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Purpose: Sleep-disordered breathing (SDB) in children has been associated with craniofacial characteristics. Facial photography provides a radiation-free means of estimating facial morphology through facial landmark analysis. Our objective was to determine whether facial analysis provides information about SDB severity. Specifically, we aimed to determine whether facial photographic measurements differ with SDB status, or were associated with SDB severity., Methods: Single-center cohort of children undergoing overnight polysomnography for assessment of SDB; non-snoring controls were recruited from the community to undergo polysomnography. Standardized front and lateral facial photographs were analyzed according to previously published protocols. Multivariate analysis of variance was used to determine if facial measurements differed between SDB groups and controls. Linear regression was performed to determine if facial measurements were associated with SDB severity., Results: Seventy-eight children (9 controls, 17 primary snoring, 23 mild SDB, 27 moderate-severe SDB) were included. Facial angles and upper-to-lower face height ratio showed variation between SDB groups (p = 0.038). Facial measurements related to SDB severity, specifically an increased cervicomental angle (p = 0.001), and increased lower-to-upper face height (p = 0.006)., Conclusion: Evaluation of craniofacial features using clinical photography is feasible. Preliminary investigation shows some relationship with SBD severity. Further work is needed to determine if craniofacial photography is useful for stratifying SDB risk in children.

Background and Objective: Frequent central apnoeas are sometimes observed in healthy children; however; the pathophysiology of an elevated central apnoea index (CAI) is poorly understood. A raised CAI may indicate underlying ventilatory control instability (i.e. elevated loop gain, LG) or a depressed ventilatory drive. This pilot study aimed to compare LG in otherwise healthy children with an elevated CAI to healthy controls., Methods: Polysomnographic recordings from children (age > 6 months) without obstructive sleep apnoea and with a CAI > 5 events/h (n = 13) were compared with age and gender-matched controls with a CAI < 5 events/h (n = 13). Spontaneous sighs were identified during non-rapid eye movement (NREM) sleep, and breath-breath measurements of ventilation were derived from the nasal pressure signal. A standard model of ventilatory control (gain, time constant and delay) was used to calculate LG by transforming ventilatory fluctuations seen in response to a sigh into a ventilatory-drive signal that best matches observed ventilation., Results: The high CAI group had an elevated LG (median = 0.36 (interquartile range, IQR = 0.35-0.53) vs 0.28 (0.23-0.36); P ≤ 0.01). There was no difference in either the time constant (P = 0.63) or delay (P = 0.29) between groups. Elevated LG observed in the high CAI group remained after accounting for degree of hypoxia (average oxygen saturation (SpO 2 ) during each analysable window) experienced (0.40 (0.30-0.53) vs 0.25 (0.23-0.37); P = 0.04)., Conclusion: An elevated CAI in otherwise healthy children is associated with a raised LG compared to matched controls with a low CAI, irrespective of level of hypoxia. This relative ventilatory instability helps explain the high CAI and may ultimately be able to help guide diagnosis and management in patients with high CAI., (© 2019 Asian Pacific Society of Respirology.)

Study Objectives: Sleep disordered breathing (SDB) in children has significant effects on daytime functioning and cardiovascular control; attributed to sleep fragmentation and repetitive hypoxia. Associations between electroencephalograph (EEG) spectral power, autonomic cardiovascular control and cerebral oxygenation have been identified in adults with SDB. To date, there have been no studies in children. We aimed to assess associations between EEG spectral power and heart rate variability as a measure of autonomic control, with cerebral oxygenation in children with SDB., Methods: One hundred sixteen children (3-12 years) with SDB and 42 controls underwent overnight polysomnography including measurement of cerebral oxygenation. Power spectral analysis of the EEG derived from C4-M1 and F4-M1, quantified delta, theta, alpha, and beta waveforms during sleep. Multiple regression tested whether age, SDB severity, heart rate (HR), HR variability (HRV), and cerebral oxygenation were determinants of EEG spectral power., Results: There were no differences in EEG spectral power derived from either central or frontal regions for any frequency between children with different severities of SDB so these were combined. Age, HR, and HRV low frequency power were significant determinants of EEG spectral power depending on brain region and sleep stage., Conclusion: The significant findings of this study were that age and autonomic control, rather than cerebral oxygenation and SDB severity, were predictive of EEG spectral power in children. Further research is needed to elucidate how the physiology that underlies the relationship between autonomic control and EEG impacts on the cardiovascular sequelae in children with SDB., (© Sleep Research Society 2019. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.)

