International Journal of Pediatric Otorhinolaryngology 120 (2019) 108–111

Contents lists available at ScienceDirect

International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Sleep disordered breathing in children – Diagnostic questionnaires, T

comparative analysis☆
Marcin Burgharda, Eliza Brożek-Mądryb,∗, Antoni Krzeskib
a
Medical Center in Ostrołęka, Branch in Różan, Poland
b
Medical University of Warsaw, Faculty of Medicine and Dentistry, Department of Otorhinolaryngology, Poland

ARTICLE INFO ABSTRACT

Keywords: Study objectives: The purpose of this work is to present available questionnaires enabling diagnostic screening
Sleep disordered breathing when obstructive sleep disordered breathing (SDB) in a child is suspected or its effects are observed and poly-
Pediatrics somnography is unavailable. These questionnaires are designed to facilitate further diagnostic process or even
OSA therapeutic decisions, aid in selecting the optimal one for the specified conditions of clinical practice, with the
Questionnaires
caveat that none of these represents a diagnostic equivalent to PSG.
SDB
Methods: The questionnaires subjected to analysis: Pediatric Sleep Questionnaire (PSQ), Sleep Clinical Record
(SCR), OSA-18 score (OSA-18), Brouilette score (BS), “I'm Sleepy” questionnaire (I'M SLEEPY), and “Sleeping
Sleepless Sleepy Disturbed Rest” questionnaire (SSSDR).
The comparative analysis of questionnaires included the following parameters: simplicity and time of ad-
minister; necessity to engage a physician or other trained individual; taking into account examination of the
patient; type and scope of considered symptoms and consequences of obstructive SDB, sensitivity, specificity,
recommendations of the guidelines.
Results: Seven questionnaires were subjected to analysis with presentation of their similarities and differences.
Six out of seven were evaluated as simple in administration. Time required to fulfill the questionnaires ranged
between 1 and 60 min. Three of them involved a physician or a trained personnel. Physical examination was
necessary in two out of seven questionnaires. Sensitivity was estimated in 5 of them and ranged between 59 and
96%. Specificity ranged between 46 and 72%.
Conclusions: Several questionnaires enabling quick, simple, and inexpensive screening for OSAS have been
created. Four (of the seven analyzed) questionnaires may be useful in diagnosis of obstructive SDB in children –
two follow current (2015) recommendations. However, there is a need for further work on optimizing such tools,
particularly on improving their specificity.

1. Introduction
Sleep disordered breathing (SDB) represents a possible serious threat
during the active development of a child's body. The consequences of
obstructive SDB include disorders of the cardiovascular and central ner-
vous systems, enuresis, growth disorders and reduced quality of life.
Table 1 contains obstructive SDB definitions and diseases. The incidence of
the selected clinical entities of obstructive SDB in the pediatric population
is distributed as follows: habitual snoring (HS) or simple snoring (SS),
7.45%; obstructive sleep apnea syndrome (OSAS), 0.1–13%, 1–4% ac-
cording to most research [1].Taking this epidemiology into account, every
doctor working with children has in their care patients affected by this
problem. The diagnostic gold standard for obstructive SDB is all-night
polysomnography (PSG). This study is conducted exclusively by specia-
lized centers possessing workspaces adapted for this purpose and appro-
priately trained personnel. The procedure is expensive, and its availability
insufficient even in highly developed countries. This delays correct diag-
nosis and treatment [2]. Furthermore, available data point to low
awareness of the above problem among both parents/caregivers and
doctors [3]. In connection with this, several different questionnaires have
been developed, enabling faster or slower diagnostic screening facilitating
further diagnostic or even therapeutic decisions when obstructive SDB is
suspected or its effects observed and polysomnography is unavailable.
Most of the questionnaires analyzed in this work take into account the

The work was performed in Medical University of Warsaw.

☆

Corresponding author. Medical University of Warsaw, Faculty of Medicine and Dentistry, Department of Otorhinolaryngology, Szpital Czerniakowski,
∗

ul.Stępińska 19/25, 00-739, Warszawa, Poland.

