An Analysis of Pediatric Obstructive Sleep Apnea Questionnaires

Authors

Richard Lu, University of the Pacific, Arthur A. Dugoni School of DentistryFollow
Evan Helin, University of the Pacific, Arthur A. Dugoni School of DentistryFollow
David Lee DDS, University of the Pacific, Arthur A. Dugoni School of DentistryFollow

Lead Author Affiliation

Doctor of Dental Surgery

Lead Author Program & Year

DDS Year 2

Presentation Category

Research

Introduction/Context/Diagnosis

Obstructive Sleep Apnea (OSA) and other Sleep-Related Breathing Disorders (SRBD) frequently gets undiagnosed (13) and can affect the development as well as manifest as behavioral problems in children (13). Screening of patients that may be at risk of SRBDs is important as it can aid in appropriate referral for the establishment of a diagnosis. According to the AAPD “Policy on Obstructive Sleep Apnea”, biomarkers and questionnaires are recommended tools for POSA screening. In the UOP pediatric clinic at present, there is no qualified questionnaire that faculty has yet determined to be of utility in our teaching clinical environment. So in search, we compared potential questionnaires with their strengths, limitations, and utility in hopes of finding one to serve as an initial questionnaire in a pediatric clinic teaching setting.

Methods/Treatment Plan

In a literature review, we evaluated four well-researched POSA questionnaires. The comparison criteria was limited to the following criteria: questionnaires with objectively the most research behind them, recognition by the AAPD, and/or sensitivity for detecting OSA. Using key terms such as pediatric obstructive sleep apnea, screening of, and questionnaire in PubMed and Google Scholar search engines, pertinent literature sources were obtained. The questionnaires that showed the most promise were the I’M SLEEPY, BEARS, STOP-BANG, and the Michigan PSQ. To analyze the effectiveness of various POSA questionnaires, analytical measures such as sensitivity, sensibility, kappa correlation coefficient, Cronbachs alpha correlation coefficient, McNemar test, and Student’s T-test were included in our selection. The criteria for utility in the clinical educational setting was the number of questions in the questionnaire and its subsequent implications for the ease of memorization.

Results/Outcome

I’M SLEEPY: The I’M SLEEPY questionnaire is a series of quick and precise questions to serve as a screening tool for obstructive sleep apnea in children. Kadmon et al. performed a study on 150 children who were referred to a pediatric sleep clinic in which both the I’M SLEEPY questionnaire and polysomnography were utilized (5). Polysomnography is the gold standard for obstructive sleep apnea diagnosis and was used to assess the sensitivity and sensibility of the I’M SLEEPY questionnaire (5)(Table 5). The researchers found that the parent version had a sensitivity of 82% and specificity of 50% while the child version had a sensitivity of 47% and a specificity of 58% (5)(Table 5). The researchers also utilized a modified version of the STOP-BANG questionnaire in which they removed the A criteria (A = Age over 50 years old?). The modified STOP-BNG questionnaire was tested on 69 children and yielded a sensitivity of 12% and specificity of 90% (5)(Table 5).

STOP-BANG: The STOP-BANG questionnaire is a series of 8 questions designed to identify patients at high risk of OSA, where the number of “yes” answers given indicates the risk-level. A meta-analysis by Nagappa et al. reviewed 17 studies and included 9,206 patients. Sensitivity was high within a sleep clinic population: 90% to detect any OSA (AHI>5), 94% to detect moderate-to-severe OSA (AHI>15), and 96% to detect severe OSA (AHI>30) (9). Probability of severe OSA also increased proportionally with increased STOP-BANG scores: probability was 25% (score of 3), 35% (score of 4), 45% (score of 5), 55% (score of 6), and 75% (score of 7-8) (9). Another study by Chung et al. corroborated these results. 746 patients had a polysomnography test after taking the questionnaire. The odds-ratio (OR) was then compared for both moderate/severe and severe OSA at different STOP-BANG scores. For a score of 5, the OR was 4.8 (moderate/severe) and 10.4 (severe). For a score of 6, the OR was 6.3 and 11.6. For a score of 7 & 8, the OR was 6.9 and 14.9 (4).

Michigan PSQ: The Michigan Pediatric Sleep Questionnaire (PSQ) is a 22-item questionnaire relating to the symptoms of POSA. A study by Chervin et al. compared questionnaire scores with PSG and found that a score 1 standard deviation above the mean predicted a 3x increased risk of POSA (OR of 2.8) (1). The study randomly assigned subjects into 2 groups. Sensitivity was found to be 0.85 and 0.81, and specificity was 0.87 and 0.87. Classification was correct for 86% and 85% (1).

BEARS: In a pilot study done by Owens et al., 195 patients between the ages of 2 and 12 years were recruited through a convenience sample (10). Sleep-related information recorded in the BEARS visit was compared to the pre-BEARS visit (subject’s most recent previous well child check (WCC)). The researchers found that the BEARS visits were significantly more likely than the pre-BEARS visits to have any sleep information recorded (98.5% vs. 87.7%, p<0.001), and to have information recorded about bedtime issues (93.3% vs. 7.7%, p<0.001), excessive daytime sleepiness (93.9% vs. 5.6%, p<0.001), snoring (92.8% vs. 7.2%, p<0.001), nighttime awakenings (91.3% vs. 29.2%, p<0.001), and regularity and duration of sleep (65.3% vs. 31.5%, p<0.001) (10). Furthermore significantly more sleep problems were identified during the BEARS visits in the domains of bedtime issues (16.3% vs. 4.1%, p<0.001), nighttime awakenings (18.4% vs. 6.8%, p<0.001) and snoring (10.7% vs. 4.6%, p=0.012) (10). Finally, almost twice as many BEARS charts had sleep mentioned in the Impression and Plan (13.1% vs. 7.3%), which approached significance (p=0.07) (10). Another study by Mohammadi et al. found similar results in which 215 children ages 2-12 recruited through a convenience sample. It was found that the BEARS is a reliable and relatively valid sleep screening tool for children (8). In determining test-retest reliability, the assumptions of kappa coefficient >0.6 and Cronbachs alpha>0.8 were used (8). The researchers found that there was good to excellent agreement in all of the BEARS items in the preschool age group (makes BEARS an appropriate screening tool) (8).

Significance/Conclusions

The STOP-BANG, Michigan (PSQ), I’M SLEEPY, and BEARS questionnaires were selected by our research to assess the feasibility of their use in a pediatric dental teaching clinic. Factors which were considered included sensitivity, sensibility, ease of memorization, questionnaire duration, and results of statistical analysis to determine effectiveness. Implementing a short, easy to memorize, and effective POSA questionnaire will help students in identifying young patients potentially suffering from obstructive sleep apnea and allows for referral for further sleep apnea testing. Based on our research, the I’M SLEEPY and BEARS questionnaires show the most promise for implementation. This takes into consideration these questionnaires effectiveness (i.e. sensitivity), ease of utilization as determined by number of questions, catchy mnemonic, and short duration when utilized. Further research should be conducted in order to analyze the usability and utility of the I’M SLEEPY and BEARS questionnaires when utilized by dental students in a pediatric instructional dental clinic.

Comments/Acknowledgements

We would like to acknowledge all members of Pediatric Obstructive Sleep Apnea Study Club of whom contributed to this research: Amy Engel, Lisa Carrington, Christopher Niu, Michael Louie, Ryan Lee, Andy Kang, Tammy Auyeung, Grace Kim, Letitia Edwards, Aaron Schubel, Joshua Beck, David W. Lee, Sammy Lee, and David Dang

Format

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