Snoring in the paediatric population has garnered increasing clinical attention due to its association with sleep-disordered breathing (SDB), developmental delay, and adverse behavioral and cognitive outcomes. Once considered a benign occurrence, habitual snoring is now recognized as a potential indicator of obstructive sleep apnea (OSA) and related airway disturbances in children [1]. Studies have shown that up to 27% of children may snore occasionally, while habitual snoring—defined as snoring on three or more nights per week—has a prevalence ranging from 7% to 12% across different populations [2,3].

Paediatric snoring, unlike in adults, is often multifactorial and can arise from anatomical, neuromuscular, or inflammatory causes. The most common etiological factor is adenotonsillar hypertrophy, particularly in children aged 2 to 8 years, where peak lymphoid tissue proliferation occurs [4]. Other contributing factors include obesity, allergic rhinitis, craniofacial anomalies, and exposure to environmental tobacco smoke [5,6]. Notably, the incidence of snoring is reportedly higher in children with co-existing conditions such as Down syndrome or neuromuscular disorders [7].

Despite the clinical relevance, paediatric snoring often goes underdiagnosed, primarily because caregivers may not recognize it as a problem warranting medical evaluation [8]. This underreporting complicates efforts to establish a clear epidemiological picture of the condition. Moreover, the lack of uniform diagnostic criteria and variability in study designs contribute to inconsistencies in reported incidence and prevalence rates [9].

Polysomnography (PSG) remains the gold standard for diagnosing sleep-disordered breathing; however, its limited availability and high cost make it an impractical tool for large-scale epidemiological screening [10]. Consequently, most prevalence data on snoring are derived from parent-reported questionnaires or screening tools, which, while cost-effective and accessible, may introduce subjective bias.

Understanding the incidence and prevalence of snoring in children is essential not only for early detection of potential sleep-related breathing disorders but also for identifying associated health risks. Habitual snoring has been linked to behavioral issues such as hyperactivity, inattention, and poor academic performance, often mimicking attention-deficit/hyperactivity disorder (ADHD) [3,6]. Additionally, persistent untreated SDB has been associated with cardiovascular alterations, including elevated blood pressure and ventricular hypertrophy in paediatric populations [5-10].

This study aims to evaluate the incidence and prevalence of snoring among paediatric patients in a defined population, with an emphasis on identifying age and gender distributions, common etiological factors, and correlations with other clinical parameters. By establishing baseline data, this research seeks to improve awareness, promote timely diagnosis, and contribute to the formulation of early intervention strategies for affected children.

Study Design and Setting

A cross-sectional observational study was conducted over a period of 6 months at the Department of Paediatrics in a tertiary care teaching hospital. The study protocol was approved by the Institutional Ethics Committee prior to data collection.

Study Population

Children aged between 2 and 14 years, attending the outpatient department or admitted to the pediatric ward for non-respiratory ailments, were eligible for inclusion. Written informed consent was obtained from parents or guardians, and assent was taken from children aged ≥7 years.

Inclusion Criteria

• Children aged 2–14 years
• Availability of a primary caregiver for interview
• No acute respiratory illness at the time of data collection

Exclusion Criteria

• Children with known craniofacial syndromes or neuromuscular disorders
• Previously diagnosed obstructive sleep apnea (OSA) or undergoing treatment for the same
• History of adenotonsillectomy

Sample Size Estimation

Based on an expected prevalence of habitual snoring of 10% from previous literature [1], with 95% confidence interval and 5% margin of error, the minimum required sample size was calculated as 138 children. Anticipating a 10% non-response rate, a total of 152 participants were targeted.

Data Collection Tool

A structured questionnaire was administered to the caregiver by a trained investigator. It included demographic details, sleep-related symptoms (including snoring frequency), past medical history, and family history of snoring or sleep apnea. Snoring was classified as:

• Occasional snoring: <3 nights/week
• Habitual snoring: ≥3 nights/week

The questionnaire incorporated elements from validated sleep questionnaires such as the Pediatric Sleep Questionnaire (PSQ) [2], adapted for the local language and context.

Anthropometric Measurements

Height and weight were measured using standard equipment. Body mass index (BMI) was calculated and categorized according to WHO growth standards. Children with BMI-for-age ≥85th percentile were classified as overweight/obese.

Clinical Examination

Each child underwent a general physical and ENT examination to identify potential anatomical factors contributing to snoring, such as:

• Adenotonsillar hypertrophy
• Deviated nasal septum
• Allergic rhinitis signs

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to report frequencies and percentages. Chi-square test was applied to assess associations between snoring and categorical variables (age group, BMI category, etc.). A p-value <0.05 was considered statistically significant.

A total of 152 children were included in the study, with a mean age of 7.8 ± 3.4 years. There were 85 males (55.9%) and 67 females (44.1%). The overall prevalence of snoring was 32.9% (n=50), with habitual snoring reported in 17.1% (n=26).

