Can history and physical examination reliably diagnose
pediatric obstructive sleep apnea/hypopnea syndrome?
A systematic review of the literature
SCOTT E. BRIETZKE, MD, MPH, MAJ, MC, USA, ELIOT S. KATZ, MD,
OBJECTIVE: Using an evidence-based technique,
systematically review the literature to evaluate the
accuracy of routine clinical history and physical
examination in the diagnosis of obstructive sleep
apnea/hypopnea syndrome (OSAHS) in the pedi-
atric patient.
STUDY DESIGN AND SETTING: The biomedical litera-
ture was systematically reviewed. Articles compar-
ing the results of clinical evaluation to polysomnog-
raphy (PSG) were selected. The level of evidence
was assessed using established evidence-based
medicine (EBM) guidelines.
RESULTS: Twelve articles were identified using the
search criteria. Eleven of 12 articles concluded that
clinical evaluation is inaccurate in the diagnosis of
OSAHS. The level of evidence was good to very
good (Grade B/Bⴙ).
CONCLUSION/SIGNIFICANCE: Clinical history and
physical examination are not reliable for diagnos-
ing OSAHS compared with overnight PSG. Compli-
cating the interpretation of this work is the lack of a
validated PSG threshold of clinically significant dis-
ease. There is an urgent need for the development
of adequate screening tests with validated clinical
outcomes. EBM rating: B-3. (Otolaryngol Head
Neck Surg 2004;131:827-32.)
O bstructive sleep apnea/hypopnea syndrome
(OSAHS) has become a leading indication for pediatric
adenotonsillectomy. (The term OSAHS is used as it
appropriately recognizes the importance of hypopneas
in pediatric sleep-disordered breathing [SDB].) Ac-
From the Department of Otolaryngology (Drs Brietzke and Roberson) and
the Department of Pulmonology (Dr Katz), Boston Children’s Hospital,
Boston, MA.
This work supported in part by a research award from the American Society of
Pediatric Otolaryngology.
Dr Katz was supported by NIH/NHLBI HL 073238-01.
The opinions and assertions of the authors contained herein are the private
views of the authors and are not to be construed as reflecting the views of
the Department of Defense or the Department of the Army.
Reprint requests: Scott E. Brietzke, MD, MPH, Walter Reed Army Medical Center,
6900 Georgia Ave., Washington, DC 20307; e-mail, SEBrietzke@msn.com.
0194-5998/$30.00
Copyright © 2004 by the American Academy of Otolaryngology–Head and
Neck Surgery Foundation, Inc.
doi:10.1016/j.otohns.2004.07.002
and DAVID W. ROBERSON, MD, Boston, Massachusetts
cording to a recent survey of otolaryngologists, 59% of
adenotonsillectomies were performed for “obstructed
breathing” and 39% specifically for OSAHS.1 How-
ever, according to this same survey, less than 10% of
children underwent any objective testing prior to sur-
gery and less than 5% underwent laboratory-based
polysomnogram (PSG). The use of the clinical evalua-
tion alone (i.e., the clinical history and physical exam-
ination) to diagnose OSAHS contradicts the evidence
presented in the literature of 4 different specialties
(Pediatrics, Pediatric Pulmonology, Sleep Medicine,
and Otolaryngology), which indicate that clinical eval-
uation for the diagnosis OSAHS is often inaccurate
compared to PSG. The purpose of this investigation
was to systematically review the biomedical literature
using an evidence-based medicine (EBM) approach to
compile and assess the current evidence addressing the
question of “Can the clinical history and/or routine
physical examination reliably diagnose OSAHS in the
pediatric patient?”
