Clinical reviewDiagnosis of obstructive sleep apnea in children: A systematic review
Introduction
Obstructive sleep apnea (OSA) is a form of sleep-disordered breathing that occurs in children of all ages. Its characteristics include prolonged episodes with increased upper airway resistance and respiratory effort with partial or complete upper airway obstruction and various combinations of snoring, intermittent hypoxemia, hypercarbia, restless sleep and an increased number of awakenings.1 Estimations concerning the prevalence of OSA range from 0.7% to 10.3%, with a peak prevalence between 2 and 8 y of age.2 Considering the increasing prevalence of OSA and its serious neurocognitive and cardiovascular consequences, it has been recommended that children with suspected OSA (e.g., those with habitual snoring) should be objectively evaluated.3 The gold standard for diagnosing OSA is full nighttime sleep laboratory-based polysomnography (PSG).*2, *3 According to the international classification of sleep disorders second edition,1 a diagnosis of OSA is based on history, an apnea hypopnea index (AHI) ≥ 1, and other respiratory disturbances on PSG.
A technical report on diagnosis and management of childhood OSA published in 2002 concluded that overnight PSG, performed in a sleep-lab, was the only diagnostic method for a reliable differentiation between OSA and primary snoring.2 Although overnight, sleep lab-based PSG was recognized as the reference standard for the diagnosis of OSA in that report, it was also suggested that PSG criteria for OSA needed further validation.2 Moreover, PSG has several important limitations: i) it is stressful to children and parents; ii) requires hospitalization; iii) is not widely available (i.e., long waiting lists); and iv) is expensive. To overcome these problems, simple, cheap, abbreviated, and valid alternatives to PSG are urgently needed.
On the other hand, prediction of consequences and sequelae of OSA based on PSG is doubtful, because the latter is only poorly correlated with outcome parameters.4 Despite these shortcomings, there is currently no generally accepted and valid diagnostic test procedure that permits identification of at-risk patients. Today, no comprehensive systematic work-up of the available evidence concerning diagnostic tests for OSA in children (i.e., a systematic review) has yet been performed on this issue. We therefore set out to perform a comprehensive systematic review of the available evidence on a diagnosis of OSA in children. We aimed to assess diagnostic test accuracy (DTA) of available diagnostic tests and compare them to PSG as the standard reference test.
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Search strategy
Detailed individual search strategies for each of the following bibliographic databases were developed: Medline (1950-present), Embase (1988-present), CINAHL (1982-present), and BIOSIS (1926-present). The strategy used several combinations of searches related to the specific patient population, index test, and the reference standard for the target condition. All references were managed by reference manager software and duplicate hits removed. Both English and non-English studies were
Selection of studies
We identified 741 citations from electronic databases: 386 from PubMed/Medline, 100 from Embase, 249 from CINAHL and 6 from Biosis. Of these, 85 were duplicates. After a comprehensive evaluation of the remaining 656 abstracts, 135 publications (105 original publications; 30 reviews, letters, and personal opinions) were obtained as full text. From the handsearch, 14 additional studies were identified and the corresponding authors of the respective abstract contacted. Only one author, however,
Discussion
This systematic review investigated the available evidence on DTA of tests for diagnosing OSA in children. We found a diversity of tests that were compared to the current gold standard. Although several promising tests were identified, only few showed a DTA good enough to be considered potentially useful. The quality of the identified studies showed some flaws especially concerning blinding of the analysis and the time period between index test and gold standard evaluation. None of the
Conclusions
Considering the high prevalence and consequences of untreated OSA, there is an urgent need for cheap, simple, and easily accessible diagnostic tests. The present systematic review identified several index tests with acceptable or excellent DTA in the prediction of OSA on PSG. Of these, sleep lab-based polygraphy, anterior rhinomanometry, and urinary biomarkers performed best. However, study quality was generally low, sample size small, OSA often not appropriately defined, and confirmatory
Conflict of interest
The authors have no conflict of interest to declare.
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Future directions
2023, Snoring and Obstructive Sleep Apnea in ChildrenThe role of the nasopharyngeal prong in craniofacial disorders in particular the Pierre Robin sequence
2021, Seminars in Fetal and Neonatal MedicineDiagnostic approaches to respiratory abnormalities in craniofacial syndromes
2021, Seminars in Fetal and Neonatal MedicineManaging infants with craniofacial malformations – Where to go next?
2021, Seminars in Fetal and Neonatal MedicineChinese guideline for the diagnosis and treatment of childhood obstructive sleep apnea (2020)
2021, World Journal of Otorhinolaryngology - Head and Neck Surgery
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Both authors contributed equally to this publication.
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The most important references are denoted by an asterisk.