INTRODUCTION

Sleep is a complex physiological and behavioral process that enables people to disconnect from the external environment ¹ . Healthy people usually fall asleep 20 minutes after lying down. It has been reported that 20% to 30% of people have sleeping difficulties ² . Normal sleep is important to development at all stages of life. On average, a person spends one third of their life sleeping, reflecting the fact that sleep is essential to performing and completing important physiological functions that ensure complete physical and mental equilibrium throughout the day. Sleeping is key to physical and psychological development in childhood and adolescence ^{3, 4} .

Sleep-disordered breathing (SDB) is a group of different disorders involving breathing anomalies during sleep. Obstructive type SDBs are not a specific disease, but an upper airway dysfunction syndrome. In some cases, the breathing anomaly occurs while the patient is awake ^{4, 5} .

Lack of sleep is harmful to cognition, decision making, psychomotor function, mood and immune function. Poor sleep is a risk factor for cardiovascular disease, dementia, obesity, diabetes, depression, pain and mortality, among other disorders.

Snoring, the main sign of sleep-disordered breathing, is one of its most common manifestations. SDB comprises a variety of disorders, ranging from the simplest, which is habitual or primary snoring, all the way to sleep apnea-hypopnea syndrome (SAHS), including intermediate disorders such as upper airway resistance syndrome (UARS) and central hypoventilation syndrome ⁶ . Primary snoring is a characteristic disorder of breathing sound during sleep, without apneas, hypoventilation or interrupting sleep, although it does reduce sleep percentage and increase microarousals due to breathing effort or gas exchange effort. Snoring is a hoarse sound caused by obstruction of the air flow through the nose and pharynx. Structures with soft tissues (tongue, soft palate, uvula, tonsils, adenoids and pharynx wall) are highly collapsible, which places them in contact with each other and causes them to vibrate when someone breathes during sleep ⁷ .

SDB and sleep apnea are well known in adults. However, they also occur in the pediatric population, with prevalence ranging from 7% to 17%, depending on how they are defined, and the instruments used in each study. In Mexico, the prevalence of child obesity has recently increased to the highest rate in the world, leading to higher prevalence of SDB, including disorders such as obstructive sleep apnea and primary snoring related to obesity. Timely diagnosis and management of SDB in children can prevent associated comorbidities ^8-10 .

Among the range of sleep-disordered breathing symptoms, primary snoring is the least harmful. Primary snoring is sometimes not considered either for diagnosis or for the possibility of providing treatment. It has been reported that more than one third of children with primary snoring develop sleep apnea-hypopnea within four years, and 7% develop a moderate to severe disease such as central hypoventilation syndrome. The most significant risk factor for progression of the disease is child obesity, for which prevalence is reported as 8% to 12% ¹¹ .

Among 3- to 6-year-olds, the main cause of snoring is physiological hypertrophy of adenoids and tonsils, which at these ages are larger in relation to airway diameter. Most snoring incidents during sleep are therefore expected at these ages ¹² .

The gold standard for diagnosing SDB and sleep apnea is assisted polysomnography (PSG) in the lab. However, it is expensive, time consuming, technically complex, and requires patients to sleep in the laboratory. In Mexico, there may be significant delays in the diagnosis and treatment of STB due to the limited availability of PSG. Nevertheless, simpler tools such as validated sleep questionnaires can also be used to detect SDB and have gained considerable clinical relev ance for recording initial symptoms in epidemiological studies ^13-15 .

Sleep questionnaires are used as a subclinical tool to describe psychometric qualities in the field of sleep medicine to screen for signs, symptoms and factors that foster the development of SDB. Pediatric sleep questionnaires are mainly directed to parents. Most of these questionnaires for SDB screening, such as the Pediatric Sleep Questionnaire (PSQ), are long and tedious, so various mobile applications, such as RoncoLab, have been proposed for diagnosing SDB signs and symptoms.

The RoncoLab app is attractive, innovative and easy for parents to use ^16-18 . It shows whether, how much and how long a patient snores; analyzes snoring; can be programmed to activate after a given number of minutes and can play background sound to help the patient fall asleep. It shows the different sleep analyses performed during the night and provides a list of possible remedies to snoring and a list of different factors that may foster the onset of snoring.

By default, RoncoLab record samples of the patient’s snoring, as well as other sounds occurring during the night. Once the recording has been made, the app provides a graph showing silent and snoring times. It also records total sleep time and how long the patient has been in bed and assigns a score to patient snoring. It can play back the recorded snoring. The main aim of the application is to ascertain rest quality and snoring intensity.