E-mail address: eliza.madry@gmail.com (E. Brożek-Mądry).

https://doi.org/10.1016/j.ijporl.2019.02.008
Received 31 December 2018; Received in revised form 16 January 2019; Accepted 3 February 2019
Available online 05 February 2019
0165-5876/ © 2019 Elsevier B.V. All rights reserved.
M. Burghard, et al. International Journal of Pediatric Otorhinolaryngology 120 (2019) 108–111

Table 1
Definitions of obstructive sleep disordered breathing and its forms [1].
Definitions Nature of disorder

Obstructive sleep disordered breathing (SDB)
Obstructive SDB – diseases
• Primary snoring
• Syndrome
airways
of increased resistance of the upper
• Obstructive hypoventilation
• Obstructive sleep apnea syndrome (OSAS)
Syndrome of dysfunction of the upper airways during sleep characterized by snoring and/or increased respiratory effort
resulting from increased resistance of the upper airways and narrowing of the throat space
Habitual snoring (more than three nights per week) without apnea, shallow breaths, frequent waking, or disturbed gas
exchange
Snoring, increased respiratory effort, frequent waking without recognizable incidents of obstruction or disturbed gas
exchange
Snoring and abnormal increase in end-expiratory partial pressure of carbon dioxide without recognizable incidents of
obstruction
Recurring incidents of partial or complete obstruction of the upper airways (shallow breaths, obstructed or mixed apnea)
with accompanying disruptions of correct oxygenation, ventilation, sleep structure

current guidelines of the European Respiratory Society Task Force, which
date to 2015. The two newest questionnaires appeared during or after the
end of work on the guidelines and therefore were not taken into account.
One of them appears especially interesting, due to its simplicity, very short
time to administer, and relatively high sensitivity. It must still be em-
phasized that none of the diagnostic methods for obstructive SDB in
children can equal PSG, despite the latter's limitations.
reliability according to the classification of the American Academy of
Neurology (AAN) [1,15]. It is interesting that, both in detecting neuro-
behavioral consequences and in assessing their regression after adeno-
tonsillectomy, PSQ appears at least as effective as or better than even PSG
[4], the diagnostic gold standard. PSQ does not take into account: symp-
toms of cardiovascular consequences dependent on obstructive SDB, re-
duced quality of life, and physical examination of the child.

