1 Volume 24 2025 e252692 Original Research Braz J Oral Sci. 2025;24:e252692http://dx.doi.org/10.20396/bjos.v24i00.8672692 1 Department of Clinical Dentistry, Area of Integrated Clinic, School of Dentistry, Universidade Estadual do Piauí (UESPI), Parnaíba, PI, Brazil. 2 Medical Clinic Department, School of Medicine, Federal University of Piauí (UFPI ), Teresina, PI, Brazil. Corresponding author: Ana de Lourdes Sá de Lira Universidade Estadual do Piauí, Faculdade de Odontologia Rua Senador Joaquim Pires 2076 Ininga Fone (86) 999595004 CEP: 64049-590 Teresina-PI-Brasil e-mail: anadelourdessl@hotmail.com Editor: Dr. Altair A. Del Bel Cury Received: October 10, 2023 Accepted: June 18, 2024 Parents’ knowledge about obstructive sleep apnea syndrome in childhood Felipe dos Santos Carvalho1 , Breno Wesley Leal Carvalho1 , Emylle Eduarda da Silva Sousa1 , Sávio Henrique Lira Campos2 , André Vinícius Lira Campos2 , Ana de Lourdes Sá de Lira1 Aim: To evaluate parents’ knowledge about obstructive sleep apnea syndrome in preschoolers in the primary dentition in the city of Parnaíba-PI. Methods: The questionnaire on obstructive sleep apnea syndrome (OSAS) in children was applied to parents of children between 2 and 6 years of age, in the deciduous dentition who were attending preschool in public and private kindergarten. It contained objective questions distributed in two parts: the first that determined the epidemiological profile of parents and children; the second part with 22 questions that checked the parents’ knowledge about the child’s sleep and behavior during the day. As an interpretation, the questionnaires that presented 36.3% of the answers YES to the 22 specific questions, the child was considered at high probability for developing OSAS. Results: The average age of the children was approximately 4 years old. Regarding weight, an average of 22 kilos and an average height of 107.45 cm and an average BMI of 18.75, confirmed by notes on the vaccination card. Loud snoring, loud or heavy breathing, and overweight were significantly associated with OSAS (p < 0.001). From a total of 250 children, it was observed that the prevalence rate of high possibility for the development of OSAS was 6% (n=15). Conclusion: Parents were not aware of OSAS, but after applying the questionnaire, they were able to understand the suggestive signs of the syndrome and the importance of early diagnosis. Keywords: Sleep apnea syndromes. Child. Sleep wake disorders. https://orcid.org/0000-0002-5961-0570 https://orcid.org/0000-0001-5115-3929 https://orcid.org/0000-0001-5919-4792 https://orcid.org/0000-0003-0393-0492 https://orcid.org/0000-0002-9973-7015 https://orcid.org/0000-0002-9299-1416 2 Carvalho et al. Braz J Oral Sci. 2025;24:e252692 Introduction Obstructive sleep apnea syndrome in childhood (OSAS) is one of several sleep dis- orders, characterized by an intermittent partial or complete obstruction of the upper airways that disrupts sleep and its normal patterns, occurring more frequently in the age group between 2 and 6 year olds having very different characteristics from sleep apnea in adults in terms of their etiology, symptoms and treatment1-4. According to the literature, it is recognized as one of the causes of morbidity among children, and can manifest itself in both genders, at any age, including newborns. The highest incidence of the problem in childhood is in preschool children, an age group in which tonsil and adenoid hypertrophy is more frequent5-8. In children, the risk factors for OSAS that stand out the most are overweight, hyper- trophy of the tonsils and adenoids, the presence of maxillary or mandibular retrog- nathism, long face, transverse deficiency of the upper arch, craniofacial syndromes, muscle weakness and Down syndrome2,9,10. It is noteworthy that during sleep, there is a considerable decrease in muscle tone and in the airways. If the tonsils and adenoids are hypertrophied, they will obstruct the airways, making airflow difficult. Many of the short pauses (lasting only a few seconds) cause brief excitement, micro-arousals, increasing muscle tone, opening the airways, thus allowing the child to resume breathing11-13. While the actual number of minutes of arousal during the night may be small, repeated interruptions can result in a poor night’s sleep, which can lead to signifi- cant daytime problems in