Awareness of Pediatric Obstructive Sleep Apnea among parents in Majmaah, Saudi Arabia

INTRODUCTION

Pediatric Obstructive Sleep Apnea is a relatively common disorder defined as a condition when the upper airway is partially or completely blocked during sleep. Besides a range of disorders associated, it is distressing in children due to the potential difficulty in their physical development, cognitive function, and behavior. The prevalence of the disease varies, and, according to different authors, affects 1-5% of the world’s child population.². Nevertheless, beyond the influence, it is less studied and diagnosed, particularly in the third world and developing countries.

The causes of the disorder are diverse due to environmental and individual factors, and lymphadenoid hypertrophy, obesity, facial features, and malformed neuronic control can be highlighted as the most frequent ones 4.5. The main symptoms of the disorder are loud snoring, missing breathing, restless sleep, hyperactivity, and aloofness6,7. Unaddressed, pediatric OSA may lead to severe problems—infection of cardiovascular conditions is one of the long-term consequences—other critical areas of concern include growth floors and cognitive dysfunction. Early recognition and intervention are crucial to mitigate these adverse outcomes.

Previous studies on pediatric OSA have predominantly been conducted in Western countries, where the condition is more widely recognized and diagnosed. Saran et al. carried out a study in Italy whose results indicated that most respondents (68%) knew about otorhinolaryngologists and oral areas when going for checkups. However, they acknowledged that the study was limited by the complexity of the research.

Among the handful of studies on awareness of OSA in Saudi Arabia is Alosaimi et al.’s study, which revealed low awareness levels and knowledge about pediatric OSA among residents of Jeddah10. The study recommended the implementation of health campaigns and training programs on the same. Bashir et al. carried out an assessment of pediatric OSA among parents in Saudi Arabia and found that many parents did not know about it11. Flemban et al. carried out a similar study among parents in KSA and found that the level of awareness and knowledge was high—41% of respondents had high knowledge and 38% had moderate knowledge—only 1% of respondents reported poor knowledge of pediatric OSA12.

To the best of our knowledge, there was no previous research on pediatric OSA awareness in Majmaah, Saudi Arabia. Therefore, the purpose of this study was to investigate the level of parents’ awareness of pediatric OSA in Majmaah, Saudi Arabia.

METHODOLOGY

This research utilized a cross-sectional design and was carried out from October 2023 up to April 2024 among the parents in Majmaah, Saudi Arabia. The study aimed to determine the parents’ awareness of pediatric obstructive sleep apnea in Majmaah, Saudi Arabia. The inclusion criteria for the study encompassed all parents residing in Majmaah who were currently married and had children. This includes both male and female parents who are in a marital relationship and actively involved in the upbringing of their children. The exclusion criteria eliminated any individuals who are not married, regardless of their gender, as well as married individuals who do not have children.

The questionnaire was developed from recent literature with alignment to the study objective. The questionnaire's feasibility, understandability, and readability were evaluated by ten respondents during the piloting phase, and the reliability of the questionnaire was calculated. In addition, the author took the questionnaire from a previous study conducted by Alosaimi A et al13 and made minor modifications. The main study did not include the respondents who participated in the pilot study. The Cronbach's alpha was equal 0.817

The questionnaire was distributed to parents in Majmaah, Saudi Arabia via WhatsApp, Facebook, and Telegram groups after being adjusted in response to pilot feedback. The study involved 16 knowledge questions. The respondents who correctly answered 11 out of 16 questions were deemed to have high knowledge. The respondents who correctly answered 5-10 questions had moderate knowledge, while those who answered less than 5 questions correctly had poor knowledge.

The data collected was initially entered into an Excel database for cleaning. The data cleaning exercise involved checking for outliers and removing duplicates and incomplete entries. Afterward, the data was coded and transferred into SPSS software version 27 for analysis. Categorical variables were reported as counts and frequencies, whereas continuous variables were presented as means and standard deviations. To identify associations between categorical variables, inferential statistics, the Chi-square test were employed, with the significance level set at p<0.05.

The ethical approval was obtained from the ethics committee of Majmaah University. Data collection was conducted anonymously, with no personal identifiers, ensuring that individual identities could not be linked to the study results. Confidentiality measures were rigorously implemented, and informed consent was secured. Participants were fully briefed on the study's objectives, procedures, potential risks, and benefits before their participation. Consent was obtained voluntarily, without any coercion. Researchers were dedicated to safeguarding participants' privacy by maintaining their anonymity and protecting sensitive data.