METHODS
The medical literature was reviewed using the
PUBMED and Cochrane medical databases using key-
words “pediatric sleep apnea,” “pediatric sleep-disor-
dered breathing,” “pediatric obstructive sleep apnea,”
and “diagnosis.” Only articles whose primary objective
was to evaluate the ability of the clinical history and/or
physical examination to accurately diagnose OSAHS
were selected. Articles predominantly evaluating other
diagnostic modalities (e.g., radiographs and pulse
oximetry) were excluded. Only articles using mul-
tichannel, nocturnal PSG as the “gold standard” refer-
ence test compared to history and/or physical examina-
tion were selected. Searches were also restricted to
patients 0 to 18 years of age and to articles published in
the English language only. Additional articles were
identified by reviewing the reference sections of previ-
ously identified articles. Articles were separated into
those that evaluated both history and physical exami-
nation versus those that evaluated only history. The
study design of each article was then determined. A
cohort study was distinguished from a case series by the
presence of a comparison group and more thorough
follow-up. Statistical analysis was performed with the
827

828 BRIETZKE et al
Table 1. Evidence table
Evidence
Author Study design
History and physical examination:
Jain A, Sahni JK2 2002 Prospective cohort AHI ⬎ 5
defined as OSAHS
Nieminen P, et al.3 2000 Prospective cohort AHI ⬎ 1
defined as OSAHS
Rosen CL4 1999 Retrospective cross:sectional
AHI ⬎ 1 defined as
OSAHS
Wang RC, et al.5 1998 Retrospective case series
AHI ⬎ 5 defined as
OSAHS
Nieminen P, et al.6 1997 Prospective cohort AHI ⬎1
defined as OSAHS
Sanchez-Armengol A, et Retrospective case series
al.7 1996
Suen JS, et al.8 1995 Prospective cohort AHI ⬎ 5
defined as OSAHS
Goldstein NA, et al.9 1994 Prospective cohort AHI ⬎
15
Leach J, et al.10 1992 Retrospective case series
PSG criteria ⫽ NR
History (questionnaire) only:
Preutthipan A, et al.11 Prospective cohort All
2000 patients with OSAHS of
differing severity
Carroll JL, et al.12 1995 Retrospective case series
AHI ⬎ 1 defined as
OSAHS
Brouillette R, et al.13 1984 Case control Case ⫽
OSAHS on PSG Control
⫽ normal volunteer
*The “Questionnaire” evaluated in these studies included the instrument developed by Brouillette et al.
OSAHS, obstructive sleep apnea/hypopnea syndrome; PSG, polysomnogram; AHI, apnea/hypopnea index; NR, not reported.
assistance of computer software (STATA version 8,
STATA Corporation, College Station, TX).
The level of evidence was assigned by applying the
Center for Evidence-Based Medicine (CEBM) criteria
level n Significant findings
3b 40 22 of 30 (73%) patients with
“obstructive symptoms”
found to have OSASH
1b 88 27 of 58 (46%) with
OSAHS by clinical
evaluation with OSAHS
by PSG
2b 326 192 of 326 (59%) with
clinical concern for
OSAHS with OSAHS by
PSG Questionnaire* with
sensitivity of 47% and
specificity of 28%
2b 82 Overall accuracy of clinical
suspicion was only 30%
(25 of 82)
1b 78 Parental report of “nightly
apnea” with Risk Ratio ⫽
3.6, “restless sleep” ⫽ 2.1
3b 12 Formal OSAHS diagnosis
not established
1b 69 35 of 69 (51%) with clinical
concern for OSAHS with
OSAHS by PSG
1b 30 10 of 18 (56%) patients with
“definite OSAHS” by
clinical evaluation with
OSAHS by PSG
sensitivity ⫽ 92%
specificity ⫽ 29%
3b 93 34 of 93 (37%) patients with
clinical concern for
OSAHS with OSAHS by
PSG
2b 65 Loud snoring, observed
apnea, shaking shaking
child more common in
severe OSAHS
2b 83 Questionnaire* indeterminate
in 48 patients (58%)
Correctly diagnosed 26 of
remaining 35 (74%)
4 92 Questionnaire (OSA Score)
correctly identified all
normal controls and 22 of
23 (96%) with OSAHS
(www.cebm.net) under the heading of “Diagnosis”
studies. The ratings that were used included: 1b: a
validating cohort study (goal was to test the quality of