Table 1: Prevalence of Snoring by Frequency

Out of 152 children evaluated, snoring was reported in 50 children, giving an overall snoring prevalence of 32.9%. Among them, 24 children (15.8%) were classified as occasional snorers (snoring less than 3 nights per week), while 26 children (17.1%) were habitual snorers (≥3 nights per week). The remaining 102 children (67.1%) reported no snoring. This demonstrates that nearly one in every six children in the study population had habitual snoring, which has clinical relevance for screening and early intervention.

Table 2: Association between Snoring and Age Group

                                  *Chi-square test applied; p < 0.05 considered statistically significant

→ Peak prevalence was noted in children aged 6–9 years, significantly higher than other age groups (p = 0.018).

When stratified by age, snoring was most prevalent in children aged 6–9 years, where 24 out of 60 children (40%) reported snoring. This was significantly higher than in the 2–5 years age group (22.2%) and the 10–14 years group (34%), with a statistically significant difference observed (p = 0.018). This suggests that mid-childhood may be a peak period for the onset of snoring symptoms, potentially linked to adenotonsillar development or lifestyle factors during early schooling years.

Table 3: Association between BMI and Habitual Snoring

*Statistically significant association between higher BMI and habitual snoring
(p = 0.003, Chi-square test)

A statistically significant association was found between increased BMI and habitual snoring. While only 11.9% of children with normal weight reported habitual snoring, the prevalence rose to 25.8% among overweight children and 30% among obese children (p = 0.003). These findings highlight obesity as an important modifiable risk factor for habitual snoring in the paediatric population and underscore the need for routine screening in children with elevated BMI.

Table 4: Association of Snoring with Adenotonsillar Hypertrophy

→ Adenotonsillar hypertrophy was significantly associated with increased snoring incidence (p < 0.001).

Children with clinically identified adenotonsillar hypertrophy showed a significantly higher prevalence of snoring (68.3%) compared to those without hypertrophy (19.8%) (p < 0.001). Among the 41 children diagnosed with adenotonsillar hypertrophy, 28 were snorers, clearly supporting the role of upper airway obstruction in the pathogenesis of paediatric snoring. This finding reinforces the importance of ENT evaluation in children who present with habitual snoring.

This study examined the incidence and prevalence of snoring in children aged 2–14 years and explored its association with age, BMI, and adenotonsillar hypertrophy. The findings reveal that snoring is prevalent in 32.9% of the paediatric population surveyed, with habitual snoring (≥3 nights/week) observed in 17.1% of children. These numbers fall within the global reported range of 7–27%, reinforcing that paediatric snoring is not uncommon and deserves greater clinical attention [11–13].

Prevalence Patterns and Epidemiological Significance

The habitual snoring rate of 17.1% aligns with data from various epidemiological studies. For instance, Ersu et al. found that habitual snoring was present in 11.1% of Turkish primary school children [11], and a large population-based Chinese study reported similar figures [12]. Variations across studies are influenced by demographic, cultural, and environmental factors, as well as differences in study design and diagnostic criteria [13]. Our study used a structured and adapted Pediatric Sleep Questionnaire (PSQ), enhancing the accuracy of caregiver reports.

Snoring is often perceived as a benign condition by parents; however, emerging evidence underscores its association with adverse developmental and cognitive outcomes, such as reduced attention span, academic underperformance, and behavioral issues [14,15]. These consequences are independent of clinically diagnosed obstructive sleep apnea, making habitual snoring a valid concern on its own [16].

Age Distribution and Implications

Age-wise distribution in our study revealed a significantly higher prevalence of snoring (40%) in the 6–9 years age group (p = 0.018). This corresponds with the typical period of peak adenotonsillar tissue hypertrophy, which narrows the upper airway and promotes increased resistance during sleep [15,17]. The relative decline in snoring prevalence beyond 10 years could reflect natural involution of lymphoid tissue and maturation of the upper airway [18].

These findings are clinically important because mid-childhood is a period of critical cognitive and psychosocial development. If left undiagnosed, habitual snoring in this age bracket may hinder a child’s academic and behavioral potential. Pediatricians and general practitioners should routinely screen for snoring during health check-ups, especially in early school-age children presenting with inattentiveness or hyperactivity.

Impact of BMI on Snoring Risk

A significant association was found between elevated BMI and habitual snoring in our study (p = 0.003). Habitual snoring was reported in 11.9% of normal-weight children, compared to 25.8% of overweight and 30% of obese children. These results mirror those of Brockmann et al., who noted a higher prevalence of primary snoring and obstructive sleep apnea in obese schoolchildren [20].