children. The child is often unaware that he or she is wak- ing up, and parents often describe very restless sleep, but generally do not describe the child’s full awakening1,14,15. Parents play a fundamental role in the diagnosis when they observe the most fre- quent symptoms and clinical signs, which are: snoring, night awakenings, enuresis, restlessness during sleep, daytime sleepiness, restlessness, reduced neurocognitive performance, school performance and growth below normal predicted for age9,14. The pediatric sleep questionnaire was developed and validated by the American Acad- emy of Pediatrics16 and translated into Portuguese by authors17, and can be applied to parents by health professionals when there is suspicion of OSAS. The child should be referred to a sleep doctor for a definitive diagnosis, when the suspicion is confirmed after applying the questionnaire. It is believed that if preventive measures were adopted and an early diagnosis of OSAS was carried out, sequelae would be avoided, such as: behavioral disorders, learning deficits, pulmonary hypertension and impaired somatic growth. Thus, the application of the pediatric sleep questionnaire to parents is justified, in order to direct suspected cases to a thorough investigation with the sleep doctor, for the application of the poly- somnographic examination, thus favoring an early diagnosis and adequate treatment by a multidisciplinary team consisting of a sleep doctor, otorhinolaryngologist, ortho- dontist and speech therapist18,19. 3 Carvalho et al. Braz J Oral Sci. 2025;24:e252692 The aim of this research was to evaluate parents’ knowledge about obstruc- tive sleep apnea syndrome in preschoolers in the primary dentition in the city of Parnaíba-PI. Material and methods Ethical aspects The research was approved by the Ethics and Research Committee of UNINOVAFAPI, number: 4.470.974. This was a cross-sectional study with a quantitative approach, carried out with parents of preschoolers in the city of Parnaíba, PI. This research was guided by compliance with all the ethical principles that guide research involv- ing human beings, as provided for in Resolution No. 466/12 (CNS/MS). Parents over 18 years of age would sign the Free and Informed Consent Term (TCLE) and minors would sign the Term of Assent (TALE), after being advised that the partici- pation would not be mandatory. They were informed that they could withdraw from the research at any time. Only information collected strictly within the limits of the research objectives was used. Population Study The sample calculation was based on the target audience: preschoolers from public and private day care centers in 2021. Thus, seeking to achieve the objective of this work, it was based on the survey carried out by the Brazilian Institute of Geography and Statistics, which pointed out a number of 6209 people in the target popula- tion: number of people enrolled in preschool. Thus, the sample size formula was calculated, considering the calculation formula: n=NZ2.P.(1−P)Z2.P.(1−P)+e2N−1⁄., in which n: sample calculated, Z: normal variable, P: real probability of the event, and sampling error), obtaining as a result a number of 250, with approximation to 260, since there is a possibility of withdrawal of participation by parents of pre- schoolers. This minimum number of participants is considered sufficient taking into account the proposed analyses, the sampling error of 5%, in addition to a 95% con- fidence level, indicating that the probability of the error made by the research does not exceed 5%20. Calibration Two researchers were calibrated at the Clinical School of Dentistry (CEO) of the State University of Piauí (UESPI). They applied the questionnaire to 10 profes- sors from the UESPI dentistry course twice with an interval of 15 days, to acquire skills in applying the questionnaire and ability to interpret the results, as well as to obtain intra-examiner and inter-examiner agreement. Kappa values were 0.84 for inter-examiner agreement (between the two researches), 0.85 and 0.87 for intra-examiner agreement. Once qualified, the examiners applied the question- naire on OSAS in children to the parents, after school directors authorized the development of the research. 