www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Sleep
disorders
in
children
with
moderate
to
severe
persistent
allergic
rhinitis
夽
Jessica
Loekmanwidjaja,
Ana
Cláudia
F.
Carneiro,
Maria
Lúcia
T.
Nishinaka,
Daniela
A.
Munhoes,
Gabriela
Benezoli,
Gustavo
F.
Wandalsen
∗,
Dirceu
Solé
UniversidadeFederaldeSãoPaulo(UNIFESP),EscolaPaulistadeMedicina(EPM),DepartamentodePediatria,SãoPaulo,SP,Brazil
Received5December2016;accepted20January2017 Availableonline27February2017
KEYWORDS Sleepdisorders; Allergicrhinitis; Children; Writtenquestionnaire Abstract
Introduction:Allergicrhinitisisassociatedwithseveralcomplications,includingsleep disor-ders.TheChildren’sSleepHabitsQuestionnairehasbeenrecentlytranslatedandvalidatedin Portuguesefortheevaluationofsleepdisordersinchildren.
Objective:Toassess sleepdisordersinchildren withmoderate tosevere persistentallergic rhinitisandtocorrelatethefindingswithdiseaseseveritymarkers.
Methods:Weevaluated167children(4---10years),112withallergicrhinitisand55controls. Parents/guardiansofthechildrenansweredtheChildren’sSleepHabitsQuestionnaire, consist-ingof33questionsdividedintoeightsubscales,whichreferstothepreviousweek.Patients withrhinitiswerealsoevaluatedregardingthescoreofnasalandextra-nasalsymptomsrelated tothepreviousweekandthepeaknasalinspiratoryflow.
Results:Therewerenosignificantdifferencesbetweengroups ofdifferentage.Allpatients withrhinitiswerebeingtreatedwithnasaltopicalcorticosteroids.ThetotalChildren’sSleep HabitsQuestionnairescorewassignificantlyhigheramongchildrenwithrhinitisthanincontrols (median48vs.43,p<0.001).Significantlyhighervalueswerealsoobservedfortheparasomnia (9vs.8),respiratorydisorders(4vs.3)anddaytimesleepiness(14vs.12)subscales.Among thepatientswithrhinitis,nosignificantcorrelationwasobservedbetweenthetotalChildren’s SleepHabitsQuestionnairescoreanddiseaseactivityvariables,butmoderatecorrelationswere observedfortherespiratorydistresssubscalevs.nasalsymptomscore(r=0.32)andvs. extra-nasalsymptomscore(r=0.32).
夽 Pleasecitethisarticleas:LoekmanwidjajaJ,CarneiroAC,NishinakaML,MunhoesDA,BenezoliG,WandalsenGF,etal.Sleepdisorders inchildrenwithmoderatetoseverepersistentallergicrhinitis.2018;84:178---84.
∗Correspondingauthor.
E-mails:gfwandalsen@uol.com.br,gfwandalsen@unifesp.br(G.F.Wandalsen).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2017.01.008
1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Conclusion: Childrenwithmoderatetoseverepersistentallergicrhinitis,evenwhensubmitted toregulartreatment,haveahigherfrequencyofsleepdisordersthancontrols,particularly concerningnocturnalbreathingdisorders,daytimesleepiness,andparasomnias.Theintensity ofsleepdisordersfound insomesubscaleswascorrelatedwithobjectivemarkersofallergic rhinitisseverity.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Distúrbiosdesono; Rinitealérgica; Crianc¸as; Questionárioescrito
Distúrbiosdosonoemcrianc¸ascomrinitealérgicapersistentemoderada-grave Resumo
Introduc¸ão: A rinite alérgica está associada a diversas complicac¸ões, como por exemplo os distúrbios do sono. O Children’s Sleep Habits Questionnaire é um questionário para avaliac¸ão dos distúrbios do sono em crianc¸as, recentemente traduzido e validado para o português.
Objetivos: Avaliar distúrbios do sono em crianc¸as com rinite alérgica persistente moder-ada/graveecorrelacionarosachadoscommarcadoresdegravidadedadoenc¸a.
