Screening of pediatric sleep-disordered breathing: a proposed unbiased discriminative set of questions using clinical severity scales

Abstract

Background: Identification of sleep-disordered breathing (SDB) using questionnaires is critical from a clinical and research perspective. However, which questions to use and how well such questionnaires perform has thus far been fraught with substantial uncertainty. We aimed at delineating the usefulness of a set of questions for identifying pediatric SDB.

Methods: Random prospective sampling of urban 5- to 9-year-old children from the community and enriched for habitual snoring underwent overnight sleep study. Subjective indicators or questions were evaluated to further characterize and discriminate SDB.

Results: Of 1,133 subjects, 52.8% were habitual snorers. This sample was analyzed based on a clinical grouping (ie, established apnea-hypopnea index cutoffs). Several statistical steps were performed and indicated that complaints can be ranked according to a severity hierarchy: shake child to breathe, apnea during sleep, struggle breathing when asleep, and breathing concerns while asleep, followed by loudness of snoring and snoring while asleep. With a posteriori cutoff, a predictive score > 2.72 on the severity scale was found (ie, area under the curve, 0.79 ± 0.03; sensitivity, 59.03%; specificity, 82.85%; positive predictive value, 35.4; negative predictive value, 92.7), making this cutoff applicable for confirmatory purposes.

Conclusions: As a result, the set of six hierarchically arranged questions will aid the screening of children at high risk for SDB but cannot be used as the sole diagnostic approach.

Figures

Figure 1.

Severity hierarchy of respiratory complaints in children for the clinical AHI cutoff groups. Q1: shake child to breathe. Q2: apnea during sleep. Q3: struggle breathing when asleep. Q4: breathing concerns while asleep. Q5: loudness of snoring. Q6: snoring during sleep. Daytime mouth breathing (excluded by Mokken Scale Analysis). With a high score on a question it is likely that previous questions within the hierarchy will be scored high as well; also, the higher the mean score the more severe the complaints. The lines depict the mean score per question for each AHI cutoff group when the proposed hierarchy is preserved; hence, they can be a clinical rule of thumb. Visually, the disparities among the lines of severity hierarchy further suggest the closeness and distinctiveness of AHI cutoff groups based on the applied questionnaire. The lower x-axis applies for AHI_G4-6 (or AHI > 3). AHI = apnea-hypopnea index.

Figure 2.

Severity hierarchy of respiratory complaints in children for the a posteriori AHI ≤ 3 and AHI > 3. Q1: shake child to breathe. Q2: apnea during sleep. Q3: struggle breathing when asleep. Q4: breathing concerns while asleep. Q5: loudness of snoring. Q6: snoring during sleep. Daytime mouth breathing (excluded by Mokken Scale Analysis). The scores on the green and red line may aid the diagnostic process. If the average score on the severity hierarchy is > 2.72, the child likely has SDB.