Published online August 31, 2005
PEDIATRICS
Vol. 116
No. 3
September 2005, pp.
798
(doi:10.1542/peds.2005-1327)
Increased Behavioral Morbidity in School-Aged Children With Sleep-Disordered Breathing: In Reply
Carol L. Rosen, MD
Amy Storfer-Isser, MS
H. Gerry Taylor, PhD
H. Lester Kirchner, PhD
Judith L. Emancipator, MS
Susan Redline, MD, MPH
Department of Pediatrics
Rainbow Babies and Children's Hospital
University Hospitals of Cleveland
Case Western Reserve University School of Medicine
Cleveland, OH 44106-6003
In Reply.—
We appreciate the interest of Drs Pelayo and Sivan in our article about behavioral morbidity of sleep-disordered breathing in our community-based cohort of children. Our colleagues were surprised that of the 40 children with objective evidence of obstructive sleep apnea (OSA), only 55% had parent-reported snoring. They expressed concern that pediatricians and parents screening for OSA by asking caregivers about snoring "may miss close to half of the cases." They ask whether the "lower than expected" prevalence of parent-reported snoring in our OSA group might be related to our study's definition of snoring, which had specific requirements for intensity ("loud"), frequency ("at least 2 nights per week"), and its temporal features ("in the past month") and whether a higher prevalence of snoring might be present with a less restrictive definition such as "any snoring." Further understanding of the impact of alternative definitions of snoring is important, given the lack of standardization of snoring history across studies and clinical settings.
Several points should be made about our study's definition of snoring. Most importantly, the questionnaire that we used was not designed to be a screening instrument, for which a more inclusive definition of snoring would have been chosen to optimize sensitivity. Rather, because our goal was to identify children at increased risk for sleep-disordered breathing–related morbidities, we chose a definition that we believed would be relatively specific. It is possible that use of the adjective "loud" in relationship to snoring frequency reduced the overall prevalence of this symptom. However, the prevalence of snoring in our cohort was 17%, which is consistent with the range of prevalences (5–20%) reported by other large epidemiologic studies in children using a variety of snoring definitions. Additional examination of our data shows that in 2 children, parents reported "unsure" to snoring frequency, emphasizing that some parents of middle school children are simply unaware of their children's sleeping behavior. Changing the threshold frequency for loud snoring to at least "rarely" would have only reclassified an additional 3 children. Thus, even considering symptoms occurring less frequently would not have substantially increased the proportion of children classified as snorers. In contrast, use of a question on "ever snoring" (ie, not specific to the time before the sleep study) would have classified 85% of the children with OSA as snorers, but it also would have classified 56% of the children without OSA as snorers. Changing this definition certainly would have increased sensitivity but also likely would have reduced the specificity of this symptom, as well as its likely predictive association with current comorbidities. As suggested by Pelayo and Sivan, it would have been of interest to have had data on snoring from the polysomnogram to further assess differences in subjective and objective reports. However, such data were unavailable, and quantification of snoring sounds has not been standardized.
The American Academy of Pediatrics has published a clinical practice guideline to help clinicians with diagnosis and management of children with OSA.1,2 However, we strongly agree with Drs Pelayo and Sivan that, given the growing evidence that children with both snoring and/or evidence of OSA suffer increased behavioral3 and physiologic morbidities, there is an important need to develop sensitive means for screening at-risk children. Specifically, more work is required to understand the limits and role for sleep-symptom questions in such evaluations and their variation in children across different age and cultural backgrounds in which parent reports may differ.
REFERENCES
- American Academy of Pediatrics, Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome.
Pediatrics. 2002;109
:704
–712[Abstract/Free Full Text]
- Schechter MS; Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome.
Pediatrics. 2002;109
(4). Available at: www.pediatrics.org/cgi/content/full/109/4/e69
- Rosen CL, Storfer-Isser A, Taylor HG, Kirchner HL, Emancipator JL, Redline S. Increased behavioral morbidity in school-aged children with sleep-disordered breathing.
Pediatrics. 2004;114
:1640
–1648[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
