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 Table of Contents  
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 18-22

Prevalence of risk to develop obstructive sleep apnea in Bengali children using pediatric sleep questionnaire

Department of Pedodontics and Preventive Dentistry, Guru Nanak Institute of Dental Sciences and Research, Kolkata, West Bengal, India

Date of Web Publication11-Oct-2019

Correspondence Address:
Dr. Trisha Das Sarma
157/F, Nilganj Road, Sahid Colony, Panihati, Kolkata - 700 114, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmd.ijmd_7_19

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Context: Obstructive sleep apnea (OSA) is being recognized as a serious medical condition, having various long-term effects on a child's well-being. However, very few epidemiological data are present for the Indian children who could be at risk for this condition.
Aim: The aim of the study was to determine children aged 2–14 years who are at risk to develop OSA using the pediatric sleep questionnaire (PSQ).
Settings and Design: A cross-sectional study was carried out in the postgraduate clinic of the department of pedodontics where participants were selected by a simple random sampling method. A sample size of 120 children aged 2–14 years was taken, whose parents were asked to fill the PSQ.
Subjects and Methods: Children who had 8 “yes” responses of 22 questions were given a PSQ score ≥0.33 and were considered the OSA risk group. OSA risk group was further subgrouped based on gender, age, and questions with frequent yes answers.
Statistical Analysis Used: Test of proportion and Chi-square test with the help of Epi Info (TM) were used in this study.
Results: No statistically significant association was seen between risk to develop OSA with gender and age of patients. However, proportion of males with PSQ >0.33 was higher than that of females. Similarly, proportion of patients with PSQ >0.33 in the age group of 6–10 years, followed by the age group of 0–5 years, was significantly higher. Statistically significant association was found between OSA and hyperactive and interruptive behaviors displayed by the child patients.
Conclusions: PSQ is a reliable tool to determine children at risk to develop OSA and can be routinely used for early diagnosis of pediatric OSA.

Keywords: Bengali; obstructive sleep apnea; pediatric sleep questionnaire

How to cite this article:
Jalan P, Sarma TD, Chandra B, Kundu GK. Prevalence of risk to develop obstructive sleep apnea in Bengali children using pediatric sleep questionnaire. Indian J Multidiscip Dent 2019;9:18-22

How to cite this URL:
Jalan P, Sarma TD, Chandra B, Kundu GK. Prevalence of risk to develop obstructive sleep apnea in Bengali children using pediatric sleep questionnaire. Indian J Multidiscip Dent [serial online] 2019 [cited 2022 Oct 5];9:18-22. Available from: https://www.ijmdent.com/text.asp?2019/9/1/18/268995

  Introduction Top

Obstructive sleep apnea (OSA) is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns (American Thoracic Society, 1996). It has also been given recognition in the International Classification of Sleep Disorders 2005. Pediatric dentists are in a unique position to identify patients at the greatest risk to develop OSA by routine dental examinations and with suitable referrals and collaborations with other specialties to formulate a comprehensive treatment plan.[1],[2]

The aim of this epidemiological study was to determine the risk of developing OSA in children aged 2–14 years in the city of Kolkata, West Bengal, using the pediatric sleep questionnaire (PSQ).

  Subjects and Methods Top

A cross-sectional study was carried out in the Department of Pedodontics of Guru Nanak Institute of Dental Sciences and Research (GNIDSR), Kolkata, West Bengal, where participants were selected by a simple random sampling method.

Children aged 2–14 years, whose parents were willing to participate in the study, as well as children who had no previous surgical history or any congenital anomaly were included in our study. Children with any severe medical condition such as acute infections at the time of examinations, epilepsy, need for ENT surgery, cleft lip/palate or midface hypoplasia, or any mental disorder were excluded from the study. A total of 142 children and their parents were approached for our survey. The final study sample consisted of 120 children in which 66 were male and 54 were female. At a probability type (A1 error) or level significant 0.05 = 5% and estimate percentage of satisfaction 73% from the a previous study done by Bertran et al., 2015, and Al-Talib et al., 2017, with power 0.095, the sample size should be at least 83. Proper ethical clearance was obtained from the Ethical Committee of GNIDSR, and informed consent was obtained from the parents/caregivers who accompanied the child to our pediatric dental Out Patient Department before beginning the study.

The parents of the children completed the PSQ developed and validated by Chervin et al.[1] The questionnaire was also translated in the regional language Bengali for their convenience.

The questionnaire consisted of 22 simple and concise close-ended questions, which had to be marked as either yes, no, or don't know. All the questions, whose answers were marked as “yes” in the questionnaire, were later added up. A PSQ score was obtained by applying the formula: Total number of questions with “yes” answer/total number of questions, i.e., 22.

Among 22 questions, if 8 or more questions were given a “Yes” answer, it gave a PSQ score ≥0.33 and indicated a positive risk for developing OSA, thus were called OSA risk group.

