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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the present issue of the Jornal de Pediatria&#44; the paper by Estanislau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> assesses the association between the hours of sleep and the suffering from asthma in adolescents&#46; The study was designed considering that the independent variable in the regression analyses is sleep&#44; while the dependent one is asthma&#46; The authors conclude that asthma prevalence is significantly higher in individuals who sleep less hours&#46; It is a study which has the great strength of including 59&#44;442 adolescents in the analyses&#46; Still&#44; there is an important issue when considering the results&#58; it is a crossover study&#44; which does not allow the knowledge of whether asthma precedes sleep disturbance or the other way around&#46; Casual relationship in epidemiology need three conditions&#58; association&#44; direction and temporal relationship&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The authors find an interesting association&#44; but does the lack of sleep have a causal relationship to asthma&#63;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is perfectly known that asthma presents frequently nocturnal symptoms which are associated with a bad quality of sleep&#44; usually including arousing&#44; parasomnias and breathing difficulties&#44; apart for a lower quality of life of parents when the patients are children&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There is an interesting question that one might ask to oneself&#44; and this is whether asthmatic condition associates an altered sleep architecture or a consequence of a higher prevalence of obstructive sleep apnea syndrome &#40;OSA&#41;&#44; which is the most frequent sleep disorder in childhood&#46; On the other hand&#44; could asthma be the cause of the sleep disorder or vice-versa&#63; It is even possible to consider a bi-directional association and thus asthma would be a risk factor for OSA in some children while OSA might be a risk factor for asthma in other&#46; OSA is considered a disorder in which by &#8211;ideally&#8211; polysomnography an abnormal number of apnea episodes of obstructive origin are detected during normal sleep&#46; However&#44; respiratory sleep disorder &#40;RSD&#41; is a wider term and includes any respiratory disorder during sleep and not only OSA&#46; In children&#44; the assessment of RSD is frequently performed by means of questionnaires&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Is there an altered sleep architecture in asthmatic children and adolescents&#63;</span><p id="par0020" class="elsevierStylePara elsevierViewall">As it has been already said previously&#44; asthma has nocturnal symptoms which may alter the normal sleep architecture as compared with the healthy population&#46; In fact&#44; the study by Khassawneh et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> found significant differences in the aforementioned architecture as assessed by polysomnography in a selected group of 85 asthmatic adolescents with low risk of OSA&#44; as evaluated by the Pediatric Sleep Questionnaire&#46; Those patients had less sleep time&#44; less sleep time in REM phase&#44; less sleep latency and less SatO2 nadir&#46; They had also more time awake after they initially slept &#40;wake after sleep onset &#8212; WASO&#41;&#44; higher arousal index both spontaneous and due to respiratory causes and&#44; finally&#44; higher apnea&#47;hypopnea index &#40;AHI&#41;&#46; In fact&#44; 29&#37; of participants had patterns compatible with OSA in spite of having low risk scores&#46; But even in asthmatic patients with normal AHI&#44; that is&#44; without OSA&#44; those sleep values are significantly altered as compared to normal values&#59; except&#44; of course&#44; for the arousal index from respiratory causes and the AHI&#46; It is also of interest that sleep disturbances were not related to asthma control&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Is asthma a risk factor of OSA or RSD&#63;</span><p id="par0025" class="elsevierStylePara elsevierViewall">The association between asthma and OSA in children has been studied widely&#46; There is even a systematic Review and meta-analysis<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> which includes 17 studies with a total of 45&#44;155 children &#40;53&#37; male&#41; of a mean age of 8&#46;6&#8239;&#177;&#8239;2&#46;5 years&#46; The authors found a higher risk of OSA among asthmatic patients &#40;OR 1&#46;91&#59; 95&#37;CI&#58; 1&#46;04&#8211;2&#46;13&#41; independently of the diagnostic method &#40;polygraph or polysomnography&#41;&#46; Some years later&#44; the same authors performed a new systematic review with the aim of unravelling the relationship between asthma and SRD&#44; with special focus on the impact of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This study selected 32 previous ones and include 143&#44;343 children &#40;51&#37; male&#41; with a mean age of 8&#46;4&#8239;&#177;&#8239;2&#46;5 years&#58; the man conclusion is that asthmatic children have higher likelihood of suffering from OSA&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally&#44; the same group made a systematic search in the attempt to demonstrate asthma causes RSD considering the whole nine criteria for associations&#58; strength of the association&#44; consistency&#44; specificity&#44; temporality&#44; biological gradient&#44; plausibility&#44; coherence&#44; experimentality and analogy&#46; This