Elsevier

Sleep Medicine Reviews

Volume 17, Issue 5, October 2013, Pages 331-340
Sleep Medicine Reviews

Clinical review
Diagnosis of obstructive sleep apnea in children: A systematic review

https://doi.org/10.1016/j.smrv.2012.08.004Get rights and content

Summary

Objective

To investigate diagnostic test accuracy (DTA) of different tests for obstructive sleep apnea (OSA) compared to polysomnography (PSG) in children.

Methods

We performed a systematic review according to DTA criteria published by the Cochrane Collaboration. Studies that compared any possible diagnostic test with PSG for diagnosing OSA were considered. Study quality assessment was conducted in each selected study and DTA measures recalculated by hand whenever possible. Excellent DTA was defined as positive likelihood ratio (PLR) > 10 and negative likelihood ratio (NLR) < 0.1.

Results

We identified 1064 potentially relevant studies, of which 33 met inclusion criteria. Study quality was generally low; 5 studies fulfilled all quality criteria and 11 studies included >100 subjects. Included studies compared 40 different tests to PSG. Only 13 studies used the currently accepted definition for OSA (i.e., apnea hypopnea index ≥1). In these studies, PLR ranged from 1.017 to ∞, NLR from 0 to 1.089. Sleep lab-based polygraphy, urinary biomarkers, and rhinomanometry (one study each) showed excellent DTA.

Conclusion

There is limited evidence concerning diagnostic alternatives to PSG for identifying OSA in children. However, polygraphy, urinary biomarkers, and rhinomanometry may be valid tests if their apparently high DTA is confirmed by subsequent studies.

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.

Section snippets

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.

References* (89)

  • S.E. Brietzke et al.

    Can history and physical examination reliably diagnose pediatric obstructive sleep apnea/hypopnea syndrome? a systematic review of the literature

    Otolaryngol - Head Neck Surg

    (2004)
  • H. Caulfield

    Investigations in paediatric obstructive sleep apnoea: do we need them?

    Intern J Pediatr Otorhinolaryngol

    (2003)
  • J. Coleman

    Disordered breathing during sleep in newborns, infants, and children: symptoms, diagnosis, and treatment

    Otolaryngologic Clin North Am

    (1999)
  • L.A. D'Andrea

    Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications

    Pediatr Clin North Am

    (2004)
  • B. Fauroux et al.

    What's new in paediatric sleep in 2007?

    Paediatric Respir Rev

    (2008)
  • J.Y.A. Foo

    Pulse transit time in paediatric respiratory sleep studies

    Med Eng Phys

    (2007)
  • G. Francois et al.

    Obstructive sleep apnea syndrome in infants and children

    Arch Pediatr

    (2000)
  • A.C. Halbower et al.

    Childhood obstructive sleep-disordered breathing: a clinical update and discussion of technological innovations and challenges

    Chest

    (2007)
  • G. Owen et al.

    Screening for obstructive sleep apnoea in children

    Intern J Pediatr Otorhinolaryngol

    (1995)
  • B.A. Phillips et al.

    Monitoring sleep and breathing: methodology. Part I: monitoring breathing

    Clin Chest Med

    (1998)
  • L.S. Brooks et al.

    Adenoid size is related to severity but not the number of episodes of obstructive apnea in children

    J Pediatr

    (1998)
  • N.S. Howard et al.

    Pediatric tonsil size: objective vs subjective measurements correlated to overnight polysomnogram

    Otolaryngol-Head Neck Surg

    (2009)
  • O. Sardon Prado et al.

    Diagnostic utility of nocturnal in-home respiratory polygraphy

    Pediatr (Barc)

    (2006)
  • A.M. Li et al.

    Prevalence and risk factors of habitual snoring in primary school children

    CHEST

    (2010)
  • L.P. Parker et al.

    Rhinomanometry in children

    Intern J Pediatr Otorhinolaryngol

    (1989)
  • American Academy of sleep medicine

    International classification of sleep disorders

    (2005)
  • M.S. Schechter

    Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome

    Pediatrics

    (2002)
  • American Academy of Pediatrics et al.

    Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome

    Pediatrics

    (2002)
  • P.F. Whiting et al.

    Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies

    BMC Med Res Methodol

    (2006)
  • G. Aljadeff et al.

    Heart rate variability in children with obstructive sleep apnea

    Sleep

    (1997)
  • M.L. Alonso Alvarez et al.

    Reliability of respiratory polygraphy for the diagnosis of sleep apnea-hypopnea syndrome in children

    Arch Bronconeumol

    (2008)
  • E.Y. Chan et al.

    Modified epworth sleepiness scale in chinese children with obstructive sleep apnea: a retrospective study

    Sleep Breath

    (2009)
  • K.W. Chau et al.

    Clinical risk factors for obstructive sleep apnoea in children

    Singapore Med J

    (2003)
  • R.D. Chervin et al.

    Pediatric sleep questionnaire: prediction of sleep apnea and outcomes

    Arch Otolaryngol Head Neck Surg

    (2007)
  • N.A. Goldstein et al.

    Clinical diagnosis of pediatric obstructive sleep apnea validated by polysomnography

    Otolaryngol - Head Neck Surg

    (1994)
  • S.V. Jacob et al.

    Home testing for pediatric obstructive sleep apnea syndrome secondary to adenotonsillar hypertrophy

    Pediatr Pulmonol

    (1995)
  • A.G. Kaditis et al.

    Obstructive sleep-disordered breathing and fasting insulin levels in nonobese children

    Pediatr Pulmonol

    (2005)
  • C. Lamm et al.

    Evaluation of home audiotapes as an abbreviated test for obstructive sleep apnea syndrome (OSAS) in children

    Pediatr Pulmonol

    (1999)
  • A.M. Li et al.

    Child health series: use of tonsil size in the evaluation of obstructive sleep apnoea

    Arch Dis Childhood

    (2002)
  • H.E. Montgomery-Downs et al.

    Snoring and sleep-disordered breathing in young children: subjective and objective correlates

    Sleep

    (2004)
  • R.B. Shouldice et al.

    Detection of obstructive sleep apnea in pediatric subjects using surface lead electrocardiogram features

    Sleep

    (2004)
  • S. Sritippayawan et al.

    Validity of tidal breathing flow volume loops in diagnosing obstructive sleep apnea in young children with adenotonsillar hypertrophy: a preliminary study

    J Med Assoc Thai

    (2004)
  • S. Blonshine

    Sleep waves. The clinical evaluation of sleep-disordered breathing in children

    AARC Times

    (2003)
  • K.M. Bauer et al.

    How accurate is subjective reporting of childhood sleep patterns? a review of the literature and implications for practice

    Curr Pediatr Rev

    (2008)
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    c

    Both authors contributed equally to this publication.

    d

    Tel.: +49 7071 29 84742; fax: +49 7071 29 3969.

    *

    The most important references are denoted by an asterisk.

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