Abstract
Introduction
Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder among children with attention deficit hyperactivity disorder (ADHD). This study aims to determine the prevalence of OSA in children with ADHD, compare the differences in clinical characteristics between children with ADHD-OSA and those without OSA (ADHD-nonOSA), and to identify the correlation between OSA and ADHD in children.
Methods
This cross-sectional descriptive study was conducted on 524 children with ADHD, aged 6–12 years, at the Vietnam National Children’s Hospital from October 2022 to September 2023. Respiratory polygraphy was used to determine the prevalence of OSA in this study population; clinical data of children with ADHD-OSA and ADHD-nonOSA were collected and analyzed in each group. The severity of ADHD symptoms was measured by the Vanderbilt ADHD Parent Diagnosis Rating Scale (VADPRS questionnaire), and the severity of OSA was defined by Apnea–Hypopnea Index (AHI).
Results
The prevalence of OSA in children with ADHD was 23.3%, with the majority of moderate-to-severe OSA. Significant differences were observed in sleep onset time, total sleep duration, and various sleep-related behaviors, such as bedtime resistance and difficulty waking up in the morning, between children with ADHD-OSA and ADHD-nonOSA (p < 0.001, p < 0.001, p < 0.05, and p < 0.005, respectively). The severity levels of inattention, hyperactivity, and behavioral disorders were significantly higher in children with moderate-to-severe OSA compared to those with mild OSA (p < 0.005, p < 0.005, and p < 0.001, respectively). There were significant correlations between AHI with inattention scores (r = 0.677; p < 0.0001), hyperactivity scores (r = 0.438; p = 0.05), behavioral disorder scores (r = 0.342; p < 0.05), and anxiety/depression scores (r = 0.357; p < 0.05) measured by VADPRS questionnaire.
Conclusions
OSA is a common sleep-related breathing disorder in children with ADHD, which might exacerbate ADHD symptoms. Thus, screening of OSA in children with ADHD is essential during the management of ADHD in this population.
Keywords: OSA, ADHD, Sleep-related behavior, Children
Key Summary Points
| Why carry out this study? |
| Children with attention deficit hyperactivity disorder (ADHD) frequently experience sleep disturbances, which can worsen ADHD symptoms. Limited data exist on the overlap between ADHD and obstructive sleep apnea (OSA) in Vietnam. |
| This study aimed to determine the prevalence of OSA in children with ADHD, to demonstrate clinical characteristics between ADHD-OSA and ADHD-nonOSA groups, and to measure the correlation between OSA severity and ADHD symptoms. |
| What was learned from the study? |
| The prevalence of OSA in children with ADHD was 23.3%, with a predominance of moderate-to-severe OSA. Children with moderate-to-severe OSA had more severe ADHD symptoms, including inattention, hyperactivity, and behavioral disorders. |
| This study suggests the importance of OSA screening in children with ADHD. Early detection and treatment of OSA in this population may improve ADHD symptoms and overall outcomes. |
Introduction
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in children, characterized by two core symptom groups: inattention and/or hyperactivity/impulsivity, which affect or reduce the quality of social, academic, or occupational activities [1]. ADHD often persists from childhood to adulthood subjects and is also a risk factor for various psychiatric disorders such as oppositional defiant disorder, mood disorder, conduct disorder, substance abuse, and criminal behavior [2]. Unfortunately, over the past 20 years, the prevalence of this disorder has increased from 6 to 10% [3–5]. This prevalence is consistent with the results of published studies on ADHD in Vietnamese children [6, 7]. However, the management of ADHD presents numerous challenges due to the association of comorbid psychiatric disorders [8]. One of the most common comorbidities is sleep disorders. Previous studies showed experience sleep disturbances [9, 10]. Among these sleep disturbances, obstructive sleep apnea (OSA) is a sleep-related breathing disorder that has been shown to have a strong correlation with ADHD [11, 12]. Currently, OSA has been defined as a pathological phenomenon characterized by the narrowing or collapse of the upper airway, leading to sleep disruption or fragmentation and oxygen desaturation during sleep. These consequences lead to a variety of clinical manifestations in children with OSA, including sleep disturbances and daytime symptoms, which closely resemble those of ADHD or are referred to as ADHD-like symptoms [13].