a specific diagnostic technique) with good reference
Otolaryngology–
Head and Neck Surgery
December 2004
Overall conclusion
“Found no significant
correlation of tonsil
hypertrophy to AHI”
“Not possible to establish the
diagnosis without PSG”
“Clinical evaluation has not
been shown to reliably
distinguish primary snoring
from OSAHS”
“Multiple regression did not
find an association between
clinical parameters and
OSAHS by PSG”
“OSAHS cannot be reliably
diagnosed without PSG”
“No association between PSG
parameters and symptom
severity scores”
“History and clinical features
were not useful in predicting
abnormal PSG”
“Clinical assessment of OSAHS
is sensitive but not specific”
“No significant differences in
age, sex, symptoms between
OSAHS and normal PSG
group”
No observation(s) found to
have “high values for both
sensitivity and specificity”
“Primary snoring cannot be
distinguished from OSAHS”
“Use of OSA Score should
decrease need for PSG”
Otolaryngology–
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Volume 131 Number 6
standards, 2b: an exploratory cohort study (goal was to
test associations of diagnostic categories) with good
reference standards, 3b, a study without consistently
applied reference standards, and 4, a case control study.
The study design, sample size, diagnostic criteria used
for OSAHS, statistical highlights (prevalence of OS-
AHS in the cohort, sensitivity/specificity, etc.), and the
overall conclusion of the paper were compiled into an
evidence table.
RESULTS
Twelve articles were identified using the stated cri-
teria (Table 1). Seven articles were from otolaryngol-
ogy journals, 4 were from pediatric journals, and 1
article was from a sleep journal. Six articles were of a
prospective cohort design, 4 were retrospective case
series, 1 was a retrospective cross-sectional study, and
1 was a case control study. Sample sizes ranged from
12 patients to 326 patients. The studies were very
heterogeneous with different PSG-based diagnostic cri-
teria for OSAHS ranging from 1 event per hour to 15.
The definitions of what constituted an actual “event”
(e.g., apnea, hypopnea) were also very heterogeneous.
A variety of data analysis techniques were employed
including logistic regression, receiver operating curve
analysis, formal calculations of sensitivity and speci-
ficity, and simple tests of association between the his-
torical features of those with OSAHS and those with-
out.
Despite the fact that the methodology of the articles
was quite varied, the overall conclusions of the articles
were very consistent. Eleven of 12 articles concluded
that history and/or physical examination cannot reliably
diagnose OSAHS in the pediatric patient in comparison
to PSG. The 1 article13 that did present a contrary view,
did so by developing a diagnostic questionnaire (“OSA
Score”) that was later invalidated by subsequent stud-
ies.4,12 This instrument was developed to distinguish
normal, nonsnoring patients from OSAHS patients, but
could not differentiate snoring children with and with-
out OSAHS.
The positive predictive value (PPV) of the clinical
evaluation in comparison to PSG results was extracted
from the presented data in 10 of the 12 studies (Fig 1).
The remaining 2 studies did not provide sufficient or
appropriate data for calculation of the PPV. The general
design of the 10 selected studies included presenting a
cohort of patients with a positive clinical evaluation
who where then evaluated with PSG. Very few subjects
with a negative clinical evaluation were included in any
of the studies, which precluded the calculation of sen-
sitivity, specificity, or negative predictive value. The
PPV ranged from 30.5%5 to 95.7%.13 The study that
demonstrated the highest PPV (95.7%) was by Brouil-
BRIETZKE et al 829
lette et al.13 As discussed above, this study compared
normal, nonsnoring children to children with OSAHS.
