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Diagnosis
The clinical presentation of a child with SDB is usually very nonspecific, requiring increased awareness of the primary care professional. Since symptoms of OSAS are often subtle in children, a thorough history should be taken including detailed information on nighttime and daytime symptoms as well as OSAS associated morbidities such as neurobehavioral deficits, behavior, sleepiness, failure to thrive and systemic hypertension. The routine clinical evaluation of a snoring child is usually unlikely to demonstrate significant and obvious findings. Attention should be directed to the size of the tonsils and their position, the presence of allergic rhinitis or any other condition likely to increase nasal airflow resistance and the relative size (micrognathia) and positioning (retrognathia) of the mandible.
The accuracy of OSAS prediction based on history and physical examination is poor, even when the diagnostic interview is conducted by a sleep specialist. This relatively poor predictive ability has prompted the recognition and recommendation to refer symptomatic children to polysomnographic evaluation to confirm or rule out the diagnosis of OSAS and to assess the degree of OSAS severity. The American Academy of Pediatrics has published a consensus statement outlining the requirements for pediatric polysomnographic evaluation. Although there is still substantial debate as to what is the polysomnographic cut-off that defines clinically relevant OSAS, normative reference values are available for the pediatric population, but do not define when disease is present. The role of ambulatory sleep studies including home video, nocturnal oxymetry, restricted unichannel or multichannel studies, and sound recordings is being investigated.
In an effort to more accurately delineate polysomnographic cut-offs and potentially identify the number of distinct categories in children with habitual snoring, we have recently conducted a machine-based classification of a large number of sleep studies in children. Such unbiased procedures revealed the existence of six distinct clusters that clearly encompass 97% of the cases. Based on such encouraging results, a web-based applet enabling accurate assignment of any pediatric sleep study to one of the six clusters has been made available online. We should, however, point out that this effort is currently semantic and needs to be expanded across multiple centers and linked to outcomes, before it becomes uniformly implemented in clinical practice. The aforementioned difficulties and uncertainties in delineating the specific and universally accepted polysomnographic criteria of OSAS in children have also prompted us to propose alternative approaches. Indeed, use of a specific apnea–hypopnea index as a cut-off would definitely exclude from treatment a substantial number of symptomatic children whose polysomnographic characteristics did not fulfill such cut-off. Conversely, implementation of a more lenient protreatment decision polysomnographic cut-off would promote excessive and unnecessary treatment in a large proportion of children exposing them to excessive risk–benefit ratios. Based on such considerations, it would seem that until a more accurate diagnostic method is developed, the polysomnographic measures should be incorporated into a more comprehensive scheme of symptoms, and signs ranked based on empirically defined hierarchical values.
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