Results

Table 1 shows that a total of 273 participants were surveyed. The majority of the participants, 265 (97.1%), surveyed were Saudi nationals, while only 8 (2.9%) were non-Saudi. In addition, 163 (59.7%) were men, while 110 (40.3%) were women. Marital status: Most of the participants, 176 (64.5%), were married, while 97 (35.5%) were single. Education level: 229 (83.9%) had a university-level education, 30 (11.0%) had a secondary school education, 8 (2.9%) had intermediate and 6 (2.2%) had a primary school education. Finally, 185 (67.8%) had 1-2 children, 62 (22.7%) had 3-5 children, 20 (7.3%) had 6-8 children, and 6 (2.2%) had 9-12 children.

Table 2 shows that 112 (41.0%) of the participants knew that a child's academic performance could be impacted by childhood obstructive sleep apnoea. Seventy-two (26.4%) of the respondents knew that depression is more common in children with obstructive sleep apnea, and 109 (39.9%) knew that attention and behavior are impacted by childhood obstructive sleep apnea. In addition, 157 (57.5%) thought that the genetic factor could have a role in the cause of childhood obstructive sleep apnea, 217 (79.5%) thought that childhood obstructive sleep apnea could be managed, and 235 (86.1%) believed that early intervention and treatment of children with obstructive sleep apnea can lower the potential risk of complications. Moreover, 239 (87.5%) of the participants believe that raising parents' knowledge of obstructive sleep apnea in children may reduce the load on both the population and the parents. 227 (83.2%) thought that obstructive sleep apnea can cause restless sleep, and 211 (77.3%) thought that obstructive sleep apnea can cause mouth breathing. Further, 211 (77.3%) of the participants thought that obstructive sleep apnea can cause snoring, 197 (72.2%) thought that obstructive sleep apnea can cause noticed episodes of breathing pauses during sleep, 212 (77.7%) thought that obstructive sleep apnea can cause sleep arousal, and 166 (60.8%) thought that obstructive sleep apnea can cause daytime sleepiness. Finally, 181 (66.3%) thought that obstructive sleep apnea can cause sleep terrors, 102 (37.4%) thought that obstructive sleep apnea can cause hyperactivity, and 107 (39.2%) thought that obstructive sleep apnea can cause bed-wetting.

Figure 1 shows that most of the participants, 169 (61.9%), had moderate knowledge of OSA, 66 (24.2%) had high knowledge, and 38 (13.9%) had low knowledge.

Table 3 shows that there is no statistically significant difference in the level of awareness among the OSA risk factors (P>0.05).

DISCUSSION

The study aimed to assess the awareness of parents about obstructive sleep apnea in children in Majmaah, Saudi Arabia. The finding of the study reveals that 112 (41.0%) of the participants knew that the child's academic performance can be impacted by childhood obstructive sleep apnoea. Less than half (26.4%) of the respondents knew that depression is more common in children with obstructive sleep apnea, and 109 (39.9%) knew that attention and behavior are impacted by childhood obstructive sleep apnea. Moreover, slightly more than half, 157 (57.5%), of the participants thought that the genetic factor can have a role in the cause of childhood obstructive sleep apnea. In addition, most of the participants, 217 (79.5%) and 235 (86.1%), thought that OSA can be managed and early intervention and management can reduce the possible risk of complications in children with obstructive sleep apnea, respectively. Similar to this finding, a study by Bashir et al. found that only less than half of the individuals surveyed knew that childhood obstructive sleep apnea can affect a child’s school performance and can cause higher levels of depression among the affected children compared to non-affected children11. Consistent with this finding, a study by DiNardo et al. noted that most of the respondents were aware that it is possible to manage obstructive sleep apnea and that early intervention and management can reduce the possible risk of complications in children with obstructive sleep apnea12,13.

Moreover, the findings of this study indicated that most of the participants, 239 (87.5%), thought that parents' awareness about childhood obstructive sleep apnea can help reduce the burden on them and the population, 227 (83.2%) thought it can cause restless sleep, and 211 (77.3%) thought it can cause mouth breathing. Further, most of the participants, 211 (77.3%), thought obstructive sleep apnea could cause snoring; 197 (72.2%) thought it could cause noticed episodes of breathing pauses during sleep; 212 (77.7%) thought that it could cause sleep arousal; and 166 (60.8%) thought it could cause daytime sleepiness. This is in line with the finding obtained in a study by Bitners et al., who revealed that most of the respondents surveyed were aware that OSA can cause snoring15. On the other hand, in support of this finding, a study by Ioan et al. revealed that most of the surveyed participants were aware OSA can cause daytime sleepiness16.