Método: Foramavaliadas167crianc¸as(4---10anos),112comrinitealérgicae55controles.Todos osresponsáveispelascrianc¸asresponderamoquestionáriocompostopor33questõesdividasem oitosubescalasereferentesàúltimasemana.Ospacientescomriniteforamavaliadostambém peloescoredesintomasnasaiseextra-nasaisreferentesàúltimasemanaepelopicodefluxo inspiratórionasal.
Resultados: Nãohouvediferenc¸assignificantesentreosgruposcomrelac¸ãoàidade.Todosos pacientescomrinitevinhamsendotratadoscomcorticosteroidetópiconasal.Oescoretotaldo questionáriofoisignificantementemaiorentreoscomrinitequeoscontroles(mediana48vs. 43;p<0,001).Valoressignificantementemaiorestambémforamobservadosparaassubescalas deparassonias(9vs.8),distúrbiosrespiratórios(4vs.3)esonolênciadiurna(14vs.12).Entre ospacientescomrinitenãofoiobservadacorrelac¸ãosignificanteentreoescoretotaldo ques-tionárioeasvariáveisdeatividadedadoenc¸a,porémcorrelac¸õesmoderadasforamobservadas paraasubescaladedistúrbiosrespiratóriosvs.escoredesintomasnasais(r=0,32)evs.escore desintomasextra-nasais(r=0,32).
Conclusões: Crianc¸ascomrinitealérgicapersistentemoderada-grave,mesmoemtratamento regular,apresentammaiorfrequênciadedistúrbiosdosonodoquecontroles,particularmente emrelac¸ãoaosdistúrbiosrespiratóriosnoturnos,sonolênciadiurnaeparassonias.Aintensidade dasalterac¸õesdosonoencontradasemalgumassubescalassecorrelacionoucommarcadores objetivosdegravidadedarinitealérgica.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Data obtained by the International Study of Asthma and
Allergies in Childhood (ISAAC) indicate that the
preva-lenceof rhinitis symptomsin Brazilian schoolchildren and
adolescents is 25.7% and 29.6%, respectively, and that of
allergicrhinoconjunctivitisis 12.6%forchildren and14.6%
foradolescents.1
Althoughallergicrhinitisisoftenviewedasadiseaseof
lesser severitythan asthma, it is capable of dramatically
altering the patients’ quality of life, as well as their
performance, learning and productivity.2---7 In addition
to symptoms themselves, the treatment regimen may be
blamedforthediscomfortreportedbypatientswithallergic
rhinitis, especially those with more severe forms.8 Sleep
disorders,difficultyconcentrating,decreasedperformance
(school/work) and daytime sleepiness have often been
reportedbypatientswithallergicrhinitis,especiallyinthe
persistentforms.2---8
Theevaluationoftheinterferenceofallergicrhinitison
sleephasbeentheobjectofstudybyresearchers;however,
theuseofobjectivemethods,suchaspolysomnography,is
verylimitedinpopulationstudiesduetotechnicaland
prac-ticaldifficulties.Thus,thedevelopmentof questionnaires
andassessmentscalestobeutilizedinpediatricpopulations
has been developed for use in larger studies.9---16 Among
these,theuseoftheChildren’sSleepHabitsQuestionnaire
(CSHQ)is emphasized,17 thepurposeof whichis toassess
sleep behavior in school-age children including the most
to the International Classification of Sleep Disorders.18
DevelopedintheEnglishlanguage,theCSHQwasrecently
translatedandvalidatedintoPortugueseandameanglobal
scoreof47pointswasobservedamonghealthychildren.19
Todate,onlyasinglestudyhasassessedthepresenceof
sleepdisordersinchildren withrespiratoryallergies using
theCSHQquestionnaire.4Inthismulticenterstudy,carried
outinseveralLatinAmericancenters,itwasdemonstrated
that children with asthma and/or allergic rhinitis had a
higher prevalence of sleep disorders when compared to
controls.4
The aim ofthis study wastoevaluate thepresence of
sleepdisorders in children withmoderate to severe
per-sistentallergicrhinitisandtocorrelatethesefindingswith
diseaseseveritymarkers.
