Testing of the Czech questionnaire for identifying children at risk of obstructive sleep apnea 

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Compiling items from established English questionnaires and supplementing them with additional items, we designed the first version of the Czech questionnaire and tested it in a pilot study with parents of 30 children. After pilot feedback, a revised version with dichotomous and 5-item Likert scale questions was tested on another 70 children's parents. All children (7–12 years old) underwent a home sleep apnea test to record their apnea-hypopnea index (AHI). The second (40-item) version showed high reliability (93%), with 17 items identified as the most significant. Findings from the final 17-item SEN CZ questionnaire correlated positively with AHI (p < 0.001), demonstrating 84% sensitivity, 86% specificity, and 93% reliability. Three factors, namely breathing problems, inattention, and hyperactivity (characterized by multiple items), were identified to form a higher-order factor of POSA risk, which was further supported by the correlations of their total scores with AHI (p < 0.001). The resulting SEN CZ questionnaire can serve as a tool for POSA risk screening in the Czech Republic without the need to involve medical professionals. Health sciences/Diseases/Neurological disorders/Sleep disorders Health sciences/Diseases/Oral diseases questionnaire pediatric obstructive sleep apnea validation Likert scale apnea-hypopnea index risk factor Figures Figure 1 Figure 2 1. Introduction Although pediatric obstructive sleep apnea (POSA) was first described as soon as 1976, only in 2005 was this disorder listed separately from the adult form in the second International Classification of Sleep Disorders (ICSD-2) [ 1 , 2 ]. POSA may be affecting as much as 1–5% of the pediatric population, with the most significant contributing factors being obesity, adenotonsillar hypertrophy, allergic rhinitis, inflammatory factors, and abnormal craniofacial anatomy [ 1 , 2 ]. Considering the differences in symptoms of obstructive sleep apnea (OSA) in children and adults, it usually takes a well-trained and attentive physician to register the increased risk of the presence of this disorder. In developed countries, the awareness of OSA in adults is pretty good; the situation is, however, a bit more complicated when it comes to POSA. Multiple sleep scales for POSA have been developed, such as (but not limited to) the OSA Score, Sleep clinical record, OSA-18 questionnaire, and Pediatric Sleep Questionnaire (PSQ) with Sleep-Related Breathing Disorders Scale (SRBD scale) [ 2 – 7 ]. The OSA Score, i.e., the Obstructive Sleep Apnea Score, was created in 1984 by Brouilette et al . [ 3 ]. The questionnaire covers areas related to symptoms of upper airway obstruction, nocturnal habits, behavioral abnormalities, learning, and development. In 2013, Villa et al . created the Sleep Clinical Record, a questionnaire consisting of three parts: the first part of the questionnaire concerns information obtained in clinical examination of the orofacial area, the second part collects the subjective symptoms of the patient, and the third part investigates the clinical history focused on symptoms of inattention and hyperactivity. This questionnaire was tested on 279 children and yielded a sensitivity of 96% [ 6 ]. The OSA-18 questionnaire, as its name already suggests, consists of 18 items [ 7 ] focusing on the quality of life in association with sleep-disordered breathing in children and on the subjective perception of the disorder. Chervin et al . developed the Pediatric Sleep Questionnaire and, within its scope, they have also designed the Sleep-Related Breathing Disorders scale (SRBD scale), which covers three basic areas of symptoms related to POSA [ 4 , 5 ]. Based on a meta-analysis published in 2020 [ 8 ] comparing the PSQ, OSA-18, and pulse oximetry, the PSQ was found to be the tool with the highest sensitivity for screening mild POSA. In patients with moderate and severe POSA, however, sensitivities of PSQ and pulse oximetry were comparable. Therefore, a combination of PSQ and pulse oximetry was recommended for early detection of POSA in children [ 8 ]. A review study identified the PSQ to be the only diagnostically sufficiently accurate questionnaire for screening of impaired breathing in children, and, at the same time, emphasized the importance and benefit of the involvement of dentists in primary screening of POSA [ 9 ]. In the Czech Republic, the Epworth Sleepiness Scale [ 10 ] is the most commonly used questionnaire for OSA screening; it, however, should be used only for adult patients. Even though there are several questionnaires used by specialists for screening disturbed sleep in children worldwide, no official pediatric sleep questionnaire has been introduced in the Czech Republic so far (not even an official translation of international questionnaires into Czech language). The main aim of this study was to create a questionnaire in Czech language that could detect the increased risk of POSA and at the same time would: i) be complex and reflect the multifactorial etiology of POSA, ii) be short and quick to fill in, iii) be easy to understand and complete by doctors with different specializations as well as by parents/caregivers of the child, iv) be used without the need to include clinical parameters or examination results, and v) have sensitivity and specificity comparable with reputable pediatric sleep questionnaires. 2. Methods The process of developing a Czech questionnaire for identifying children at risk of obstructive SleEp apNea, so called SEN CZ, is described in detail in the Supplementary Methods and Results and illustrated also in the workflow scheme (see Fig. 1 ). The process also included a pilot study and testing of the SEN CZ (version 1 and version 2, respectively). SEN CZ was designed to primarily address the symptoms of POSA (both night and day symptoms) and their frequency. Our intention was to avoid the necessity of incorporating clinical parameters or examination results in the questionnaire items. The questionnaire specificity and sensitivity assessment were evaluated using the result of the home sleep apnea test (HSAT). The Supplementary Methods and Results also include the detailed description of participants enrolled in this study and the clinical examinations that they underwent. This study was approved by St. Anne’s University Hospital Ethics Committee (33V/2020; 10th June, 2020). The informed consent was obtained from all parents or legal guardians (hereinafter referred to as parents) of every child prior to their inclusion in the study, in line with the Helsinki Declaration. 3. Results 3.1. Demographic and clinical characteristics of children enrolled in the study In total, 100 child-parent pairs were enrolled in this study. Of the children, 43 were boys and 57 girls, all aged 7 to 12 years (mean age ± standard deviation, 9.6 ± 1.7 years). BMI categorization was determined based on the z-score: 7% of the children were underweight, 66% normal, 22% of the children had an increased risk of being overweight, and 5% were overweight. Based on the data, only 32 children out of 100 were found to have the physiological finding of AHI (i.e. AHI < 1). 61% of children fell within the category of AHI ≥ 1 to < 5, indicating mild POSA. 7% of the children had an AHI within the range of ≥ 5 to < 10, indicating the moderate form of POSA; and no children enrolled in the study had a severe form of POSA (AHI ≥ 10). The demographic description of the enrolled children is presented in Table 1 . Table 1 Characteristics of the 100 children enrolled in the pilot study and testing of the SEN CZ Characteristic All children N = 100 Subgroup for testing of the SEN CZ ver. 2 N = 70 (%) Sex (male) 43 36 (51.4) Average age (± SD) in years BMI in the norm AHI < 1; physiological finding AHI ≥ 1 to < 5; mild POSA AHI ≥ 5 to 4 mm Skeletal class I according to the ANB angle Neutral growth according to the SN-ML angle Presence of tooth agenesis(s) The presence of orthodontic dental anomaly 9.6 ± 1.7 66 32 61 7 0 73 79 47 60 53 8 99 9.6 ± 1.7 49 (70.0) 18 (25.7) 50 (71.4) 2 (2.9) 0 50 (71.4) 59 (84.3) 34 (48.6) 40 (57.1) 41 (58.6) 7 (10.0) 70 (100) Adenoidectomy 24 13 (18.6) N, number; SD, standard deviation; BMI, body mass index; AHI, apnea-hypopnea index based on polygraphy examination; ANB, the angle between the point A, nasion and point B; SEN CZ, Czech questionnaire for identifying children at risk of obstructive sleep apnea; SN-ML, the angle of craniometric bases 3.2. Characteristics of the different versions of the SEN CZ Characteristics of the different versions of the SEN CZ are shown in Table 2 and in detail described in Supplementary Methods and Results. The results of the partial steps of the SEN CZ genesis are shown in the Supplementary Table S1 . The SEN CZ questionnaire is presented in Fig. 2 ; the non-tested English version is in Supplementary Figure S1 . Table 2 Sensitivity and specificity of the SEN CZ Questionnaire Total N of questions/N of questions used for the analysis of sensitivity and specificity Sensitivity Specificity SEN CZ ver. 1 38/28 76% 86% SEN CZ ver. 2 