The association between OSA and ADHD has been demonstrated in numerous studies within the high comorbidity rate between these two conditions [11, 12]. Obviously, children with ADHD seem to have a higher prevalence of OSA (25–30%) compared with children without ADHD (3%) [12]. The risk of OSA developing is markedly higher in children with ADHD than in the control group [12]. Inversely, among children with OSA, up to 30% meet the diagnostic criteria for ADHD [11]. It has been suggested that sleep fragmentation and intermittent hypoxia in subjects with OSA may lead to metabolic changes in certain brain regions, especially in the frontal lobe. These changes might induce dysfunction of higher-order neurocognitive functions, leading to behavioral disorders, problems with maintaining attention, and other related symptoms [14–16].
However, in Vietnam, OSA still receives little attention from pediatric doctors in the management of children with OSA, especially those with ADHD. The clinical phenotype of OSA and ADHD overlap, making more complex in the management of both conditions. For giving clinicians an appropriate and effective approach in the management of children with OSA and ADHD overlap, we conducted this study to determine the prevalence of OSA in children with ADHD, compare the differences in clinical characteristics between the ADHD-OSA and ADHD-nonOSA groups, and identify the correlation between OSA and ADHD in these children.
Methods
Study Design
This was a cross-sectional descriptive study. The study involved children aged 6–12 years diagnosed with ADHD according to DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria by pediatric psychiatrists at the Viet Nam National Children’s Hospital from October 2022 to September 2023. The children and their caregivers were instructed to complete the research medical records, The Pediatric Sleep Questionnaire (PSQ), and The Vanderbilt ADHD Parent Diagnosis Rating Scale (VAPDRS), and maintain a sleep diary for 2 weeks. Children with a PSQ > 7 underwent respiratory polygraphy (RPG) during their nighttime sleep. Each participant underwent respiratory polygraphy until accurate and reliable results were obtained. This ensured the precision and consistency of the data collected for the study.
General characteristics of the study subjects included age (years), gender, subtype of ADHD, comorbid disorders (ADHD comorbidities), and body mass index (BMI) z-score classification. Additional variables included the Apnea–Hypopnea Index (AHI) index, the lowest saturation of peripheral oxygen (SpO2), clinical symptoms of OSA and ADHD as assessed by pediatric psychiatrists, and ADHD symptoms according to the VADPRS questionnaire.
This study was conducted in accordance with the Helsinki Declaration of 1964 and its later amendments. Ethical approval was obtained from the Biomedical Research Ethics Board of Hanoi Medical University (Approval Number: 794/GCN-HĐĐĐNCYSH-ĐHYHN).
Participants
The study included 524 children aged 6–12 years diagnosed with ADHD based on DSM-5 criteria at the Vietnam National Children’s Hospital between October 2022 and September 2023. Participants were newly diagnosed and had not received ADHD-specific medications. Exclusion criteria included a known history of OSA, prior adenotonsillectomy, ongoing PAP (positive airway pressure) therapy, use of medications affecting sleep (e.g., melatonin, antihistamines), lack of consent, incomplete data, acute or chronic illnesses, other sleep disorders such as RLS (restless legs syndrome), insomnia, circadian rhythm disorders, or parasomnias, and additional comorbidities such as genetic disorders or craniofacial anomalies. These exclusions were determined through clinical evaluations to focus on the relationship between OSA and ADHD. In this study, the participants’ parents/caregivers/legal guardians provided informed consent for their child to participate in this study.
Measurements
The research medical records were developed based on the study’s objectives and included both general information and pathological details on OSA and ADHD. Sleep diaries were used to capture data on sleep duration and daily sleep habits over a 2-week period. Caregivers provided detailed documentation of evening bedtime, sleep onset time, morning wake-up time, total sleep duration within 24 h, and sleep-related habits and behaviors observed before, during, and after sleep.
The Pediatric Sleep Questionnaire (PSQ): the survey questionnaires of OSA in children aged 2 – < 18 years, were completed by caregivers [17]. The questionnaire consists of 22 questions divided into three groups: seven questions about sleep disorders, nine questions about snoring, and six questions about hyperactivity and inattention. Each question could be answered with "yes," "no," or "don’t know." If more than seven questions were answered with "yes," OSA was suspected in the child [17]. In this study, we used the PSQ adapted and validated for Vietnamese children [18]. This version has been confirmed to be reliable and suitable for assessing sleep-disordered breathing in this population.