Purpose: Allergic rhinitis (AR) is a common risk factor for sleep disordered breathing (SDB) in children. Allergy to pollen is a trigger for allergic rhinitis, causing nasal inflammation, upper airway congestion and obstruction. We aimed to determine if the pollen count on the day of diagnostic polysomnography for SDB affected the result., Methods: Children (3-18 years; n = 90) who participated in research studies between 1 October and 31 December, when daily regional pollen counts were available, in the years 2005-2016 were eligible for inclusion. All children underwent overnight polysomnography for assessment of SDB severity. Pollen was categorised as grass or other pollen. Multiple stepwise linear regression was performed to determine whether the pollen count for that day, a diagnosis of asthma, age, and BMI-z-score were determinants of respiratory parameters measured on polysomnography, including the obstructive apnoea hypopnoea index (OAHI), SpO 2 nadir, average SpO 2 drop, SpO 2 < 90%, oxygen desaturation index > 4% (ODI4), and average transcutaneous CO 2 (TCM)., Results: Sixteen/90 children had AR. In children with AR, an increase in grass pollen of 1 grain/m 3 predicted an increase in OAHI of 0.2 events/h, ODI4 of 0.18 times/h, SpO 2 < 90% of 0.03 times/h, and TCM of 0.07 mmHg. None of the factors were determinants of SDB severity in children without AR., Conclusion: Our findings highlight that daily pollen counts may be an important factor influencing the severity of SDB on a single night of polysomnography in children with clinical allergic rhinitis and should be taken into account when determining treatment options.

Key Points: Sleep disordered breathing (SDB) affects 4-11% of children and is associated with adverse neurocognitive, behavioural and cardiovascular outcomes, including reduced autonomic control. The relationship between heart rate variability (HRV; a measure of autonomic control) and age found in non-snoring control children was absent during sleep in children with SDB. Age significantly predicted increasing cerebral oxygenation during wake in non-snoring control children, whereas during sleep, HRV significantly predicted decreasing cerebral oxygenation. Cerebral oxygenation was not associated with either age or HRV in children with SDB during both wake and sleep. SDB significantly disrupts the normal maturation of autonomic control and the positive association between autonomic control and cerebral oxygenation found in non-snoring children, and we speculate that the dampened autonomic control exhibited by children with SDB may have an attenuating effect on cerebral autoregulation via the moderating influence of HRV on cerebral blood flow., Abstract: The repetitive episodes of hypoxia that are features of sleep disordered breathing (SDB) in children are associated with alterations in autonomic control of heart rate in an age-dependent manner. We aimed to relate heart rate variability (HRV) parameters to age and measures of cerebral oxygenation in children (3-12 years old) with SDB and non-snoring controls. Children (SDB, n = 117; controls, n = 42; 3-12 years) underwent overnight polysomnography. Total (TP), low- (LF) and high-frequency (HF) power, tissue oxygenation index (TOI) and fractional tissue oxygen extraction (FTOE) were analysed during wake and sleep. Pearson's correlations determined the association between age and HRV parameters, and multiple linear regressions between HRV, age and cerebral oxygenation parameters. During wake, age had a positive association with LF power, reflecting increased parasympathetic and sympathetic activity with increasing age for both control and SDB groups. This association was also evident during sleep in controls, but was absent in children with SDB. In controls, during wake TOI had a positive, and FTOE a negative association with age. During sleep, TP, LF and HF power were significant, negative determinants of TOI and positive determinants of FTOE. These associations were not seen in children with SDB during wake or sleep. SDB disrupts the normal maturation of the autonomic control of heart rate and the association between HRV and cerebral oxygenation exhibited by non-snoring control children of primary school age. These results highlight the impact SDB has on cardiovascular control and the potential impact on adverse cardiovascular outcomes., (© 2018 The Authors. The Journal of Physiology © 2018 The Physiological Society.)