40/32 80% 86% SEN CZ 17 84% 86% N, number; SEN CZ, Czech questionnaire for identifying children at risk of obstructive sleep apnea 3.3. Identification of key clinical and behavioral factors and their correlations with AHI Subsequently, we continued with explorative factor analysis and performed the analysis of the final SEN CZ on 70 child-parent pairs. While the Kaiser criterion suggests considering three factors, the sum of the squares of the factor loadings suggests inferring a maximum of five factors. Therefore, we decided to continue with the exploratory factor analysis up to five factors. As we did not find any outliers, we used the ML estimator. Simultaneously, we chose the oblimin rotation due to the assumption that the factors may intercorrelate. To evaluate the model fit, we monitored the change of the following fit indices: χ 2 , TLI and RMSEA [ 11 ], see Supplementary Table S2 . The fit indices provide a sufficient fit with two interrelated factors (breathing and neurobehavioral problems) and satisfactory fit with three interrelated factors (breathing problems, inattention, and hyperactivity). This shows that there may be three symptomatic factors which together create a higher-order factor of POSA risk. The validity of these three factors was further supported by the correlations of their total scores with AHI in Table 3 . We also provide the correlation of the SEN CZ with AHI for comparison. Moreover, each of the three factors also achieves high reliability, see Table 3 . More details are described and shown in Supplementary Methods and Results, Supplementary Table S3 and Table S4 . Table 3 Correlation of the individual factors with the total score of SEN CZ and AHI rAHI rSEN CZ Reliability SEN CZ ver. 1 total score 0.71 - 0.91 SEN CZ ver. 2 total score 0.69 - 0.93 SEN CZ total score 0.72 - 0.93 Breathing problems 0.58 0.83 0.89 Inattention 0.73 0.92 0.90 Hyperactivity 0.61 0.86 0.83 AHI, apnea-hypopnea index; CZ, Czech language; r, correlation coefficient; rAHI, correlation with AHI; rSEN CZ, correlation with SEN CZ total score; SEN CZ, Czech questionnaire for identifying children at risk of obstructive sleep apnea All correlations reach p < 0.001. 3.4. Prediction of the POSA risk based on the SEN CZ total score To further evaluate the ability of the SEN CZ to predict the increased POSA risk, we performed a logistic regression – analysis of the relationship between one or more existing independent variables (such as the SEN CZ total score, POSA risk according to AHI). After verification that our data meet the assumptions of logistic regression, we proceeded to the analysis itself. In the first step, we entered the total score from the questionnaire into the regression, and in the second, we entered the control variables age and maxillary constriction, see Table 4 . Table 4 Logistic regression of the total score of the SEN CZ and the risk of POSA according to AHI B SE Wald Exp(B) Exp(B) 95% CI Model 0 Constant 0.80* 0.26 9.74 2.23 Model 1 Constant -4.92** 1.38 12.70 0.01 POSA risk 0.18** 0.05 15.21 1.20 [1.09; 1.31] Model 2 Constant -4.63 3.08 2.26 0.01 Age -0.03 0.24 0.02 0.97 [0.61; 1.54] Maxillary constriction > 4 mm 0.07 0.19 0.14 1.07 [0.74; 1.55] POSA risk 0.17** 0.05 12.16 1.19 [1.08; 1.31] * p < 0.01, ** p < 0.001 AHI, apnea-hypopnea index; POSA risk, the risk of pediatric obstructive sleep apnea (according to the SEN CZ total score); B, coefficient B; SE, standard error; Wald’s test; Exp(B), exponential function of the coefficient B; SEN CZ, Czech questionnaire for identifying of children at risk of obstructive sleep apnea; Model 0; model without predictors; Model 1, model takes into account the predictor (score of the questionnaire as a predictor of POSA risk); Model 2; model takes into account the predictor (score of the questionnaire as a predictor of POSA risk) and other intervening variables Model 1, considering the SEN CZ score as a predictor, was statistically significant compared to the null model (χ 2 (1) = 29.79, p < 0.001) and explained 48% of the variance (Nagelkerke R 2 ) of POSA risk. Model 2, considering the SEN CZ score and potential intervening variables, did not significantly improve the fit of the original model (Nagelkerke R 2 = 0.49, χ 2 (3) = 29.98, p < 0.001). Therefore, we continued to work with Model 1. Model 1 yielded sensitivity of 86%, specificity of 77%, and classification accuracy of 83% at a cut-off value corresponding to a 50% probability of finding POSA. The increasing score in the SEN CZ significantly predicted the diagnosis of the disease, thus meeting the criterion validity of the questionnaire. The regression that illustrates this relationship corresponds to the expression logit(POSA)=-4.92 + 0.18*A where parameter A is the total sum score in the questionnaire. We may convert this logit using an exponential function to get the odds of POSA risk. Therefore, if the child reaches a score of 40 in the SEN CZ according to the parent's report, the chance (odds of POSA = exp(logit(POSA))) that this child would be diagnosed with POSA in polygraphy is 9.78 to 1. Therefore, we have a roughly 91% probability of finding POSA in this child. A 50% probability of finding POSA risk approximately corresponds to the score of 23 in the SEN CZ. Using the cut-off value for mild, moderate, and severe POSA according to AHI, the approximate cutoff values in the SEN CZ itself can be determined based on the linear regression of AHI on the SEN CZ score. This relationship can be expressed by the equation POSA = 23.98 + 6.11*A. AHI values above 1 (mild POSA), therefore, correspond to SEN CZ score above 30.09. The calculated SEN CZ total score cut-off values for POSA risk assessment are shown in Table 5 . However, the given cut-off values should be considered with a grain of salt due to the sample size, exploratory factor analysis, possible measurement error and the pilot nature of the research. If we also adjust the logistic regression according to the cut-off value of at least mild POSA (31; 66% probability of finding), the model correctly determines 85% of cases, while the sensitivity is 84% and the specificity is 86%. Although there is an improvement in specificity, this result also indicates the need for a larger sample with a sufficient representation of the healthy population (here, according to the AHI cut-off value, N = 22). Table 5 Cut-off scores in the SEN CZ for POSA risk prediction according to AHI SEN CZ total score AHI < 1; physiological finding [1; 30] AHI ≥ 1 to < 5; mild POSA [31; 54] AHI ≥ 5 to < 10; moderate POSA [55; 84] AHI ≥ 10; severe POSA 85 AHI, apnea-hypopnea index; POSA, pediatric obstructive sleep apnea; SEN CZ, Czech questionnaire for identifying children at risk of obstructive sleep apnea 4. Discussion In this pilot study, our multidisciplinary team created a Czech questionnaire for identifying children at risk of POSA. This is the very first such questionnaire originally designed in the Czech language and tested in the Czech population. Examinations such as PSG or polygraphy are known to have a good diagnostic ability to reveal POSA; however, given the lack of and workload of sleep laboratories for children and specialists in this area in the Czech Republic, these examinations are often inaccessible. In view of the fact that early diagnosis and proper treatment are crucial in children suffering from POSA, an ideal screening tool that could reveal the need for these examinations, should not be only easy to use and interpret but, most importantly, widely accessible. The use of a sleep questionnaire focusing on children can be a workable way to improve the early detection of POSA risk. Considering the fact that several pediatric sleep questionnaires abroad2-7, we initially wanted to simply translate a highly evaluated questionnaire and adapt it from English to Czech. We searched the literature and based on several studies, including a recent meta-analysis published by Wu et al ., we have chosen the PSQ as it was found to have the highest screening sensitivity for detecting mild POSA and sensitivity comparable to pulse oximetry in patients with moderate and severe forms of POSA [ 8 ]. Based on these results, the authors recommended a combination of PSQ and pulse oximetry for early detection of POSA [ 8 ]. Another review identified the PSQ as the only questionnaire that is diagnostically accurate enough to screen for impaired breathing in children, while also highlighting the importance and benefit of involving dentists in the primary screening of POSA [ 9 ]. However, after the translation and adapting PSQ-SRBD scale4 in collaboration with a multidisciplinary team of professionals and experts from different medical fields associated with pediatric sleep medicine in the Czech Republic, we agreed on the fact that a simple translation would not be sufficient. We considered also the cultural differences and differences in the structure of sentences in both Czech and English languages and their exact meaning and decided to take further steps and design a questionnaire for identifying POSA risk for Czech users, which we named SEN CZ. After preliminary testing of SEN CZ ver. 1, we proceeded to further improve it to produce SEN CZ ver. 2, which