Respiratory polygraphy (RPG) was conducted using the ApneaLink Air device (ResMed, San Diego, CA, USA), with the measurement duration matching the child’s nighttime sleep for a minimum of four continuous hours. Parameters collected included the AHI and the lowest saturation of SpO2 during sleep. According to the 3rd International Classification of Sleep Disorders (ICSD-3), the diagnostic criteria for OSA in children include one or more of the following symptoms: snoring; labored, paradoxical, or obstructed breathing during sleep; daytime sleepiness; hyperactivity; behavioral problems; or learning issues, associated with an AHI ≥ 1 event per hour. The severity of OSA was determined by the AHI: mild OSA with 1–5 events/hour, moderate OSA: 5–10 events/hour, and severe OSA: > 10 events/hour [19].
The Vanderbilt ADHD Parent Diagnosis Rating Scale (VAPDRS) is an assessment tool designed to evaluate hyperactivity and inattention behaviors/symptoms in children aged 6–12 years. It assesses the severity of ADHD symptoms, with higher scores indicating more severe symptoms. The research team used the VAPDRS provided by the Center for Creative Initiatives in Health and Population, with permission granted, as previously made available on the website https://a365.vn/.
Statistical Analysis
Categorical variables were presented as frequencies and percentages, while continuous variables were presented as means and standard deviations (SD). Differences between proportions were tested using the chi-square test, while mean values for normally distributed data were tested using the t test, and the Mann–Whitney U test was used for non-normally distributed data. The Spearman correlation coefficient was calculated to determine correlations between quantitative variables. All statistical analyses were performed using SPSS version 20.0, with a p value < 0.05 considered statistically significant.
Results
Prevalence of OSA in Children with ADHD
There were 524 children with ADHD, mean age was 7.8 ± 1.5 years of age (87.4% boys). The use of PSQ revealed that 184 children whose scores > 7 points. The RPG results showed 122 children had an AHI ≥ 1, giving the prevalence of OSA in children with ADHD was 23.3% (Fig. 1).
Fig. 1.
Study flowchart. ADHD attention deficit hyperactivity disorder, AHI Apnea–Hypopnea Index, DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, OSA obstructive sleep apnea, RPQ respiratory polygraphy, PSQ Pediatric Sleep Questionnaire
More than 50% of children with ADHD in the study had moderate-to-severe OSA (AHI ≥ 5). The lowest SpO2 during sleep was 73.7% (Table 1).
Table 1.
Respiratory polygraphy parameters (n = 122)
| Parameters | Value |
|---|---|
| AHI (events/hour), (mean ± SD) | 11.2 ± 3.9 |
| 1 ≤ AHI < 5, mild | 54 (44.3) |
| Classification of AHI, n (%) | |
| 5 ≤ AHI < 10, moderate | 42 (34.4) |
| AHI ≥ 10, severe | 26 (21.3) |
| Lowest SpO2 during sleep (%),(mean ± SD) | 73.7 ± 10.8 |
AHI Apnea–Hypopnea Index, SD standard deviations
Comparison of Clinical Characteristics Between Children with ADHD-OSA and ADHD-nonOSA
Children with ADHD-OSA frequently experience health issues such as obesity, adenoid and tonsil hypertrophy, asthma, and allergic rhinitis. The inattentive subtype is significantly more common in the ADHD-OSA group (p < 0.005) (Table 2).
Table 2.