concludes that temporality criteria cannot be demonstrated&#44; as there are no cohort studies showing that asthma precedes OSA&#46; Therefore&#44; directionality &#40;asthma causing OSA&#41; cannot be established&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Thus&#44; the current knowledge seems to indicate that asthmatic children have a higher prevalence of OSA&#44; being asthma a potential risk factor for RSD&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Is RSD risk factors for asthma&#63;</span><p id="par0040" class="elsevierStylePara elsevierViewall">This is the direction of the study by Estanislau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and other studies&#44; from which it is worth mentioning one published in 2015 by Li et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> for in one hand they assess this association by a cross-sectional study by means of questionnaires in a big population of 20&#44;672 children &#40;response rate 91&#46;9&#37; and age range 5&#8211;12 years&#41;&#59; and on the other&#44; they include a meta-analysis of 12 previous studies including 38&#44;766 children&#46; In the cross-sectional study the find that both snoring &#40;OR&#8239;&#61;&#8239;1&#46;28&#44; 95&#37;CI&#58; 1&#46;01&#8211;1&#46;62&#41; and OSA &#40;OR&#8239;&#61;&#8239;1&#46;92&#59; 95&#37;CI&#58; 1&#46;34&#8211;2&#46;76&#41; are statistically significant asthma predictors&#46; The meta-analysis also showed that RSD is a risk factor for asthma &#40;OR&#8239;&#61;&#8239;1&#46;55&#59; 95&#37;CI&#58; 1&#46;44&#8211;1&#46;66&#41; both considering cross-sectional studies &#40;OR&#8239;&#61;&#8239;1&#46;56&#44; 95&#37;CI&#58; 1&#46;45&#8211;1&#46;68&#41; and cohort studies &#40;OR&#8239;&#61;&#8239;1&#46;46&#59; 95&#37;CI&#58; 1&#46;16&#8211;1&#46;75&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The review by S&#225;nchez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> also shows that RSD is associated to more severe cases of asthma and that OSA treatment &#40;tonsillectomy&#41; was associated to a significant improvement of asthma&#46; On the other hand&#44; Ross et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> studied 108 asthmatic children that were followed prospectively over one year that had been managed according to international guidelines and observed that asthma grave was found in 55&#37; of children with RSD but only in 20&#37; of children without SRD &#40;OR&#8239;&#61;&#8239;3&#46;63&#59; 95&#37;CI&#58; 1&#46;26&#8211;10&#46;4&#41; after adjusting for obesity&#44; gender and ethnicity&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">More recently&#44; the study by Oka et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> showed in a numerous population of 27&#44;935 children between 6 and 17 years of age admitted to hospital due to an asthma attack&#44; that in 1&#46;4&#37; of them in which OSA coexisted&#44; non-invasive ventilation was more frequently needed &#40;OR&#8239;&#61;&#8239;1&#46;2&#59; 95&#37;CI&#58; 1&#46;16&#8211;1&#8211;24&#41; to manage the attack&#59; and that hospital stays were longer &#40;OR&#8239;&#61;&#8239;1&#46;2&#59; 95&#37;CI 1&#46;16&#8211;1&#8211;24&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In a systematic review on the effect of tonsillectomy on asthma control Kohli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> found that the procedure might be of help&#44; although it is cautioned that there are few studies and that their design is not the most adequate&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">According to the previous evidence&#44; it could be concluded that SRD and OSA are risk factors for asthma&#44; end even of an increased severity of the condition&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Is it plausible a bidirectionality in the relationship between asthma and SRD&#63;</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors can certainly find arguments to try and understand this relationship&#58; certain comorbidities are frequent in both conditions and could contribute in both directions&#46; Obesity is a factor related to asthma<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and with SRD&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Gastroesophageal reflux is also related to asthma<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and it has also been demonstrated that more than 40&#37; of children with OSA due to tonsillar hypertrophy have abnormal esophageal pHmetry&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Finally&#44; the prevalence of allergic rhinitis among asthmatics is very high<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and it is also associated with SRD&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">On the other hand&#44; asthma and OSA are conditions which share inflammatory characteristics with interrelationships between them<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> and it has been described that OSA may contribute to airway remodeling in severe cases of asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The clinical implications of the associations between SRD and asthma are obvious because asthma is aggravated and further disturbs the quality of life of patients&#46; Pediatricians must be aware of this comorbidity that is so frequent&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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Editorial
Does asthma cause sleep disorders … or the other way around?
Luis Garcia-Marcosa,b,c,
Corresponding author
lgmarcos@um.es

Corresponding author.