has already achieved very good results (Cronbach's α = 0.928); however, it was quite lengthy, and we have decided to shorten it as much as possible. The final version of the SEN CZ kept the good sensitivity and specificity, as well as reliability but contains less than half the items compared with the SEN CZ ver. 2, making it more user-friendly. In the context of sensitivity and specificity, the performance of the final version of the SEN CZ is very good, comparable with the best sleep questionnaires included in the meta-analysis by Wu et al . [ 8 ]. In our questionnaire, we originally intended to keep dichotomous items for the simplicity of assessment; however, to detect the behavior in children, the use of Likert scale is often preferred to dichotomous questions (yes/no/unknown) [ 12 ]. For screening purposes, it is better if we capture the answer on a scale rather than dichotomously as it is more accurate. The majority of the items in the final version of the SEN CZ cover very similar areas of POSA symptoms as items in foreign pediatric sleep questionnaires [ 2 – 7 ]. This supports their importance as factors contributing to this disease. In our questionnaire, based on the results of the validation, we have excluded several items associated with the nocturnal symptoms due to their high difficulty for parents. Even though snoring and difficulty breathing during sleep are probably most common complaint voiced by parents of children with POSA [ 13 ], more recent studies reported that parents were able to report snoring in only 15% of children diagnosed with POSA [ 14 , 15 ]. These findings are suggestive of the fact that parents may often fail to notice the nocturnal symptoms, especially if the children have a separate room, or if not enough attention is paid to this problem. In our questionnaire, a lot of items are focused on the area of daytime symptoms. For example, in the case of nasal obstruction and adenotonsillar hypertrophy, a transition to mouth breathing occurs, which subsequently affects changes in the orofacial region, such as the narrow hard palate, posteriorotation of the mandible and/or disproportions in the sagittal plane, as well as the elongation of the lower third of the face, which can be expressed in varying degrees and forms [ 16 , 17 ]. These features may present risk factors for the development of POSA; moreover, mouth breathing preference has been identified as an early contributor to SRBD that can be often found in primary snorers and patients with POSA [ 18 , 19 ]. At the same time, these contributing factors may be, compared to nocturnal symptoms, easily detectable also by parents, which makes them important for screening. Interrupted sleep and nocturnal hypoxia affect, among other things, the prefrontal cortex and thus the cognitive executive functions of the individual [ 20 ]. Affected children have impairments in planning, plan execution, organization, decision-making, and information processing. These factors, together with impaired attentional retention, impaired concentration, impulsivity, hyperactivity, and emotional lability, often cause errors of inattention and impaired school performance [ 21 – 23 ]. Children with POSA also tend to have increased irritability (or even aggression) and may show disinterest in daily activities and tendencies to depression. It has even been suggested that sleep disruption and difficulty in early childhood may predict behavioral and emotional problems during adolescence [ 24 ]. There is also evidence of a significant association between reduced or disturbed sleep and the severity of behavioral changes. Studies also suggest that children presenting with POSA display symptoms of attention deficit and hyperactivity disorder (ADHD) more often than those without it [ 25 , 26 ]. Most studies agree on a bidirectional association between POSA and ADHD [ 27 ]. The results of the factor analysis and logistic regression indicate that the SEN CZ is slightly more likely to recommend a comprehensive POSA examination when it is not needed than to fail to recommend an examination when it should be performed. Given the screening nature of the questionnaire, this is a very good result. Moreover, the SEN CZ could be also a good predictor of ADHD. Therefore, it might be useful to continue the research with data obtained from children diagnosed with ADHD. We may then be able to analyze which items discriminate well between POSA and ADHD (i.e., identify questions in which parents of children with POSA score significantly differently than parents of children with ADHD). Even though according to the latest AASM guidance, PSG is the gold standard for diagnosing pediatric sleep disorders [ 28 ] it may not be readily available in all clinical settings. In our study, we encountered practical challenges in accessing PSG for children due to its limited availability in the Czech Republic and long waiting times. In light of these limitations and considering that HSAT is recommended as a screening tool before the referral for PSG, when applied under controlled settings by sleep specialist [ 29 , 30 ] we opted for including HSAT, polygraphy, as a part of our validation process. Important fact is also that SEN CZ should only be used as the first alert of generally disturbed nocturnal breathing with recommendation for further examinations, not to serve as a replacement for any sleep-monitoring or as a precise diagnostic tool. 5. Conclusion We have designed and validated the SEN CZ questionnaire for screening of POSA risk reflecting the multifactorial etiology of this disease. Our questionnaire with 17 items and a 5-item Likert scale is the first tested questionnaire for identifying children at risk of POSA in the Czech language and could be filled in not only by doctors of different specializations but also by parents/caregivers of the children. It performs excellently, achieving high reliability and high correlation with AHI as an objective criterion for the POSA diagnosis, and shows comparable sensitivity and specificity to the already existing foreign pediatric sleep questionnaires. Declarations Author contribution Z.M.V. and P.B.L. designed the study, provided interpretation of results, and drafted the paper; Z.M.V. was responsible for the clinical part of the study; T.K. provided data analysis; M.P.V. critically reviewed the manuscript. All authors revised the final version of the manuscript. Each author made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or have drafted the work or substantively revised it. Acknowledgments We thank Prof. Ronald Chervin for the revision of the manuscript and his valuable comments. We thank the pediatric neurologist Iva Prihodova, pediatric ENT specialists Martina Ondrova and Pavel Hornik, a pneumologist Pavel Turcani for the cooperation and revisions in the development of SEN CZ. We thank Jaroslav Janosek for his help with the translation of questionnaires and valuable comments. We thank Pavel Hornik also for the ENT examinations of children enrolled in the study and the Cardiovascular sleep laboratory in Brno, Czech Republic, for external consultations and assistance with the analysis of polygraphy data. Disclosure Statement This work was supported by the project provided by the University Hospital Brno, Ministry of Health of the Czech Republic – RVO (FNBr, 65269705). This work was supported from the European Union’s Horizon 2020 research and innovation program under grant agreement No 857560. This publication reflects only the author´s view and the European Commission is not responsible for any use that may be made of the information it contains. Authors also thank the Research Infrastructure RECETOX RI (No LM2023069, MEYS CR) and the project CETOCOEN EXCELLENCE (No CZ.02.1.01/0.0/0.0/17_043/0009632) financed by the Ministry of Education, Youth, and Sports for supportive background. Availability of data and materials The data of the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate The study was performed with the approval of the Ethics Committee of the St. Anne’s Faculty Hospital (No. 33V/2020; date: 10th June, 2020). Written informed consent was obtained from all parents or caregivers of participating children in line with the Declaration of Helsinki before inclusion in the study. Competing interests The authors declare that they have no competing interests. References Xu, Z. et al . Risk factors of obstructive sleep apnea syndrome in children. J. Otolaryngol. Head Neck Surg . 49 (1) , 11; 10.1186/s40463-020-0404-1 (2020). Gulotta, G. et al . Risk factors for obstructive sleep apnea syndrome in children: state of the art. Int. J. Environ. Res. Public Health . 16 (18) , 3235; 10.3390/ijerph16183235 (2019). Brouilette, R. et al . 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Sleep Med. Rev . 10 (2) , 97-107; 10.1016/j.smrv.2005.10.002 (2006). Youssef, N. A., Ege, M., Angly, S. S., Strauss, J. L., Marx, C. E. Is obstructive sleep apnea associated with ADHD?. Ann. Clin. Psychiatry . 23 (3) , 213-224 (2011). Urbano, G. L., Tablizo, B. J., Moufarrej, Y., Tablizo, M. A., Chen, M. L., Witmans, M. The link between pediatric obstructive sleep apnea (osa) and attention deficit hyperactivity disorder (ADHD). Children (Basel) . 