Methods
Patients(aged4---10years)enrolledwereregularlyfollowed
foratleastoneyearinanoutpatientclinicduetoPersistent
Moderate-to-SevereAllergicRhinitis(PMSAR).Healthy,
non-allergiccontrolsof thesameagegroupalsowereenrolled
in the study. All children underwent a complete physical
examinationat admissiontoruleoutpossible chronic
dis-easescapableofinterferingwithsleepquality,inaddition
tomedicationconsumption.Children(patientsandcontrols)
withupperairwaymechanicalobstruction,neurological
dis-eases,psychiatricdisordersorthosetakinganticonvulsants,
aswellasthosewithuncontrolledasthma,wereexcluded,20
includingchildrenreceivingfirst-generationantihistamines.
The childrens’ parents/guardians answered the CSHQ,
which was translated and validated into the Portuguese
language.19 TheCHSQconsistsof33questionsdividedinto
subscalesasfollows:resistancetosleep(goestobedatthe
sametime,fallsasleeponlyinhis/herownbed,fallsasleep
insomeoneelse’sbed, needsa parentinthe bedroom,is
reluctanttogotosleep(score:6---18points);startofsleep (score:1---3points),sleepduration(sleepslittle,sleepsthe
necessary hours, sleeps the same number of hours every
day---score:3---9points);sleepanxiety(needsaparentin
thebedroom,fearofsleepinginthedark,fearofsleeping
alone,problems sleeping outside thehome --- score:4---12
points);nocturnal awakenings(switchestosomeoneelse’s
bedinthemiddleofthenight;wakesuponceanight,wakes
upmorethanonce---score:3---9points);parasomnias(wets
thebedat night,talksduringsleep,isrestlessandtosses
orthrashesduringsleep;sleepwalks;teethgrindingduring
sleep;wakesupscreaming,sweating;wakesupscaredafter
anightmare---score:7---21points);respiratorysleep
disor-ders(breathesloudly;seemstostopbreathingduringsleep,
snoring---score:3---9points)anddaytimesleepiness(wakes
upaloneinthemorning,wakesupinabadmood,is
awak-enedbyothers,hasdifficultygettingoutofbed,isslowto
befullyawake,seemstiredwhen:watchingTV,ridingacar
---score:8---24points).Thescoreisobtainedbyaddingthe
pointsreferringtothequestionsandthetotalscore(range:
35---105points)byaddingthescoresoftheeightitems.17
Patients with PMSAR were also evaluated for clinical
nasalsymptom score(NSS --- nasalobstruction, nasal
pru-ritus, sneezing and rhinorrhea) and extra-nasal symptom
score(ENSS,ocularhyperemia,ocularpruritus,tearingand
pharyngeal pruritus) in relation to the previous week. A
score wasattributedtoeach symptom, varying from 0to
3(0=absent,1=mild,2=moderateand3=intense).21Thus,
totalNSSandtotalENSSrangedfrom0to12points.Patients
withNSS≤3,whennotrelatedtoasinglesymptom,were
consideredtohavecontrolledrhinitis.
Inadditiontothescores,patientswithPMSARwere
eval-uatedfornasalcavityfunctionbymeasuringthePeakNasal
InspiratoryFlow(PNIF)usinga specificdevice(Peak Nasal
InspiratoryFlowMeter®,HSClementClarke,UK).Duringthe
procedure,patients,aftermaximallungexpiration,withthe
peak flow meter coupled tothe face, were instructed to
performmaximalinspirationthroughthenose,while
keep-ingthelipsfullyclosed,uptothetotallungcapacity.Three
measurementsweremadeandthebestwasrecorded,since
therewasnodifferencegreaterthan10%amongthem.22The
maximumnasalinspiratoryflowwasrecordedbythedevice
cursorinlitersperminute.
The study was approved by the institution’s Research
Ethics Committee (824,192/2014). The children’s parents
and/or guardians, aswell asthe children, agreed to
par-ticipateinthestudybysigningtheinformedconsentform,
aswellastheassentformforthechildren.
Statisticalanalysis
Parametric and nonparametric tests were used according
to the nature of the assessed variables. The comparison
between the ages of patients and controls was carried
out byStudent’s t-test.The comparative analysisof total
scores and subscales between patients and controls and
between those with controlled and uncontrolled rhinitis
wasperformed usingtheMann---Whitneytest.The studyof
the association between the global scores and the CHSQ
subscales and the NSS andthe PNIF was performed using
Spearman’scorrelationcoefficient.Inalltests,thelevelof
rejectionforthenullhypothesiswassetat5%.
