Well-child visits are the appropriate time to screen all children for a history of snoring and apnea (strength of recommendation [SOR]: C, based on expert opinion). Children should be further evaluated for obstructive sleep apnea if parents note habitual nightly snoring, especially if accompanied by pauses, snorts, or gasps (SOR: C, based on case series and expert opinion)

Brown, Perry

Schnall, Janet G.

University of Missouri: MOspace

	 vol	56,	No	4	/	april	2007	 317www.jfponline.comCliniCal iNquiries From the Family Physicians Inquiries NetworkWhen (and how) should you evaluate a child for obstructive sleep apnea?Evidence-based answerWell-child	visits	are	the	appropriate	time	to	screen	all	children	for	a	history	of	snoring	and	apnea	(strength	of	recommendation	[sor]:	C,	based	on	expert	opinion).	Children	should	be	further	evaluated	for	obstructive	sleep	apnea	if	parents	note	habitual	nightly	snoring,	especially	if	accompanied	by	pauses,	snorts,	or	gasps	(sor:	C,	based	on	case	series	and	expert	opinion).	single	overnight	polysomnography	is	the	test	of	choice	to	evaluate	a	child	for	obstructive	sleep	apnea,	since	it	can’t	be	excluded	by	history	or	physical	exam.	other	evaluation	methods	for	sleep	apnea	lack	either	adequate	sensitivity	or	specificity	(sor:	C,	based	on	case	series,	systematic	review	of	case	series,	and	expert	opinion).Clinical commentaryAdd a question about snoring to your parental questionnaireHow	many	of	us	routinely	ask	about	snoring	or	sleep	apnea	at	a	wellness	visit	for	our	young	patients?	Here	we	learn	that	asking	a	simple	question—“Does	your	child	snore	heavily	most	nights	or	seem	to	stop	breathing	when	he	or	she	sleeps?”—improves	our	ability	to	recognize	obstructive	sleep	apnea	in	children.	in	addition,	a	relatively	simple,	one-time,	noninvasive	test	tells	us	whether	the	child	has	obstructive	sleep	apnea—or	not.	in	light	of	this	information,	i	plan	on	putting	a	revised	well-child	visit	questionnaire	that	asks	about	snoring/apnea	in	my	waiting	room	right	away.	John D. Hallgren, MDuniformed	services	university	of	the	Health	sciences,	raF	Menwith	Hill,	united	KingdomPerry Brown, MD, FaaPFamily Medicine Residency  of Idaho, BoiseJanet G. Schnall, MS, aHiPHealth Sciences Libraries,  University of Washington, Seattlez Evidence summaryExperts advise screening all children for obstructive sleep apnea by asking about snoring and sleep apnea at rou-tine health supervision visits.1 Obstruc-tive sleep apnea among children has an overall prevalence of 2% but occurs in approximately 13% to 25% of those who snore regularly and heavily.1,2 Obstructive sleep apnea is unlikely in the absence of habitual snoring (ex-pert opinion), and snoring loudness does not correlate with severity. Children with obstructive sleep apnea tend to exhibit symptoms typical of attention-deficit and hyperactivity disorder rather than daytime somnolence.2Adenotonsillar hypertrophy  may be to blameThe most common cause of obstructive sleep apnea is adenotonsillar hypertrophy. Additional risk factors include obesity, fast trackObstructive sleep apnea among kids has a prevalence of 2%, but occurs in 13% to 25% of those who snoreCopyright® Dowden Health Media  For personal us onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.fast track318 vol	56,	No	4	/	april	2007		ThE JournAl of fAmily PrACTiCECliniCal iNquiriesallergic rhinitis, neuromuscular disease, craniofacial anomalies, Down syndrome, premature birth, and family history.1A prospective case-series of 62 con-secutive children referred to a sleep clinic for suspected obstructive sleep apnea correlated nightly snoring (relative risk [RR]=10.67; 95% confidence interval [CI], 2.72–41.8) and observed apnea (RR=3.43; 95% CI, 1.42–6.76) with ob-structive sleep apnea diagnosed by