Whether a child covered by Medicaid gets tested for obstructive sleep apnea may depend less on their symptoms than on their ZIP code. That is the conclusion of the first population-based study to map how polysomnography — the overnight, in-lab test used to diagnose pediatric sleep-disordered breathing — is actually used across the United States.
The study, led by Colleen C. McLaughlin of the Center for Child Health Equity and Outcomes Research at Nationwide Children's Hospital in Columbus, Ohio, and published in the Journal of Clinical Sleep Medicine, analyzed claims from the Transformed Medicaid Information System covering 2017 through 2019. Medicaid and the Children's Health Insurance Program together insure roughly half of all children in the country, making the dataset one of the most complete pictures available of how pediatric sleep medicine actually reaches families.
A Fourfold Gap Between States
Researchers identified 478,568 polysomnography studies among Medicaid-enrolled children during the study period, for a national rate of 50.1 tests per 10,000 enrolled children per year. But that national average masks enormous variation underneath it.
At the state level, rates ranged nearly fourfold — from 23 tests per 10,000 child-years in Kansas to 93 per 10,000 in Michigan. New England and the Great Lakes region had the highest concentration of testing, while the Pacific region and the West South Central states (which include Texas, Oklahoma, Arkansas, and Louisiana) had the lowest.
That spread is difficult to explain by disease prevalence alone. Obstructive sleep apnea in children — driven largely by enlarged tonsils and adenoids, and increasingly by obesity — does not plausibly occur four times more often in Michigan than in Kansas. The more likely explanation, the researchers argue, is uneven access to the pediatric sleep labs, ENT referrals, and primary care awareness needed to get a child from "snores loudly" to a diagnostic study.
The Racial and Geographic Pattern
The study did not stop at state lines. Using ZIP code-level data cross-referenced with Rural-Urban Commuting Area classifications and racial and ethnic composition, the researchers found that testing rates climbed in ZIP codes that were both more metropolitan and more than 90% white — a combination that concentrates access in affluent, urban and suburban areas.
That pattern tracks with other recent findings on pediatric sleep-disordered breathing. A related analysis from the same research group, published earlier this year, documented racial and ethnic disparities in care pathways for children with suspected sleep apnea, finding that Black and Hispanic children were less likely to be referred for testing and treatment even after accounting for symptom severity.
Taken together, the research suggests the gap is not simply about which families seek care, but about which systems are built to deliver it. Rural areas often lack a pediatric sleep lab within a reasonable drive, and the same is true of many lower-income urban neighborhoods, where pediatric sleep medicine specialists are concentrated in large academic children's hospitals that are not evenly distributed across the country.
Why Undiagnosed Sleep Apnea Matters in Children
Untreated pediatric obstructive sleep apnea is linked to poorer school performance, behavioral problems that are sometimes misdiagnosed as ADHD, slowed growth, and — in more severe or prolonged cases — cardiovascular strain. Unlike in adults, the standard fix for pediatric OSA caused by enlarged tonsils and adenoids is often a straightforward surgical procedure, adenotonsillectomy, which is highly effective but only possible once a child has been diagnosed in the first place.
That makes testing access a bottleneck with outsized consequences. A child whose apnea goes undetected does not simply sleep poorly — they can carry the downstream effects on learning and behavior for years before anyone connects the dots back to sleep.
What This Means for Patients
Parents whose children snore loudly, gasp or pause while breathing during sleep, or struggle with daytime attention and behavior should not assume that a doctor will automatically order a sleep study — access to one may depend heavily on where they live and which providers are nearby. Families in rural areas or those who feel their concerns about a child's sleep have been dismissed should ask specifically about referral to a pediatric sleep specialist or ENT, and, if local options are limited, ask about telehealth consultations or home sleep testing alternatives, which are increasingly used to extend access beyond traditional sleep labs. Pediatricians and policymakers, meanwhile, have a clearer target now than before: a fourfold testing gap between states is not a subtle disparity, and the authors argue it points to specific, addressable gaps in the pediatric sleep workforce and referral infrastructure rather than differences in who actually needs care.
