et al. Neck circumference: a useful screening tool of cardiovascular risk in children. Pediatr Obes. 2012;7:187–95.
Ho AW, Moul DE, Krishna J. Neck circumference-height ratio as a predictor of sleep related breathing disorder in children and adults. J Clin Sleep Med. 2016;12:311–7.
Katz S, Murto K, Barrowman N, Clarke J, Hoey L, Momoli F, et al. Neck circumference percentile: a screening tool for pediatric obstructive sleep apnea. Pediatr Pulmonol. 2015;50:196–201.
Ogden C, Kuczmarski R, Flegal K, Mei Z, Guo S, Wei R, et al. Centers for disease control and prevention 2000 growth charts for the united states: improvements to the 1977 national center for health statistics version. Pediatrics. 2002;109:45–60.
Horne RS, Yang JS, Walter LM, Richardson HL, O’Driscoll DM, Foster AM, et al. Elevated blood pressure during sleep and wake in children with sleep-disordered breathing. Pediatrics. 2011;128:e85–92.
Iber C, Ancoli-Israel S, Chesson A, Quan SF. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specification. 1st ed. Illinois: American Academy of Sleep Medicine Westchester; 2007.
Nixon GM, Hyde M, Biggs SN, Walter LM, Horne RS, Davey MJ. The impact of recent changes to the respiratory scoring rules in pediatrics. J Clin Sleep Med. 2014;10:1217–21.
Araujo Lda S, Fernandes JF, Klein MR, Sanjuliani AF. Obstructive sleep apnea is independently associated with inflammation and insulin resistance, but not with blood pressure, plasma catecholamines, and endothelial function in obese subjects. Nutrition. 2015;31:1351–7.
O’Connor GT, Caffo B, Newman AB, Quan SF, Rapoport DM, Redline S, et al. Prospective study of sleep-disordered breathing and hypertension: the Sleep Heart Health Study. Am J Respir Crit Care Med. 2009;179:1159–64.
Walter LM, Nixon GM, Davey MJ, Anderson V, Walker AM, Horne RS. Autonomic dysfunction in children with sleep disordered breathing. Sleep Breath. 2013;17:605–13.
Goldstein DS, Bentho O, Park MY, Sharabi Y. Low-frequency power of heart rate variability is not a measure of cardiac sympathetic tone but may be a measure of modulation of cardiac autonomic outflows by baroreflexes. Exp Physiol. 2011;96:1255–61.
Spicuzza L, Bernardi L, Calciati A, Di Maria GU. Autonomic modulation of heart rate during obstructive versus central apneas in patients with sleep-disordered breathing. Am J Respir Crit Care Med. 2003;167:902–10.
Rodriguez-Colon SM, Bixler EO, Li X, Vgontzas AN, Liao D. Obesity is associated with impaired cardiac autonomic modulation in children. Int J Pediatr Obes. 2011;6:128–34.
Thayer JF, Lane RD. The role of vagal function in the risk for cardiovascular disease and mortality. Biol Psychol. 2007;74:224–42.
Correa CM, Gismondi RA, Cunha AR, Neves MF, Oigman W. Twenty-four hour blood pressure in obese patients with moderate-to-severe obstructive sleep apnea. Arq Bras Cardiol. 2017;109:313–320.
Pang KP, Pang EB, Pang KA, Vicini C, Chan YH, Rotenberg BW. Upper airway surgery for obstructive sleep apnea reduces blood pressure. Laryngoscope. 2018;128:523–527.
Vlahandonis A, Nixon GM, Davey MJ, Walter LM, Horne RS. Improvement of sleep-disordered breathing in children is associated with a reduction in overnight blood pressure. Sleep Med. 2013;14:1295–303.
Katz SL, Vaccani JP, Clarke J, Hoey L, Colley RC, Barrowman NJ. Creation of a reference dataset of neck sizes in children: standardizing a potential new tool for prediction of obesity-associated diseases? BMC Pediatr. 2014;14:159.
Nagy P, Kovacs E, Moreno LA, Veidebaum T, Tornaritis M, Kourides Y, et al. Percentile reference values for anthropometric body composition indices in European children from the IDEFICS study. Int J Obes. 2014;38(Suppl 2):S15–25.
We would like to thank the children and their parents who participated in this study.
This research was supported by the National Health and Medical Research Council of Australia [grant numbers 384142, 491001 and 10008919], the Heart Foundation of Australia [grant number G12M6564], and the Victorian Government’s Operational Infrastructure Support Program.
LMW conceptualised and designed the study, obtained funding for the study, analysed the data, drafted the initial manuscript and revised the manuscript. LMW is the corresponding author and confirms that she has had full access to the data in the study and final responsibility for the decision to submit for publication. RSCH, GMN and MJD conceptualised and designed the study, obtained funding for the study, and reviewed and revised the manuscript. KT and LCN collected the data and reviewed and revised the manuscript. All authors approved the final manuscript as submitted.
Conflict of interest
The authors declare that they have no conflict of interest.
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Walter, L.M., Tamanyan, K., Nisbet, L.C. et al. Obesity and anthropometric determinants of autonomic control in children with sleep-disordered breathing—which measurements matter?. Int J Obes 42, 1195–1201 (2018). https://doi.org/10.1038/s41366-018-0130-1
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