poly-somnography.3 Children with underlying neurological or craniofacial problems were excluded. A retrospective, nonconsecutive cohort study of 50 children previously diagnosed with obstructive sleep apnea found that all presented with “continuous heavy snoring, interrupted by pauses and associated with snorts.”4 Don’t count on the physical exam and history Experts consider overnight polysomnog-raphy to be the gold standard test for ob-structive sleep apnea.2 Physical examina-tion alone usually has normal results. A systematic review of 12 studies including 1058 children under age 18 compared evaluation by polysomnography with clinical evaluation by history and physi-cal examination alone. Clinical evalua-tion had a positive predictive value (PPV) of 55.8% (95% CI, 42.1%–69.6%); no single component demonstrated sensitiv-ity and specificity more than 65%.5Symptom questionnaires or scales did not correlate well with polysomnogra-phy results in 3 studies (which excluded children with craniofacial anomalies, significant medical problems, or prior up-per airway surgery). The best study—a prospective, randomized, investigator-blinded, controlled trial of 59 consecu-tive children clinically diagnosed with obstructive sleep apnea—compared a “clinical assessment score” (comprised of standardized history, physical exam, voice recording, sleep audio recording, lateral neck radiograph, and echocardiogram) with overnight polysomnography. The majority of children had mild obstruc-tive sleep apnea. Overall, the clinical as-sessment score did not correlate well with polysomnography (PPV=48%).6Avoid sequential  and abbreviated tests Sequential overnight polysomnogra-phy did not dramatically improve sen-sitivity or specificity over a single test in 2 prospective studies of children with suspected obstructive sleep apnea. The larger study recruited 70 consecutive children (ages 2 to 17 years) from a sleep lab and performed polysomnography on 2 consecutive nights. The first test cor-rectly identified obstructive sleep apnea in 64 children; the second identified 6 ad-ditional cases, all of which were “mild.”7Abbreviated polysomnographies have inadequate sensitivity. A retrospective chart review included 143 children be-tween 1 and 18 years of age with adeno-tonsillar hypertrophy referred for over-night polysomnography after normal or mildly abnormal “nap polysomnogra-phy.” Mildly abnormal nap polysomnog-raphy predicted abnormal overnight poly-somnography (PPV=77%; P<.0001), but normal nap polysomnography were not predictive of normal overnight polysom-nography (NPV=49%; P=.8).8 Video recordings  have low specificityA prospective cohort study of home sleep video recordings included 58 consecutive children who were 2 to 6 years of age with snoring or labored breathing during sleep. Parents filmed 30 minutes of sleep during “worst breathing” episodes. An expert investigator evaluated the record-ings using both a standardized scoring system and subjective impression, and compared these with overnight polysom-nography results, finding 94% sensitivity and 68% specificity.9Two prospective trials compared standardized scoring of home sleep audio recordings with overnight polysomnog-raphy testing. The best study, an inves-tigator-blinded RCT, scored 20-minute A clinical  assessment score did not correlate well with  polysomnographyfast track320 vol	56,	No	4	/	april	2007		ThE JournAl of fAmily PrACTiCECliniCal iNquiriesrecordings of “worst breathing” in 59 consecutive children referred for snor-ing or nocturnal breathing problems, 47% of whom had sleep apnea. Results: PPV=62%, NPV=83%, sensitivity=88%, specificity=52%.7 Abnormal pulse ox  is highly predictiveA retrospective, cross-sectional study of 349 children between the ages of 6 months and 18 