# Exploring comorbid insomnia in children with obstructive sleep apnea (COMISA)

Lisa Brunel, Marion Comajuan, Benjamin Putois, Julien Lioret, Marine Thieux, Laurianne Coutier, Patricia Franco, Aurore Guyon

► To cite this version:

Lisa Brunel, Marion Comajuan, Benjamin Putois, Julien Lioret, Marine Thieux, et al. Exploring comorbid insomnia in children with obstructive sleep apnea (COMISA). European Respiratory Society Congress, Sep 2025, Amsterdam, Netherlands. hal-05401031

HAL Id: hal-05401031

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Submitted on 5 Dec 2025

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# Exploring comorbid insomnia in children with obstructive sleep apnea (COMISA)

Brunel L¹, Comajuan M¹,², Plancoulaine S¹, Putois B¹,³, Lioret J¹, Thieux M¹, **Coutier L**¹,²,⁴, Franco P¹,², Guyon A¹,²

1. INSERM U1028/CNRS UMR 5292, Lyon Neuroscience Research Center (CRNL), University Lyon 1, France; 2. Paediatric Sleep Unit, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon (HCL), France; 3. Faculty of Psychology, Swiss Distance Learning University, Switzerland; 4. Service de pneumologie infantile, allergologie et centre de référence en mucoviscidose, Hôpital Femme Mère Enfant, HCL, France

## Introduction

In adults, comorbid insomnia and sleep apnea (COMISA) is associated with worse sleep and daytime functioning, more cardiovascular and psychiatric comorbidities, and complex treatment. Few studies exist in children [1,2].

**Objectives of the present study:**

1. To determine the frequency of COMISA in children

2. To identify demographic, clinical, and polysomnographic characteristics associated with COMISA

## Methods

Retrospective medical chart review of all patients aged 6 months to 16 years old; referred for polysomnography (PSG) in 2018-2024; with complete “disorders of initiating and maintaining sleep” (DIMS) sub-score on the Sleep Disturbance Scale for Children (SDSC); without central sleep apnea.

Collected information included demographic and clinical characteristics, PSG data of sleep architecture and breathing, and questionnaires assessing sleepiness (Epworth), anxiety (CBCL), depression (CDI), and hyperactivity (Conners).

* Obstructive Sleep Apnea (OSA) : OAHI ≥2/h

* Insomnia : pathological SDSC insomnia sub-score

⇒ 4 groups: no-OSA/no-INS, INS-only, OSA-only, COMISA

Comparisons were conducted per age group: <4 vs ≥4 years old. In the younger sample, only the groups OSA-only and COMISA were compared because of the small sample size. In the older sample, comparisons were made between the four groups (Fig 1).

<figure><img src="image_4.png" /><figcaption>Figure 1. Proportion of the four groups based on insomnia and OSA status in patients (A) <4 and (B) ≥4 years old.</figcaption></figure>

## Results

N = 200 (median age: 9 years; 48% females)

<table><caption>Table 1. Sample characteristics per age group.</caption><thead><tr><th></th><th>&lt;4 years old (n=46)</th><th>≥4 years old (n=154)</th><th>p</th></tr></thead><tbody><tr><td><strong>Demographic characteristics</strong></td><td></td><td></td><td></td></tr><tr><td>Age (years)</td><td>2.5 [0.6-3.9]</td><td>10.9 [4.1-16.7]</td><td>-</td></tr><tr><td>Sex (females)</td><td>21 (45.7)</td><td>74 (48.1)</td><td>0.9</td></tr><tr><td>BMI z-score</td><td>0.4 [-2.7-5.5]</td><td>0.5 [-2.1-18.3], n=153</td><td>0.2</td></tr><tr><td><strong>Clinical characteristics</strong></td><td></td><td></td><td></td></tr><tr><td>Neurodevelopmental disorders</td><td>9 (19.6)</td><td>65 (42.2)</td><td>&lt;0.05</td></tr><tr><td>Medication impacting sleep</td><td></td><td></td><td></td></tr><tr><td>Wake-promoting</td><td>0 (0.0)</td><td>15 (9.7)</td><td>0.03</td></tr><tr><td>Sleep-inducing</td><td>2 (4.3)</td><td>17 (11.0)</td><td>0.3</td></tr><tr><td>Both</td><td>0 (0.0)</td><td>21 (13.6)</td><td>&lt;0.05</td></tr><tr><td><strong>OSA and insomnia</strong></td><td></td><td></td><td></td></tr><tr><td>OAHI</td><td>5.0 [0.0-43.9]</td><td>1.6 [0.0-64.9]</td><td>&lt;0.05</td></tr><tr><td>OSA</td><td>36 (78.3)</td><td>66 (42.9)</td><td>&lt;0.05</td></tr><tr><td>Severe OSA (OAHI ≥10/h)</td><td>17 (47.2)</td><td>19 (28.8)</td><td>0.08</td></tr><tr><td>OSA type III</td><td>19 (52.8)</td><td>35 (53.0)</td><td>1</td></tr><tr><td>Insomnia</td><td>21 (45.7)</td><td>29 (18.8)</td><td>&lt;0.05</td></tr><tr><td>COMISA in all patients</td><td>18 (39.1)</td><td>9 (5.8)</td><td>&lt;0.05</td></tr><tr><td>COMISA in OSA subgroup</td><td>18 (50.0), n=36</td><td>9 (13.6), n=66</td><td>&lt;0.05</td></tr></tbody></table>

Most patients came for suspected OSA (64.5%). Other complaints were insomnia (20.5%), hypersomnia (12.5%) and parasomnia (2.5%).

PSG revealed OSA in 51% of the sample. In the younger group, OAHI was higher and OSA more frequent (Table 1).

Insomnia affected 25% of the sample (Fig 2). It was more frequent in the younger group.

1. COMISA affected 27% of patients with OSA (vs 39-55% in adult studies [3]). Frequency was higher in the younger group.

<figure><img src="image_5.png" /><figcaption>Figure 2. Insomnia frequency according to age.</figcaption></figure>

2. Demographic and clinical characteristics were similar in COMISA vs OSA-only and INS-only.

Arousal index was higher in COMISA and OSA-only than in INS-only (16.8/h and 22.4/h vs 9.9/h, p=0.02). Otherwise sleep architecture was similar in COMISA compared to others.

In the older group, OAHI was lower in COMISA compared to OSA-only (3.3/h vs 4.7/h, p <0.001).

Questionnaires showed a higher anxiety level in COMISA and INS-only compared to OSA-only (Fig 3). Excessive daytime sleepiness was more frequent in OSA-only than INS-only (37% vs 0%, p=0.006) but there was no statistical difference with COMISA (13%).

<figure><img src="image_6.png" /></figure>

<figure><img src="image_7.png" /><figcaption>Figure 3. CBCL anxiety scores per group. *: p<0.05</figcaption></figure>

## Conclusions

COMISA was less frequent than previously reported in adults. Insomnia, OSA and COMISA were more frequent in patients <4 years old.

In older patients, COMISA had lower OAHI than isolated OSA and more fragmented sleep than isolated insomnia, but this was not accompanied by any other difference in sleep architecture.

Insomniacs were more anxious regardless of the presence/absence of OSA. Anxiety may be a major risk factor of COMISA in children. OSA and insomnia do not seem to exacerbate one another in children.

## References

[1] Meira E Cruz M et al. J Sleep Res 2023, 32(1), e13705.

[2] Yelov L et al. J Clin Sleep Med 2024, 20(2), 245-251.

[3] Sweetman A et al. Sleep Med Rev 2021, 60, 101519.

ext-lisa.brunel@chu-lyon.fr