8 (9) , 824; 10.3390/children8090824 (2021). Berry, R. B. et al . Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J. Clin. Sleep Med . 8 (5) , 597-619; 10.5664/jcsm.2172 (2012). Delesie, M. et al . Polygraphy as a new screening method for obstructive sleep apnea in patients with atrial fibrillation? European Heart Journal . 42 (Supplement_1) , 10.1093/eurheartj/ehab724.0585 (2021). Revana, A., Vecchio, J., Guffey, D., Minard, C. G., Glaze, D. G. Clinical application of home sleep apnea testing in children: a prospective pilot study. J. Clin. Sleep Med . 18 (2) , 533-540; 10.5664/jcsm.9650 (2022). Additional Declarations No competing interests reported. Supplementary Files SupplementaryFigureS1.pdf Supplementary Figure S1. Questionnaire for identifying children at risk of obstructive sleep apnea (SEN CZ) in the English language SupplemetaryTableS1.pdf Supplementary Table S1. Genesis of the Czech questionnaire for identifying children at risk of obstructive sleep apnea (SEN CZ) – inclusion and exclusion of items SupplemetaryTableS2.pdf Supplementary Table S2. Descriptive statistics of the Czech questionnaire for identifying children at risk of obstructive sleep apnea (SEN CZ) ver. 2 SupplementaryTableS3.pdf Supplementary Table S3. Model fit of factor analysis of POSA SupplementaryTableS4.pdf Supplementary Table S4. Factor loadings in the SEN CZ questionnaire based on 2 and 3 factors SupplementaryMethodsandResults..docx Supplementary Methods and Results Cite Share Download PDF Status: Published Journal Publication published 15 Aug, 2024 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 23 Jul, 2024 Reviews received at journal 21 Jul, 2024 Reviewers agreed at journal 15 Jul, 2024 Reviews received at journal 14 Jul, 2024 Reviewers agreed at journal 12 Jul, 2024 Reviewers invited by journal 11 Jul, 2024 Editor assigned by journal 11 Jul, 2024 Editor invited by journal 11 Jul, 2024 Submission checks completed at journal 10 Jul, 2024 First submitted to journal 09 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4713475","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":330586626,"identity":"c4fca138-6874-4e5f-b2c7-bd495d6d46f6","order_by":0,"name":"Zuzana Marincak Vrankova","email":"","orcid":"","institution":"Clinic of Stomatology, St. Anne´s University Hospital, Pekarska 53, 656 91, Brno","correspondingAuthor":false,"prefix":"","firstName":"Zuzana","middleName":"Marincak","lastName":"Vrankova","suffix":""},{"id":330586628,"identity":"c5f1ff77-02ae-4afa-bc34-f24f6cdef5dd","order_by":1,"name":"Tomas Kratochvil","email":"","orcid":"","institution":"Faculty of Social Studies, Masaryk University, Jostova 218, 60200, Brno","correspondingAuthor":false,"prefix":"","firstName":"Tomas","middleName":"","lastName":"Kratochvil","suffix":""},{"id":330586631,"identity":"68d0d312-a33f-4e0b-9fd3-4b631cc0c999","order_by":2,"name":"Maria Pia Villa","email":"","orcid":"","institution":"Pediatric Sleep Disease Center, Child Neurology, NESMOS Department, School of Medicine and Psychology, S. Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035-39, 00189 Rome","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Pia","lastName":"Villa","suffix":""},{"id":330586633,"identity":"491cb80d-9457-4cbf-b051-9909a2fc2400","order_by":3,"name":"Petra Borilova Linhartova","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABLklEQVRIie2QMUvDQBSAXziIy0E3uZCif+HkIDFwmr9y4SAu3QTJWBCcAlkj+COEQuaEQKfgXHCwUnByiBQkQweTRiVNWmeH++Aex7338d49AIXi/3KOgXxfRzsJsa8aNYG0SlofY9ot/UOBX4WmB0tb7KNoXlZAxrZ5+7Yug/yUPedZ+VFxb3pcWMslXLo9xQlzdB/WgzkPcxanRX6WPPnSiIXPwJzYVIBEPYUu6qf6I5guBIPszteSAlsIi/ykViwiINX7yssKaZutcrVuFHcWjj7RRuT4R8GDLgihtsuk6cK9R4x1BJ0upKc4oWRoTLfKNRQFl3GhMyP0faab/g0RVNLBxrKV9h5wtx5sBkFALqIQvZYV515kysSogsHGaCf20A+k9hYrFAqFYocvh+hh5RhRF5MAAAAASUVORK5CYII=","orcid":"","institution":"Clinic of Maxillofacial Surgery, University Hospital Brno, Jihlavska 20, 625 00, Brno","correspondingAuthor":true,"prefix":"","firstName":"Petra","middleName":"Borilova","lastName":"Linhartova","suffix":""}],"badges":[],"createdAt":"2024-07-09 16:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4713475/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4713475/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-69958-4","type":"published","date":"2024-08-15T15:58:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62157506,"identity":"2c2e33cb-2d50-4afd-b778-122b19b301bd","added_by":"auto","created_at":"2024-08-09 21:18:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":533986,"visible":true,"origin":"","legend":"\u003cp\u003eWorkflow of the Czech questionnaire for identifying children at risk of obstructive sleep apnea (SEN CZ) development\u003c/p\u003e\n\u003cp\u003eAHI, apnea-hypopnea index; CZ, Czech language; EN, English language; *The items were excluded if: i) they did not use the Likert scale, ii) they had uniform distribution and, thus, low discriminatory power, iii) they were difficult to answer for the responders, iv) they had a weak correlation with AHI (r\u0026lt; 0.2), v) they had a weak correlation with the total score of the questionnaire, vi) another item related to the same symptom had a higher discriminatory power, and/or vii) their contribution to creating the shortest yet functional screening was considered insufficient.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4713475/v1/2f7e57492fe1a3811018738f.png"},{"id":62157511,"identity":"87b5f4ec-8695-411d-be4c-61a6c11cd4bf","added_by":"auto","created_at":"2024-08-09 21:18:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1204710,"visible":true,"origin":"","legend":"\u003cp\u003eCzech questionnaire for identifying children at risk of obstructive sleep apnea (SEN CZ)\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4713475/v1/7c81c9db208328d489d914d5.png"},{"id":63071403,"identity":"0a603188-13fe-4ff6-be55-40538ae7e47f","added_by":"auto","created_at":"2024-08-22 20:06:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2307738,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4713475/v1/e1b45aab-a7f0-4273-bcf1-bcbe5db23239.pdf"},{"id":62157510,"identity":"fb448e3c-45a9-4b01-b52d-07413a0e4c26","added_by":"auto","created_at":"2024-08-09 21:18:56","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":728960,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Figure S1. \u003c/strong\u003eQuestionnaire for identifying children at risk of obstructive sleep apnea (SEN CZ) in the English language\u003c/p\u003e","description":"","filename":"SupplementaryFigureS1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4713475/v1/04df665887a0c03f25f16da0.pdf"},{"id":62157509,"identity":"52d9a058-0b9c-4804-a516-dec8a1948a8d","added_by":"auto","created_at":"2024-08-09 21:18:56","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":71566,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Table S1. \u003c/strong\u003eGenesis of the Czech questionnaire for identifying children at risk of obstructive sleep apnea (SEN CZ) – inclusion and exclusion of items\u003c/p\u003e","description":"","filename":"SupplemetaryTableS1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4713475/v1/f473d4e639906dff9b357d47.pdf"},{"id":62157508,"identity":"5612d7ec-a2bd-4b11-8a72-a6eee4f9efe2","added_by":"auto","created_at":"2024-08-09 21:18:56","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":68019,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Table S2. \u003c/strong\u003eDescriptive statistics of the Czech questionnaire for identifying children at risk of obstructive sleep apnea (SEN CZ) ver. 2\u003c/p\u003e","description":"","filename":"SupplemetaryTableS2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4713475/v1/cf17ef7f8d3877e0a76995b2.pdf"},{"id":62157965,"identity":"c1675b19-ddab-4bd2-9a63-0068a3044579","added_by":"auto","created_at":"2024-08-09 21:26:56","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":287080,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Table S3.\u003c/strong\u003e Model fit of factor analysis of POSA\u003c/p\u003e","description":"","filename":"SupplementaryTableS3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4713475/v1/a28b42be5f6b5bfb0ba058b5.pdf"},{"id":62157513,"identity":"23e36c77-8413-4930-bbd4-fdcd45ff1764","added_by":"auto","created_at":"2024-08-09 21:18:56","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":198184,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Table S4.\u003c/strong\u003e Factor loadings in the SEN CZ questionnaire based on 2 and 3 factors\u003c/p\u003e","description":"","filename":"SupplementaryTableS4.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4713475/v1/074aac533c2e5c9c5df6e95d.pdf"},{"id":62157512,"identity":"45773f73-8344-4ee8-ad8b-eb287ccbd77b","added_by":"auto","created_at":"2024-08-09 21:18:56","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":40456,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Methods and Results\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"SupplementaryMethodsandResults..docx","url":"https://assets-eu.researchsquare.com/files/rs-4713475/v1/ee7155c13fe463f79adf93de.