Are physicians aware of obstructive sleep apnea in children?

Sleep Medicine 7 (2006) 580–584
www.elsevier.com/locate/sleep
Original article
Are physicians aware of obstructive sleep apnea in children?
Zeynep Tamay a,*, Ahmet Akcay b, Gurkan Kilic a, Ayse Suleyman a,
Ulker Ones a, Nermin Guler a
a
Division of Allergy and Chest Diseases, Department of Pediatrics, Istanbul Medical Faculty, Çapa, 34390 Istanbul, Turkey
b
Department of Pediatrics, Pamukkale Medical Faculty, Pamukkale, Turkey
Received 31 January 2006; received in revised form 11 April 2006; accepted 21 April 2006
Abstract
Background and purpose: Childhood obstructive sleep apnea (OSA) affects 1–3% of preschool children. If left untreated, it can result in
serious morbidity including growth retardation, cor pulmonale, and neurocognitive deficits, such as poor learning and behavioral problems.
Early recognition and treatment is important to prevent morbidity and sequela and to provide better quality of life both for the child and his or
her family members. The purpose of this study was to elucidate the knowledge and attitude physicians have about pediatric OSA, using the
Obstructive Sleep Apnea Knowledge and Attitudes in Children (OSAKA-KIDS) questionnaire.
Patients and methods: The first section of the OSAKA-KIDS questionnaire, which includes 18 items presented in a true-or-false format, was
developed to assess the knowledge physicians have about pediatric OSA. The second section, including five items, was developed to assess
attitudes and was measured on a five-point Likert scale ranging from 1 to 5.
Results: A total of 230 questionnaires were completed by physicians: 138 (60.3%) pediatricians, 70 (30.5%) general practitioners and 21
(9.2%) pulmonologists. The mean total knowledge score was 66.7%. The knowledge score positively correlated with having sub-specialty
training (rZ0.205, PZ0.002) and negatively correlated with having a higher degree (rZK0.283, P!0.001). The mean total attitude score
was 3.4. The knowledge score positively correlated with the attitude score (rZ0.27, P!0.001).
Conclusions: This study shows that among physicians there are deficits in knowledge about childhood OSA and its treatment. More focused
educational programs are needed within medical schools and within pediatric residency and post-graduate training programs.
q 2006 Elsevier B.V. All rights reserved.
Keywords: Children; Obstructive sleep apnea; Physician; Pediatrician
1. Introduction
Although childhood obstructive sleep apnea (OSA) was
described more than a century ago [1], it has gained
importance only in recent decades since the first scientific
case series reported by Guilleminault et al. [2] appeared.
Childhood OSA is a syndrome affecting 1–3% of preschool
children [3–5]. If left untreated, it can result in serious
morbidity, including growth retardation, cor pulmonale and
neurocognitive deficits such as poor learning and behavioral
problems [6–10]. Severe cases may even result in death.
Childhood OSA differs from adult type in its etiology,
clinical manifestations, polysomnographic characteristics
* Corresponding author. Tel.: C90 212 4142196; fax: C90 212 6319301.
E-mail address: [email protected] (Z. Tamay).
1389-9457/$ - see front matter q 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.sleep.2006.04.004
and sequela [4,11]. Early recognition and treatment is
important to prevent morbidity and sequela and to provide
better quality of life for both the child and his or her family
members.
Studies conducted to investigate the training, knowledge,
and practices of pediatricians regarding sleep and sleep
disorders in children and adolescents demonstrated that
significant gaps exist in the management of this issue among
pediatricians [12,13]. The Obstructive Sleep Apnea Knowledge and Attitudes in Children (OSAKA-KIDS) questionnaire was recently developed by Uong et al. [14] for use
in measuring physicians’ knowledge and attitudes about
childhood OSA. They reported deficits in basic knowledge
about childhood OSA among pediatricians and family
practitioners and emphasized the need for more focused
education on this subject. Pediatricians and primary care
physicians have a primary role in the assessment of
children’s health care in Turkey and thus should have
Z. Tamay et al. / Sleep Medicine 7 (2006) 580–584
adequate knowledge for diagnosis and management of
children with OSA. The purpose of this study was to
elucidate physicians’ knowledge and attitudes about
pediatric OSA and assess whether there is a need for
additional educational programs focusing on OSA.