Children with PSQ ≥0.33, i.e., the OSA risk group were further subgrouped according to their gender and age as 2–5, 6–10, and 11–14 years and on the basis of the frequently presenting symptoms related to OSA in the risk group which was determined from the questions that were marked as yes. All the data were collected, tabulated, and statistically analyzed using Epi Info (TM) (CDC, Atlanta, Georgia, USA). to determine children at the greatest risk to develop OSA.

  Results Top

A total of 120 children participated in the study. Mean age of the study population was 7.4 (±2.85) years, with more number of male children as compared to female children in the study sample. Statistical analysis was performed with the help of Epi Info (TM) Epi Info is a trademark of the Centers for Disease Control and Prevention.

Descriptive statistical analyses were performed to the frequencies and corresponding percentages. Test of proportion was used to find the standard normal deviate (Z) to compare the different proportions, and Chi-square (χ) test was performed to find the associations. P <0.05 was considered to be statistically significant.

The distribution of male and female children in the OSA risk group (PSQ ≥0.33) was determined after tabulating data obtained from the questionnaires [Table 1].
Table 1: Distribution of obstructive sleep apnea risk group and gender of the patients

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Chi-square test (χ =2.19) showed that there was no significant association between PSQ and gender of the patients ( P = 0.14) since P > 0.05.

However, when proportion difference was compared between the genders, it was seen that proportion of males with PSQ >0.33 (18.5%) was higher than that of females (12.5%), but it was not statistically significant either (Z = 1.15; P = 0.24) since P > 0.05 [Graph 1].

It is seen that the mean age at which PSQ score is ≥0.33 and the prevalence of OSA is high is 7.16 (±0.567 years) [Table 2].
Table 2: Distribution of pediatric sleep questionnaire and age of the patients

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Chi-square test (χ =2.53) showed that there was no significant association between OSA and age of the patients ( P = 0.28) since P > 0.05.

However, proportion of patients with PSQ >0.33 ( n = 30) in the age group of 6–10 years (53.3%), followed by the age group of 0–5 years (26.6%), was significantly higher than that of the patients in the age group of 11–14 years (Z = 2.63; P = 0.008) [Graph 2].

When proportion difference of the signs and symptoms displayed in the OSA risk group was compared, it was seen that most of the patients were suffering from hyperactive behavior (20.0%), followed by interruptive behavior (16.6%). Statistically significant association was found between OSA and the signs and symptoms displayed by the child patients (Z = 2.27; P < 0.01) since P < 0.05, thus giving us a clue to the possible signs and symptoms that can be seen as warning signs in OSA risk patients.

Hence, in short, OSA risk group was more or less equally distributed over gender in our study. The prevalence of OSA was more or less equally distributed over age of the patients. Hyperactive and interruptive behaviors are the two most common signs in OSA risk pediatric patients.

  Discussion Top

An untreated or undiagnosed case of OSA can cause many untoward complications such as cardiovascular complications, impairment of growth, and various learning and behavioral problems for the children in the long term.[1] According to the guidelines of the American Academy of Sleep Medicine, polysomnography (PSG) is the gold standard for diagnosing OSA. Apart from routine clinical and radiological examinations, various questionnaires are also used nowadays for determining the population who are at a risk to develop sleep apnea (e.g., STOP-BANG questionnaire and pediatric sleep questionnaire).[2]

OSA is one of the most common sleep-related breathing disorders (SRBDs) that are shown to affect 2%–3% of the pediatric population, i.e., from newborns to adolescents, causing various health problems and posing a high risk of morbidity and mortality in children.[3] Pediatric OSA is commonly seen in the age group of 2–8 years when the pharyngeal lymphatic tissues are developing and so the lumen of the airway is narrow.[4]

While earlier apart from pharmacotherapy and lifestyle modifications, surgery was the preferred mode of treatment in children, nowadays various oral appliances such as mandibular advancing devices, tongue lift prosthesis, and rapid maxillary expansion (RME) are being preferred as alternative treatment strategies.[5]

Nowadays, pediatric OSA is highly prevalent, but many times, it is neglected due to ignorance among general physicians, pediatricians, and pedodontics. In various studies, high prevalence (9.6%) of OSA among Indian children is observed.[6]

According to the American Academy of Pediatric Dentistry policy on pediatric OSA, various questionnaires including the PSQ can be used as a very reliable method for diagnosing children at risk for developing OSA and helping in early interventions and treatment planning.

Bertran et al.[3] aimed to determine the diagnostic test accuracy of the scale of the PSQ. PSQ cutoff value of 0.33 showed a specificity of 0.72 and a sensitivity of 0.78. They concluded that PSQ was able to identify 89% of the children with OSA correctly, separating them from those with primary snoring. Chervin et al.[1] observed in their study that PSQ scales for childhood SRBDs, snoring, sleepiness, and behavior are valid and reliable instruments that can be used in clinical research when PSG is not feasible.