Further, the finding of this study reveals that 181 (66.3%) of the participants thought that obstructive sleep apnea can cause sleep terrors, 102 (37.4%) thought it can cause hyperactivity, and 107 (39.2%) thought that obstructive sleep apnea can cause bed-wetting. This concurs with the finding in a study by Saelim et al., who found that most of the participants were not aware that OSA can cause hyperactivity17. On the other hand, aligned to the finding of this study, a study by Kuti et al. found that only a few participants were aware that obstructive sleep apnea can cause bed-wetting18.

Finally, this study found that most of the participants, 169 (61.7%) had moderate knowledge of OSA, 66 (24.2%) had high knowledge, and 38 (13.9%) had low knowledge. This finding adheres to the results obtained in a study by Andersen et al., which found that most of the participants had moderate knowledge regarding obstructive sleep apnea signs and risk factors19. Nevertheless, a study by McDowall et al. noted that individuals surveyed had little information regarding OSA symptoms and risk factors20. This implies that most of the parents have little information concerning obstructive sleep apnea.

Additional research in different regions of Saudi Arabia involving a larger sample size would be necessary to validate our findings. Some of the drawbacks of this study include the use of a self-reported survey, which is prone to desirability and remembering biases, and a small sample size, which limits the generalizability of this study's findings.

Potential strategies for increasing awareness and education about pediatric OSA among parents:

A variety of focused initiatives may be utilized to improve parental awareness and education regarding pediatric Obstructive Sleep Apnea (OSA). Community-based activities, such as workshops and seminars at schools, healthcare facilities, and community groups, may help to educate parents about OSA symptoms, dangers, and treatment choices. Another successful strategy to convey information is to use social media and digital platforms, which provide broad reach and participation. Collaboration with healthcare practitioners, especially paediatricians and family physicians, may also play an important role by adding educational sessions or handing out useful leaflets during regular checkups. Furthermore, public health campaigns organized by local governments or non-profit organizations may stress the need for early identification and treatment of OSA by employing relevant messages customized to local culture and language. Incorporating qualitative data, such as interviews or focus group discussions with parents, may give more detailed information on their knowledge levels, attitudes, and possible hurdles to comprehending OSA. Personal stories given by parents of children diagnosed with OSA help humanize the situation, making it more relevant and meaningful. These accounts may highlight the real-life issues that families confront and emphasize the significance of early intervention while also identifying inadequacies in the present healthcare system and educational programs. By combining these qualitative findings with awareness efforts, a more complete and sympathetic strategy may be devised to address the knowledge gap and encourage improved understanding and treatment of pediatric OSA.

Conclusion

The outcomes of this research highlight a considerable gap in parental understanding of pediatric Obstructive Sleep Apnea (OSA) in Majmaah, Saudi Arabia. While the majority of participants had intermediate awareness of OSA, a total of 75.6% of parents (moderate or poor knowledge) lacked a thorough grasp of its classification, symptoms, risk factors, and treatment choices. This lack of awareness increases the risk of delayed diagnosis and care, possibly increasing the negative consequences of OSA on children, including the neurological, cardiovascular, endocrine, and metabolic systems. This research emphasizes the critical need for focused educational programs to improve parents' understanding of pediatric OSA. Comprehensive awareness campaigns, seminars, and community-based interventions should be emphasized to provide parents with the information they need to recognize warning signals early on and seek proper medical treatment. Collaboration among healthcare professionals, schools, and local governments will be important in communicating this knowledge successfully. By raising parental awareness, early identification and care of paediatric OSA may be improved, reducing long-term health implications and improving the overall well-being of afflicted children. This research lays the groundwork for future attempts to address the public health issue presented by pediatric OSA in the area.

Funding

None

Conflict of Interest

The authors declare no conflict of interest.

Acknowledgments

The authors extend their gratitude to the Deanship of Scientific Research and the Deanship of Community Services at Majmaah University, Kingdom of Saudi Arabia, for their technical support.