The identical questionnaire (“OSA Score”) developed
in this study was applied to snoring children in 2 later
studies,4,12 each of which demonstrated a much lower
level of PPV (58.8%4 and 74.3%12). The weighted
average (weight ⫽ inverse of study variance ⫹ between
study variance) of the PPV for the combined 10 studies
using a random effects model to account for between-
study variation was 55.8% (95% confidence interval,
42.1-69.6%). In general terms, this means that approx-
imately only 55% of patients with a “positive” clinical
evaluation for OSAHS were subsequently found to
have OSAHS by the specified PSG criteria. This sum-
mary measure of PPV should be interpreted with ex-
treme caution, given the highly significant heterogene-
ity amongst the studies (test of heterogeneity Q⫽
153.392 P ⬍ 0.001), primarily in the area of the various
PSG criteria used to define OSAHS.
To further delineate the diagnostic performance of
history and physical examination, the 4 most common
questions included in a typical sleep history and the
most common component of the physical examination
(tonsil size) were separately tabulated. If sufficient raw
data were present in the given article, the sensitivity
and specificity for that individual characteristic in pre-
Fig 1. Forest plot of the positive predictive value (PPV %)
of the clinical examination compared to PSG diagnosis.
Note that with a PPV far below 1.0, the clinical examina-
tion generally results in an over-diagnosis of OSAHS as
compared to PSG. Error bars reflect the 95% confidence
interval for the diagnostic accuracy point estimate and
the size of the box reflects the weight of the estimate
towards the summary estimate. The combined estimate
represents a weighted average (weight⫽ inverse of the
study variance ⫹ between study variance) of the individ-
ual values of PPV using a random effects model. Note:
Sanchez-Armengol A, et al.7 and Preutthipan A, et al.11
did not provide sufficient or appropriate data for this
calculation and have been excluded.

830 BRIETZKE et al
Table 2. Diagnostic characteristics of various components of the clinical evaluation
Nieminen et al3
Characteristic Sensitivity Specificity
Snores nightly 74% 52%
Witnessed apnea 59% 90%
Mouth-breathing 78% 27%
Severe daytime somnolence 23% 0%
Tonsil size greater than 3⫹ 4⫹ 93% 35%
*In this study, the clinical characteristics were evaluated in their ability to distinguish severe OSAHS from nonsevere OSAHS.
dicting the presence of OSAHS were calculated (Table
2). Six articles provided sufficient raw data to calculate
individual sensitivities and specificities. No component
of the clinical evaluation in any article was found to
have a sensitivity and specificity greater than 65%.
The overall level of evidence was good to excellent.
There were 4 level 1b studies, 4 level 2b studies, 3 level
3b studies, and 1 level 4 study. This conservatively
constitutes Grade B evidence (consistent level 2 and
level 3 studies) according to the Center of Evidence-
Based Medicine (CEBM) criteria. However, one could
very reasonably consider the overall grade of evidence
to be even higher (B⫹/A–), given that there were 4 of
4 level 1b studies all concluding the clinical examina-
tion was inadequate (grade A evidence) and that the
only dissenting study was a level 4 study.
DISCUSSION
This systematic review of the literature clearly dem-
onstrates that the use of the clinical history and physical
examination alone in comparison to overnight PSG is
not adequate to diagnose OSAHS. The level of evi-
dence supporting this conclusion is high. The general-
izability of this conclusion is also high given the het-
erogeneity of the populations studied and the varying
diagnostic criteria for OSAHS used amongst the differ-
ent studies. The ability of the history and physical
examination to adequately diagnose OSAHS by any of
several different PSG criteria within several different
study populations was uniformly poor.
What are the consequences of the inaccuracy of the
clinical evaluation? To fully evaluate these conse-
quences, we must first consider the manner in which
patients are typically being misclassified by the use of
clinical evaluation alone. Table 2 shows the pooled
sensitivity and specificity of the common components
of the clinical evaluation extracted from the studies that
presented sufficient raw data to allow their calculation.