Comparison of clinical characteristics between ADHD-OSA and ADHD-nonOSA
| Characteristics, n (%) | ADHD-nonOSA (n = 402) | ADHD-OSA (n = 122) | Total (n = 524) | p value |
|---|---|---|---|---|
| Age (years), (mean ± SD) | 7.7 ± 1.6 | 7.9 ± 1.5 | 7.8 ± 1.5 | 0.463 |
| Male | 349 (86.8) | 109 (89.3) | 458 (87.4) | 0.461 |
| BMI z-score ≥ + 1 | 138 (34.4) | 67 (54.9) | 205 (39.1) | < 0.001 |
| Adenoid hypertrophy | 23 (5.7) | 67 (54.9) | 90 (17.2) | < 0.001 |
| Tonsillar hypertrophy | 22 (5.5) | 88 (72.1) | 110 (21.0) | < 0.001 |
| Asthma | 5 (1.2) | 15 (12.3) | 20 (3.8) | < 0.001 |
| Allergic rhinitis | 22 (5.5) | 43 (35.2) | 65 (12.4) | < 0.001 |
| ADHD subtypes | ||||
| Hyperactive-impulsive subtype | 40 (10.0) | 13 (10.7) | 53 (10.1) | 0.004 |
| Inattentive subtype | 73 (18.2) | 39 (32.0) | 112 (21.4) | |
| Combined subtype | 289 (71.9) | 70 (57.4) | 359 (68.5) | |
| ADHD comorbidities | 245 (60.9) | 76 (62.3) | 321 (61.3) | 0.789 |
| Type of ADHD comorbidities | ||||
| Learning disorder | 58 (14.4) | 19 (15.6) | 77 (14.7) | 0.754 |
| Tic disorder | 83 (20.6) | 24 (19.7) | 107 (20.4) | 0.815 |
| Behavioral disorders | 21 (5.2) | 17 (13.9) | 38 (7.3) | < 0.005 |
| Anxiety-depressive disorder | 43 (10.7) | 12 (9.8) | 55 (10.5) | 0.786 |
| Oppositional defiant disorder | 129 (32.1) | 45 (36.9) | 174 (33.2) | 0.325 |
| Sleep duration (mean ± SD) | ||||
| Evening bedtime | 22.1 ± 2.1 | 21.2 ± 1.2 | 21.9 ± 2.2 | < 0.001 |
| Evening sleep onset time | 41.9 ± 30.6 | 16.3 ± 12.7 | 38.6 ± 29.8 | < 0.001 |
| Total sleep duration within 24 h | 8.5 ± 1.2 | 9.8 ± 1.2 | 8.8 ± 1.2 | < 0.001 |
Chi-square test: tests for differences between proportions; t test: tests for mean values, p < 0.05
ADHD attention deficit hyperactivity disorder, BMI body mass index, OSA obstructive sleep apnea, SD standard deviations
Children with ADHD-nonOSA had a later bedtime and longer sleep onset time compared to those with ADHD-OSA. The total sleep duration was longer for children with ADHD-OSA compared to those with ADHD-nonOSA (p < 0.001) (Table 2).
Difficulty initiating sleep and bedtime resistance were significantly higher in the ADHD-nonOSA group. Loud snoring, enuresis, difficulty waking up in the morning, tiredness upon waking, and daytime dozing were more common in the ADHD-OSA group (p < 0.05) (Table 3).
Table 3.
Comparison of sleep-related behavioral characteristics between ADHD-OSA and ADHD-nonOSA
| Behavioral characteristics | ADHD-nonOSA (n = 402) | ADHD-OSA (n = 122) | Total (n = 524) | p value |
|---|---|---|---|---|
| Difficulty initiating asleep | 253 (62.9) | 62 (50.8) | 315 (60.1) | 0.013 |
| Bedtime resistance | 237 (60.0) | 63 (51.6) | 300 (57.3) | 0.010 |
| Difficulty maintaining sleep | 131 (32.7) | 49 (40.2) | 180 (34.4) | 0.127 |
| Loud snoring | 25 (6.2) | 88 (72.1) | 113 (21.6) | < 0.001 |
| Restless and moves a lot during sleep | 74 (18.4) | 30 (24.6) | 104 (19.8) | 0.134 |
| Enuresis | 65 (16.2) | 37 (30.3) | 102 (19.5) | 0.001 |
| Nightmares | 59 (14.7) | 21 (17.2) | 80 (15.3) | 0.233 |
| Talks during sleep | 166 (41.3) | 54 (44.3) | 220 (42.0) | 0.561 |
| Sleepwalking | 26 (6.5) | 12 (9.8) | 38 (7.3) | 0.209 |
| Sleep terrors | 58 (14.4) | 20 (16.4) | 78 (14.9) | 0.593 |
| Difficulty waking up in the morning | 125 (31.1) | 56 (45.9) | 181 (35.4) | 0.003 |
| Tiredness upon waking | 188 (46.8) | 88 (72.1) | 276 (52.7) | < 0.001 |
| Daytime dozing | 67 (16.7) | 40 (32.8) | 107 (20.4) | < 0.001 |
Chi-square test: tests for differences between proportions, p < 0.05
ADHD attention deficit hyperactivity disorder, OSA obstructive sleep apnea
Correlation Between OSA and ADHD
The moderate-to-severe OSA group exhibited significantly higher scores for inattention, hyperactivity/impulsivity, behavioral disorders, and anxiety/depression compared to the mild OSA group (p < 0.05) (Fig. 2).