, Manuel Sanchez-Solisa,b,c
a University of Murcia, Arrixaca University Children’s Hospital, Respiratory and Allergy Units, Murcia, Spain
b Biomedical Research Institute of Murcia (IMIB-Arrixaca), Murcia, Spain
c Carlos III Health Institute, Network of Asthma, and Adverse and Allergy Reactions (ARADyAL) Network, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the present issue of the Jornal de Pediatria&#44; the paper by Estanislau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> assesses the association between the hours of sleep and the suffering from asthma in adolescents&#46; The study was designed considering that the independent variable in the regression analyses is sleep&#44; while the dependent one is asthma&#46; The authors conclude that asthma prevalence is significantly higher in individuals who sleep less hours&#46; It is a study which has the great strength of including 59&#44;442 adolescents in the analyses&#46; Still&#44; there is an important issue when considering the results&#58; it is a crossover study&#44; which does not allow the knowledge of whether asthma precedes sleep disturbance or the other way around&#46; Casual relationship in epidemiology need three conditions&#58; association&#44; direction and temporal relationship&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The authors find an interesting association&#44; but does the lack of sleep have a causal relationship to asthma&#63;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is perfectly known that asthma presents frequently nocturnal symptoms which are associated with a bad quality of sleep&#44; usually including arousing&#44; parasomnias and breathing difficulties&#44; apart for a lower quality of life of parents when the patients are children&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There is an interesting question that one might ask to oneself&#44; and this is whether asthmatic condition associates an altered sleep architecture or a consequence of a higher prevalence of obstructive sleep apnea syndrome &#40;OSA&#41;&#44; which is the most frequent sleep disorder in childhood&#46; On the other hand&#44; could asthma be the cause of the sleep disorder or vice-versa&#63; It is even possible to consider a bi-directional association and thus asthma would be a risk factor for OSA in some children while OSA might be a risk factor for asthma in other&#46; OSA is considered a disorder in which by &#8211;ideally&#8211; polysomnography an abnormal number of apnea episodes of obstructive origin are detected during normal sleep&#46; However&#44; respiratory sleep disorder &#40;RSD&#41; is a wider term and includes any respiratory disorder during sleep and not only OSA&#46; In children&#44; the assessment of RSD is frequently performed by means of questionnaires&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Is there an altered sleep architecture in asthmatic children and adolescents&#63;</span><p id="par0020" class="elsevierStylePara elsevierViewall">As it has been already said previously&#44; asthma has nocturnal symptoms which may alter the normal sleep architecture as compared with the healthy population&#46; In fact&#44; the study by Khassawneh et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> found significant differences in the aforementioned architecture as assessed by polysomnography in a selected group of 85 asthmatic adolescents with low risk of OSA&#44; as evaluated by the Pediatric Sleep Questionnaire&#46; Those patients had less sleep time&#44; less sleep time in REM phase&#44; less sleep latency and less SatO2 nadir&#46; They had also more time awake after they initially slept &#40;wake after sleep onset &#8212; WASO&#41;&#44; higher arousal index both spontaneous and due to respiratory causes and&#44; finally&#44; higher apnea&#47;hypopnea index &#40;AHI&#41;&#46; In fact&#44; 29&#37; of participants had patterns compatible with OSA in spite of having low risk scores&#46; But even in asthmatic patients with normal AHI&#44; that is&#44; without OSA&#44; those sleep values are significantly altered as compared to normal values&#59; except&#44; of course&#44; for the arousal index from respiratory causes and the AHI&#46; It is also of interest that sleep disturbances were not related to asthma control&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Is asthma a risk factor of OSA or RSD&#63;</span><p id="par0025" class="elsevierStylePara elsevierViewall">The association between asthma and OSA in children has been studied widely&#46; There is even a systematic Review and meta-analysis<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> which includes 17 studies with a total of 45&#44;155 children &#40;53&#37; male&#41; of a mean age of 8&#46;6&#8239;&#177;&#8239;2&#46;5 years&#46; The authors found a higher risk of OSA among asthmatic patients &#40;OR 1&#46;91&#59; 95&#37;CI&#58; 1&#46;04&#8211;2&#46;13&#41; independently of the diagnostic method &#40;polygraph or polysomnography&#41;&#46; Some years later&#44; the same authors performed a new systematic review with the aim of unravelling the relationship between asthma and SRD&#44; with special focus on the impact of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This study selected 32 previous ones and include 143&#44;343 children &#40;51&#37; male&#41; with a mean age of 8&#46;4&#8239;&#177;&#8239;2&#46;5 years&#58; the man conclusion is that asthmatic children have higher likelihood of suffering from OSA&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally&#44; the same group made a systematic search in the attempt to demonstrate asthma causes RSD considering the whole nine criteria for associations&#58; strength of the association&#44; consistency&#44; specificity&#44; temporality&#44; biological