We find no significant association between PSQ and gender of the patients ( P = 0.14) which are in accordance with studies done by Anuntaseree et al., Kelmanson et al., and Corbo et al.[7] However, proportion of males in OSA risk group was higher than that of females. Higher prevalence of OSA symptoms among boys is also seen in studies done by Sauer et al.[8] ( P = 0.003), Delasnerie-Laupretre et al., Ersu et al., Ng et al., and Liu et al.[9] Puberty-related hormonal or physiologic changes may potentiate the effect of sex on OSA or snoring prevalence but cannot be the sole mechanism responsible for the differences. However, the opposite is implied in just a single study done by Smedje et al. who reported a higher prevalence of snoring in girls.[10]

As per our study, 30 of 120 children give a positive questionnaire score (>0.33). No significant association between OSA and age of the patients is observed. A similar result is obtained by Archbold et al., Owens et al., and Goodwin et al.[11] where no differences in OSA frequencies were noted among 2–13 years old nor among 4–11 years old. However, we found that proportion of patients with OSA risk group is higher in the age group of 6–10 years which is in congruence with studies done by Corbo et al.[12] According to Ersu et al., the prevalence of habitual snoring was the most common among 11–13 years old ( P = 0.0001). In contrast with our study, Sauer et al.[8] have seen that 6.3 ± 0.78 years, an age at which lymphatic tissue is pronounced, the prevalence of OSA is high.

Our finding of “hyperactive” (20%) and “interruptive behaviors” (16.60%) is significantly higher than that noted in the literature done by Sauer et al. (7.3% and 8.1%, respectively).[8] On the other side, mouth breathing habit is comparatively lower (10%) in our study than them (18%). “Snoring” (6.6%) is a more common sign in our study than the study done by Spruyt et al. (2.5%).[13]

Long-term complications of OSA include significant neurocognitive, behavioral, cardiovascular, and metabolic disorders. Early age detection of children who could be at risk to develop OSA or have OSA is very important as untreated cases of OSA are often associated with poor school performance, aggressive behavior, and various emotional problems of the child apart from neurological and cardiac complications. To our knowledge, this is the first study to have evaluated the association between OSA risk group and age and gender and the distribution of sign and symptoms of the patients affected by OSA with the help of PSQ on this specific population. Long-term studies on bigger sample size are expected in the future with proper orthodontic and ENT examination.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): Validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med 2000;1:21-32.  Back to cited text no. 1
American Academy of Pediatric Dentistry. Policy on obstructive sleep apnea. Oral Health Policies Ref Manual 2016;38:87-9.  Back to cited text no. 2
Bertran K, Mesa T, Rosso K, Krakowiak MJ, Pincheira E, Brockmann PE, et al. Diagnostic accuracy of the Spanish version of the pediatric sleep questionnaire for screening of obstructive sleep apnea in habitually snoring children. Sleep Med 2015;16:631-6.  Back to cited text no. 3
Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc 2008;5:242-52.  Back to cited text no. 4
Medical Advisory Secretariat. Oral appliances for obstructive sleep apnea: An evidence-based analysis. Ont Health Technol Assess Ser 2009;9:1-51.  Back to cited text no. 5
Goyal A, Pakhare AP, Bhatt GC, Choudhary B, Patil R. Association of pediatric obstructive sleep apnea with poor academic performance: A school-based study from India. Lung India 2018;35:132-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
Corbo GM, Forastiere F, Agabiti N, Pistelli R, Dell'Orco V, Perucci CA. Snoring in 9- to 15-year-old children: Risk factors and clinical relevance. Pediatrics 2001;108:1149-54.  Back to cited text no. 7
Sauer C, Schlüter B, Hinz R, Gesch D. Childhood obstructive sleep apnea syndrome: An interdisciplinary approach: A prospective epidemiological study of 4,318 five-and-a-half-year-old children. J Orofac Orthop 2012;73:342-58.  Back to cited text no. 8
Liu X, Ma Y, Wang Y, Jiang Q, Rao X, Lu X, et al. Brief report: An epidemiologic survey of the prevalence of sleep disorders among children 2 to 12 years old in Beijing, China. Pediatrics 2005;115:266-8.  Back to cited text no. 9
Smedje H, Broman JE, Hetta J. Parents' reports of disturbed sleep in 5-7-year-old Swedish children. Acta Paediatr 1999;88:858-65.  Back to cited text no. 10
Goodwin JL, Babar SI, Kaemingk KL, Rosen GM, Morgan WJ, Sherrill DL, et al. Symptoms related to sleep-disordered breathing in white and Hispanic children: The Tucson children's assessment of sleep apnea study. Chest 2003;124:196-203.  Back to cited text no. 11
Corbo GM, Fuciarelli F, Foresi A, De Benedetto F. Snoring in children: Association with respiratory symptoms and passive smoking. BMJ 1989;299:1491-4.  Back to cited text no. 12
Spruyt K, O'Brien LM, Macmillan Coxon AP, Cluydts R, Verleye G, Ferri R, et al. Multidimensional scaling of pediatric sleep breathing problems and bio-behavioral correlates. Sleep Med 2006;7:269-80.  Back to cited text no. 13


  [Table 1], [Table 2]


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