The aim of this study was to compare the efficacy of the RoncoLab mobile app to that of the Pediatric Sleep Questionnaire for diagnosing the primary sign (snoring) of SDB in the pediatric population.

The aim of this study was to compare the efficacy of the RoncoLab mobile app to that of the Pediatric Sleep Questionnaire for diagnosing the primary sign (snoring) of SDB in the pediatric population.

MATERIALS AND METHOD

This was an observational analytical study. Children aged 7 to 11 years, who had been referred to the postgraduate Pediatric Dentistry clinic at the School of Stomatology at Benemérita Universidad Autónoma de Puebla for a sleep study, were invited to participate. Prior to registration, the Ethics and Research Committee (2021160) obtained informed consent from the parents and oral and written assent from the children. Exclusion criteria were patients (1) under respiratory treatment, (2) under maxillary orthopedic treatment (maxillary expansion), (3) with intellectual disability, (4) under psychiatric treatment, or (5) with craniofacial anomalies. The PSQ for SDB diagnosis, validated and adapted to the pediatric population, was applied to the 31 children. The 22 questions were answered by a parent or legal guardian.

A snorer was defined as any child whose guardián provided affirmative answers to at least one of the 2 following questions in the questionnaire: ‘Does your child snore more than half the time?’ ‘Does your child snore all the time?’ Probable sleep-disordered breathing was identified when 8 or more questions were answered affirmatively (score <0.33) (Table 1). Any questions answered “No” o “Don’t know” were not counted.

Then the parent or guardián was instructed on how to download and use the mobile application to record information while the child was sleeping at home.

The parent or guardian was instructed to use RoncoLab for two nights at home in the patient’s bedroom, beginning on the day that the PSQ sleep questionnaire was answered. The mobile application was switched on when the patient went to bed and began to rest in a quiet environment isolated from any other area or object that emitted sounds that could alter the records. RoncoLab was programmed to actívate after the first 20 minutes, corresponding to the beginning of the deep sleep phase. Snoring was recorded throughout all the patient’s sleeping hours.

RoncoLab defined as a snorer any child who snored for more than 15 minutes. (Figs. 1 a-b).

Cross tabulation was used to calculate RoncoLab sensitivity and specificity.

Statistical analysis was performed on IBM SPSS version 22. Agreement between diagnostic instruments was analyzed using Cohen’s Kappa index at 95% confidence interval, and considered insignificant if the result was 0.0 to 0.2, low for 0.2 to 0.4, moderate for 0.4 to 0.6, good for 0.6 to 0.8 and very good for 0.8 to 1.0.

RESULTS

A total 31 children and their parents signed consents and assents, respectively, and joined the study, answered the questionnaire and used the mobile application between August 2022 and December 2022. There were 20 boys (64.5%) and 11 girls. (35.5%). Mean age was 8.8 years.

Screening prevalence for sleep-disordered breathing among Mexican children was 42% according to the Pediatric Sleep Questionnaire (PSQ) validated and adapted for SDB screening in the pediatric population. The RoncoLab application identified 51.6% of the patients as snorers, while the PSQ identified 45.2%. RoncoLab sensitivity was .92, and specificity was .82. Data were recorded on the presence of the primary sign of SDB (Table 2). The Kappa index for identification of primary snoring between the PSQ and the RoncoLab mobile application was 0.743 with p<0.05 (Table 3).

Fig. 1a-b Screenshots of the RoncoLab application provided by parents.  

DISCUSSION

Although validation is required, the RoncoLab mobile application may be implemented in diagnosis and screening for Sleep-Disordered Breathing, since it has been found to be efficient, useful and practical for diagnosing snorers.

Among Mexican children, there is a high percentage of possible cases of sleep-disordered breathing compared to reports in the worldwide literature. In Argentina, Frairea A. et al. ¹⁰ used the PSQ to study a pediatric population and reported 7% SDB prevalence and 9.7% snorers.

It is therefore important to raise awareness and conduct further studies on SDB in the Mexican pediatric population using validated, adapted instruments to standardize figures. It is suggested to consider other factors such as body mass index, high blood pressure, place of origin, and ethnicity, among others, to help decipher the high percentage of probable SDB in Mexican children.

To conclude, agreement between PSQ and the RoncoLab application for diagnosing primary snoring in the pediatric population was good, displaying acceptable sensitivity and specificity.