Screening for sleep related breathing disorders and assessing the risk of obstructive sleep apnea in 2-18 years of children using paediatric sleep questionnaire: an observational study

Geetanjali; Preeti Malhotra; Gurmeet Singh; Gursharan Singh

doi:10.18203/2349-3291.ijcp20262417

Authors

Geetanjali Department of Paediatrics, Sri Guru Ram Das Institute of Medical Sciences and Research, Vallah, Amritsar, Punjab, India
Preeti Malhotra Department of Paediatrics, Sri Guru Ram Das Institute of Medical Sciences and Research, Vallah, Amritsar, Punjab, India
Gurmeet Singh Department of Paediatrics, Sri Guru Ram Das Institute of Medical Sciences and Research, Vallah, Amritsar, Punjab, India
Gursharan Singh Department of Paediatrics, Sri Guru Ram Das Institute of Medical Sciences and Research, Vallah, Amritsar, Punjab, India

DOI:

https://doi.org/10.18203/2349-3291.ijcp20262417

Keywords:

Obstructive sleep apnea, Children, Paediatric sleep questionnaire, Sleep-disordered breathing, Screening, Adenoid hypertrophy, Obesity

Abstract

Background: Paediatric obstructive sleep apnea (OSA) is a prevalent yet under-recognised condition associated with significant neurocognitive, behavioural, and cardiovascular morbidity. Polysomnography, the diagnostic gold standard, remains inaccessible in many resource-limited settings. The paediatric sleep questionnaire (PSQ) offers a validated, non-invasive alternative for outpatient screening. Objectives were to screen children aged 2-18 years for sleep-related breathing disorders (SRBD) and assess the risk of OSA using the PSQ, along with associated clinical risk factors.

Methods: An observational study was conducted at a tertiary care paediatric outpatient department. Children presenting with at least one sign or symptom of SDB were enrolled using a validated structured checklist. The 22-item PSQ (Chervin et al) was administered via caregiver interview. A PSQ score≥0.33 defined high OSA risk. Associations with clinical variables were assessed by chi-square test.

Results: Of 386 children enrolled (65.5% male; majority aged 6-10 years), 235 (60.9%) had PSQ ≥0.33. Neurobehavioural daytime symptoms-hyperactivity, attention deficit, aggressive behaviour, poor school performance, and difficulty in arousing-were significantly associated with high PSQ score (all p<0.05). Nighttime symptoms including snoring, mouth breathing, restless sleep, frequent awakenings, enuresis, increased work of breathing, and diaphoresis showed significant associations (all p<0.05). Physical signs significantly associated with high PSQ score included hypertrophied nasal turbinate, tonsillar hypertrophy, adenoid facies, and obesity (all p<0.05). Among children with confirmed adenoid enlargement on lateral nasopharyngeal radiograph (n=112), higher grades of adenoid hypertrophy were significantly associated with higher PSQ score categories (p=0.001).

Conclusions: A substantial proportion (60.9%) of symptomatic children in an outpatient setting were at high OSA risk. The PSQ is a practical, validated screening tool enabling early identification of at-risk children, particularly in resource-limited settings where polysomnography is unavailable.

References

Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, et al. Nelson Textbook of Pediatrics. 21st ed. Philadelphia: Elsevier. 2020.

Pandey A, Vala B, Shah M. Upper airway resistance syndrome. Int J Head Neck Surg. 2019;10(1):18-21.

Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130:576-84.

Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Am J Respir Crit Care Med. 2008;178:242-52.

Gouthro K, Kadam SJ, Sankari A, Slowik JM. Pediatric obstructive sleep apnea. In: StatPearls. Treasure Island (FL): StatPearls Publishing. 2025.

Alexander NS, Schroeder JW. Pediatric obstructive sleep apnea syndrome. Pediatr Clin North Am. 2013;60(4):827-40.

Rundo JV, Downey R. Polysomnography. Handb Clin Neurol. 2019;160:381-92.

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(1):21-32.

Li XD, Tai J, Xu ZF, Peng XX, Feng GS, Zhang YM, et al. Validity and reliability of simplified Chinese version of the pediatric sleep questionnaire for screening children with obstructive sleep apnea syndrome. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2016;51(11):812-8.

Gupta R, Ali R, Verma S, Joshi K, Dhyani M, Bhasin K, et al. Study of sleep disorders among young children using Hindi translated and validated version of pediatric sleep questionnaire. J Neurosciences Rural Pract. 2017;8(2):165.

Vila T. Spanish version of the Pediatric Sleep Questionnaire (PSQ). Anales de Pediatria. 2007;66(2):121-8.

Yuksel H, Sogut A, Yilmaz O, Kutluay E. Reliability and validity of the Turkish version of the pediatric sleep questionnaire. Tuberk Toraks. 2011;59(3):236-41.

Jordan L, Beydon N, Razanamihaja N, Garrec P, Carra MC, Fournier BP, et al. Translation and cross-cultural validation of the French version of the Sleep-Related Breathing Disorder scale of the Pediatric Sleep Questionnaire. Sleep Med. 2019;58:123-9.

