Development of a Simplified Pediatric Obstructive Sleep Apnea (OSA) Screening Tool

Abstract

Study Objectives: To develop and test a pediatric screening tool to gauge the risk that an individual child would have OSA prior to a dental procedure by a pediatric dentist requiring minimal or moderate oral conscious sedation. Methods: 180 pediatric patients completed a polysomnogram at the VCU Center for Sleep Medicine between February 2011 and February 2013. A modified STOP-Bang questionnaire was validated with polysomnography. Results: A validated adult questionnaire, STOP-Bang, was modified using more typical pediatric risk factors for OSA: presence of snoring (S), tonsillar hypertrophy (T), obstruction (O), daytime tiredness or neuropsychological-behavioral symptoms such as ADHD or daytime irritability (P), BMI percentile for age (B), age at diagnostic screening (A), presence of neuromuscular disorder (N), and presence of genetic/congenital disorder (G). A positive scoring from these variables was measured against the patients acquired in-laboratory polysomnogram using the standard OSA measure, apnea-hypopnea index. A multiple logistic regression analysis found a statistically significant relationship (p = 0.0007), with a minimum of 4 variables needed to have a sensitivity of 57% and a specificity of 78%. Only obstruction, BMI, and age showed a strong significant relationship to OSA. The presence of an obstruction was positively related to apnea (p = 0.0010). Most of the other components had an odds ratio larger than one (indicating a nominally positive relationship). Conclusions: The pediatric modified STOP-Bang screening tools showed a statistically significant relationship. Only obstruction, BMI, and age showed a predictive relationship to OSA. Although the PM-STOP-Bang results do not lend support to including other known risk factors of pediatric OSA, further studies are warranted of a revised screening tool that include recognized risk factors. Keywords: pediatric obstructive sleep apnea, simplified screening tool Citation: Chiang HK, Cronly JK, Best AM, Brickhouse TH, Leszczyszyn DJ. Development of a simplified pediatric obstructive sleep apnea (OSA) screening tool. Journal of Dental Sleep Medicine 2015;2(4):163-173. S leep disordered breathing encompasses a wide range of upper airway disorders from primary snoring (PS) to obstructive sleep apnea (OSA). OSA results from impedance to airflow in the upper airway during sleep; these periodic obstructions of the upper airway interfere with normal respiratory gas exchange and subsequently interrupt sleep. 1,2 OSA has become recognized as one of the most common, underdiagnosed chronic diseases. 3-5 People of all ages are affected with OSA. Recently studies have shown increased numbers among pediatric and adolescent populations. 6 The prevalence of obstructive sleep apnea (OSA) in children is estimated to be 1% to 3%, 7 while primary snoring occurs in 3% to 12% of the pediatric population. 8 Mild cases of pediatric OSA are recognized and at times treated; however, measurable effects on development, cardio-pulmonary, or metabolic systems have been difficult to validate. OSA is associated with behavioral problems, poor school achievement, and, in severe cases, pulmonary hypertension. 2 Many studies have been conducted to identify adverse effects of sleep disorders, yet few studies have examined how health care providers may identify and treat sleep disorders. 10 Dentists see their patients more frequently than their primary care doctors, and so have a greater opportunity to observe signs and symptoms of OSA. 6 However, many potential sleep disorders in children are unrecognized and underreported, and overall the condition is under-diagnosed. 11 Dentists who practice sedation dentistry should exercise extra precautions when treating patients with risk of sleep apnea. Minimal and moderate oral conscious sedation and general anesthesia are commonly used in pediatric dentistry. During sedation, children with OSA have an increased vulnerability of their airway undergoing pharyn-geal collapse and of having upper airway obstruction. 7 Thus pediatric dentists have an acute responsibility to be able to identify patients who may have OSA. 5 The risk of postoperative respiratory complications among the pediatric population ranges from 0 to 1.3%; however, for children with OSA, the rates have been reported to be 16% to 27%. 12,13 The prevalence of OSA in children is most elevated between 2 to 6 years of age. In this age range, pharmacologic measures are most often used to complete diagnostic and therapeutic procedures. 7 While polysomnography (PSG) remains the gold standard for diagnosing OSA, there are many challenges due to the limited number of sleep laboratories and the high cost of performing a PSG on each child who snores and who may be at risk. 8 Available non-PSG screening tests have poor sensitivity for milder OSA, and overall poor specificity. 8 Moreover, there remains a challenge to differentiate PS from OSA in a "cost-effective, reliable, and accurate manner before recommending invasive or intrusive therapies, such as surgery or continuous positive airway pressure." 8 Sleep questionnaires that are completed by the parent and child are a crucial component of behavioral and physiological sleep assessment. Pediatric questionnaires are mostly