Are physicians aware of obstructive sleep apnea in children?

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1 Sleep Medicine 7 (2006) 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, 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.: C ; fax: C address: eztamay@yahoo.com (Z. Tamay) /$ - see front matter q 2006 Elsevier B.V. All rights reserved. doi: /j.sleep 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

2 Z. Tamay et al. / Sleep Medicine 7 (2006) 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 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%; 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 No. (%) of physicians Gender Male 112 (48.9) Female 117 (51.5) Age, meangsd in years 35G7 Range (years) Specialty training Pediatrics 138 (60.3) General practice 70 (30.5) Pulmonology 21 (9.2) Family practice 6 (2.6) Sub-specialty training Pediatric allergy 19 (8.3) Other pediatric sub-specialties 31 (13.1) Academic degree Professor 14 (6.1) Associate professor 14 (6.1) Fellow 86 (37.6) Resident 45 (19.7) General practitioner 70 (30.5) Duration of practice post residency 11G8 (1 42) (meangsd (range) in years)

3 582 Z. Tamay et al. / Sleep Medicine 7 (2006) Table 2 OSAKA-KIDS questionnaire [14] Correct response rate (%) Knowledge questions Questions regarding etiology including contributing factors as Enlarged tonsils and adenoids 95 Excessive upper airway muscle tone loss during sleep 75 Questions regarding complications including Pulmonary hypertension 81 Learning deficits 94 Cardiac arrhythmias 79 Failure to thrive 90 Questions concerning Occurrence without snoring 77 Required oropharynegeal, head and neck examination 99 Questions regarding Pre-operator evaluation of children with OSA!2 years of age 52 Differentiation OSA from primary snoring by polysomnography 70 Questions regarding symptoms including Hyperactivity 68 Prevalence of snoring 55 Prevalence of OSA 62 Questions concerning Increased risk of sickle cell disease 29 Inadequacy of cardiorespiratory monitoring in detecting both central and obstructive apnea in infants 31 Non-correlation between degree of snoring and severity of OSAS 39 Post-operative possible transient worsening of respiratory symptoms in children with severe OSA 42 Attitude questions Importance questions (questions are answered from multiple choices: not importantz1, somewhat importantz2, Mean score GSD importantz3, very importantz4, extremely importantz5) Importance of OSA as A clinical disorder 3.9G0.7 Identifying children with possible OSA 3.9G0.7 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 3.4G0.8 Ability to manage children with OSA 2.9G1.0 Ability to manage children receiving CPAP therapy 3.0G1.1 (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. 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 Pediatricians Pulmonologists General practitioners 69G16 70G11 61G a One-way ANOVA was used for the comparison of the groups. P a

4 Z. Tamay et al. / Sleep Medicine 7 (2006) Table 4 The mean attitude scores of physicians due to their branches Total attitude score Importance score Confidence score Pediatricians Pulmono logists General practitioners 3.6G G G0.6! G G G G G G0.7!0.001 a 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 P a 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. References [1] Osler W. Chronic tonsillitis. In: Osler W, editor. 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