2. Methods
The OSAKA-KIDS questionnaire developed by Uong
et al. [14] was translated into Turkish and distributed to
physicians, including pediatricians (both community-based
and academic-based), primary care physicians (communitybased) and pulmonologists working in different districts of
Istanbul and attending symposia about allergy and pediatric
respiratory tract disease in Turkey.
The OSAKA-KIDS questionnaire is a self-administered,
23-item questionnaire. The first section (18 questions) was
developed to assess knowledge and the second section (5
questions) to assess attitudes about pediatric OSA. In the
first section, items were presented in a true-or-false format;
‘do not know’ was included as a third response choice to
minimize the effect of guessing and was scored as an
incorrect response. The second section consisted of two subsections: two items assessing the importance of the disease
as a clinical disorder and the importance of identifying
patients with OSA, and three items concerning the selfconfidence of the physician in the diagnosis and management of children with OSA [14]. Response to attitude-based
questions was measured on a five-point Likert scale ranging
from 1 to 5 (1, strongly disagree; 2, disagree; 3, neither
agree nor disagree; 4, agree; and 5, strongly agree). There
was a third section, which included questions on age,
gender, specialty and sub-specialty training, and duration of
practice post-residency. Before the study, a pilot study was
performed on a group of 20 pediatric residents, and minor
modifications were made.
Statistical analyses were performed by using the
statistical package for the Social Sciences software version
12.0 for Windows (SPSS, Inc, Chicago, IL). P values less
than 0.05 were considered significant. One-way analysis of
variance (ANOVA) was used to analyze the differences in
mean knowledge scores and attitude scores by specialty.
Pearson’s correlation was used to evaluate the associations
between knowledge and attitude scores and variables.
Multivariate stepwise analysis was used to assess independent risk factors such as sex, age, specialty and duration of
practice post-residency affecting knowledge and attitude
scores.
3. Results
A total of 236 questionnaires were completed. Six
questionnaires were excluded from the analysis, leaving a
sample size of 230; four of the respondents did not complete
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the second section and demographic characteristics, and two
of the respondents had trained in other specialties (one from
internal medicine and the other from the ear, nose and throat
section). Respondents included 138 (60.3%) pediatricians,
70 (30.5%) general practitioners, and 21 (9.2%) pulmonologists. Duration of practice post-residency ranged from 1 to
42 years and was distributed as follows: %5 years, 31.5%;
6–10 years, 21.9%; 11–20 years, 35.1%; and R21 years,
11.5%. Characteristics of the respondents are given in
Table 1. Mean and standard deviation (SD) of the total
knowledge score of physicians was 66.7G15.9%; correct
response rates to questions are given in Table 2. Questions
regarding etiology, physical signs, symptoms and some of
the complications (items 4, 7, 8, 9, 10, 12, 15 and 16) were
correctly answered by more than three-quarters of the
respondents. Questions concerning prevalence, pre-operator
evaluation of children with OSA who are less than 2 years of
age, some symptoms and differentiation of OSA from
primary snoring by polysomnography (1, 2, 3, 5, 11, and 14)
were answered correctly by more than half of the
respondents. Questions concerning increased OSA risk in
sickle-cell disease, inadequacy of cardiorespiratory monitoring in detecting both central and obstructive apnea in
infants, non-correlation between degree of snoring and
severity of OSA and post-operative possible transient
worsening of respiratory symptoms in children with severe
OSA (items 13, 18, 6 and 17) were answered correctly by
less than 50% of respondents. There was a significant
difference in mean knowledge scores between different