4 Carvalho et al. Braz J Oral Sci. 2025;24:e252692 Eligibility Criteria The inclusion criteria that were adopted were: parents of children between 2 and 6 years of age, in the deciduous dentition, who were attending preschool in a public or private day care center and did not have visual, auditory, motor or psychic disorders. As exclusion criteria: parents who did not want to participate in the research, incom- plete or improperly completed questionnaires and parents unable to understand and answer the questions. Pilot Study For standardization, the questionnaire was applied to 30 parents of children treated at the Clinic School of Dentistry (CSD) of the State University of Piauí, in Parnaíba-PI, who did not participate in the research, to evaluate the methods to verify if there was a need to make changes in the methodology initially proposed. The previously vali- dated questionnaire was reapplied after an interval of 15 days, in order to evaluate the method and check whether there would be a need to make changes to the initially proposed methodology, which did not need to be changed, as the parents were able to answer all the questions in the questionnaire applied. Data collect Public and private day care centers were chosen by lot, so that the number of parents of students participating in the sample was equally distributed. Parents from public schools formed group 1 (G1) and those from private schools formed group 2 (G2). It is believed that the socioeconomic factor may influence parents’ knowledge about OSAS, possibly due to the higher educational level of parents in group 2 and greater access to medical and dental information and guidance. Three times a week, in both shifts (morning and afternoon), the questionnaire adapted from previous study17, was applied to parents, containing objective ques- tions divided into two parts: the first part that determined the epidemiological profile of the parents and of children; the second part with 22 questions that checked the parents’ knowledge about the child’s sleep and behavior during the day. As an inter- pretation, based on previous study17, the questionnaires that presented 36.3% of the answers YES to the 22 specific questions, the child was considered to have a high possibility of developing OSAS. Statistical analysis The results were stored in the Excel Windows 2016 Microsoft® database in graphs and tables for better presentation, interpretation and discussion, after appropriate statistical analysis. Means, dispersion, and the chi-square association test were obtained, with a statistical significance level of 5%, to compare the results between G1 and G2. Results The final sample of 250 children consisted of 55.2% females and 44.8% males. They were divided into two groups, 54% belonged to (G1) children from public schools, and 5 Carvalho et al. Braz J Oral Sci. 2025;24:e252692 46% belonged to (G2) children from private schools. It was observed that 12% of our sample was black, followed by 38% brown and 50% white. As for income, 92% of parents in G2 earn more than 3 minimum wages, while in G1, 94% earn less than 3 minimum wages. Regarding maternal education, 208 moth- ers studied for more than 8 years, with 46% belonging to G1 and 54% belonging to G2. Regarding paternal education, 207 fathers studied for more than 8 years, 44.5% belong to G1 and 55.5% to G2 (Table 1). Table 1. Epidemiological data of G1 and G2 Variables G1 G2 Total p value Gender Male 70 42 112 0.02 Female 65 73 138 Race White 71 54 125 0.65Black 16 14 30 Brown 48 47 95 Family income 1 to 3 minimum wages 135 9 144 < 0.001*** (2.2 x 10-16)>3 minimum wages 0 106 106 Maternal education 0-7 39 3 42 < 0.001** (5.89 x 10-8)≥8 96 112 208 Paternal education 0-7 43 0 43 < 0.001*** (2.91 x 10-11)≥8 92 115 207 Footnote: Chi-square test;***(significance at 0.001%); G1(children from public schools); G2(children from private schools). The children’s information about age, weight and height was confirmed by notes on the vaccination card. The age range of the children ranged from 2 to 6 years, with a mean age of approximately 4 years. Regarding weight, an average of 22 kg and an average height of 107.45 cm can be observed, resulting in an average body mass index (BMI) of 18.75 (Table 2). Table 2. Descriptive data analysis Descriptive analysis Age Weight Height BMI Average 4.03 22.03 107.45 18.75 Median 4 20 106 17 Standard deviation 1.17 6.42 11.60 4.30 Minimum 2 12 80 12 Maximum 6 39 140 29 6 Carvalho et al. Braz J