The sample calculation wasperformed considering the
meanoftheCSHQ totalscoreof47pointsobservedinthe
validationofthePortuguesequestionnaire,19aminimum
dif-ference of 4 points in relation to the controls, standard
deviation of8 points,80% power andp=0.05. This would
require51 childrenper group.To studythe correlation of
the questionnaire withthe allergic rhinitis severity
varia-bles, we considered aminimum correlation coefficient of
0.25,powerof80%andp=0.05;whichrequiredatleast98
childreninthegroupwithallergicrhinitis.
Results
A total of 112 children with AR and 55 control children
completed the study.The two groups weresimilar in age
(Table 1). Among the patients, 48 (43%) were females;
88 (79%) had asthma and 8 (7%) had allergic
conjunctivi-tisassociatedwithPMSAR.Allpatientswerebeingtreated
with nasal topical corticosteroids and some of them, 46
(41%)receivedsecond-generation oralH1antihistamine in
theweekprecedingtheevaluation.PNIFmeasurementwas
appropriatelyperformedin94%(94/112)ofthepatients.
Thecomparativeanalysisbetweenthetwogroupsin
Table1 Comparativeanalysisofchildrenwithmoderatetoseverepersistentallergicrhinitisandnon-allergiccontrolsaccording tothetotalscoreandsubscalescore(medianandinterquartilerange)oftheChildren’sSleepHabitsQuestionnaire(CSHQ).
Control Allergicrhinitis p
N 55 112 Age(years)b 7.3±1.5 8.0±1.8 0.2 TotalCSHQscorec 43(38---49) 48(44---54)a <0.0001 Subscales Resistancetosleepc 7(6---10) 7(6---10) 0.7 Startofsleepc 1(1---2) 1(1---2) 0.4 Sleepdurationc 3(3---3) 3(3---5) 0.06 Sleepanxietyc 5(4---7) 6(4---8) 0.3 Nocturnalawakeningsc 3(3---4) 4(3---4) 0.08 Parasomniasc 8(7---10) 9(8---10)a 0.002 Respiratorydisordersc 3(3---4) 4(3---5)a 0.003 Daytimesleepinessc 12(9---14) 14(10---17)a 0.003
a Medianandinterquartileinterval---significantlyhigher. b Student’st-test.
c Mann---Whitney.
oftotalscoresandscoresoftheparasomnia,respiratory
dis-orders,anddaytimesleepinesssubscalesinPMSARpatients
(Table1).
The presence of asthma among the patients did not
induce significant changesin the totalscore andthoseof
the subscales when comparedto thosewith PMSAR alone
(totalrhinitiswithasthmascorevs.rhinitiswithoutasthma:
Median [Me]=49; interquartile interval [IQI]=43---54) vs.
Me=47[IQI=44---53];p=0.8).
Using the NSS>3 criterion toclassify PMSAR as
uncon-trolled,wefoundthat53(47.3%)patientshaduncontrolled
PMSAR. The total CSHQ score was significantly higher
amongthosewithuncontrolledrhinitis(Me=49;IQI=44---54)
when comparedtothosewithcontrolledrhinitis (Me=46;
IQI=41---50)(Fig.1).These twosubgroupsofchildrenwith
allergicrhinitisshowedsignificantlyhigherscoresthanthose
in the control group (Fig. 1). Similarly, the use of oral
antihistamineswasnotassociatedwithchangesinthe
ques-tionnaireresponses(totalscoreuseversusnon-use:Me=46
[IQI=42---52]vs.Me=49[IQI=44---53],p=0.2).
ConsideringthemeanoftheCSHQtotalscoreobserved
in its Portuguese validation (47 points) asa criterion for
sleep disorder diagnosis, we found that among patients
withPMSAR,57(51%)couldbeconsideredashavingsleep
Table 2 Spearman’s correlation coefficients (significant values:p<0.05) betweenthetotalscoreandthesubscale scoresoftheChildren’sSleepHabitsQuestionnaire(CSHQ) andallergicrhinitiscontrolmarkers.a
NSS ENSS PNIF r TotalCSHQscore 0.15 0.16 −0.22 Nocturnalawakenings --- 0.16 ---Parasomnias --- 0.25 ---Respiratorydisorders 0.32 0.32 ---Daytimesleepiness 0.17 --- −0.27
a NSS,nasalsymptomscore;ENSS,extra-nasalsymptomscore;
PNIF,peaknasalinspiratoryflow.
disorders.Regarding the control of rhinitis, 58% of those
withuncontrolled rhinitis showed alterations in the total
CSHQscore,incomparisonwith44%ofthosewithcontrolled
rhinitis.