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Testing of the Czech questionnaire for identifying children at risk of obstructive sleep apnea ","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAlthough pediatric obstructive sleep apnea (POSA) was first described as soon as 1976, only in 2005 was this disorder listed separately from the adult form in the second International Classification of Sleep Disorders (ICSD-2) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. POSA may be affecting as much as 1\u0026ndash;5% of the pediatric population, with the most significant contributing factors being obesity, adenotonsillar hypertrophy, allergic rhinitis, inflammatory factors, and abnormal craniofacial anatomy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Considering the differences in symptoms of obstructive sleep apnea (OSA) in children and adults, it usually takes a well-trained and attentive physician to register the increased risk of the presence of this disorder.\u003c/p\u003e \u003cp\u003eIn developed countries, the awareness of OSA in adults is pretty good; the situation is, however, a bit more complicated when it comes to POSA. Multiple sleep scales for POSA have been developed, such as (but not limited to) the OSA Score, Sleep clinical record, OSA-18 questionnaire, and Pediatric Sleep Questionnaire (PSQ) with Sleep-Related Breathing Disorders Scale (SRBD scale) [\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe OSA Score, i.e., the Obstructive Sleep Apnea Score, was created in 1984 by Brouilette \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The questionnaire covers areas related to symptoms of upper airway obstruction, nocturnal habits, behavioral abnormalities, learning, and development. In 2013, Villa \u003cem\u003eet al\u003c/em\u003e. created the Sleep Clinical Record, a questionnaire consisting of three parts: the first part of the questionnaire concerns information obtained in clinical examination of the orofacial area, the second part collects the subjective symptoms of the patient, and the third part investigates the clinical history focused on symptoms of inattention and hyperactivity. This questionnaire was tested on 279 children and yielded a sensitivity of 96% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe OSA-18 questionnaire, as its name already suggests, consists of 18 items [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] focusing on the quality of life in association with sleep-disordered breathing in children and on the subjective perception of the disorder. Chervin \u003cem\u003eet al\u003c/em\u003e. developed the Pediatric Sleep Questionnaire and, within its scope, they have also designed the Sleep-Related Breathing Disorders scale (SRBD scale), which covers three basic areas of symptoms related to POSA [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on a meta-analysis published in 2020 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] comparing the PSQ, OSA-18, and pulse oximetry, the PSQ was found to be the tool with the highest sensitivity for screening mild POSA. In patients with moderate and severe POSA, however, sensitivities of PSQ and pulse oximetry were comparable. Therefore, a combination of PSQ and pulse oximetry was recommended for early detection of POSA in children [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A review study identified the PSQ to be the only diagnostically sufficiently accurate questionnaire for screening of impaired breathing in children, and, at the same time, emphasized the importance and benefit of the involvement of dentists in primary screening of POSA [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the Czech Republic, the Epworth Sleepiness Scale [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] is the most commonly used questionnaire for OSA screening; it, however, should be used only for adult patients. Even though there are several questionnaires used by specialists for screening disturbed sleep in children worldwide, no official pediatric sleep questionnaire has been introduced in the Czech Republic so far (not even an official translation of international questionnaires into Czech language).\u003c/p\u003e \u003cp\u003eThe main aim of this study was to create a questionnaire in Czech language that could detect the increased risk of POSA and at the same time would: i) be complex and reflect the multifactorial etiology of POSA, ii) be short and quick to fill in, iii) be easy to understand and complete by doctors with different specializations as well as by parents/caregivers of the child, iv) be used without the need to include clinical parameters or examination results, and v) have sensitivity and specificity comparable with reputable pediatric sleep questionnaires.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThe process of developing a Czech questionnaire for identifying children at risk of obstructive SleEp apNea, so called SEN CZ, is described in detail in the Supplementary Methods and Results and illustrated also in the workflow scheme (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The process also included a pilot study and testing of the SEN CZ (version 1 and version 2, respectively). SEN CZ was designed to primarily address the symptoms of POSA (both night and day symptoms) and their frequency. Our intention was to avoid the necessity of incorporating clinical parameters or examination results in the questionnaire items. The questionnaire specificity and sensitivity assessment were evaluated using the result of the home sleep apnea test (HSAT).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe Supplementary Methods and Results also include the detailed description of participants enrolled in this study and the clinical examinations that they underwent. This study was approved by St. Anne\u0026rsquo;s University Hospital Ethics Committee (33V/2020; 10th June, 2020). The informed consent was obtained from all parents or legal guardians (hereinafter referred to as parents) of every child prior to their inclusion in the study, in line with the Helsinki Declaration.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Demographic and clinical characteristics of children enrolled in the study\u003c/h2\u003e \u003cp\u003eIn total, 100 child-parent pairs were enrolled in this study. Of the children, 43 were boys and 57 girls, all aged 7 to 12 years (mean age\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, 9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 years). BMI categorization was determined based on the z-score: 7% of the children were underweight, 66% normal, 22% of the children had an increased risk of being overweight, and 5% were overweight.\u003c/p\u003e \u003cp\u003eBased on the data, only 32 children out of 100 were found to have the physiological finding of AHI (i.e. AHI\u0026thinsp;\u0026lt;\u0026thinsp;1). 61% of children fell within the category of AHI\u0026thinsp;\u0026ge;\u0026thinsp;1 to \u0026lt;\u0026thinsp;5, indicating mild POSA. 7% of the children had an AHI within the range of \u0026ge;\u0026thinsp;5 to \u0026lt;\u0026thinsp;10, indicating the moderate form of POSA; and no children enrolled in the study had a severe form of POSA (AHI\u0026thinsp;\u0026ge;\u0026thinsp;10). The demographic description of the enrolled children is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the 100 children enrolled in the pilot study and testing of the SEN CZ\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll children\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;100\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubgroup for testing of the SEN CZ ver. 2\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;70 (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (51.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage age (\u0026plusmn;\u0026thinsp;SD) in years\u003c/p\u003e \u003cp\u003eBMI in the norm\u003c/p\u003e \u003cp\u003eAHI\u0026thinsp;\u0026lt;\u0026thinsp;1; physiological finding\u003c/p\u003e \u003cp\u003eAHI\u0026thinsp;\u0026ge;\u0026thinsp;1 to \u0026lt;\u0026thinsp;5; mild POSA\u003c/p\u003e \u003cp\u003eAHI\u0026thinsp;\u0026ge;\u0026thinsp;5 to \u0026lt;\u0026thinsp;10; moderate POSA\u003c/p\u003e \u003cp\u003eAHI\u0026thinsp;\u0026ge;\u0026thinsp;10; severe POSA\u003c/p\u003e \u003cp\u003eMouth breathing preference\u003c/p\u003e \u003cp\u003ePhysiological sublingual frenulum\u003c/p\u003e \u003cp\u003eMaxillary constriction\u0026thinsp;\u0026gt;\u0026thinsp;4 mm\u003c/p\u003e \u003cp\u003eSkeletal class I according to the ANB angle\u003c/p\u003e \u003cp\u003eNeutral growth according to the SN-ML angle\u003c/p\u003e \u003cp\u003ePresence of tooth agenesis(s)\u003c/p\u003e \u003cp\u003eThe presence of orthodontic dental anomaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003cp\u003e66\u003c/p\u003e \u003cp\u003e32\u003c/p\u003e \u003cp\u003e61\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e73\u003c/p\u003e \u003cp\u003e79\u003c/p\u003e \u003cp\u003e47\u003c/p\u003e \u003cp\u003e60\u003c/p\u003e \u003cp\u003e53\u003c/p\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003cp\u003e49 (70.0)\u003c/p\u003e \u003cp\u003e18 (25.7)\u003c/p\u003e \u003cp\u003e50 (71.4)\u003c/p\u003e \u003cp\u003e2 (2.9)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e50 (71.4)\u003c/p\u003e \u003cp\u003e59 (84.3)\u003c/p\u003e \u003cp\u003e34 (48.6)\u003c/p\u003e \u003cp\u003e40 (57.1)\u003c/p\u003e \u003cp\u003e41 (58.6)\u003c/p\u003e \u003cp\u003e7 (10.0)\u003c/p\u003e \u003cp\u003e70 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenoidectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eN, number; SD, standard deviation; BMI, body mass index; AHI, apnea-hypopnea index based on polygraphy examination; ANB, the angle between the point A, nasion and point B; SEN CZ, Czech questionnaire for identifying children at risk of obstructive sleep apnea; SN-ML, the angle of craniometric bases\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Characteristics of the different versions of the SEN CZ\u003c/h2\u003e \u003cp\u003eCharacteristics of the different versions of the SEN CZ are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and in detail described in Supplementary Methods and Results. The results of the partial steps of the SEN CZ genesis are shown in the Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e. The SEN CZ questionnaire is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e; the non-tested English version is in Supplementary Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSensitivity and specificity of the SEN CZ\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestionnaire\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal N of questions/N of questions used for the analysis of sensitivity and specificity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSEN CZ ver. 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38/28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSEN CZ ver. 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40/32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSEN CZ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eN, number; SEN CZ, Czech questionnaire for identifying children at risk of obstructive sleep apnea\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Identification of key clinical and behavioral factors and their correlations with AHI\u003c/h2\u003e \u003cp\u003eSubsequently, we continued with explorative factor analysis and performed the analysis of the final SEN CZ on 70 child-parent pairs.\u003c/p\u003e \u003cp\u003eWhile the Kaiser criterion suggests considering three factors, the sum of the squares of the factor loadings suggests inferring a maximum of five factors. Therefore, we decided to continue with the exploratory factor analysis up to five factors. As we did not find any outliers, we used the ML estimator. Simultaneously, we chose the oblimin rotation due to the assumption that the factors may intercorrelate. To evaluate the model fit, we monitored the change of the following fit indices: χ\u003csup\u003e2\u003c/sup\u003e, TLI and RMSEA [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], see Supplementary Table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e. The fit indices provide a sufficient fit with two interrelated factors (breathing and neurobehavioral problems) and satisfactory fit with three interrelated factors (breathing problems, inattention, and hyperactivity). This shows that there may be three symptomatic factors which together create a higher-order factor of POSA risk.\u003c/p\u003e \u003cp\u003eThe validity of these three factors was further supported by the correlations of their total scores with AHI in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. We also provide the correlation of the SEN CZ with AHI for comparison. Moreover, each of the three factors also achieves high reliability, see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. More details are described and shown in Supplementary Methods and Results, Supplementary Table \u003cspan refid=\"MOESM3\" class=\"InternalRef\"\u003eS3\u003c/span\u003e and Table \u003cspan refid=\"MOESM4\" class=\"InternalRef\"\u003eS4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation of the individual factors with the total score of SEN CZ and AHI\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003erAHI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003erSEN CZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReliability\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSEN CZ ver. 1 total score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSEN CZ ver. 2 total score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSEN CZ total score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreathing problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInattention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperactivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAHI, apnea-hypopnea index; CZ, Czech language; r, correlation coefficient; rAHI, correlation with AHI; rSEN CZ, correlation with SEN CZ total score; SEN CZ, Czech questionnaire for identifying children at risk of obstructive sleep apnea\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAll correlations reach p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Prediction of the POSA risk based on the SEN CZ total score\u003c/h2\u003e \u003cp\u003eTo further evaluate the ability of the SEN CZ to predict the increased POSA risk, we performed a logistic regression \u0026ndash; analysis of the relationship between one or more existing independent variables (such as the SEN CZ total score, POSA risk according to AHI). After verification that our data meet the assumptions of logistic regression, we proceeded to the analysis itself. In the first step, we entered the total score from the questionnaire into the regression, and in the second, we entered the control variables age and maxillary constriction, see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression of the total score of the SEN CZ and the risk of POSA according to AHI\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExp(B)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eExp(B) 95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.80*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-4.92**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePOSA risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.18**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e[1.09; 1.31]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-4.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e[0.61; 1.54]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaxillary constriction\u0026thinsp;\u0026gt;\u0026thinsp;4 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e[0.74; 1.55]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePOSA risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.17**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e[1.08; 1.31]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eAHI, apnea-hypopnea index; POSA risk, the risk of pediatric obstructive sleep apnea (according to the SEN CZ total score); B, coefficient B; SE, standard error; Wald\u0026rsquo;s test; Exp(B), exponential function of the coefficient B; SEN CZ, Czech questionnaire for identifying of children at risk of obstructive sleep apnea; Model 0; model without predictors; Model 1, model takes into account the predictor (score of the questionnaire as a predictor of POSA risk); Model 2; model takes into account the predictor (score of the questionnaire as a predictor of POSA risk) and other intervening variables\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eModel 1, considering the SEN CZ score as a predictor, was statistically significant compared to the null model (χ\u003csup\u003e2\u003c/sup\u003e(1)\u0026thinsp;=\u0026thinsp;29.79, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and explained 48% of the variance (Nagelkerke R\u003csup\u003e2\u003c/sup\u003e) of POSA risk. Model 2, considering the SEN CZ score and potential intervening variables, did not significantly improve the fit of the original model (Nagelkerke R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.49, χ\u003csup\u003e2\u003c/sup\u003e(3)\u0026thinsp;=\u0026thinsp;29.98, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Therefore, we continued to work with Model 1. Model 1 yielded sensitivity of 86%, specificity of 77%, and classification accuracy of 83% at a cut-off value corresponding to a 50% probability of finding POSA. The increasing score in the SEN CZ significantly predicted the diagnosis of the disease, thus meeting the criterion validity of the questionnaire. The regression that illustrates this relationship corresponds to the expression logit(POSA)=-4.92\u0026thinsp;+\u0026thinsp;0.18*A where parameter A is the total sum score in the questionnaire. We may convert this logit using an exponential function to get the odds of POSA risk. Therefore, if the child reaches a score of 40 in the SEN CZ according to the parent's report, the chance (odds of POSA\u0026thinsp;=\u0026thinsp;exp(logit(POSA))) that this child would be diagnosed with POSA in polygraphy is 9.78 to 1. Therefore, we have a roughly 91% probability of finding POSA in this child. A 50% probability of finding POSA risk approximately corresponds to the score of 23 in the SEN CZ.