Oral Sci. 2025;24:e252692 The prevalence distribution of factors that indicate a high possibility of developing obstructive sleep apnea syndrome (OSAS) is described in Table 3. These data sug- gest that: loud snoring, loud or heavy breathing and overweight were significantly associated with OSAS (p < 0.001). Factors that were clearly not associated with OSAS included: breathing through the mouth during the day, waking up tired in the morning, acting as if the plug were plugged in, and being distracted by extraneous stimuli (p > 0.30). Table 3. Variables about the child Variables (G1) (G2) Total X2 p valor Does he(she) snore more than half of your sleep time? Yes 18 12 30 X2 = 0.02 p = 0.89No 117 103 220 Does he(she) always snore? Yes 15 16 31 X2 = 0.03 p = 0.86No 120 99 219 Does he(she) snore loudly? Yes 12 27 39 X2 = 10.04 p < 0.001**No 123 88 211 Does he(she) have trouble breathing or struggle to breathe? Yes 16 28 44 X2 = 0.13 p = 0.72No 119 87 206 Does he(she) have loud or “heavy” breathing? Yes 19 26 45 X2 = 12.69 p < 0.001**No 116 89 205 Have you ever seen your child stop breathing at night? Yes 3 4 7 X2 = 3.31 p = 0.07No 132 111 243 Does he(she) tend to breathe through his mouth during the day? Yes 9 7 16 X2 = 0.03 p = 0.85 No 126 108 234 Does he(she) have a dry mouth when he wakes up in the morning? Yes 11 19 30 X2 = 4.12 p = 0.04*No 124 96 220 Does heshe) occasionally wet the bed? Yes 19 23 42 X2 = 1.56 p = 0.21No 116 92 208 Does he(she) wake up feeling tired in the morning? Yes 13 11 24 X2 < 0.001 p = 0.99No 122 104 226 Does he(she) have a problem with drowsiness during the day? Yes 6 5 11 X2 = 0.001 p = 0.97No 129 110 239 Some teacher commented that your child gets drowsy during the day? Yes 7 9 16 X2 = 0.72 p = 0.40No 128 106 234 Is it difficult to wake your child in the morning? Yes 20 31 51 X2 = 5.64 p = 0.02*No 115 84 199 Does the child wake up with a headache in the morning? Yes 1 6 7 X2 = 4.57 p = 0.03*No 134 109 243 Continue 7 Carvalho et al. Braz J Oral Sci. 2025;24:e252692 Continuation Has he(she) stopped growing at a normal rate at any age since birth? Yes 5 3 8 X2 = 0.24 p = 0.62No 130 112 242 Is the child overweight? Yes 16 36 52 X2 = 14.26 p < 0.001***No 119 79 198 Does the child seem to not listen when we talk to him(her)? Yes 15 11 26 X2 = 0.16 p = 0.69No 120 104 224 Does he(she) have difficulty organizing tasks and activities? Yes 51 38 89 X2 = 0.61 p = 0.44No 84 77 161 Is the child distracted by extraneous stimuli? Yes 45 37 82 X2 = 0.04 p = 0.85No 90 78 168 Does the child have restless feet and hands or squirm when sitting down? Yes 28 17 45 X2 = 1.49 p = 0.22No 107 98 205 Does the child act as if “plugged in”? Yes 49 47 96 X2 = 0.55 p = 0.46No 86 68 154 Does the child intrude or interrupt others? Yes 28 25 53 X2 = 0.04 p = 0.85No 107 90 197 Footnote: As an interpretation, if 8 of the answers are YES to the 22 specific questions, the child is considered at high possibility for developing OSAS. Chi-square test; *(significance at 0.05%) ***(significance at 0.001%); G1(parents of children from public schools); G2(parents of children from private schools). In the present study, data indicate that 15 children were considered with high possibil- ity, 10 from private schools (2 males and 8 females) and 5 from public schools (1 male and 4 females). After confirming the homogeneity of the data, the results indicated that there was no statistically significant difference between the groups, with regard to the values of the mean ages in relation to gender (p=0.31), race (p=0.60) and type of schools (p=0.04), not influencing the answers to the questionnaire, after applying the Analysis of Variance test (MANOVA), with a 1% significance parameter. Discussion Sleep-disordered breathing (SDB) is relatively common in the pediatric population, including primary snoring (PR) and obstructive sleep apnea syndrome (OSAS). Primary snoring is defined as respiratory noise, but sleep architecture, alveolar ventilation and blood oxygen levels are normal. It is found in 7% to 9% of children aged between 1 and 10 years21. In the present study, based on data collected from 250 children, it was possible to observe that the prevalence rate of high pos- sibility of developing OSAS was 6%. That is, 15 children presented risk behavior, corroborating another study, whose estimated prevalence of OSAS ranged