References

1. Bitners AC, Arens R. Evaluation and Management of Children with Obstructive Sleep Apnea Syndrome. Lung. 2020;198(2):257-270. doi:10.1007/s00408-020-00342-5

1. Obstructive Sleep Apnea in Children (OSA). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/14312-obstructive-sleep-apnea-in-children

1. Alosaimi RM, Alqarni G, Musslem MT, et al. Knowledge and Awareness of Parents About Pediatric Obstructive Sleep Apnea in Jeddah: A Cross-Sectional Study. Cureus. 2023;15(5):e38960. Published 2023 May 13. doi:10.7759/cureus.38960

1. Chang SJ, Chae KY. Obstructive sleep apnea syndrome in children: Epidemiology, pathophysiology, diagnosis, and sequelae. Korean Journal of Pediatrics. 2010;53(10):863. doi:https://doi.org/10.3345/kjp.2010.53.10.863

1. Wang J, Zhao Y, Yang W, et al. Correlations between obstructive sleep apnea and adenotonsillar hypertrophy in children of different weight statuses. Sci Rep. 2019;9(1):11455. Published 2019 Aug 7. doi:10.1038/s41598-019-47596-5

1. Pediatric obstructive sleep apnea—symptoms and causes. Mayo Clinic. Published 2018. https://www.mayoclinic.org/diseases-conditions/pediatric-sleep-apnea/symptoms-causes/syc-20376196

1. Gouthro K, Slowik JM. Pediatric Obstructive Sleep Apnea. PubMed. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK557610/

1. Singer LP, Saenger P. Complications of pediatric obstructive sleep apnea. Otolaryngol Clin North Am. 1990;23(4):665-676.

1. Saran S, Saccomanno S, Viti S, et al. Analysis of General Knowledge on Obstructive Sleep Apnea Syndrome (OSAS) among Italian Pediatricians. Children. 2024;11(2):148-148. doi:https://doi.org/10.3390/children11020148

1. Alosaimi RM, Musslem MT, Filfilan FF, et al. Knowledge and Awareness of Parents Attending Pediatric Clinic Regarding Pediatric Obstructive Sleep Apnea in Jeddah: A Cross-Sectional Study. Cureus. 2023;15(2):e35339. Published 2023 Feb 22. doi:10.7759/cureus.35339

1. Bashir AF, Al-Ghamdi A, Alsaadi AS, AlQahtani BG, Alshihri SA, Alshahrani HA, Alshareef HF. Knowledge, and Awareness of Parents about pediatric obstructive sleep apnea in KSA, cross-section study, 2019. MIDDLE EAST JOURNAL OF FAMILY MEDICINE.;7(10):207.

1. Flemban R, Kutubkhana R, Alotaibi A, Alnajjar J, Alshaikh L, Alasmi R, Alzahrani K. Knowledge of Pediatric Obstructive Sleep Apnea among Parents in Saudi Arabia: Questionnaire-Based Study. Pharmacophore. 2023;723-8797.

1. Alosaimi, R. M., Musslem, M. T., Filfilan, F. F., Alqarni, G. S., Alazmi, E. A., Alghamdi, T. Y., ... & Filfilan Sr, F. F. (2023). Knowledge and awareness of parents attending pediatric clinic regarding pediatric obstructive sleep apnea in jeddah: a cross-sectional study. Cureus, 15(2).‏

1. DiNardo LA, Reese AD, Raghavan M, Seeley J, Pandit S, Behar P, Hassinger AB, Carr MM. Parental knowledge of obstructive sleep apnea symptoms and tonsillectomy in children. Annals of Otology, Rhinology & Laryngology. 2023 Jul;132(7):738-44.

1. Bitners AC, Arens R. Evaluation and management of children with obstructive sleep apnea syndrome. Lung. 2020 Apr;198(2):257-70.

1. Ioan I, Weick D, Schweitzer C, Guyon A, Coutier L, Franco P. Feasibility of parent-attended ambulatory polysomnography in children with suspected obstructive sleep apnea. Journal of Clinical Sleep Medicine. 2020 Jul 15;16(7):1013-9.

1. Saelim K, Uthairat M, Ruangnapa K, Prasertsan P, Anuntaseree W. Practice, self-confidence, and understanding of pediatric obstructive sleep apnea survey among pediatricians. The Turkish Journal of Pediatrics. 2021 Feb 25;63(1):68-76.

1. Kuti BP, Kuti DK. Is childhood obstructive sleep apnea properly taught in medical schools? An assessment of doctors' knowledge of obstructive sleep apnea. African Journal of Respiratory Medicine. 2017 Sep 1;13(1).

1. Andersen IG, Holm JC, Homøe P. Obstructive sleep apnea in children and adolescents with and without obesity. European Archives of Oto-Rhino-Laryngology. 2019 Mar 14;276:871-8.

1. McDowall PS, Elder DE, Campbell AJ. Relationship between parent knowledge of child sleep and child sleep practices and problems: a pilot study in a children's hospital cohort. Journal of Paediatrics and Child Health. 2017 Aug;53(8):788-93.