Fig. 2.
Comparison of VAPDRS between mild OSA and moderate-severe OSA groups. AHI Apnea–Hypopnea Index, VAPDRS The Vanderbilt ADHD Parent Diagnosis Rating Scale, OSA obstructive sleep apnea
There is a correlation between AHI and inattention scores (r = 0.677; p < 0.0001), hyperactivity scores (r = 0.438; p = 0.05), behavioral disorder scores (r = 0.342; p < 0.05), and anxiety/depression scores (r = 0.357; p < 0.05) on the VADPRS questionnaire (Fig. 3).
Fig. 3.
Correlation between AHI and VAPDRS. AHI Apnea–Hypopnea Index, VAPDRS The Vanderbilt ADHD Parent Diagnosis Rating Scale
Discussion
The present study revealed the prevalence of obstructive sleep apnea (OSA) in children with attention deficit hyperactivity disorder (ADHD) was 23.3%, significantly higher than the prevalence of OSA in the general pediatric population (1–5%) [20], consistent with most studies on OSA in children with ADHD [12]. This result provides further evidence of clinical overlap between these two conditions, as demonstrated by previous studies [12, 15]. Our study also demonstrated the mean Apnea–Hypopnea Index (AHI) for this study population was higher than 10/h, with more than 50% of children with ADHD-OSA overlap were moderate to severe (Table 1).
The present study showed that the nadir SpO2 during sleep was very low (Table 1), alarming the severe intermittent hypoxia at night. This finding supports the hypothesis of a link between OSA and ADHD on the consequences of OSA, which may have a negative impact on cognitive functions such as memory, emotion, impulse control, problem-solving, social interaction, and motor function, called ADHD-like [14, 21]. Therefore, hypoxia during sleep may be a significant factor contributing to the manifestations of ADHD [21].
Our study also revealed that the prevalence of adenoid/tonsil hypertrophy was significantly higher in the ADHD-OSA group compared to the ADHD-nonOSA group (Table 2), supporting the theory that adenoidtonsillar hypertrophy are common causes of OSA in children [22]. Additionally, the association between OSA, asthma, allergic rhinitis, and ADHD has been demonstrated in numerous recent studies. These studies have shown that the prevalence of OSA is higher in children with asthma and allergic rhinitis, which are also identified as risk factors for ADHD [21, 23, 24]. Therefore, it is essential to assess and manage these conditions to reduce their negative impact on sleep quality and ADHD symptoms. Previous studies have identified a correlation between obesity, sleep disorders, and ADHD, suggesting that abnormal eating behaviors related to ADHD may contribute to obesity, which in turn has a strong correlation with OSA [25]. This could explain why the obesity rate tends to be higher in children with ADHD-OSA. Our findings support this conclusion and also confirm a significantly greater prevalence of obesity in the ADHD-OSA group than in the ADHD-nonOSA group (Table 2).
Obviously, sleep characteristics in children with ADHD are often reported, including difficulty falling asleep—taking more than 30 min, difficulty maintaining sleep, and reduced total sleep duration [20, 26, 27]. In our study, based on two-week sleep diary recordings, we observed that the sleep characteristics of children with ADHD without OSA were consistent with those reported in previous studies. However, when comparing between groups, the present study showed that children with ADHD-OSA had significantly shorter sleep onset time and longer total sleep time within 24 h (Table 2). This suggests that OSA may impact the quality and structure of sleep in children with ADHD. As a result, children with both disorders may fall asleep more easily but experience poorer sleep quality within more total sleep time [11].