\u003c/p\u003e \u003cp\u003eUsing the cut-off value for mild, moderate, and severe POSA according to AHI, the approximate cutoff values in the SEN CZ itself can be determined based on the linear regression of AHI on the SEN CZ score. This relationship can be expressed by the equation POSA\u0026thinsp;=\u0026thinsp;23.98\u0026thinsp;+\u0026thinsp;6.11*A. AHI values above 1 (mild POSA), therefore, correspond to SEN CZ score above 30.09.\u003c/p\u003e \u003cp\u003eThe calculated SEN CZ total score cut-off values for POSA risk assessment are shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. However, the given cut-off values should be considered with a grain of salt due to the sample size, exploratory factor analysis, possible measurement error and the pilot nature of the research. If we also adjust the logistic regression according to the cut-off value of at least mild POSA (31; 66% probability of finding), the model correctly determines 85% of cases, while the sensitivity is 84% and the specificity is 86%. Although there is an improvement in specificity, this result also indicates the need for a larger sample with a sufficient representation of the healthy population (here, according to the AHI cut-off value, N\u0026thinsp;=\u0026thinsp;22).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCut-off scores in the SEN CZ for POSA risk prediction according to AHI\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSEN CZ\u003c/p\u003e \u003cp\u003etotal score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAHI\u0026thinsp;\u0026lt;\u0026thinsp;1; physiological finding\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[1; 30]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAHI\u0026thinsp;\u0026ge;\u0026thinsp;1 to \u0026lt;\u0026thinsp;5; mild POSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[31; 54]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAHI\u0026thinsp;\u0026ge;\u0026thinsp;5 to \u0026lt;\u0026thinsp;10; moderate POSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[55; 84]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAHI\u0026thinsp;\u0026ge;\u0026thinsp;10; severe POSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eAHI, apnea-hypopnea index; POSA, pediatric obstructive sleep apnea; SEN CZ, Czech questionnaire for identifying children at risk of obstructive sleep apnea\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this pilot study, our multidisciplinary team created a Czech questionnaire for identifying children at risk of POSA. This is the very first such questionnaire originally designed in the Czech language and tested in the Czech population. Examinations such as PSG or polygraphy are known to have a good diagnostic ability to reveal POSA; however, given the lack of and workload of sleep laboratories for children and specialists in this area in the Czech Republic, these examinations are often inaccessible. In view of the fact that early diagnosis and proper treatment are crucial in children suffering from POSA, an ideal screening tool that could reveal the need for these examinations, should not be only easy to use and interpret but, most importantly, widely accessible. The use of a sleep questionnaire focusing on children can be a workable way to improve the early detection of POSA risk.\u003c/p\u003e \u003cp\u003eConsidering the fact that several pediatric sleep questionnaires abroad2-7, we initially wanted to simply translate a highly evaluated questionnaire and adapt it from English to Czech. We searched the literature and based on several studies, including a recent meta-analysis published by Wu \u003cem\u003eet al\u003c/em\u003e., we have chosen the PSQ as it was found to have the highest screening sensitivity for detecting mild POSA and sensitivity comparable to pulse oximetry in patients with moderate and severe forms of POSA [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Based on these results, the authors recommended a combination of PSQ and pulse oximetry for early detection of POSA [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Another review identified the PSQ as the only questionnaire that is diagnostically accurate enough to screen for impaired breathing in children, while also highlighting the importance and benefit of involving dentists in the primary screening of POSA [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, after the translation and adapting PSQ-SRBD scale4 in collaboration with a multidisciplinary team of professionals and experts from different medical fields associated with pediatric sleep medicine in the Czech Republic, we agreed on the fact that a simple translation would not be sufficient. We considered also the cultural differences and differences in the structure of sentences in both Czech and English languages and their exact meaning and decided to take further steps and design a questionnaire for identifying POSA risk for Czech users, which we named SEN CZ.\u003c/p\u003e \u003cp\u003eAfter preliminary testing of SEN CZ ver. 1, we proceeded to further improve it to produce SEN CZ ver. 2, which has already achieved very good results (Cronbach's α\u0026thinsp;=\u0026thinsp;0.928); however, it was quite lengthy, and we have decided to shorten it as much as possible. The final version of the SEN CZ kept the good sensitivity and specificity, as well as reliability but contains less than half the items compared with the SEN CZ ver. 2, making it more user-friendly. In the context of sensitivity and specificity, the performance of the final version of the SEN CZ is very good, comparable with the best sleep questionnaires included in the meta-analysis by Wu \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our questionnaire, we originally intended to keep dichotomous items for the simplicity of assessment; however, to detect the behavior in children, the use of Likert scale is often preferred to dichotomous questions (yes/no/unknown) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. For screening purposes, it is better if we capture the answer on a scale rather than dichotomously as it is more accurate.\u003c/p\u003e \u003cp\u003eThe majority of the items in the final version of the SEN CZ cover very similar areas of POSA symptoms as items in foreign pediatric sleep questionnaires [\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This supports their importance as factors contributing to this disease. In our questionnaire, based on the results of the validation, we have excluded several items associated with the nocturnal symptoms due to their high difficulty for parents. Even though snoring and difficulty breathing during sleep are probably most common complaint voiced by parents of children with POSA [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], more recent studies reported that parents were able to report snoring in only 15% of children diagnosed with POSA [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These findings are suggestive of the fact that parents may often fail to notice the nocturnal symptoms, especially if the children have a separate room, or if not enough attention is paid to this problem.\u003c/p\u003e \u003cp\u003eIn our questionnaire, a lot of items are focused on the area of daytime symptoms. For example, in the case of nasal obstruction and adenotonsillar hypertrophy, a transition to mouth breathing occurs, which subsequently affects changes in the orofacial region, such as the narrow hard palate, posteriorotation of the mandible and/or disproportions in the sagittal plane, as well as the elongation of the lower third of the face, which can be expressed in varying degrees and forms [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These features may present risk factors for the development of POSA; moreover, mouth breathing preference has been identified as an early contributor to SRBD that can be often found in primary snorers and patients with POSA [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. At the same time, these contributing factors may be, compared to nocturnal symptoms, easily detectable also by parents, which makes them important for screening.\u003c/p\u003e \u003cp\u003eInterrupted sleep and nocturnal hypoxia affect, among other things, the prefrontal cortex and thus the cognitive executive functions of the individual [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Affected children have impairments in planning, plan execution, organization, decision-making, and information processing. These factors, together with impaired attentional retention, impaired concentration, impulsivity, hyperactivity, and emotional lability, often cause errors of inattention and impaired school performance [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChildren with POSA also tend to have increased irritability (or even aggression) and may show disinterest in daily activities and tendencies to depression. It has even been suggested that sleep disruption and difficulty in early childhood may predict behavioral and emotional problems during adolescence [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. There is also evidence of a significant association between reduced or disturbed sleep and the severity of behavioral changes. Studies also suggest that children presenting with POSA display symptoms of attention deficit and hyperactivity disorder (ADHD) more often than those without it [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Most studies agree on a bidirectional association between POSA and ADHD [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results of the factor analysis and logistic regression indicate that the SEN CZ is slightly more likely to recommend a comprehensive POSA examination when it is not needed than to fail to recommend an examination when it should be performed. Given the screening nature of the questionnaire, this is a very good result. Moreover, the SEN CZ could be also a good predictor of ADHD. Therefore, it might be useful to continue the research with data obtained from children diagnosed with ADHD. We may then be able to analyze which items discriminate well between POSA and ADHD (i.e., identify questions in which parents of children with POSA score significantly differently than parents of children with ADHD).