title: Clinical assessment of pediatric obstructive sleep apnea: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Clinical symptoms and signs are routinely used to investigate pediatric obstructive sleep apnea (OSA). This study aimed to systematically assess the evidence for the diagnostic accuracy of individual or combined clinical symptoms and signs in predicting pediatric OSA.
  
  
  METHODS
  A systematic review of the literature and diagnostic meta-analysis.
  
  
  METHODS
  Four medical databases were searched (from inception to August 2011). Studies were included that compared the clinical assessment with the current gold standard (full polysomnography). The study quality was assessed using the quality assessment tool for diagnostic accuracy studies. Summary estimates of diagnostic accuracy were determined using the sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and hierarchical summary receiver operating characteristic (HSROC) model for meta-analyses.
  
  
  RESULTS
  Ten diagnostic studies with 1,525 patients were included in the review. There was substantial variation in the sensitivity and specificity among different symptoms and signs, as well as across studies. Tonsillar size and snoring reported by parents or caregivers had high sensitivity but low specificity. In contrast, excessive daytime somnolence, observed apnea, and difficulty in breathing during sleep had high specificity but low sensitivity. Seven models of a combination of symptoms and signs presented moderate sensitivity (range, 0.04-0.94) and specificity (range, 0.28-0.99). The HSROC indicates poor diagnostic performance of the symptoms and signs in predicting pediatric OSA.
  
  
  CONCLUSIONS
  Neither single nor combined symptoms and signs have satisfactory performance in predicting pediatric OSA. Alternative diagnostic models are necessary to improve the accuracy.
authors.affiliation: Department of Otorhinolaryngology, Hospital Sao Sebastiao, Santa Maria da Feira, Portugal. victorcertal@gmail.com
authors.forename: Victor
authors.initials: V
authors.lastname: Certal
authors.forename: Emanuel
authors.initials: E
authors.lastname: Catumbela
authors.forename: João C
authors.initials: JC
authors.lastname: Winck
authors.forename: Inês
authors.initials: I
authors.lastname: Azevedo
authors.forename: Armando
authors.initials: A
authors.lastname: Teixeira-Pinto
authors.forename: Altamiro
authors.initials: A
authors.lastname: Costa-Pereira
mesh_terms: D002648:Child; D002675:Child, Preschool; D003955:Diagnostic Tests, Routine; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D010372:Pediatrics; D017286:Polysomnography / Q000379:methods*; D018570:Risk Assessment; D012720:Severity of Illness Index; D020181:Sleep Apnea, Obstructive / Q000175:diagnosis* / Q000453:epidemiology