IMPORTANCE Pediatric vocal fold pathology is important because having a healthy voice free from disorders is crucial in a child's emotional and educational development. OBJECTIVE To determine whether there is an association between singing in a children's choir and the development of voice disorders. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of children (aged 8 to 14 years) singers selected from local children's choirs and nonsingers selected from local schools evaluated at Clarós Otorhinolaryngology Clinic in Barcelona, Spain, from October 2016 through April 2018. EXPOSURES Singing for a mean time of 7.5 hours per week for 2.5 years. MAIN OUTCOMES AND MEASURES The primary outcome of the study was the prevalence of voice disorders measured using videostroboscopy. The obtained values were analyzed statistically and used to compare the characteristics of the children and the frequency of voice disorders between the groups. RESULTS Of 1495 enrolled children (745 male [49.8%]; median age, 9.3 years [range, 8-14 years]), 752 were singers and 743 were nonsingers. No differences in baseline characteristics were observed between the groups. Voice disorders were more frequent in the nonsinging group than in the singing group (32.4% vs 15.6%; difference, 16.8%; 95% CI, 12.3%-21.4%). Of 12 voice disorders considered in this study, all 12 were more frequent in the nonsinging group. Functional voice disorders were more frequent in the nonsinging group than in the singing group (20.2% vs 9.4%; difference, 10.8%; 95% CI, 7.2%-14.3%), as were organic voice disorders (12.2% vs 6.1%; difference, 6.1%; 95% CI, 2.6%-9.6%). CONCLUSIONS AND RELEVANCE Voice disorders were less common among children in the cohort who sing in choirs, possibly because of voice training and the commonly observed habit of attending regular ear, nose, and throat examination. Voice disorders may be prevented in nonsinging children if the same solicitude for voice is observed.

To the Editor We thank Clarós et al 1 for their study investigating the association between singing in a children's choir and the development of voice disorders. The authors reported a significantly greater number of voice disorders in nonsingers compared with singers, thus emphasizing the importance of introducing conscientious voice care in nonsinging children. However, we have identified several notable limitations in this study.First, the presence of laryngopharyngeal reflux disease was formally examined in singing children, but not in the nonsinging group. Only the presence of reflux symptoms in the latter was mentioned haphazardly. The significance of this should not be understated because previous studies have demonstrated the association of reflux symptoms with voice disorders 2 and dysphonia, 3 ie, the primary and secondary outcomes of the study respectively. Both groups should have been formally examined for reflux symptoms and disease. Failure to do so would mean an unfair comparison between the 2 groups, which could potentially invalidate the findings of this study.In addition, the authors remarked that instances of vocal trauma could result from shouting during team sports or playing with other children. 1 They further postulated that this could be owing to the possibility that there are lower levels of vocal care awareness among nonsinging participants. However, the study importantly also noted that singing children had higher levels of participation in team sports than nonsinging children but still reported lower levels of vocal trauma. Any assumption that singing children who also participate in team sports would shout any differently cannot be made. The contradictory nature of this analysis thus implies that there is no clear correlation between participation in team sports and the development of vocal trauma, or that the risk is greater for nonsinging children.We would also like to draw attention to the subjective nature of this study, in particular the fact that parents who were responsible for signing up their children for choir, were also accountable for reporting the presence of voice symptoms. The possibility that parents of singing children were more susceptible to hypersensitivity in detection of voice symptoms ought not to be discounted. More objective measures of detecting voice quality and symptoms should be taken into consideration to minimize bias.Nevertheless, Clarós and colleagues 1 have made important contributions to our understanding of how vocal training and choral participation may decrease the risk of development of voice disorders among prepubescent children. Further work is necessary to strengthen the nature of this association.