Prefrontal Activation and Cognitive Heterogeneity in Pediatric Sleep-Disordered Breathing

Importance: Activation of the prefrontal cortex during attention and executive-function tasks can moderate associations between sleep-disordered breathing (SDB) symptoms and parent-reported behavior. However, conventional severity measures do not explain why cognitive outcomes vary among children with SDB. Objective: To assess whether prefrontal cortex (PFC) activity, reflecting attention and impulse control, is associated with SDB severity and cognition, and whether it distinguishes children whose cognition diverges from their SDB severity. Design, Setting, and Participants: This cross-sectional study included patients aged 5 to 11 years who were referred for evaluation of SDB at 2 academic pediatric otolaryngology centers from January 2024 to March 2026. Patients with neuromuscular disorders, prior airway surgery, continuous positive airway pressure treatment, sickle cell disease, stimulant use, or developmental delay were excluded. Exposures: SDB severity measured by the Pediatric Sleep-Related Breathing Disorders Questionnaire, Apnea-Hypopnea Index (AHI), and oxygen saturation (SpO2) nadir. PFC activation measured by functional near-infrared spectroscopy (fNIRS) during a computer-based go or no-go task in which children respond to frequent cues and withhold responses to infrequent ones. Main Outcomes and Measures: Parent-reported executive function (Behavior Rating Inventory of Executive Function) and cognition (US National Institutes of Health [NIH] Toolbox Cognition Battery), and their associations with PFC activation. Linear mixed-effects models with false discovery rate (FDR) correction tested associations and moderation effects. Results: Among 284 children (mean [SD] age, 7.9 [1.8] years; 130 [45.8%] female), 237 (83.5%) were at high risk for SDB. The mean (SD) AHI was 11.7 (14.5) events per hour and SpO2 nadir was 86.4% (8.2%). Higher AHI was associated with greater left dorsolateral PFC activation (oxyhemoglobin: β, 0.08; 95% CI, 0.03 to 0.12; deoxyhemoglobin: β, -0.07; 95% CI, -0.11 to -0.03), and lower SpO2 nadir was associated with greater activation (β, 0.14; 95% CI, 0.06 to 0.23). Greater activation in the right dorsolateral PFC was associated with worse parent-reported executive function after FDR correction. No severity measure was directly associated with NIH Toolbox performance after correction. However, PFC activation moderated the SDB severity-cognition association: children with greater activation maintained comparable performance despite more severe SDB. Conclusions and Relevance: In this cross-sectional study, task-related PFC activation was associated with SDB severity and moderated the severity-cognition association. fNIRS may help identify children whose cognitive profiles deviate from conventional severity metrics, thereby supporting individualized cognitive risk assessment.