2. Study objectives 4.2. Sleep clinical record (SCR)

The purpose of this work is to present and thoroughly compare the
questionnaires used in diagnosis of obstructive SDB in children and to help
the reader in choosing the best tool of this type under specific conditions of
clinical practice. These questionnaires are designed to facilitate further
diagnostic process or even therapeutic decisions, aid in selecting the op-
timal one for the specified conditions of clinical practice, with the caveat
that none of these represents a diagnostic equivalent to PSG.
3. Methods
The questionnaires subjected to analysis: Pediatric Sleep
Questionnaire (PSQ), Sleep Clinical Record (SCR), OSA-18 score (OSA-
18), Brouilette score (BS), “I'm Sleepy” questionnaire (I'M SLEEPY), and
“Sleeping Sleepless Sleepy Disturbed Rest” questionnaire (SSSDR).
The comparative analysis of questionnaires included the following
parameters: simplicity and time of administration; need to engage a phy-
sician or other trained individual; taking into account examination of the
patient; type and scope of considered symptoms and consequences of ob-
structive SDB, sensitivity, specificity, recommendations of the guidelines.
4. Results
4.1. Pediatric sleep questionnaire (PSQ)
PSQ is a survey conducted with a parent/caregiver of the child. It
contains 22 close-ended questions (answers are “yes” or “no”). A set of 8 or
more affirmative answers is considered a positive result. The questions
concern: nocturnal and diurnal symptoms of obstructive SDB; con-
sequences of obstructive SDB involving: the central nervous system, en-
uresis, and growth disorders; and possible overweight of the child. PSQ is
fairly easy to administer at a medical facility, does not take more than
15 min and does not require engaging a physician or specially trained
personnel. PSQ focuses exclusively on patient history (it does not take into
account physical examination of the child). The questions are un-
ambiguous and usually do not raise doubts. In the current guidelines of the
European Respiratory Society Task Force, PSQ is referred to as a “useful
tool” in predicting OSAS with an apnea-hypopnea index (AHI) > 5, de-
tecting neurobehavioral consequences associated with OSAS, and/or as-
sessment of their regression after adenotonsillectomy, the first choice of
treatment of OSAS in children. The sensitivity and specificity of PSQ are
respectively assessed to be 78% and 72%, with Class I and II data
SCR is the most complex and time-consuming diagnostic questionnaire
of those analyzed. In contrast to the others, apart from the survey, it in-
cludes fairly detailed physical examination of the child. Conducting SCR
requires involvement of a physician and the presence of the patient and
their caregiver/parent. The required time is about 30–60 min. At a medical
facility, it is thus necessary to devote a full specialist appointment to it. It
generally consists of three parts. The first consists of physical examination of
the: nose (with particular attention to the septum, patency, and oral
breathing route), palatine tonsils (assessment of hypertrophy), palate and
tongue (Friedman Palate/Tongue Position, “gothic palate”), occlusion
(open, deep, cross bite, horizontal bite, Angle class), facial phenotype
(normal, adenoid or “adult type”). The second part is a patient history, the
survey conducted with the parent/caregiver of the child. It includes simple
close-ended questions concerning nocturnal symptoms of obstructive SDB,
though these require graduated responses (never, sometimes, often, always).
The third part is also a history examination and concerns symptoms re-
sulting from obstructive SDB and involving the central nervous system and
enuresis. The sleep clinical score (SCS) is calculated using a specially de-
veloped algorithm (including a separate algorithm for the aforementioned
second part). The SCS can be calculated by the physician at the end of the
SCR or by another employee specially trained for this purpose. The current
guidelines of the European Respiratory Society Task Force acknowledge
SCR in the diagnostic process. An SCS = 6.5 or greater is considered a
positive result. The sensitivity and specificity are respectively assessed as
96% and 67% for OSAS, with AHI > 1, with the above data being weakly
reliable (class IV according to AAN) [1]. SCR does not consider: symptoms
of consequences of obstructive SDB involving the cardiovascular system,
reduced quality of life, growth disorders, and overweight/obesity. The al-
gorithm for calculating “favors” the results of the physical examination, thus
assigning less weight to observations (expanded in PSQ) of nocturnal and
diurnal symptoms of obstructive SDB and symptoms of consequences of
obstructive SDB involving the central nervous system and enuresis.
4.3. OSA-18 score (OSA-18)
OSA-18 assesses the influence of diurnal and nocturnal symptoms of
obstructive SDB on quality of life (of both the child and the caregiver).
It contains 18 questions requiring graduated responses. Unfortunately,
the sensitivity and specificity of this method in diagnosing OSAS have
both proven low [7]. It was classified as poor in the current guidelines
of the European Respiratory Society Task Force.