Reyes MA, Etinger V, Hronek C, Hall M, Davidson A. Pediatric respiratory illnesses: obstructive sleep apnea. Pediatrics. 2023;152(2):125-34.

Khadilkar V, Yadav S, Agrawal KK, Tamboli S, Banerjee M. Revised IAP growth charts for height, weight and body mass index for 5- to 18-year-old Indian children. Indian Pediatr. 2015;52:47-55.

Huang G, Wang Q, Chang L, Ye S, Liu J, Lu Y, et al. Impact of gender, age, and obesity on childhood obstructive sleep apnea: a cross-sectional study of 4,668 children. Nat Sci Sleep. 2025;17:1391-404.

Piotto M, Gambadauro A, Rocchi A, Lelii M, Madini B, Cerrato L, et al. Pediatric sleep respiratory disorders: a narrative review of epidemiology and risk factors. Children (Basel). 2023;10(6):1-16.

Csabi E, Gaal V, Hallgato E, Schulcz RA, Katona G, Benedek P. Increased behavioral problems in children with sleep-disordered breathing. Ital J Pediatr. 2022;48(1):173.

Boyajian SD, Salameh MA, Alzyoud K, Amaireh EA, Badah L, Al Qutami M, et al. Prevalence of symptoms suggestive of sleep apnea among children and its impact on academic performance. J Egypt Public Health Assoc. 2025;100(1):2.

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(2):132-6.

Lal C, Weaver TE, Bae CJ, Strohl KP. Excessive daytime sleepiness in obstructive sleep apnea: mechanisms and clinical management. Ann Am Thorac Soc. 2021;18(5):757-68.

Kulsum M, Shariff MA. Incidence and prevalence of snoring in paediatric patients: an original research. J Contemp Clin Pract. 2025;11:981-6.

Izu SC, Itamoto CH, Pradella-Hallinan M, Pizarro GU, Tufik S, Pignatari S, et al. Obstructive sleep apnea syndrome (OSAS) in mouth breathing children. Braz J Otorhinolaryngol. 2010;76:552-6.

Diab AY, AlNatsheh T, Tkwa S, Al-Juboori S, Jaber N, Toubasi AA. Obstructive sleep apnea and nocturnal enuresis in the pediatric population: a systematic review and meta-analysis. Sleep Breath. 2026;30(1):58.

Lundetrae RS, Saxvig IW, Pallesen S, Aurlien H, Lehmann S, Bjorvatn B. Prevalence of parasomnias in patients with obstructive sleep apnea: a registry-based cross-sectional study. Front Psychol. 2018;9:1140.

Orradre-Burusco I, Fonseca J, Alkhraisat MH, Serra-Negra JM, Eguia A, Torre A, et al. Sleep bruxism and sleep respiratory disorders in children and adolescents: a systematic review. Oral Dis. 2024;30(6):3610-37.

Zalzal HG. Nasal surgery for pediatric obstructive sleep apnea. Oper Tech Otolaryngol Head Neck Surg. 2023;34(3):165-9.

Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography. Laryngoscope. 2007;117(10):1844-54.

Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J, Simakajornboon N, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med. 2010;182(5):676-83.

Zhan X, He W, Xu M, Ji J, Hu W, Tai J. The effect of adenoid hypertrophy duration on craniofacial development. Int J Pediatr Otorhinolaryngol. 2025;195:112397.

Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children. Am J Respir Crit Care Med. 1999;159(5):1527-32.

Verhulst SL, Schrauwen N, Haentjens D, Suys B, Rooman RP, Van Gaal L, et al. Sleep-disordered breathing in overweight and obese children and adolescents: prevalence, characteristics and the role of fat distribution. Arch Dis Child. 2007;92(3):205-8.

Alonso-Alvarez ML, Cordero-Guevara JA, Teran-Santos J, Gonzalez-Martinez M, Jurado-Luque MJ, Corral-Penafiel J, et al. Obstructive sleep apnea in obese children. Sleep. 2014;37:943-9.

Esteller E, Villatoro JC, Aguero A, Lopez R, Matino E, Argemi J, et al. Obstructive sleep apnea syndrome and growth failure. Int J Pediatr Otorhinolaryngol. 2018;108:214-8.

Tagaya M, Nakata S, Yasuma F, Miyazaki S, Sasaki F, Morinaga M, et al. Relationship between adenoid size and severity of obstructive sleep apnea in preschool children. Int J Pediatr Otorhinolaryngol. 2012;76(12):1827-30.

Brooks LJ, Stephens BM, Bacevice AM. Adenoid size is related to severity but not the number of episodes of obstructive apnea in children. J Pediatr. 1998;132(4):682-6.

Parenti SI, Fiordelli A, Bartolucci ML, Martina S, D'Anto V, Alessandri-Bonetti G. Diagnostic accuracy of screening questionnaires for obstructive sleep apnea in children: a systematic review and meta-analysis. Sleep Med Rev. 2021;57:101464.

Umano GR, Rondinelli G, Luciano M, Pennarella A, Aiello F, Di Sessa A, et al. PSQ in obese children. Children (Basel). 2022;9:1303.