to the editor: I would like to comment on a few points raised by the authors of “Obstructive Sleep Apnea in Children,”¹ in American Family Physician. First, they state that “in children, an apnea-hypopnea index greater than 1…is considered abnormal.”¹ This is incorrect: the study² the authors cited clearly states that the recommended normal value of apnea index (not apnea-hypopnea index) is less than or equal to 1. The normal value of apnea-hypopnea index has not been established for children even though hypopnea is as important as apnea. Apnea-hypopnea index values of 5, 10, 15, 20, and 30 were used as definitions of obstructive sleep apnea in children.³ Using an apnea-hypopnea index greater than 1 as the definition of obstructive sleep apnea is not supported by the current evidence. The authors¹ commented that adenotonsillectomy has been shown to improve weight problems. This is certainly true for failure to thrive, but not for obesity. It has been well documented that obesity often worsens after adenotonsillectomy.^4,5 Hence, dietary and exercise advice is an essential component in managing children who are obese and have obstructive sleep apnea. One study⁶ reported resolution of sleep apnea after weight loss in five children who were morbidly obese.

in reply: As seen in previous studies,^1,2 episodes of complete airway obstruction in children are relatively uncommon. Obstructive sleep apnea may manifest mainly as hypopneas and continuous hypoventilation with partial cessation of airflow. Therefore, incorporating information about hypopneas may be as important as data on apneas. Hopefully, further research in this area will lead to clearer guidelines regarding hypopneas and apneas.

We agree that adenotonsillectomy has been shown to be effective in improving weight in children with failure to thrive and not in children with obesity.^3,4 It is stated in several places in our article⁵ that medical management of obesity may benefit the overweight child and potentially resolve their obstructive sleep apnea.^5,6