109
M. Burghard, et al.
Table 2
Comparison of diagnostic questionnaires for obstructive SDB in children with regard to practical aspects, sensitivity, specificity, and recommendations.
Questionnaire Simplicity Time to Need to involve a physician or
administer trained personnel
PSQ yes 10–15 min no
SCR no 30–60 min yes
OSA-18 yes 10–15 min no
BS yes 5 min yes
I'M SLEEPY yes 5 min yes
OSAsq3 greatest 1 min no
SSSDR yes 10–15 min no
4.4. Brouillette score (BS)
BS assesses the nocturnal symptoms of obstructive SDB and by itself
is too imperfect as a tool for diagnosing OSAS; however, it has found
use as an integral part of the SCR (mentioned above as the second part
of the SCR). The sensitivity and specificity of this method in diagnosing
OSAS have both proven low [8]. It was classified as poor in the current
guidelines of the European Respiratory Society Task Force.
4.5. “I'm sleepy” questionnaire (I'M SLEEPY)
I'M SLEEPY is a short survey conducted with the child's parent/care-
giver. It contains 8 close-ended questions. A set of 3 or more affirmative
answers is considered a positive result. The questions concern nocturnal (3
questions) and diurnal (3 questions) symptoms of obstructive SDB. One
question requires specification of the percentile of the child's mass, one the
potential hypertrophy of the palatine tonsils and/or the lymphatic tissue of
the throat. Conducting I'M SLEEPY is simple and quick under the condi-
tions of a medical facility. It requires just several minutes (less than PSQ,
many times less than SCR). It is necessary (in contrast to PSQ) to involve a
physician or trained individual such as a nurse (to specify the body mass
percentile and detect hypertrophy of the tonsils or throat lymphatic tissue,
unless this was done earlier and the parent/caregiver can provide the
answer). The current guidelines of the European Respiratory Society Task
Force, dating to 2015, do not cover I'M SLEEPY, which was produced
recently. This questionnaire appears to be a valuable tool above all due to
its short time to administer (thanks to its exceptional conciseness). One
may encounter earlier versions of the questionnaire (IF SLEEPY, I
SLEEPY), from which I'M SLEEPY was derived. The sensitivity is assessed
to be relatively high given the tool's simplicity and is 82%, while speci-
ficity is 50% [5]. I'M SLEEPY does not consider: symptoms of cardiovas-
cular consequences dependent on obstructive SDB, reduced quality of life,
growth disorders, enuresis. For the purpose of maximally quick detection
of likelihood of OSAS, there exists a modified variant, OSAsq3: a 3-item
survey created for use before anesthesiological treatment, requiring only
several seconds and limited to selected nocturnal symptoms of obstructive
SDB [6]; too few data are available for detailed assessment of this method.
4.6. “Sleeping Sleepless Sleepy Disturbed Rest” questionnaire (SSSDR)
SSSDR is a new survey, part of an educational platform being de-
veloped for parents/caregivers of children and promoting increased
knowledge of healthy sleep and assisting in early identification of di-
verse, broadly defined sleep disorders, including (but not limited to)
obstructive SDB [9]. It contains 30 close-ended questions (“yes” or “no”
answers) with the suggestion of the possibility of changes/expansion,
such as graduated responses. Even one “yes” answer to certain questions
(Red flag questions) indicates a risk of sleep disturbances and requires
further diagnosis/identification of the problem. These questions concern
nocturnal symptoms of obstructive SDB, headache after awakening and
enuresis. SSSDR is fairly simple to conduct. It does not require involve-
ment of a physician or trained personnel. As a new development
International Journal of Pediatric Otorhinolaryngology 120 (2019) 108–111
Consideration of physical Sensitivity Specificity Recommended in
examination guidelines
no 78% 72% yes
yes 96% 67% yes
no 59%(best 48%(best no
obtained) obtained)
no 65% 46% no
sketchy 82% 50% no reference
no no data no data no reference
no no data no data no reference
presented during the AAMS (Academy of Applied Myofunctional Sci-
ences) Congress in Rome in September of 2018, it is not covered in the
current guidelines of the European Respiratory Society Task Force.
Tables 2 and 3 present a comparison of the diagnostic questionnaires
for obstructive SDB in children with regard to their various traits. The
presentation covers the practical aspects and reliability (Table 2) and the
considered symptoms (Table 3). Under the diverse conditions of clinical
practice, the presented traits may affect the choice of method.
5. Discussion
Among the analyzed diagnostic questionnaires for obstructive SDB in
children, four fulfill the conditions of diagnostic screening in OSAS, which
may implicate further diagnostic and/or therapeutic decisions: PSQ, SCR
(because of recommendations), I'MSLEEPY (because of: shortness, sim-
plicity, sensitivity 82%), and SSSDR (because of: simplicity, expanded
anamnesis, similarity to recommended PSQ). The questionnaires differ
among themselves, which may affect the preferred choice in various
clinical situations. The presented differences concern: the degree of com-
plexity (most complex: SCR), time to administer (shortest: I'M SLEEPY,
especially the OSAsq3 variant), need to involve a physician or other
trained person (especially SCR), consideration of physical examination
(especially SCR), consideration of the number and kinds of symptoms
(most: PSQ), sensitivity (greatest: SCR 96%), specificity (greatest: PSQ
72%), and the recommendations of the current guidelines of the European
Respiratory Society Task Force from 2015 (recommended: PSQ, SCR; not
covered due to recency: I’M SLEEPY, SSSDR). The presentation points to
the strong focus of all the analyzed questionnaires on nocturnal symptoms
of obstructive SDB (SCR and SSSDR being particularly extensive in this
regard). The more subtle diurnal symptoms are studied in diverse ways,
with varying accuracy (PSQ the most accurate, includes 9 strict questions
about diurnal symptoms), or not at all (OSAsq3, BS). SCR, I'M SLEEPY and
PSQ exhibit sensitivity 78% or more, with specificity between 50% and
72%. They are therefore well suited to diagnostic screening, less so for
confirming an OSAS diagnosis. OSA-18 and BS come out worse in both
parameters, while there is a lack of data for OSAsq3 and SSSDR.
Particularly high sensitivity (96%) is exhibited by SCR, which is the only
to require physical examination of the patient. The greatest specificity
(72%) accompanies PSQ, which possesses the most extensive history ex-
amination with the greatest impact on the end result. In facilities suffering
from a lack of qualified staff (relative or absolute), it may prove easiest to
implement PSQ or SSSDR (for the broadly defined question of sleep dis-
orders) or I'M SLEEPY (in the case of additional time restrictions). In the
case of less-than-optimal cooperation with parents/caregivers or when
these are not watchful observers of their wards, SCR, and especially PSQ
and SSSDR, may encounter limitations due to a lack of clear answers to the
detailed questions they pose. In diagnosis of OSAS and subsequent steps,
knowledge of the possible occurrence of the symptoms of its consequences
is important. These include: symptoms involving the cardiovascular
system, the central nervous system, enuresis, growth disorders, and re-
duced quality of life [1]. Most of the analyzed questionnaires to a greater
or lesser degree consider this subject matter, but none of them considers
110
M. Burghard, et al. International Journal of Pediatric Otorhinolaryngology 120 (2019) 108–111

