Obstructive sleep apnea syndrome in children with cerebral palsy in Brazil: a multicenter study

Dias, Bruno Leonardo Scofano; Lima, Fernanda Marinho de; Fava, Daniela; Marques, Fernanda Jordão Pinto; Godinho, Frederico José de Carvalho; Carvalho, Alessandra Lemos de; Santos, Sara Virgínia Paiva; Pinto, Fernanda de Lourdes da Cunha; Jardim, Danielle Bruno; Bessa, Wilerson Marques

doi:10.1016/j.jped.2025.101432

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Original article • J. Pediatr. (Rio J.) 101 (5) • 2025 • https://doi.org/10.1016/j.jped.2025.101432 linkcopy

Obstructive sleep apnea syndrome in children with cerebral palsy in Brazil: a multicenter study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives To evaluate the prevalence of high risk for obstructive sleep apnea syndrome (HR-OSAS) in Brazilian children with cerebral palsy (CP) using the Pediatric Obstructive Sleep Apnea Screening Tool (PosaST) and to analyze its association with demographic, clinical and functional (Gross Motor Function Classification System [GMFCS]) variables.

Methods Multicenter, cross-sectional, exploratory study.

Results There were 312 children (median age 6.0 years, IQR 5.0-8.0) included. The prevalence of HR-OSAS in GMFCS I-V was 9.0 %. The prevalence of HR-OSAS in GMFCS V (14.7 %) was significantly higher compared to GMFCS I-IV (6.4 %) and to the frequency of OSAS in typically developing (TD) children assessed by polysomnography (5.8 %) according to literature data. Significantly higher frequencies of palatine tonsil hypertrophy, hospitalizations and outpatient antibiotic use for respiratory causes (last 12 months), gastroesophageal reflux disease, drooling and epilepsy were found in GMFCS V. Palatine tonsil hypertrophy was significantly associated with HR-OSAS. GMFCS V was significantly correlated with HR-OSAS at the expense of its significantly higher prevalence of palatine tonsil hypertrophy.

Conclusions The prevalence of HR-OSAS in Brazilian children with CP (GMFCS V) was higher than the frequency of OSAS in TD children assessed by polysomnography. HR-OSAS was significantly more prevalent in GMFCS V compared with GMFCS I-IV. Palatine tonsil hypertrophy was significantly associated with HR-OSAS. GMFCS V was significantly correlated with HR-OSAS due to its significantly higher prevalence of palatine tonsil hypertrophy. PosaST may be a reliable questionnaire for Brazilian children with CP, but studies are needed to define the HR-OSAS cutoff score in this population.

Keywords
Sleep apnea, Obstructive; Cerebral palsy; Children; Risk; Questionnaire

	GMFCS I-V
	n = 312
Characteristic	n ( %)
Age (years)
3 - 5	128 (41.0)
6 - 9	184 (59.0)
Sex
Female	147 (47.1)
Male	165 (52.9)
Friedman classification
0	36 (11.5)
1	98 (31.4)
2	105 (33.7)
3	69 (22.1)
4	4 (1.3)
Friedman classification
0 - 2	239 (76.6)
3 - 4	73 (23.4)
Hospitalizations for respiratory causes (last 12 months)
0	264 (84.6)
1 - 2	35 (11.2)
3 - 4	8 (2.6)
5 - 6	3 (1.0)
> 6	2 (0.6)
Hospitalizations for respiratory causes (last 12 months)
Yes	48 (15.4)
No	264 (84.6)
Hospitalizations for respiratory causes (> 1 in the last 12 months)
Yes	13 (4.2)
No	299 (95.8)
Outpatient use of antibiotics (last 12 months)
0	129 (41.3)
1 - 2	96 (30.8)
3 - 4	50 (16.0)
5 - 6	10 (3.2)
> 6	27 (8.7)
Outpatient use of antibiotics (last 12 months)
Yes	183 (58.7)
No	129 (41.3)
Outpatient use of antibiotics (> 1 in the last 12 months)
Yes	87 (27.9)
No	225 (72.1)
GERD
Yes	36 (11.5)
No	276 (88.5)
Drooling
Yes	136 (43.6)
No	176 (56.4)
Epilepsy
Yes	138 (44.2)
No	174 (55.8)
GMFCS
I	85 (27.2)
II	35 (11.2)
III	45 (14.4)
IV	52 (16.7)
V	95 (30.5)
GMFCS
I-IV	217 (69.5)
V	95 (30.5)
HR-OSAS
Yes	28 (9.0)
No	284 (91.0)