The study of the association between the total CSHQ
score and its subscales with NSS, ENSS and PNIF values
documentedthe partial significanceof these comparisons
(Table2).Moderatecorrelation coefficients(r>0.30)were
observedonlybetweentherespiratorydisordersubscaleand
nasal (r=0.32) and extra-nasal (r=0.32) symptom scores
(Table2,Fig.2).
Discussion
Itisbelievedthatallergicrhinitiscanaffectsleepthrough
different mechanisms. Nasal congestion secondary to the
nasalmucosa inflammatoryprocess induces increased
air-way resistance and may result in oral breathing, sleep
disruptionandfatigue.23 Additionally, inflammatory
medi-atorsoftheallergicprocess,suchashistamineandcertain
cytokines,canact directly onthe central nervoussystem
byalteringsleeprhythm.23 Ithasbeenrecentlyobserved,
inchildrenwithsleepdisorders,thatthepresenceof
aller-gicrhinitis(withoutobstructivesleepapnea)decreasesREM
(RapidEyeMovement)sleeptime.24
Although considered asone of the main consequences
ofallergicrhinitis,sleepalterationsordisordershavebeen
minimallyevaluatedbytoolsvalidatedinchildren.25
Inourstudy,wedemonstratedthatchildrenwithallergic
rhinitisshowed higherscores on CSHQ whencompared to
healthychildren,indicatingagreaterchanceofsleep
disor-dersobservedinthem.However,ifweconsidertheisolated
useofCSHQ,whichscorewouldbeabletoidentifythe
pres-enceof sleep disorders?According to the creatorsof the
CSHQ,thisscorewouldbe41.17Usingthisvalueasacutoff,
wefoundthat83%ofthechildrenwithPMSARwouldbe
clas-sifiedashavingsleepdisordersandamongthecontrols,that
percentagewouldreach60%.Ontheotherhand,ifweused
70
60
50
40
30
Uncontrolled rhinitis Controlled rhinitis
p < 0.001 p = 0.03
p = 0.02
Controls
CSHQ
Figure1 Total score ofChildren’sSleepHabits Questionnaire(CSHQ) inchildren with controlled allergicrhinitis (controlled rhinitis:nasalsymptomscore≤3)(lightgray),uncontrolled(uncontrolledrhinitis:nasalsymptomscore≥4)(darkgray)andcontrols (white).
group(Me=43)asthecutoff,we wouldhave76%of sleep
alterations amongthose withPMSAR and 44% in controls.
However,this cutoff was47 in the large validation study
forthePortugueselanguage.19Byassumingthiscutoff,we
r = 0.32; p < 0.001 10 9 8 7 6 5 4 3 2 1 0 10 9 8 7 6 5 4 3 2 1 0 0 2 4 6 8 10 12 14 0 2 4 6 8 10 12 14 NSS ENSS Respir ator y disorder Respir ator y disorder r = 0.32; p < 0.001
Figure2 DispersionofvaluesintheChildren’sSleepHabits Questionnaire(CSHQ)specificsubscaleandallergicrhinitis con-trol markers (NSS, nasal symptom score, ENSS, extra-nasal symptomscore,r=Spearman’scorrelationcoefficient).
wouldhavesleepdisordersin51%ofthosewithPMSARand
in 24%of the controls.In viewof theseresults, whatever
thecriteriaused,itisclearthatpatientswithPMSARhave
ahigherfrequencyofsleepdisorders.
A recent systematic review evaluated the association
betweenallergicrhinitis andsleepdisordersin children.26
Of the18 selected studiespublished inthe last25 years,
12 found a higher prevalence of sleep disorders in
chil-dren with allergic rhinitis, with a prevalence of habitual
snoring.26 The broad differences in the methods used in
each study, involving different age groups and different
diagnostic methods, did not allow the accomplishment
of a meta-analysisand compilation of the review data,26
as well as making it difficult to compare it with our
study.