from 0.7% to 10.3%22. This wide range of expected prevalence is due, at least in part, to the fact that sleep-disordered breathing in children has been defined based on a variety of assessment methods5. There was no statistical difference between genders regard- 8 Carvalho et al. Braz J Oral Sci. 2025;24:e252692 ing the possibility of developing OSAS, similar to another study23. However, a higher prevalence of primary snoring was identified in males15. There was an association between the presence of loud snoring, overweight and loud or heavy breathing and an increase in the probability of developing OSAS. Just as BMI, waist circumference, tonsil size, nasal drainage, turbinate hypertrophy and long soft palate were associ- ated with risk factors5. There was no association with hyperactivity, tiredness in the morning or acting as if one were plugged in, which allows us to observe that although these behaviors are present in the list of characteristic symptoms of OSAS, they cannot be used alone to define the correct diagnosis, corroborating the findings of another study13, which emphasized the crucial importance of polysomnography for the diagnosis of OSAS. Based on the data collected, children were found to be at high possibility of devel- oping sequelae directly associated with OSAS, but it is not possible to be absolutely sure of the individual’s health condition, requiring specialized medical follow-up for the correct diagnosis. A similar fact was observed in another research24, which empha- sizes the importance of the correct diagnosis. Sleep-disordered breathing, including obstructive sleep apnea syndrome (OSAS), is recognized as a cause of morbidity in children. Clinical symptoms of OSAS in children include snoring, night awakenings, agitation during sleep, enuresis, daytime sleepiness and hyperactivity17. Clinical symptoms may raise suspicion, but it is not possible to establish the diag- nosis without polysomnography. As snoring and obstructive symptoms can resolve with time, a normal polysomnography finding may help the clinician decide on an observation period25,26. After applying the questionnaires, the parents were unanimous in stating that they were unaware of the importance of the questions addressed in the questionnaire regarding OSAS and that they did not know that the child could develop the disease. Parents were warned that a positive response to 8 of the 22 questions suggests the need for further investigations into OSAS, the most frequent being loud snoring, loud or heavy breathing and overweight. Some authors reported that the most common signs are: snoring, mouth breathing, restless sleep, drooling on the pillow, hyperac- tivity, aggressiveness and irritability27-29. The first step towards the diagnosis is the observation of the parents. For this, it is essential that adults know about the exis- tence of the disorder and its symptoms. The questionnaire used in this research can be applied by any health professional to the parents of a child and if there is a suspicion of OSAS, after obtaining at least 8 affir- mative answers, the child must be forwarded to the neurologist for confirmation of the diagnosis through the examination. polysomnography, investigation of etiological factors and early treatment. All parents or guardians of children who were at high risk of developing OSAS were instructed on the importance of the diagnosis. In conclusion, parents, in both groups, had no knowledge about OSAS, but after apply- ing the questionnaire, they were able to understand the suggestive signs of the syn- drome and the importance of early diagnosis. 9 Carvalho et al. Braz J Oral Sci. 2025;24:e252692 Acknowledgement Miss Ana de Lourdes Sá de Lira who was the research assistant for the project. Funding This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest None Author Contribution Felipe dos Santos Carvalho: methodology, project administration, supervision, writing – review and editing. All authors actively participated in the manuscript’s findings and have revised and approved the final version of the manuscript. Breno Wesley Leal Carvalho: methodology, project administration, supervision, writing – review and edit- ing. Emylle Eduarda da Silva Sousa: methodology, project administration, supervi- sion, writing – review and editing. 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