branches of medicine (PZ0.003). The mean knowledge
scores of pediatricians and pulmonologists were higher than
the mean knowledge scores of general practitioners
Table 1
Characteristics of the physicians
Characteristics
Gender
Male
Female
Age, meanGSD in years
Range (years)
Specialty training
Pediatrics
General practice
Pulmonology
Family practice
Sub-specialty training
Pediatric allergy
Other pediatric sub-specialties
Academic degree
Professor
Associate professor
Fellow
Resident
General practitioner
Duration of practice post residency
(meanGSD (range) in years)
No. (%) of physicians
112 (48.9)
117 (51.5)
35G7
24–66
138 (60.3)
70 (30.5)
21 (9.2)
6 (2.6)
19 (8.3)
31 (13.1)
14 (6.1)
14 (6.1)
86 (37.6)
45 (19.7)
70 (30.5)
11G8 (1–42)
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Z. Tamay et al. / Sleep Medicine 7 (2006) 580–584
Table 2
OSAKA-KIDS questionnaire [14]
Correct response rate (%)
Knowledge questions
Questions regarding etiology including contributing factors as
Enlarged tonsils and adenoids
Excessive upper airway muscle tone loss during sleep
Questions regarding complications including
Pulmonary hypertension
Learning deficits
Cardiac arrhythmias
Failure to thrive
Questions concerning
Occurrence without snoring
Required oropharynegeal, head and neck examination
Questions regarding
Pre-operator evaluation of children with OSA !2 years of age
Differentiation OSA from primary snoring by polysomnography
Questions regarding symptoms including
Hyperactivity
Prevalence of snoring
Prevalence of OSA
Questions concerning
Increased risk of sickle cell disease
Inadequacy of cardiorespiratory monitoring in detecting both central and obstructive apnea in infants
Non-correlation between degree of snoring and severity of OSAS
Post-operative possible transient worsening of respiratory symptoms in children with severe OSA
Attitude questions
Importance questions (questions are answered from multiple choices: not importantZ1, somewhat importantZ2,
importantZ3, very importantZ4, extremely importantZ5)
Importance of OSA as
A clinical disorder
Identifying children with possible OSA
Confidence questions (questions are answered from multiple choices: strongly disagreeZ1, disagreeZ2, neither agree
nor disagreeZ3, agreeZ4, strongly agreeZ5)
Confidence in
Identifying children at risk for OSA
Ability to manage children with OSA
Ability to manage children receiving CPAP therapy
(Table 3). The knowledge score positively correlated
with having sub-specialty training (rZ0.205, PZ0.002)
and negatively correlated with having a higher degree
(rZK0.283, P!0.001). In addition, the knowledge score
positively correlated with the attitude score (rZ0.27, P!
0.001).
The mean total attitude scoreGSD of physicians was
3.4G0.6. When the attitude score was classified as
importance score and confidence score, the mean importance score (3.9G0.7) was higher than the confidence score
(3.1G0.7). Attitudes of physicians according to their
specialty were significantly different from each other (P!
0.001) (Table 4). Pulmonologists had the highest importance score, and pediatricians had the highest confidence
score.
In the multiple stepwise regression analysis of knowledge and attitudes, none of the dependent variables, such as
sex, age, specialty, or duration of practice post-residency,
affected the scores.
95
75
81
94
79
90
77
99
52
70
68
55
62
29
31
39
42
Mean score GSD
3.9G0.7
3.9G0.7
3.4G0.8
2.9G1.0
3.0G1.1
4. Discussion
This study shows that there are deficits in the knowledge
physicians have about childhood OSA and its treatment.
Pediatricians and pulmonologists had higher knowledge
scores than primary practitioners. OSA is not new for
pulmonologists; however, it has been a developing area for
pediatricians all over the world. The first pediatric sleep
Table 3
Mean knowledge scores of physicians according to their field
Mean knowledge scoreGSD
95% CI for
mean lower and
upper bound
a
Pediatricians
Pulmonologists
General
practitioners
Pa
69G16
70G11
61G15
0.003
66–72
65–75
57–65
One-way ANOVA was used for the comparison of the groups.
