The upper airway resistance syndrome (UARS) is associated with neurobehavioral morbidity in children. The diagnostic gold standard for UARS is esophageal manometry. However, this is invasive. Furthermore, upper airway obstructive events in sleeping children frequently terminate without visible electrocortical (EEG) arousal. The pulse transit time (PTT) is a noninvasive marker of blood pressure and, therefore, subcortical arousal. Blood pressure elevation, associated with respiratory arousal from sleep, results in a drop in the PTT. We hypothesized that: 1) the PTT is a more sensitive measure of respiratory arousal than EEG; and 2) the PTT arousal index can distinguish children with UARS from those with primary snoring. Polysomnography, including esophageal manometry and PTT, was measured prospectively in 24 symptomatic children and 10 normal controls. Apnea, hypopnea, and respiratory effort-related arousal events terminated in a PTT arousal 91%, 83%, and 80% of the time, and in an EEG arousal in 55%, 51%, and 43% (allp< 0.05), respectively. The PTT arousal index was significantly greater in children with UARS (6.8 events/h) than primary snoring (2.2 events/h) (p< 0.05). We conclude that, in children, PTT arousals are a more sensitive measure of obstructive events than visible EEG arousals.