Background: The prevalence of obese children with sleep disordered breathing (SDB) is increasing. Obesity and SDB are independent cardiovascular risk factors, of which arterial stiffness is an early sign. Pulse wave velocity (PWV), is a marker of arterial stiffness and central systolic blood pressure (cSBP) is a better predictor of cardiovascular outcome than peripheral blood pressure. Therefore, we aimed to determine PWV and cSBP in overweight/obese or normal weight children with sleep disordered breathing (SDB), and non-snoring normal weight controls., Methods: Children (3-18 y) with SDB (overweight/obese [BMI z-scores ≥ 1.04], n = 48; normal weight n = 44) referred for clinical assessment of SDB and normal weight non-snoring controls recruited from the community (n = 38) underwent overnight polysomnography. PWV was calculated using photoplethysmography. cSBP was calculated using applanation tonometry in a subset of children older than 8 y (n = 55) who had usable waveforms., Results: Overweight/obese SDB group had higher PWV (mean cm/s (95% CI); wake: 366 (355-380); sleep: 340 (324-357)), than the normal-weight SDB group (wake: 257 (247-267), p = 0.002; sleep: 255 (242-269), p = 0.005), and non-snoring controls (wake: 238 (226-249), p = 0.002; sleep: 235 (220-250), p < 0.001). The normal-weight SDB group had higher PWV than controls (p = 0.03). Overweight/obese children with SDB had higher cSBP (105 (100-110) mmHg) compared with the normal weight children with SDB (96 (90-102)) and the non-snoring controls (97 (91-104); p < 0.05 for both)., Conclusion: This study suggests that overweight/obesity substantially worsens the cardiovascular sequelae of SDB, highlighting the imperative to treat obesity and SDB in children early in order to reduce future cardiovascular disease risk., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Purpose: This study aimed to examine slow wave activity (SWA), a marker of homeostatic regulation, as a potential mechanism linking sleep disordered breathing (SDB) with executive dysfunction in children., Methods: Executive function domains of working memory, spatial planning, information processing, and sustained attention were assessed using the Cambridge Neuropsychological Test Automated Battery (CANTAB) in children (N = 40; 5-12 years) referred for clinical diagnosis of SDB. Polysomnography records of non-snoring, age-matched controls (N = 34) were retrospectively examined for comparison of SWA. Power spectral analysis of the delta wave determined SWA. Group differences in sleep, respiratory, and SWA outcomes were examined. Mean CANTAB scores were compared to standardized norms and correlated against SWA., Results: Children with SDB showed increased SWA compared to non-snoring controls and scored < 25th percentile for planning accuracy, speed of mental processing, and task efficiency, when compared against population norms. Increasing severity of SDB was associated with an increased difficulty in solving complex tasks and time on task performance. SWA was associated with performance on tasks of early problem solving and efficiency during sustained attention., Conclusions: SWA, a subtle measure of sleep disruption and sleep regulation, is associated with deficits in problem solving and sustained attention in children with SDB. As current mechanistic theories do not account for deficits observed in children with mild forms of SDB, this study provides a promising alternative.

Objective: This study aimed to determine whether overweight and obesity increased the detrimental effects of pediatric sleep-disordered breathing (SDB) on cognition, behavior, mood, and quality of life., Methods: Children and adolescents (8-16 years) with clinically diagnosed SDB were categorized into two groups: healthy weight (Body Mass Index (BMI) z-score <1.04, N = 11) and overweight/obese (BMI z-score ≥ 1.04, N = 10). Age-matched healthy weight, non-snoring controls (N = 25) were recruited from the community. All participants underwent overnight laboratory polysomnography (PSG). Cognitive, behavioral, and quality of life assessments were conducted in the home following the PSG. Analysis of Covariance (ANCOVA) was used to assess group differences in cognitive outcomes, controlling for socio-economic status. Kruskal-Wallis ANOVA was used to determine group differences in behavior and quality of life. Where group differences were found, hierarchical linear regressions determined the effect of weight on outcomes., Results: Children with SDB had significantly poorer behavior and quality of life than controls, with overweight/obese