Table 3
Comparison of diagnostic questionnaires for obstructive SDB in children with regard to considered symptoms.
Symptom PSQ SCR OSA-18 BS I’M SLEEPY OSAsq3 SSSDR

snoring yes yes yes yes yes yes yes

halting breathing at night yes yes yes yes yes yes yes
“hard breathing” at night yes - - - yes yes yes
choking at night yes yes yes - - - yes
frequent waking/restless sleep - yes yes yes - - yes
periodic limb movements in sleep - yes - - - - yes
enuresis yes yes - yes
difficulty waking yes - yes - - - yes
unrested in morning yes - - - - - -
dry lips in morning yes - - - - - -
sleepiness during the day/frequent yawning yes yes yes - yes - yes
headaches yes yes - - - - yes
halting of growth ever observed yes - - - - - -
loss of concentration/dissociation yes yes (if ADHD was diagnosed) yes - yes - -
restlessness during the day yes yes (if ADHD was diagnosed) - - - - yes
bothering others yes yes (if ADHD was diagnosed) - - - - -
nervousness/hyperactivity/aggression - yes (if ADHD was diagnosed) yes - yes - yes
problems with swallowing - - yes - - - -
frequent infections of the upper airways - - yes - - - -
swelling of the tonsils - yes - - yes - -
overweight/obesity yes - - - yes - -
mouth breathing yes yes yes - - - yes
nasal obstruction - yes yes - - - -
curvature of the nasal septum - yes - - - - -
malocclusion - yes - - - - -
high tongue position (3rd and 4th degree per Friedmann) - yes - - - - -
narrow/"gothic” palate - yes - - - - -
“adenoid” or “adult” shape of face - yes - - - - -
disturbances in EEG - yes - - - - -
detection of ADHD - yes - - - - -
influence of child's symptoms on caregiver's/caregivers' quality of life - - yes - - - -

