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Hong Kong, SAR, China
Correspondence to: Chung-him Loong, BSc, Department of Paediatrics, Kwong Wah Hospital, Hong Kong SAR, Kowloon 852, China; e-mail: lch029{at}ha.org.hk
To the Editor:
We read with interest the article by Kalra et al,1 who found that the prevalence of habitual snoring for 1-year-old children was 15% in a high-risk group for atopy, ie, children born to atopic parents. This prevalence was significantly higher than that reported in older children, 10.9% in 6- to 12-year-old children in Hong Kong,2 and 10 to 14% in < 6-year-olds in Europe and the United States.3 This higher prevalence is most likely due to the fact that 29% of this group of infants were atopic, and it is not surprising that Kalra et al1 found that the presence of atopy increased the risk of habitual snoring (odds ratio, 2.0; 95% confidence interval, 1.2 to 3.0), a common symptom of obstructive sleep apnea syndrome (OSAS).4 This was similar to previous findings in Hong Kong,2 when we found allergic rhinitis to be a significant risk factor for witnessed apnea with an adjusted odds ratio of 2.19, another symptom of OSAS as well as in the United States.5 It is unfortunate that Kalra et al1 did not report the prevalence of nasal symptoms in their cohort, as the data would have shed light on the mechanisms that link habitual snoring and atopic status, possibly allergic rhinitis. Other important data that were not reported were the parts played by individual allergens, especially the airborne allergens vs food allergen. These data would help determine whether the inhaled route or the ingested route is important in the habitual snoring infants. In the study of Kalra et al,1 the definition of positive atopic status for egg white and whole milk was wheal 
3 cm than the negative control, and this would be associated with a high false-positive rate.6
Allergic rhinitis leads to markedly increased nasal resistance, and Rappai et al7 found that nasal congestion was a strong independent risk factor for snoring and an increased likelihood for moderate or severe sleep-disordered breathing. In conclusion, Kalra et al1 reported an important study about infantile snoring, but important data were not included that may shed more light on this underrecognized symptom. Nevertheless, all medical practitioners dealing with atopic infants should ask the same question as did Kalra et al,1 ie, how often does your baby snore?
Footnotes
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
The authors have no conflicts of interest to disclose.
References
Cincinnati Children’s Hospital Medical Center Cincinnati, OH
Correspondence to: Maninder Kalra, MD, MS, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 2021, Cincinnati, OH 45229; e-mail: maninder.kalra{at}cchmc.org
To the Editor:
We thank Ng et al for their interest in our article.1 They raise concern about lack of data on nasal symptoms and our definition for positive skin-prick test results. Using the rhinitis definition of a positive parent report to the question "In the past 12 months, has your child ever had a problem with sneezing, or a runny, or a blocked nose when he/she did not have a cold or flu?" we found a strong association between rhinitis and habitual snoring (p < 0.001) in our cohort of 681 infants. In multivariate logistic regression model with habitual snoring as the dependent variable, the adjusted odds ratio for rhinitis was 2.5 (confidence interval, 1.7 to 4.0) and atopy (defined as positive skin-prick test result to an aeroallergen or food allergen was 1.9 (confidence interval, 1.2 to 2.9). Infants with positive skin-prick test results to aeroallergens compared to infants with negative skin-prick test results to all allergens had a trend for higher prevalence of habitual snoring (20.4% vs 12.9%, p = 0.05); and infants with positive skin-prick test results to food allergens compared to infants with all negative skin-prick test results to all allergens had a significantly higher prevalence of habitual snoring (22.5% vs 12.9%, p = 0.01). It is important to mention that at age 1 year, the prevalence of atopy to food allergens was much higher than that to aeroallergens. Therefore, a smaller sample size with lower power for aeroallergens could potentially explain the lack of significance for that group. At age 2 years, we have reported a dramatic increase in aeroallergen atopy.2 Given these findings, we propose to study the independent relationship between atopy to aeroallergens and habitual snoring at age 2 years. Our definition of a positive skin-prick test result is the standard proposed by the practice parameter committee of the Academy of Allergy, Asthma, and Immunology.3 Unfortunately, as pointed out by Ng et al, there are some limitations to this criterion. In summary, our data suggest that both rhinitis and atopy are independently associated with increased risk for habitual snoring in infants.
References
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