children with SDB having the greatest dysfunction. No group differences were found in cognitive outcomes. The obstructive apnea hypopnea index (OAHI) was a significant predictor of withdrawn behavior (R 2  = 0.42), inattention (R 2  = 0.43), and aggressive behavior (R 2  = 0.30). BMI z-score added significantly to aggressive behavior (R 2  = 0.22) and was an independent predictor of externalizing behaviors (R 2  = 0.26). The OAHI predicted school functioning (R 2  = 0.30). BMI z-score predicted social functioning (R 2  = 0.38) and significantly added to physical functioning over the OAHI (OAHI R 2  = 30; BMI z-score R 2  = 0.37)., Conclusions: Overweight and obesity comorbid with SDB increase the risk of externalizing behaviors such as aggression but do not affect other behavioral associates of SDB such as inattention and school functioning., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: In both adults and children, obstructive sleep apnea (OSA) has significant adverse cardiovascular consequences. In adults, sleeping position has a marked effect on the severity of OSA; however, the limited number of studies conducted in children have reported conflicting findings. We aimed to evaluate the effect of sleeping position on OSA severity and the cardiovascular consequences in preschool-aged children., Methods: This was a retrospective analysis of children (3-5 years of age) diagnosed with OSA (n = 75) and nonsnoring controls (n = 25). Sleeping position was classified as supine, semi-supine, left lateral, right lateral, prone, and semi-prone by using video recordings during one night of attended polysomnography. OSA severity and cardiovascular parameters were compared between the positions., Results: All children spent significantly more sleep time in the supine position than in any other position. The obstructive apnea-hypopnea index was higher in the supine position than in the other sleeping positions during NREM (p < 0.05), higher in the moderate/severe OSA group when sleeping in the supine position than when sleeping in the left and right lateral positions (p < 0.05 for both) and prone position (p = 0.007) during REM. Sympathovagal balance was decreased in children with OSA in the supine and lateral positions (p < 0.05)., Conclusions: This study identified that preschool-aged children, whether nonsnoring controls or children with OSA, predominately sleep in the supine position, and OSA was more severe in the supine position. We suggest that to avoid the supine sleep position, positional therapy has the potential to ameliorate OSA severity, and the known cardiovascular consequences., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Study Objectives: Preterm birth and fetal growth restriction (FGR) are both associated with risk of hypertension in adulthood. Mechanisms leading to this pathology are unclear. In children aged 5-12 years, who were born preterm and FGR, we used sleep as a tool to assess autonomic control with assessment of cardiovascular structure and function., Methods: Eighteen children born preterm and FGR, 15 children born preterm with appropriate birth weights for gestational age (AGA), and 20 AGA term-born children were studied. Children underwent overnight polysomnography with the addition of continuous noninvasive blood pressure (Finometer™). Spectral measures of heart rate variability (HRV), blood pressure variability (BPV), and baroreflex sensitivity were assessed and overnight urinary catecholamine levels measured. Echocardiographic studies (Vivid7, GE Healthcare) were performed and vascular compliance assessed (Miller Instruments™). Statistical comparisons were adjusted for age and body size., Results: Compared to term children, preterm AGA children had increased high frequency HRV (p < .05) and BPV (p < .05) during sleep, reflecting increased parasympathetic activation and blood pressure changes related to respiration. Preterm FGR children had smaller left ventricular lengths, ascending aorta, and left ventricular outflow tract diameter (p < .05 for all) and vascular compliance was positively correlated with gestational age (r2 = 0.93, p < .05)., Conclusions: FGR combined with preterm birth did not alter autonomic control but altered heart structure in children. In contrast, preterm birth alone altered autonomic control but had no change in heart structure. These changes in children born preterm and FGR may contribute, in part, to increased risk of cardiovascular disease later in life but by different mechanisms., (© Sleep Research Society 2017. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.)

