# Risk of influenza and COVID-19 illness and pediatric obstructive sleep apnea: a TriNetX cohort with 5-year follow-up

## TL;DR

Children with obstructive sleep apnea (OSA) are at higher risk of influenza and COVID-19 compared to those without OSA, even after treatment.

## Contribution

This study is the first large-scale analysis showing increased viral infection risk in children with OSA using a 5-year follow-up.

## Key findings

- Children with OSA had twice the risk of influenza and nearly 2.5 times the risk of COVID-19 compared to controls.
- Adenotonsillectomy did not reduce the increased risk of viral infections in children with OSA.
- OSA was also linked to a higher risk of pneumonia caused by influenza or COVID-19.

## Abstract

Obstructive sleep apnea (OSA) is associated with impaired immune responses. Prior small-scale investigations suggested that pediatric OSA leads to a more severe clinical course of common childhood viruses. Whether OSA increases the risk of infection remains unknown.

To examine whether children with OSA are at increased risk of influenza or COVID-19, and to assess the effect of adenotonsillectomy.

Using TriNetX, we compared children aged 2–18 years with incident OSA and matched controls without OSA. Outcomes were ICD-10–coded influenza and COVID-19 over a five-year follow-up. We estimated risk ratios (RRs) and Kaplan–Meier hazard ratios (HRs).

Matched cohorts included 539,127 children each (mean age 5.6 ± 3.6 years). Influenza was diagnosed in 5.1% of OSA vs. 2.8% of controls (RR 1.80; 95% CI, 1.765–1.836); five-year influenza-free survival was 90.27% vs. 93.04% (HR 1.45; 95% CI, 1.421–1.479). COVID-19 was diagnosed in 2.5% vs. 1.0% (RR 2.496; 95% CI, 2.418–2.576); five-year COVID-19-free survival was 95.02% vs. 97.49% (HR 1.986; 95% CI, 1.924–2.050). Effects were similar across age groups. In the treatment sub-analysis (n = 96,004 per group), adenotonsillectomy did not reduce risk. In secondary analyses, OSA was also associated with a higher risk of pneumonia due to influenza or COVID-19.

In a period spanning 5 years after OSA diagnosis, children of all ages have a significantly higher risk of influenza and COVID-19 diagnoses. Although absolute risks are low, adenotonsillectomy does not lessen susceptibility, suggesting persistent immune dysregulation and supporting prioritization of seasonal vaccination in children with OSA.

The online version contains supplementary material available at 10.1007/s44470-025-00035-x.

The biologic link between pediatric OSA and respiratory infections is plausible, but pediatric data on influenza and COVID-19 risk are limited. We used the TriNetX database to analyze a cohort of children and adolescents newly diagnosed with OSA over 5 years, including COVID-19 as a comparator.

Children with OSA were about twice as likely to be diagnosed with influenza or COVID-19 as matched controls across age groups. Sub-analysis by treatment suggested that adenotonsillectomy did not reduce this increased risk, underscoring the importance of seasonal vaccination in children with OSA and motivating work on mechanisms and alternative management.

The online version contains supplementary material available at 10.1007/s44470-025-00035-x.