\u003c/p\u003e \u003cp\u003eEven though according to the latest AASM guidance, PSG is the gold standard for diagnosing pediatric sleep disorders [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] it may not be readily available in all clinical settings. In our study, we encountered practical challenges in accessing PSG for children due to its limited availability in the Czech Republic and long waiting times. In light of these limitations and considering that HSAT is recommended as a screening tool before the referral for PSG, when applied under controlled settings by sleep specialist [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] we opted for including HSAT, polygraphy, as a part of our validation process. Important fact is also that SEN CZ should only be used as the first alert of generally disturbed nocturnal breathing with recommendation for further examinations, not to serve as a replacement for any sleep-monitoring or as a precise diagnostic tool.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eWe have designed and validated the SEN CZ questionnaire for screening of POSA risk reflecting the multifactorial etiology of this disease. Our questionnaire with 17 items and a 5-item Likert scale is the first tested questionnaire for identifying children at risk of POSA in the Czech language and could be filled in not only by doctors of different specializations but also by parents/caregivers of the children. It performs excellently, achieving high reliability and high correlation with AHI as an objective criterion for the POSA diagnosis, and shows comparable sensitivity and specificity to the already existing foreign pediatric sleep questionnaires.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZ.M.V. and P.B.L. designed the study, provided interpretation of results, and drafted the paper; Z.M.V. was responsible for the clinical part of the study; T.K. provided data analysis; M.P.V. critically reviewed the manuscript. All authors revised the final version of the manuscript.\u0026nbsp;Each author made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or have drafted the work or substantively revised it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Prof. Ronald Chervin for the revision of the manuscript and his valuable comments. We thank the pediatric neurologist Iva Prihodova, pediatric ENT specialists Martina Ondrova and Pavel Hornik, a pneumologist Pavel Turcani for the cooperation and revisions in the development of SEN CZ. We thank Jaroslav Janosek for his help with the translation of questionnaires and valuable comments. We thank Pavel Hornik also for the ENT examinations of children enrolled in the study and the Cardiovascular sleep laboratory in Brno, Czech Republic, for external consultations and assistance with the analysis of polygraphy data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the project provided by the University Hospital Brno, Ministry of Health of the Czech Republic – RVO (FNBr, 65269705). \u0026nbsp; This work was supported from the European Union’s Horizon 2020 research and innovation program under grant agreement No 857560. This publication reflects only the author´s view and the European Commission is not responsible for any use that may be made of the information it contains. Authors also thank the Research Infrastructure RECETOX RI (No LM2023069, MEYS CR) and the project CETOCOEN EXCELLENCE (No CZ.02.1.01/0.0/0.0/17_043/0009632) financed by the Ministry of Education, Youth, and Sports for supportive background.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data of the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was performed with the approval of the Ethics Committee of the St. Anne’s Faculty Hospital (No. 33V/2020; date: 10th June, 2020). Written informed consent was obtained from all parents or caregivers of participating children in line with the Declaration of Helsinki before inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eXu, Z. \u003cem\u003eet al\u003c/em\u003e. Risk factors of obstructive sleep apnea syndrome in children. \u003cem\u003eJ. Otolaryngol. Head Neck Surg\u003c/em\u003e. \u003cstrong\u003e49\u003c/strong\u003e(1)\u003cstrong\u003e,\u003c/strong\u003e 11; 10.1186/s40463-020-0404-1 (2020).\u003c/li\u003e\n\u003cli\u003eGulotta, G. \u003cem\u003eet al\u003c/em\u003e. Risk factors for obstructive sleep apnea syndrome in children: state of the art. \u003cem\u003eInt. J. Environ. Res. 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Sleep Med\u003c/em\u003e. \u003cstrong\u003e18\u003c/strong\u003e(2)\u003cstrong\u003e,\u003c/strong\u003e 533-540; 10.5664/jcsm.9650 (2022).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"questionnaire, pediatric obstructive sleep apnea, validation, Likert scale, apnea-hypopnea index, risk factor","lastPublishedDoi":"10.21203/rs.3.rs-4713475/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4713475/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study aimed to create a Czech questionnaire for pediatric obstructive sleep apnea (POSA) risk screening, a first of its kind in the Czech Republic, where options for child polysomnography are limited. Compiling items from established English questionnaires and supplementing them with additional items, we designed the first version of the Czech questionnaire and tested it in a pilot study with parents of 30 children. After pilot feedback, a revised version with dichotomous and 5-item Likert scale questions was tested on another 70 children's parents. All children (7\u0026ndash;12 years old) underwent a home sleep apnea test to record their apnea-hypopnea index (AHI). The second (40-item) version showed high reliability (93%), with 17 items identified as the most significant. Findings from the final 17-item SEN CZ questionnaire correlated positively with AHI (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), demonstrating 84% sensitivity, 86% specificity, and 93% reliability. Three factors, namely breathing problems, inattention, and hyperactivity (characterized by multiple items), were identified to form a higher-order factor of POSA risk, which was further supported by the correlations of their total scores with AHI (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The resulting SEN CZ questionnaire can serve as a tool for POSA risk screening in the Czech Republic without the need to involve medical professionals.\u003c/p\u003e","manuscriptTitle":"Testing of the Czech questionnaire for identifying children at risk of obstructive sleep apnea ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 21:18:51","doi":"10.21203/rs.3.rs-4713475/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-23T08:18:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-21T21:30:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248688973826091089101527846342105161513","date":"2024-07-15T09:51:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-14T08:46:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220229597270404166669434523551828252967","date":"2024-07-12T06:35:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-11T22:06:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-11T22:01:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-11T17:39:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-10T09:37:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-07-09T16:21:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3cd67854-ce40-4a66-ad27-1d899ec6d4a8","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":34995206,"name":"Health sciences/Diseases/Neurological disorders/Sleep disorders"},{"id":34995207,"name":"Health sciences/Diseases/Oral diseases"}],"tags":[],"updatedAt":"2024-08-22T19:38:23+00:00","versionOfRecord":{"articleIdentity":"rs-4713475","link":"https://doi.org/10.1038/s41598-024-69958-4","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2024-08-15 15:58:20","publishedOnDateReadable":"August 15th, 2024"},"versionCreatedAt":"2024-08-09 21:18:51","video":"","vorDoi":"10.1038/s41598-024-69958-4","vorDoiUrl":"https://doi.org/10.1038/s41598-024-69958-4","workflowStages":[]},"version":"v1","identity":"rs-4713475","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4713475","identity":"rs-4713475","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}