consequences involving the cardiovascular system, including one that is
key and easy to identify – elevated arterial blood pressure – careful at-
tention to this should be paid if SDB is suspected. None of the ques-
tionnaires considers the recently raised question of the length of the
tongue frenulum, which affects the arrangement of the tongue relative to
the palate and thus the risk of obstructive SDB. It seems useful to continue
work on creating further diagnostic questionnaires for obstructive SDB and
OSAS in children, with the goal of optimizing this type of tool, especially
due to the need to improve specificity. This might include rebalancing of
history and physical examinations while maintaining their proper simpli-
city and relatively short duration, adding thus-far-unconsidered para-
meters or information (e.g., arterial blood pressure [10,11], length of
tongue frenulum [12], certain daily habits of the child), and use of an-
thropometry of the cervical and thoracic vertebrae and of the head
[13,14]. This is possible due to increased interest in sleep medicine and
sleep disordered breathing in children, as well as the advance of knowl-
edge in recent years.
Conflicts of interest
None.
References
[1] A.G. Kaditis, M.L.A. Alvarez, A. Boudewyns, et al., Obstructive sleep disordered breathing
in 2-18 year-old children: diagnosis and management, Eur. Respir. J. (2015) 1–26.
[2] M.P. Villa, M.C. Paolino, R. Castaldo, et al., Sleep clinical Record: a help to rapid and
accurate diagnosis of paediatric sleep disordered breathing, Eur. Respir. J. (2013)
1355–1361.
[3] A. Sapała-Smoczyńska, T. Jackowska, A. Lolo, et al., Częstość występowania i rodzaj
objawów zaburzeń oddychania w czasie snu u dzieci w wieku 6-12 lat w relacjach
rodziców – badania własne [Frequency of the incidence and kinds of symptoms of sleep
disordered breathing in children ages 6-12 years by parents' accounts - own study],
Postępy Nauk Medycznych [Progress in Medicine 9 (2014) 644–647.
[4] R.D. Chervin, K. Hedger, J.E. Dillon, et al., Pediatric sleep questionnaire (PSQ): validity
and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and beha-
vioral problems, Sleep Med. 1 (2000) 21–32.
[5] G. Kadmon, S.A. Chung, C.M. Shapiro, I'M SLEEPY: a short pediatric sleep apnea ques-
tionnaire, Int. J. Pediatr. Otorhinolaryngol. 78 (12) (2014) 2116–2120.
[6] J. Schnoor, T. Busch, N. Turemuratov, et al., Pre-anesthetic assessment with three core
questions for the detection of obstructive sleep apnea in childhood: an observational
study, BMC Anesthesiol. 18 (2018) 25.
[7] A. Borgstrom, P. Nerfeldt, D. Friberg, Questionnaire OSA-18 has poor validity compared
to polysomnography in pediatric obstructive sleep apnea, Int. J. Pediatr.
Otorhinolaryngol. 77 (2013) 1864–1868.
[8] M.S. Schechter, Technical report: diagnosis and management of childhood obstructive
sleep apnea syndrome, Pediatrics 109 (2002) e69.
[9] S. Moore, A Pediatric ‘sleep Formula’ and ‘red Flag’ System. AAMS (Academy Of Applied
Myofunctional Sciences) Poster Session, (September 2018) Rome.
[10] R.S. Horne, J.S. Yang, L.M. Walter, et al., Elevated blood pressure during sleep and wake
in children with sleep-disordered breathing, Pediatrics 128 (2011) e85–e92.
[11] R. Amin, V.K. Somers, K. McConnell, et al., Activity-adjusted 24-hour ambulatory blood
pressure and cardiac remodeling in children with sleep disordered breathing,
Hypertension 51 (2008) 84–91.
[12] C. Guilleminault, S. Huseni, L. Lo, A frequent phenotype for paediatric sleep apnoea: short
lingual frenulum, ERJ Open Res 2 (3) (2016) 00043-2016.
[13] C.F. Piccin, D. Pozzebon, F. Scapini, et al., Craniocervical posture in patients with ob-
structive sleep apnea, Int. Arch. Otorhinolaryngol. 20 (3) (2016) 189–195.
[14] M.M. Ozbek, K. Miyamoto, A.A. Lowe, et al., Natural head posture, upper airway mor-
phology and obstructive sleep apnoea severity in adults, Eur. J. Orthod. 20 (2) (1998 Apr)
133–143.
[15] R.D. Chervin, R.A. Weatherly, S.L. Garetz, et al., Pediatric sleep questionnaire: prediction
of sleep apnea and outcomes, Arch. Otolaryngol. Head Neck Surg. 133 (2007) 216–222.

111