years determined that abnormal home pulse oximetry studies were highly predictive of obstructive sleep apnea on polysomnography (positive likelihood ratio [LR+]=19.4; CIs not given; posttest probability=97%), but that inconclusive or normal pulse oximetry studies were not predictive of negative polysomnog-raphies (LR+ =0.58; CIs not given; post-test probability 47%). Children had been referred for suspected obstructive sleep apnea, and the pretest probability was 60%. Oximetry records were evaluated by a sleep laboratory physician blinded to clinical and polysomnography data.10Tonsillar-pharyngeal ratio  misses mild casesA prospective cohort study of 35 children compared the tonsillar-pharyngeal ratio measured from lateral neck x-rays to overnight polysomnography. X-ray mea-surements predicted moderate or severe obstructive sleep apnea on polysomnog-raphy (sensitivity=96%, specificity=82%, PPV=92%, NPV=90%), but did not ac-curately differentiate normal children from those with mild obstructive sleep apnea.11Recommendations from othersThe American Academy of Pediatrics rec-ommends that children be screened dur-ing well child visits for regular snoring or apnea episodes during sleep. Children with positive screens should have an over-night polysomnography. Children with confirmed obstructive sleep apnea should be referred to a sleep medicine special-ist to consider continuous positive air-way pressure therapy during sleep, or to an otolaryngologist for possible surgery (tonsillectomy or adenoidectomy).2 n references	 1.	 	li	aM,	Chan	DF,	Fok	TF,	Wing	YK.	Childhood	ob-structive	 sleep	 apnoea:	 an	 update.	 Hong Kong Med J 2004;	10:406–413.		 2.	 	section	on	pediatric	pulmonology,	subcommittee	on	obstructive	sleep	apnea	syndrome,	american	academy	 of	 pediatrics.	 Clinical	 practice	 guide-line:	diagnosis	and	management	of	childhood	ob-structive	sleep	apnea	syndrome.	Pediatrics 2002;	109:704–712.		 3.	 	Chau	KW,	Ng	DKK,	Kwok	CKl,	Chow	pY,	Ho	JCs.	Clinical	risk	factors	for	obstructive	sleep	apnoea	in	children.	Singapore Med J	2003;	44:570–573.		 4.	 	Guilleminault	C,	 Korobkin	 r,	 Winkle	 r.	 a	 review	of	 50	 children	with	 obstructive	 sleep	 apnea	 syn-drome. Lung	1981;	159:275–287.		 5.	 	Brietzke	se,	Katz	es,	roberson	DW.	Can	history	and	physical	examination	reliably	diagnose	pediat-ric	obstructive	sleep	apnea/hypopnea	syndrome?	a	 systematic	 review	 of	 the	 literature.	Otolaryngol Head Neck Surg	2004;	131:827–832.		 6.	 	Goldstein	Na,	pugazhendhi	v,	rao	sM,	et	al.	Clini-cal	assessment	of	pediatric	obstructive	sleep	ap-nea.	Pediatrics	2004;	114:33–43.		 7.	 	verhulst	sl,	schrauwen	N,	De	Backer	Wa,	Desager	KN.	First	night	effect	for	polysomnographic	data	in	children	 and	 adolescents	 with	 suspected	 sleep	disordered	breathing.	Arch Dis Child 2006;	91:233–237.		 8.	 	saeed	MM,	Keens	TG,	stabile	MW,	Bolokowicz	J,	Davidson	Ward	sl.	should	children	with	suspected	obstructive	sleep	apnea	syndrome	and	normal	nap	sleep	studies	have	overnight	sleep	studies?	Chest 2000;	118:360–365.		 9.	 	sivan	Y,	 Kornecki	 a,	 schonfeld	 T.	 screening	 ob-structive	 sleep	 apnoea	 syndrome	 by	 home	 vid-eotape	 recording	 in	 children.	 Eur Respir J	 1996;	9:2127–2131.	10.	 	Brouillette	rT,	Morielli	 a,	 leimanis	a,	Waters	Ka,	luciano	r,	Ducharme	FM.	Nocturnal	pulse	oxim-etry	as	an	abbreviated	testing	modality	for	pediatric	obstructive	sleep	apnea.	Pediatrics	2000;	105:405–412.	11.	 	li	aM,	Wong	e,	Kew	J,	Hui	s,	Fok	TF.	use	of	tonsil	size	in	the	evaluation	of	obstructive	sleep	apnoea.	Arch Dis Child	2002;	87:156–159.	Children with obstructive sleep apnea may  need CPAP or  a tonsillectomy  or adenoidectomy

When (and how) should you evaluate a child for obstructive sleep apnea?

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