Although there is considerable variation, the general
trend is that of high sensitivity (probability that the
symptom or sign is present given the disease is present)
and lower specificity (probability that the symptom or
Otolaryngology–
Head and Neck Surgery
December 2004
Wang et al5 Nieminen et al6
Sensitivity Specificity Sensitivity Specificity
44% 58% 76% 49%
88% 17% 55% 86%
36% 56%
20% 81% 21% 92%
12% 89% 93% 35%
sign is not present given the disease is not present).
Thus, the clinical evaluation would be expected to have
a high false positive rate (reflected by a low specificity)
and a lower false negative rate (reflected by a higher
sensitivity).
If it can reasonably be assumed that the majority of
children referred to the otolaryngologist for SDB are
going to have a “positive” clinical evaluation, then it
follows that a sizable proportion of these clinically
“positive” patients will not actually have OSAHS by
PSG. Thus, the use of the clinical evaluation alone can
be expected to “overdiagnose” OSAHS. This circum-
stance was repeatedly demonstrated in the articles se-
lected for this review, which typically presented a co-
hort of patients all considered to have OSAHS by
clinical evaluation. Subsequently, only a proportion
(positive predictive value range 30%5 to 96%13) were
actually found to have PSG findings consistent with
OSAHS (Fig 1). Furthermore, if it is reasonably as-
sumed that the majority of patients with “positive”
clinical exams and thus, “clinical OSAHS,” will pro-
ceed to undergo adenotonsillectomy, then it must fol-
low that a significant portion of patients who undergo
adenotonsillectomy for the indication of OSAHS will
not have OSAHS by PSG criteria.
As is often the case, however, things are not neces-
sarily as simple as they may appear. The underlying
basis of the argument against the use of the clinical
evaluation alone for the diagnosis of OSAHS has 2
major assumptions. Both of these assumptions have
recently been seriously questioned. First, it assumed
that PSG is the gold standard test for SDB. However,
outcomes data are severely lacking in pediatric SDB.
No study has linked diagnostic thresholds on PSG with
untoward outcomes in SDB, particularly in the area of
neurocognitive dysfunction, which may be the most
common sequelae of SDB. Thus, PSG cannot be un-
equivocally considered the “gold standard test” for
SDB if the results cannot predict harmful outcomes.
Either appropriate PSG thresholds must be defined, or
new methods of testing that can be linked to neurocog-
nitive outcomes must be developed. The second as-
Otolaryngology–
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Volume 131 Number 6
Table 2. (Continued)
Carroll et al12
Sensitivity Specificity Sensitivity
97% 4% 76%
74% 54% 47%
61% 15%
17% 93% 18%
76%
sumption that has been recently questioned is the as-
sumption that only the more severe forms of SDB,
including OSAHS and upper airway resistance syn-
drome (UARS), require aggressive (surgical) treatment.
A growing body of evidence suggests that snoring
alone, even without OSAHS or hypoxemia, may be
associated with neurocognitive impairment, particu-
larly attention deficit hyperactivity disorder (ADHD)
and learning disorders.14-16 Thus, the unfortunate cur-
rent circumstance is that a snoring child may undergo
the best diagnostic test available (PSG) and be found to
have no apnea, hypopnea, or hypoxemia, yet may still
be at risk for a poor outcome.
Further complicating the issue is that the benefit of
adenotonsillectomy in treatment of the more mild forms
of SDB (i.e., primary snoring) has not been fully sub-
stantiated. There is some evidence that the neurocog-
nitive impairments of SDB may not be completely
reversible with adenotonsillectomy.17,18 However,
these conclusions are based on early, limited evidence.
Further study linking SDB outcomes and PSG findings
in mild SDB should be a pediatric public health prior-
ity.
Aside from eliminating diagnostic uncertainty, there
are other important reasons to objectively measure the
level of SDB in pediatric patients. In patients with
OSAHS, the severity of OSAHS is prognostically im-
portant. Pediatric patients with moderate to severe OS-
AHS have been shown to have greater risk of periop-
erative complications that may warrant increased
anesthetic precautions and careful postoperative obser-
vation.19 Perhaps most importantly, patients with mod-
erate and severe OSAHS are more likely to have per-
sistent disease after adenotonsillectomy that may
require continued observation and/or possible interven-
tion (e.g., CPAP.)8 These patients should be strongly
considered for postoperative PSG to assess for persis-
tent SDB if symptoms persist.