Several studies have shown that nasal congestion is
an independent risk factor for respiratory disorders
dur-ing sleep. Sleep is more affected when nasal congestion
is severe, leadingto parasomnias, snoring, breathing
dis-ordersand, consequently,daytimesleepiness.26 Ourstudy
demonstratedthatparasomnias,respiratorydisorders,and
daytime sleepiness have higher medians in patients with
allergic rhinitis than in control patients. These sleep
dis-orders observed in children withallergicrhinitis probably
contribute to the previously described complications of
allergicrhinitis,suchasdecreaseinqualityoflifeand inad-equateschoolperformance.2---7
The present study showed a significant association
between sleep disorders and several markers of allergic
rhinitisseverityorlackofcontrol,afindingdocumentedto
dateby alimitednumberofstudies.25 Significantlyhigher
CSHQ scores were found in thosewithuncontrolled
aller-gic rhinitis(Fig.1)and therewasa significantcorrelation
betweenseveralsubscales ofthequestionnaireand
however,wereweakinmostcases,withmoderate
correla-tionsfoundonlyintherespiratorydisordersubscale.
Inourstudy,anobjectivetoolforevaluatingnasal
func-tionwasused:thepeaknasalinspiratoryflow.Wewereable
todocumenta significant andnegativecorrelation of this
variablewiththe totalscoreofthequestionnaire andthe
daytimesleepinesssubscale.
The lack of regular and effective treatment of
aller-gic rhinitis has been indicated as one of the probable
causes of the association between the disease and sleep
disorders.26 Clinical trials have observed that the
intro-duction of the intranasal corticosteroid in these patients
positively contributes to the quality of sleep and the
reduction of these disorders.27,28 Ourstudy included only
patients receivingintranasalcorticosteroid treatment and
wedemonstratedthattheassociationofrhinitiswithsleep
disordersisalsoobservedinthesechildren.It is
notewor-thythehigh rateof treatedandyetuncontrolledpatients
(47%) exists. This finding may be due, in part, to the
strict criteria defined for the control of allergic rhinitis
(symptom score of up 3 points on a 12-point scale). On
the other hand, studies in patients with allergic rhinitis
havedocumentedthepersistenceofsymptomsinmanyof
them, evenwithregularuse of medication.3,29 Finally, no
objective medication use control was carried out, since
this was not the purpose of the study and, therefore, it
is not possible to guarantee real and regular medication
use.
Although widely used, the CSHQ still lacks validation
againstclassicaltoolsforthediagnosisofsleepdisorders.To
thebestofourknowledge,onlyonestudycomparedCSHQ
subscaleswithobjectivefindingsdemonstratedinchildren’s
polysomnography.30 Inthisstudy,nosignificantcorrelation
wasfound between thepolysomnography resultsand four
subscales of the CSHQ. The authors observed that these
questionnairesubscalesshowlowsensitivityandhigh
speci-ficity in the diagnosis of sleepdisorders.30 However, it is
importanttoobservethatsleepdisturbancesencompass a
widerangeofdisorders,diseasesandsymptoms.The
ques-tionnaireused in thepresent study(CSHQ) is ascreening
tool,alimitationofwhichisnotbeingabletoconclusively
establish the presence or absence of sleep disorders and
theircharacteristics.
Thepresenceofotherallergicdiseases,suchasasthma,
or treatments withcertainmedications couldrepresent a
possible study bias. To minimize this fact, we chose to
include onlychildren with controlledasthma and exclude
thosereceivinganticonvulsantsandclassicalantihistamines.
We observed that the presence of controlledasthma and
theuse ofsecond-generationantihistamineswere not
sig-nificantlyassociatedwiththequestionnaireresponses.
Conclusion
ChildrenwithPMSAR,evenwhensubmittedtoregular
treat-ment, have a higher frequency of sleep disorders than
controls, particularly in relation to nocturnal respiratory
disordersanddaytimesleepiness.Theintensityofsleep
dis-turbancesfoundinthesesubscalescorrelatedwithobjective
markersofallergicrhinitisseverity.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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