Frequency of dips below 90% on overnight oximetry can be used to estimate severity of obstructive sleep apnea (OSA) in children. Movement can result in artifact on oximetry recordings. Clinicians may therefore be tempted to remove periods of wakefulness from the recording to improve accuracy, but removal of such periods of potential artifact is time consuming. The aim of this study was to determine whether removing periods of wakefulness had a significant impact on analysis of overnight oximetry. Children aged 2-18 years (N = 108) with suspected OSA underwent overnight simultaneous oximetry and actigraphy at home on a single night. Actigraphy defined awake periods were "trimmed" from the oximetry data and oximetry variables compared between full and trimmed analysis. There was a statistically but not clinically significant difference between the full and trimmed data for mean SpO 2 , minimum SpO 2 , 4% desaturation index, and 3% desaturation index (all P < 0.05). There was no difference between the two analyses for median SpO 2 or the frequency of dips below 90%, 85%, or 80%. In conclusion, removal of periods of wakefulness at the start and end of overnight oximetry recordings does not affect the result in the context of testing for suspected OSA in children. Pediatr Pulmonol. 2016;51:1409-1413. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background: It has been suggested that impaired dissipation of slow-wave activity (SWA) in children with sleep-disordered breathing (SDB) may be a potential mechanism for daytime dysfunction. We aimed to examine whether resolution of SDB resulted in normalisation of SWA dissipation and whether this was associated with improved cognition and behaviour., Methods: Children (aged 3-6 y) diagnosed with SDB and age-matched non-snoring control children were followed up for 3 y after a baseline study. At the follow-up, children were categorised into control (N = 13), resolved SDB (N = 15) and unresolved SDB (N = 14). Delta activity on the electroencephalogram over the sleep period was used to calculate SWA and a battery of cognitive assessments and behaviour questionnaires were conducted at both time points., Results: There was no change in the average SWA between the baseline and follow-up and no differences between the groups. Cognitive and behavioural performance in the resolved group did not improve to control levels. However, decreased SWA at the beginning of the sleep period (β = -0.04, p = 0.002) and a decrease in obstructive apnoea-hypopnoea index (β = -2.2, p = 0.022) between the baseline and follow-up predicted improvements in measures of sustained attention. Increased SWA at the beginning of the sleep period between the baseline and follow-up predicted worsening of externalising behaviour (β = 0.02, p = 0.039)., Conclusions: This study suggests that resolution of SDB is not associated with changes in the dissipation of SWA. However, the association between decreases in SWA and improvements in cognitive and behavioural outcomes suggest that irrespective of disease, children whose quantitative sleepiness improves have improved attention and reduced externalising behaviours., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Purpose: Sleep-disordered breathing (SDB) prevalence peaks in preschool children and is associated with deficits in cardiovascular functioning during sleep. No long-term studies have investigated the effects of SDB resolution in mitigating these outcomes. We hypothesized that following 3 years, normalization of alterations to heart rate (HR), pulse transit time (PTT), heart rate variability (HRV), and urinary catecholamines identified at the initial diagnosis would be associated with resolution of SDB., Methods: Forty-five children with SDB and 28 non-snoring controls underwent polysomnography at baseline (3-5 years) and follow-up (6-9 years). Children were classified into control, resolved, and unresolved SDB. Resolution was defined as an obstructive apnea-hypopnea index (OAHI) ≤1 event/h, no snoring on polysomnography (PSG), or indicated by parents. PTT is an inverse surrogate measure of blood pressure change. HRV was assessed using power spectral analysis., Results: There was no change in PTT or HR between studies for any group. Our HRV data suggest reduced parasympathetic activity in children whose SDB resolved and increased parasympathetic activity in children whose SDB remained the same or worsened at follow-up. We identified a significant correlation between low frequency power and urinary dopamine and adrenaline levels at follow-up in the unresolved group, suggesting increased sympathetic activity in children with unresolved SDB., Conclusion: Our findings suggest an association between resolution of SDB and normalization of HRV in the long term in these preschool children and an augmented sympathetic activity in the children with residual SDB. This highlights the autonomic impact of SDB in young children and the importance of detection and treatment.

Objective: To determine whether sustained resolution of sleep disordered breathing (SDB) in young children, either because of treatment or spontaneous recovery, predicted long-term improvements in quality of life, family functioning, and parental stress., Study Design: Children diagnosed with primary snoring (n = 16), mild obstructive sleep apnea (OSA, n = 11), moderate-severe (MS) OSA (n = 8), and healthy nonsnoring controls (n = 25) at ages 3-5 years underwent repeat polysomnography at 6-8 years. Parents completed quality of life and parental stress questionnaires at both time points. Resolution of SDB was determined as obstructive apnea hypopnea index (OAHI) ≤1 event/hour, or absence of snoring during polysomnography or on parent report. Linear mixed-model analyses determined the effects of resolution on psychosocial morbidity. OAHI was used to determine the predictive value of changes in SDB severity on psychosocial outcomes., Results: Fifty percent of primary snoring, 45% mild OSA, and 63% MS OSA resolved, of which 67% received treatment. Children originally diagnosed with SDB continued to show significant psychosocial impairments compared with nonsnoring controls, irrespective of resolution. A reduction in OAHI predicted improvements in physical symptoms, school functioning, family worry and family relationships, and stress related to a difficult child., Conclusions: Treatment was more likely to result in resolution of SDB if original symptoms were MS. Children originally diagnosed with SDB, irrespective of resolution, continued to experience psychosocial dysfunction suggesting additional interventions are required., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Childhood sleep disordered breathing (SDB) presents as isolated respiratory events or episodes of consecutive repetitive events. We hypothesized that the surge in blood pressure (BP) and heart rate (HR) would be greater at the termination of events during episodes of repetitive events than following isolated events., Methods: % change in HR and pulse transit time (PTT; inverse surrogate of BP) were calculated from the last half of an event to: (i) between successive repetitive events; (ii) termination of the last repetitive event; (iii) event termination for isolated events., Results: 69% of the children exhibiting both isolated and repetitive events had more repetitive than isolated events. %HR change between repetitive events (27 ± 1%) was greater than at event termination for isolated events (17 ± 1%; P < 0.001). %PTT change at the termination of the last repetitive event (-8 ± 2%) was greater than at the termination of isolated events (-2 ± 2%; P < 0.05)., Conclusion: Episodes of repetitive respiratory events evoke a greater acute cardiovascular response, including surges in BP and HR between events, than do isolated events. Given that the majority of respiratory events in preschool children occur as repetitive episodes, this finding should be taken into account when assessing the impact of respiratory events for a given child.