Where does the concerned otolaryngologist go from
here? Clearly, the first step is to recognize the diagnos-
tic limitations of the history and physical examination.
As has been suggested in this systematic review, the
use of the clinical evaluation alone will tend to signif-
BRIETZKE et al 831
Leach et al10 Preutthipan et al11*
Specificity Sensitivity Specificity
27% 86% 27%
25% 61% 65%
29% 46%
86%
59%
icantly overdiagnose OSAHS. Objective testing should
be used with greater frequency to increase diagnostic
accuracy. However, otolaryngologists should recognize
the limitations of PSG and the lack of outcomes data
associated with PSG findings. A normal PSG does not
necessarily indicate that no therapy is indicated. Mild
SDB in the form of primary snoring alone may produce
negative effects, particularly in the area of neurobehav-
ioral dysfunction. However, the utility of early, aggres-
sive treatment has not been conclusively proven.17,18
Therefore, the judgment of the evaluating otolaryngol-
ogist may still be paramount in the decision to proceed
with adenotonsillectomy. More study into this area
should be undertaken and should be a high priority for
our specialty.
Despite the potential diagnostic benefits, obtaining a
PSG on every child who is evaluated for OSAHS is
obviously not feasible or practical. Yet, the current
practice of using the clinical evaluation alone is also not
sufficient. A simple, inexpensive screening test that can
be linked to SDB outcomes would be an ideal solution
to this dilemma. Unfortunately, the simple screening
tests that have been evaluated to date have not been
successful. Audiotaping and videotaping are highly
variable in quality and require strong parental motiva-
tion.20 Home pulse oximetry has not been conclusively
shown to be useful.21 More sophisticated screening
tests such as pulse transit time (PTT),22 arterial tonog-
raphy,23 and dynamic CT scan24 are under intense
investigation but are not yet available or have not been
studied extensively in children. The informed otolaryn-
gologist would be well-advised to recognize the limits
of both the clinical evaluation and objective testing
with PSG.
CONCLUSIONS
Routine history and physical examination are not
adequate to reliably diagnose OSAHS in snoring chil-
dren who present to the otolaryngologist for evaluation.
The level of evidence for this conclusion is high despite
inconsistent diagnostic criteria for OSAHS. Overnight
PSG is the best available objective test, but no specific
threshold of disease has been linked to neurobehavioral

832 BRIETZKE et al
dysfunction. Early, limited evidence may indicate the
need for early aggressive surgical therapy in children
with mild SDB. Therefore, the clinical judgment of the
otolaryngologist to evaluate the overall clinical presen-
tation of the patient, consider objective diagnostic tests,
and weigh the risks and benefits of therapy remains
paramount in the decision to proceed with surgical
therapy. Collection of outcomes data and development
of a simple screening test linked to neurobehavioral
outcomes should be a pediatric public health priority.
REFERENCES
1. Weatherly RA, Mai EF, Ruzicka DL, et al. Identification and
evaluation of obstructive sleep apnea prior to adenotonsillectomy
in children: a survey of practice patterns. Sleep Med 2003;4:297-
307.
2. Jain A, Sahni JK. Polysomnographic studies in children under-
going adenoidectomy and/or tonsillectomy. J Laryngol Otol
2002;116:711-5.
3. Nieminen P, Tolonen U, Lopponen H. Snoring and obstructive
sleep apnea in children: a 6-month follow-up study. Arch Oto-
laryngol Head Neck Surg 2000;124:481-6.
4. Rosen CL. Clinical features of obstructive sleep apnea hypoven-
tilation syndrome in otherwise healthy children. Ped Pulm 1999;
27:403-9.