Obesity contributes to snoring via increased fat deposition around the upper airway, leading to pharyngeal narrowing and reduced airway patency during sleep [18]. Moreover, obese children often have comorbidities such as gastroesophageal reflux and asthma, which may exacerbate snoring. Given the modifiable nature of obesity, early lifestyle interventions and weight management strategies could substantially reduce snoring incidence and prevent progression to sleep apnea.

Role of Adenotonsillar Hypertrophy

Children with adenotonsillar hypertrophy had significantly higher rates of snoring (68.3%) compared to those without hypertrophy (19.8%), with p < 0.001. This strong association supports existing literature that identifies adenotonsillar enlargement as the most common anatomical cause of upper airway obstruction in children [15,17,19]. Adenotonsillectomy has been shown to improve symptoms in children with sleep-disordered breathing and remains the first-line treatment for pediatric obstructive sleep apnea syndrome in cases with confirmed adenotonsillar hypertrophy [19].

Routine otolaryngological examination in snoring children is thus vital to detect such hypertrophy early and plan appropriate management. Failure to intervene in cases of persistent snoring may result in cognitive, behavioral, metabolic, and cardiovascular complications in the long term [14,16-20].

Strengths and Limitations

The strengths of our study include a well-defined age group, use of a validated questionnaire, and integration of clinical examination for hypertrophy assessment. However, certain limitations must be acknowledged. The absence of polysomnography, though common in large-scale prevalence studies, limits the ability to differentiate simple snoring from sleep apnea. Additionally, the reliance on parental reports introduces potential recall and reporting bias. Future research should incorporate objective tools such as home sleep studies or pulse oximetry where PSG is not feasible.

Snoring is a common clinical finding in children, with an overall prevalence of 32.9% and habitual snoring in 17.1%. It is significantly associated with age (6–9 years), increased BMI, and adenotonsillar hypertrophy, indicating the need for early screening and timely intervention. Pediatric snoring should not be dismissed as benign, as it can lead to serious neurocognitive and behavioral impairments. Structured questionnaires and ENT evaluations in clinical practice can facilitate early identification. Public health measures targeting childhood obesity may also help reduce the burden of snoring and related complications in the paediatric population.

1. Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):242–52.
2. Bixler EO, Vgontzas AN, Lin HM, et al. Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009;32(6):731–6.
3. Rosen CL, Larkin EK, Kirchner HL, et al. Prevalence and risk factors for sleep-disordered breathing in 8- to 11-year-old children. Pediatr Pulmonol. 2003;36(6):491–500.
4. Li AM, Au CT, So HK, et al. Epidemiology of habitual snoring and associated risk factors in primary school children. Chest. 2010;138(3):519–27.
5. Halbower AC, Mahone EM. Neuropsychological morbidity linked to childhood sleep-disordered breathing. Sleep Med Rev. 2006;10(2):97–107.
6. Kaditis AG, Alvarez MLA, Boudewyns A, et al. Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J. 2016;47(1):69–94.
7. Shott SR. Down syndrome: common otolaryngologic manifestations. Am J Med Genet C Semin Med Genet. 2006;142C(3):131–40.
8. Ersu R, Arman AR, Save D, et al. Prevalence of snoring and symptoms of sleep-disordered breathing in primary school children in Istanbul. Chest. 2004;126(1):19–24.
9. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714–55.
10. Aurora RN, Zak RS, Karippot A, et al. Practice parameters for the respiratory indications for polysomnography in children. Sleep. 2011;34(3):379–88.
11. Ersu R, Arman AR, Save D, et al. Prevalence of snoring and symptoms of sleep-disordered breathing in primary school children in Istanbul. Chest. 2004;126(1):19–24.
12. Li AM, So HK, Au CT, et al. Epidemiology of habitual snoring and associated risk factors in primary school children. Chest. 2010;138(3):519–27.
13. Franco P, Bourdon O, Dauvilliers Y. Sleep disorders in children and adolescents: Epidemiology, diagnosis, and treatment. Neurophysiol Clin. 2020;50(6):397–412.
14. O'Brien LM, Lucas NH, Felt BT, et al. Cognitive and behavioral correlates of obstructive sleep apnea syndrome in children: a cross-sectional study. Sleep. 2012;35(1):79–86.
15. Kaditis AG, Alvarez MLA, Boudewyns A, et al. Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J. 2016;47(1):69–94.
16. Montgomery-Downs HE, Gozal D. Sleep habits and risk factors for sleep-disordered breathing in infants and young toddlers. J Clin Sleep Med. 2006;2(3):321–8.
17. Bixler EO, Vgontzas AN, Lin HM, et al. Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009;32(6):731–6.
18. Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):242–52.
19. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714–55.
20. Brockmann PE, Urschitz MS, Schlaud M, Poets CF. Primary snoring in school children: prevalence and neurocognitive impairments. Sleep Breath. 2012;16(1):23–9.