gradient&#44; plausibility&#44; coherence&#44; experimentality and analogy&#46; This concludes that temporality criteria cannot be demonstrated&#44; as there are no cohort studies showing that asthma precedes OSA&#46; Therefore&#44; directionality &#40;asthma causing OSA&#41; cannot be established&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Thus&#44; the current knowledge seems to indicate that asthmatic children have a higher prevalence of OSA&#44; being asthma a potential risk factor for RSD&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Is RSD risk factors for asthma&#63;</span><p id="par0040" class="elsevierStylePara elsevierViewall">This is the direction of the study by Estanislau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and other studies&#44; from which it is worth mentioning one published in 2015 by Li et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> for in one hand they assess this association by a cross-sectional study by means of questionnaires in a big population of 20&#44;672 children &#40;response rate 91&#46;9&#37; and age range 5&#8211;12 years&#41;&#59; and on the other&#44; they include a meta-analysis of 12 previous studies including 38&#44;766 children&#46; In the cross-sectional study the find that both snoring &#40;OR&#8239;&#61;&#8239;1&#46;28&#44; 95&#37;CI&#58; 1&#46;01&#8211;1&#46;62&#41; and OSA &#40;OR&#8239;&#61;&#8239;1&#46;92&#59; 95&#37;CI&#58; 1&#46;34&#8211;2&#46;76&#41; are statistically significant asthma predictors&#46; The meta-analysis also showed that RSD is a risk factor for asthma &#40;OR&#8239;&#61;&#8239;1&#46;55&#59; 95&#37;CI&#58; 1&#46;44&#8211;1&#46;66&#41; both considering cross-sectional studies &#40;OR&#8239;&#61;&#8239;1&#46;56&#44; 95&#37;CI&#58; 1&#46;45&#8211;1&#46;68&#41; and cohort studies &#40;OR&#8239;&#61;&#8239;1&#46;46&#59; 95&#37;CI&#58; 1&#46;16&#8211;1&#46;75&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The review by S&#225;nchez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> also shows that RSD is associated to more severe cases of asthma and that OSA treatment &#40;tonsillectomy&#41; was associated to a significant improvement of asthma&#46; On the other hand&#44; Ross et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> studied 108 asthmatic children that were followed prospectively over one year that had been managed according to international guidelines and observed that asthma grave was found in 55&#37; of children with RSD but only in 20&#37; of children without SRD &#40;OR&#8239;&#61;&#8239;3&#46;63&#59; 95&#37;CI&#58; 1&#46;26&#8211;10&#46;4&#41; after adjusting for obesity&#44; gender and ethnicity&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">More recently&#44; the study by Oka et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> showed in a numerous population of 27&#44;935 children between 6 and 17 years of age admitted to hospital due to an asthma attack&#44; that in 1&#46;4&#37; of them in which OSA coexisted&#44; non-invasive ventilation was more frequently needed &#40;OR&#8239;&#61;&#8239;1&#46;2&#59; 95&#37;CI&#58; 1&#46;16&#8211;1&#8211;24&#41; to manage the attack&#59; and that hospital stays were longer &#40;OR&#8239;&#61;&#8239;1&#46;2&#59; 95&#37;CI 1&#46;16&#8211;1&#8211;24&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In a systematic review on the effect of tonsillectomy on asthma control Kohli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> found that the procedure might be of help&#44; although it is cautioned that there are few studies and that their design is not the most adequate&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">According to the previous evidence&#44; it could be concluded that SRD and OSA are risk factors for asthma&#44; end even of an increased severity of the condition&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Is it plausible a bidirectionality in the relationship between asthma and SRD&#63;</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors can certainly find arguments to try and understand this relationship&#58; certain comorbidities are frequent in both conditions and could contribute in both directions&#46; Obesity is a factor related to asthma<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and with SRD&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Gastroesophageal reflux is also related to asthma<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and it has also been demonstrated that more than 40&#37; of children with OSA due to tonsillar hypertrophy have abnormal esophageal pHmetry&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Finally&#44; the prevalence of allergic rhinitis among asthmatics is very high<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and it is also associated with SRD&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">On the other hand&#44; asthma and OSA are conditions which share inflammatory characteristics with interrelationships between them<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> and it has been described that OSA may contribute to airway remodeling in severe cases of asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The clinical implications of the associations between SRD and asthma are obvious because asthma is aggravated and further disturbs the quality of life of patients&#46; Pediatricians must be aware of this comorbidity that is so frequent&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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Article information
ISSN: 00217557
Original language: English
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Jornal de Pediatria (English Edition)
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