5. Wang RC, Elkins TP, Keech D, et al. Accuracy of clinical
evaluation in pediatric obstructive sleep apnea. Otolaryngol
Head Neck Surg 1998;118:69-73.
6. Nieminen P, Tolonen U, Lopponen H, et al. Snoring children:
factors predicting sleep apnea. Acta Otolaryngol (Stockh) 1997;
529(Suppl):190-4.
7. Sanchez-Armengol A, Capote-Gil F, Cano-Gomez S, et al. Poly-
somnographic studies in children with adenotonsillar hypertro-
phy and suspected obstructive sleep apnea. Pediatric Pulm 1996;
22:1010-5.
8. Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy for treat-
ment of obstructive sleep apnea in children. Arch Otolaryngol
Head Neck Surg 1995;121:525-30.
9. Goldstein NA, Sculerati N, Walsleben JA, et al. Clinical diag-
nosis of pediatric obstructive sleep apnea validated by polysom-
nography. Otolaryngol Head Neck Surg 1994;111:611-7.
10. Leach J, Olson J, Hermann J, et al. Polysomnographic and
Otolaryngology–
Head and Neck Surgery
December 2004
clinical findings in children with obstructive sleep apnea. Arch
Otolaryngol Head Neck Surg 1992;118:741-4.
11. Preutthipan A, Chantarojanasiri , Suwanjutha S, et al. Can par-
ents predict the severity of childhood obstructive sleep apnea?
Acta Paediatr 2000;89:708-12.
12. Carroll J, McColley SA, Marcus CL, et al. Inability of clinical
history to distinguish primary snoring from obstructive sleep
apnea syndrome. Chest 1995;108:610-18.
13. Brouilette R, Hanson D, David R, et al. A diagnostic approach to
suspected obstructive sleep apnea in children. J Pediatr 1984;
105:10-14.
14. O’Brien LM, Holbrook CR, Mervis CB, et al. Sleep and neu-
robehavioral characteristics of 5- to 7-year-old children with
parentally reported symptoms of attention-deficit/hyperactivity
disorder. Pediatrics 2003;111:554-63.
15. Chervin RD, Archbold KH, Dillon JE, et al. Inattention, hyper-
activity, and symptoms of sleep-disordered breathing. Pediatrics
2002;109:449-56.
16. Chervin RD, Dillon JE, Bassetti C, et al. Symptoms of sleep
disorders, inattention, and hyperactivity in children. Sleep 1997;
20:1185-92.
17. Gozal D, Pope DW, Jr. Snoring during early childhood and
academic performance at ages thirteen to fourteen years. Pediat-
rics 2001;107:1394-9.
18. Gozal D. Sleep-disordered breathing and school performance in
children. Pediatrics 1998;102:616-20.
19. Brown KA, Morin I, Hickey C, et al. Urgent tonsillectomy: an
analysis of risk factors associated with post-operative respiratory
morbidity. Anesthesiology 2003;99:586-95.
20. Section on Pediatric Pulmonology, Subcommittee on Obstructive
Sleep Apnea Syndrome. Clinical practice guideline: Diagnosis
and management of childhood obstructive sleep apnea syndrome.
Pediatrics 2002;109:704-12.
21. Brouillette RT, Morielli A, Leimanis A, et al. Nocturnal pulse
oximetry as an abbreviated testing modality for pediatric obstruc-
tive sleep apnea. Pediatrics 2000;105:405-12.
22. Katz ES, Lutz J, Black C, et al. Pulse transit time as a measure
of arousal and respiratory effort in children with sleep disordered
breathing. Ped Res 2003;3:580-8.
23. Ayas NT, Pittman S, MacDonald M, et al. Assessment of a
wrist-worn device in the detection of obstructive sleep apnea.
Sleep Med 2003;4:435-42.
24. Bhattacharyya N, Blake SP, Fried MP. Assessment of the airway
in obstructive sleep apnea syndrome with 3-dimensional airway
computed tomography. Otolaryngol Head Neck Surg 2000;123:
444-9.