Z. Tamay et al. / Sleep Medicine 7 (2006) 580–584
Table 4
The mean attitude scores of physicians due to their branches
Total attitude
score
(meanGSD)
Importance score
(meanGSD)
Confidence score
(meanGSD)
a
Pediatricians
Pulmono
logists
General
practitioners
Pa
3.6G0.6
3.5G0.5
3.2G0.6
!0.001
3.4G0.7
4.3G0.5
3.8G0.7
0.006
3.3G0.7
2.7G0.6
2.7G0.7
!0.001
One-way ANOVA was used for the comparison of the groups.
laboratory was founded in 2002 at the Istanbul Faculty of
Medicine, Department of Pediatrics, in Turkey. OSA has
frequently been included in the local and national
congresses of pediatricians in Turkey. Thus, pediatricians
were more familiar with OSA than primary practitioners due
to post-graduate training programs. According to a national
survey held in the US, the American Sleep Disorders
Association Taskforce teaching time allocated to sleep and
sleep disorders was 2 h or less [15,16]. In our faculty, in
which there are OSA laboratories for both adults and
children, medical students receive only a mean of 1 h of
instruction on sleep and sleep disorders (unofficial data).
The mean total knowledge scores of physicians reported
by Mindell et al. [12], Uong et al. [14] and by Owens et al.
[13] were 71.8, 69.6 and 60%, respectively. Our result was
similar to those reported by the first two authors but higher
than the last author.
In agreement with Uong et al.’s study [14], most
physicians had the basic knowledge to answer questions
concerning enlarged tonsils and adenoids as the factor most
frequently contributing to OSA and the need for oropharyngeal examination. However, lack of physician knowledge
on frequency of snoring and OSA might keep children from
being screened for snoring; screening has been recommended by the American Academy of Pediatrics [4].
Owens et al. [13] also found that many pediatricians did not
adequately screen for sleep problems in the clinical setting.
In our study, almost all physicians (99%) knew that children
with suspected OSA should have a thorough head and neck
and oropharyngeal examination. The question that the
fewest physicians were able to answer correctly concerned
the relationship between sickle-cell disease and OSA. This
was expected, as this disease is not commonly encountered
in Turkey. The results for these two questions were similar
to Uong et al.’s results [14]. Insufficiency of cardiorespiratory monitoring in detecting both central and obstructive
apnea in infants was the second least known question,
answered correctly by two-thirds of the respondents in Uong
et al.’s study [14]; this is a specialized issue beginning in the
neonatal period of infancy and seen mostly by newborn
intensive care unit specialists.
The inverse relationship between the knowledge score
and physicians having a higher degree emphasized that
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physicians’ interest areas gradually focused on their
own sub-specialty rather than general pediatrics. The
positive relationship between the knowledge score and
having a sub-specialty might be due to the positive influence
of practicing in academic settings, e.g. the feasibility of
receiving post-graduate training programs in academic
fields. Both of the previous studies showed that more
recent graduation from medical school, which indirectly
indicates a lower degree, was associated with having higher
knowledge scores [13,14].
More knowledgeable physicians had more positive
attitudes toward childhood OSA, which was compatible
with the results of the other studies [13,14]. While
pulmonologists were best at acknowledging the importance
of OSA, pediatricians were more confident in identifying
and treating OSA. Having a good education on sleep and
sleep disorders, but not having an adequate number of
pediatric patients for pulmonologists and vice versa for
pediatricians, might explain this result.
There are several strengths of this study. First, the
OSAKA-KIDS questionnaire has been validated previously.
Second, since physicians contributed to the national allergy
congresses from all areas of Turkey, the study reflected most
areas of Turkey. A weakness of the data was that although
there were pediatricians and pulmonologists from most
areas of Turkey, the sample size was small. A second
weakness of the study was that physicians attending
symposia or congresses for allergy and pediatric respiratory
tract diseases would probably be more knowledgeable about
sleep in children and more eager to learn than physicians not
attending this kind of congress, skewing the results toward
overestimating the knowledge and attitude base of
physicians in the sample.
In conclusion, the results of this study emphasize the
need for more education on pediatric OSA within medical
schools and within pediatric residency and post-graduate
training programs.
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