Characteristic	GMFCS I-IV	GMFCS V	p*	CI 95 %	OR
	n = 217	n = 95
	n ( %)	n ( %)
Age (years)
3 - 5	86 (39.6)	42 (44.2)	0.45	−0.68, 0.30	0.83
6 - 9	131 (60.4)	53 (55.8)	0.45	−0.68, 0.30	0.83
Sex
Female	106 (48.8)	41 (43.2)	0.35	−0.26, 0.71	1.26
Male	111 (51.2)	54 (56.8)	0.35	−0.26, 0.71	1.26
Friedman classification
0 - 2	179 (82.5)	60 (63.2)	<0.001	0.47, 1.57	2.75
3 - 4	38 (17.5)	35 (36.8)	<0.001	0.47, 1.57	2.75
Hospitalizations for respiratory causes (last 12 months)
Yes	25 (11.5)	23 (31.9)	0.005	0.27, 1.53	2.45
No	192 (88.5)	72 (68.1)	0.005	0.27, 1.53	2.45
Hospitalizations for respiratory causes (> 1 in the last 12 months)
Yes	5 (2.3)	8 (8.4)	0.02	0.22, 2.51	3.89
No	212 (97.7)	87 (91.6)	0.02	0.22, 2.51	3.89
Outpatient use of antibiotics (last 12 months)
Yes	118 (54.4)	30 (31.6)	0.02	0.09, 1.11	1.82
No	99 (45.6)	65 (68.4)	0.02	0.09, 1.11	1.82
Outpatient use of antibiotics (> 1 in the last 12 months)
Yes	62 (28.6)	25 (22.1)	0.68	−0.66, 0.43	0.89
No	155 (71.4)	70 (77.9)	0.68	−0.66, 0.43	0.89
GERD
Yes	15 (7.0)	21 (19.2)	<0.001	−2.05, −0.63	0.26
No	202 (93.0)	74 (80.8)	<0.001	−2.05, −0.63	0.26
Drooling
Yes	59 (27.2)	77 (81.0)	<0.001	−3.03, −1.84	0.09
No	158 (72.8)	18 (19.0)	<0.001	−3.03, −1.84	0.09
Epilepsy
Yes	67 (30.9)	71 (74.7)	<0.001	1.35, 2.44	6.62
No	150 (69.1)	24 (25.3)	<0.001	1.35, 2.44	6.62
HR-OSAS
Yes	14 (6.4)	14 (14.7)	0.02	0.13, 1.70	2.51
No	203 (93.6)	81 (85.3)	0.02	0.13, 1.70	2.51

Sample	Prevalence	p*	CI 95 %	OR
GMFCS I-V	9.0 %	0.422	0.55, 1.28	0.84
PSQ⁷	10.5 %	0.422	0.55, 1.28	0.84
GMFCS I-V	9.0 %	0.072	0.95, 2.67	1.59
PSG⁶	5.8 %	0.072	0.95, 2.67	1.59
GMFCS V	14.7 %	0.191	0.82, 2.66	1.48
PSQ⁷	10.5 %	0.191	0.82, 2.66	1.48
GMFCS V	14.7 %	0.001	1.45, 5.41	2.80
PSG⁶	5.8 %	0.001	1.45, 5.41	2.80

	HR-OSAS				HR-OSAS				Friedman classification 3-4
Characteristic	CF	95 % CI	p	OR	CF	95 % CI	p	OR	CF	95 % CI	p	OR
Age, 3-5 years vs 6-9 years	0.89	−0.05, 1.83	0.06	2.37	0.69	−0.31, 1.69	0.17	1.99	0.45	−0.19, 1.08	0.17	1.56
Sex, female vs male	−0.03	−0.89, 0.82	0.94	1.06	0.05	−0.87, 0.97	0.92	1.05	−0.12	−0.72, 0.48	0.70	0.89
Friedman classification, 3-4 vs 0-2	-	-	-	-	2.16	1.18, 3.13	< .001	8.64	-	-	-	-
Outpatient use of antibiotics (last 12 months), yes vs no	0.94	−0.51, 2.40	0.203	2.54	0.52	−0.99, 2.04	0.50	1.69	0.69	−0.08, 1.47	0.08	2.01
Outpatient use of antibiotics (> 1 in the last 12 months), yes vs no	1.71	0.68, 2.75	0.001	5.54	1.58	0.45, 2.72	0.006	4.86	0.65	−0.08, 1.40	0.08	1.92
Hospitalizations for respiratory causes (last 12 months), yes vs no	−0.59	−1.99, 0.81	0.41	0.55	−1.04	−2.52, 0.45	0.17	0.35	0.80	−0.06, 1.65	0.07	2.22
Hospitalizations for respiratory causes (> 1 in the last 12 months), yes vs no	0.96	−0.96, 2.89	0.32	2.62	1.32	−0.75, 3.37	0.21	3.71	−0.64	−2.23, 0.95	0.43	0.53
GMFCS V, yes vs no	1.15	0.24, 2.05	0.01	3.15	0.81	−0.20, 1.82	0.12	2.25	0.92	0.20, 1.55	0.005	2.51
HR-OSAS, yes vs no	-	-	-	-	-	-	-	-	2.11	1.13, 3.09	< .001	8.24

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