Study Objective: Sleep disordered breathing (SDB) in preschool-aged children is common, but long-term outcomes have not been investigated. We aimed to compare sleep and respiratory parameters in preschool children to examine the effects of treatment or non-treatment after 3 years., Methods: Children (3-5 years) diagnosed with SDB (n = 45) and non-snoring controls (n = 30) returned for repeat overnight polysomnography (39% of original cohort), 3 years following baseline polysomnography. Children with SDB were grouped according to whether they had received treatment or not. SDB resolution was defined as an obstructive apnea hypopnea index (OAHI) ≤ 1 event/h, no snoring detected on polysomnography and habitual snoring not indicated by parents on questionnaire., Results: Fifty-one percent (n = 23) of the children with SDB were treated. Overall, SDB resolved in 49% (n = 22), either spontaneously (n = 8) or with treatment (n = 14). SDB remained unresolved in 39% (n = 9) of those treated and 64% (n = 14) of the children who were untreated. Two of the non-snoring controls developed SDB at follow-up. The treated group had significantly lower OAHI (p < 0.01), respiratory disturbance index (p < 0.001), total arousal and respiratory arousal indices (p < 0.01 for both) at follow-up compared with baseline. There were no differences between studies for the untreated group., Conclusions: Although treatment resulted in an improvement in indices related to SDB severity, 39% had SDB 3 years following diagnosis. These findings highlight that parents should be made aware of the possibility that SDB may persist or recur several years after treatment. This is relevant regardless of the severity of SDB at baseline and the treatment given., (© 2015 American Academy of Sleep Medicine.)

This study aimed to determine the long term effects of resolution of SDB in preschool children, either following treatment or spontaneous recovery, on cognition and behavior. Children diagnosed with SDB at 3-5y (N = 35) and non-snoring controls (N = 25), underwent repeat polysomnography (PSG) and cognitive and behavioral assessment 3 years following a baseline study. At follow-up, children with SDB were grouped into Resolved and Unresolved. Resolution was defined as: obstructive apnea hypopnea index (OAHI) ≤1 event/h; no snoring detected on PSG; and no parental report of habitual snoring. 57% (20/35) of children with SDB received treatment, with SDB resolving in 60% (12/20). 43% (15/35) were untreated, of whom 40% (6/15) had spontaneous resolution of SDB. Cognitive reduced between baseline and follow-up, however this was not related to persistent disease, with no difference in cognitive outcomes between Resolved, Unresolved or Control groups. Behavioral functioning remained significantly worse in children originally diagnosed with SDB compared to control children, regardless of resolution. Change in OAHI did not predict cognitive or behavioral outcomes, however a reduction in nocturnal arousals, irrespective of full resolution, was associated with improvement in attention and aggressive behavior. These results suggest that resolution of SDB in preschool children has little effect on cognitive or behavioral outcomes over the long term. The association between sleep fragmentation and behavior appears independent of SDB, however may be moderated by concomitant SDB. This challenges the assumption that treatment of SDB will ameliorate associated cognitive and behavioural deficits and supports the possibility of a SDB phenotype.