We read the article with great interest by Fagundes et al titled “Craniofacial features in children with obstructive sleep apnea: a systematic review and meta-analysis.”1 The authors sought to explore the possible link between pediatric obstructive sleep apnea (OSA) and craniofacial morphology and performed a meta-analysis, reporting no differences observed in all the considered cephalometric angles. Nevertheless, we are concerned that the methodological approach is problematic in terms of its inclusion and exclusion criteria.
The aim of this paper was to evaluate the difference in craniofacial features among the OSA and non-OSA control group. The criteria defined as control was the presence of a negative result in a nocturnal polysomnography evaluation, ie, apnea-hypopnea index < 1 or obstructive apnea-hypopnea index < 2. In fact, the included non-OSA control groups in Fagundes’s paper were a mixture of three different subgroups, ie, snoring children,2–4 children with respiratory or OSA symptoms,5–7 and nonsnoring children without any signs or symptoms of sleep-disordered breathing.8–10 And most of nonsnoring controls were excluded in this meta-analysis because polysomnography (PSG) was not done. The authors equated the PSG-negative group with the non-OSA controls. However, this grouping based on nocturnal PSG defining OSA and non-OSA controls is not reasonable. PSG-negative children are not always healthy controls. Children with snoring and sleep-disordered breathing signs and symptoms may have developed craniofacial anomalies at a very early stage, whereas their PSG test was still negative at that time.2,3
The results showed that five of the nine included studies did not report differences, and four studies reported differences in craniofacial features. When delving into those five articles that reported no differences, taking Pirilä-Parkkinen’s paper2 as an example, the original articles included three groups: (1) nonsnoring controls who did not undergo PSG, (2) children with snoring or OSA symptoms with negative PSG results, (3) children with OSA with positive PSG results. Interestingly, the original data showed that there was a significant difference between nonsnoring controls and the other two groups, while there was no significant difference between the PSG-negative group and PSG-positive group. In other words, snoring children or children with OSA symptoms already had craniofacial anomalies compared to nonsnoring children, even though they presented a negative PSG result.
Collectively, due to the inappropriate eligibility criteria, the meta-analysis result reporting no difference in all the considered cephalometric angles between OSA and non-OSA controls is misleading to the clinic. PSG-negative children are not always non-OSA controls.
DISCLOSURE STATEMENT
All authors have seen and approved this manuscript. Work for this letter was performed in the Department of Oral and Cranio-Maxillofacial Surgery, Shanghai Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China. This paper was supported by the National Science and Technology Basic Resources Project (2018FY101001) and Clinical Research Program of 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine (JYLJ202017). The authors report no conflicts of interest.
ACKNOWLEDGMENTS
Author contributions: Dr. Xiaoling Wang contributed to drafted and critically revised the manuscript; Dr. Xudong Wang and Dr. Min Zhu contributed to conception, design, acquisition drafted and critically revised the manuscript.
ABBREVIATIONS
- OSA
obstructive sleep apnea
- PSG
polysomnography
Citation: Wang X, Wang X, Zhu M. Can children with negative polysomnography results always be non-OSA controls? J Clin Sleep Med. 2023;19(12):2141–2142.
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