Children with OSA and nighttime snoring may experience episodes of apnea, also referred to as intermittent breathing stoppages, a symptom frequently reported by parents or caregivers [28]. Consequently, these children often have restless sleep and frequently move a lot during sleep. Enuresis was also significantly more common in the OSA group compared to the ADHD-nonOSA group (Table 3). It has been demonstrated that sleep fragmentation and intermittent hypoxemia in subjects with OSA may degrade sleep quality, leading to difficulty for waking up in the morning, tiredness upon waking up, and daytime sleepiness [14].
In the present study, the severity of ADHD symptoms in children with moderate-to-severe OSA was significantly higher than in the mild OSA group (Fig. 2) which associated with positive correlations between OSA severity and inattention, hyperactivity/impulsivity, behavioral disorders, and anxiety/depression scores (Fig. 3). The increased severity of ADHD symptoms in children with ADHD-OSA overlap may reflect the impact of OSA on the development of neurocognitive functions in this population., suggesting the importance of screening and treating OSA in the management of children with ADHD. This suggestion is also supported by previous studies which demonstrated examine the bi-directional correlation between OSA and ADHD [21, 29]. Thus, OSA should be treated as early as possible to reduce the prevalence of ADHD in children [21]. However, it is crucial to individualize the treatment of OSA–ADHD overlap based on the clinical phenotype of pediatric OSA to obtain optimal therapeutic outcomes [30, 31].
Although the current concept of management of OSA–ADHD overlap has been founded on numerous relevant studies with small sample sizes, our study based on a large study population using strict diagnostic criteria contributes additional information in the field. However, the lack of a healthy control group is a main limitation of the present study. Therefore, it is essential to conduct more studies focusing on effective approaches and treatment strategies for children with overlapping OSA and ADHD.
Conclusions
The prevalence of obstructive sleep apnea in children with ADHD is higher than in the general population when stratified by age groups and is predominantly moderate-to-severe OSA. This could be due to the high incidence of obesity, adenoidtonsillar hypertrophy, asthma, and allergic rhinitis in children with ADHD-OSA overlap. Children with OSA–ADHD overlap might have detrimental effects on sleep quality and various sleep-related behavior disorders such as inattention, hyperactivity, behavioral disorders, and anxiety/depression in children with moderate-to-severe OSA–ADHD overlaps. Hence, the appropriate screening and management of OSA is crucial for taking care of children with ADHD.
Acknowledgements
We would like to extend our sincere gratitude to the Psychiatry Department of the Vietnam National Children’s Hospital for their precious support and excellent collaboration in conducting this study. We would also like to thank all the parents/caregivers who actively agreed to participate in the present study. We would like to thank the Sleep Lab Center of the Vietnam Society of Sleep Medicine in Dalat, Vietnam, for their assistance and support. We express our deep gratitude to the Center for Creative Initiatives in Health and Population for allowing us to use the Vanderbilt ADHD Parent Diagnosis Rating Scale.
Medical Writing/Editorial Assistance
No medical writing or editorial assistance was received during the preparation of this manuscript. This manuscript was entirely written and edited by the author group.
Author Contribution
The literature search was performed by Mai Nguyen-Thi-Phuong, Sy Duong-Quy, Mai Nguyen-Thi-Thanh. Data collection was done by Mai Nguyen-Thi-Phuong, Sy Duong-Quy, Mai Nguyen-Thi-Thanh, Thuy Nguyen-Thi-Dieu. All authors contributed equally to the analysis and interpretation of data of the study. The manuscript was drafted with significant contributions from Mai Nguyen-Thi-Phuong and Sy Duong-Quy. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.
Funding
No funding or sponsorship was received for this study or the publication of this article.
Data Availability
The data supporting the findings of this study are available from the corresponding author upon reasonable request. However, the data are not publicly accessible due to privacy and ethical restrictions.
Declarations
Conflict of Interest
All authors, including Mai Nguyen-Thi-Phuong, Mai Nguyen-Thi-Thanh, Thuy Nguyen-Thi-Dieu, and Sy Duong-Quy, have no conflicts of interest to disclose. The authors confirm that this research was conducted without any commercial or financial relationships that could be interpreted as a potential conflict of interest. While Sy Duong-Quy serves as an Editorial Board member of Pulmonary Therapy, he was not involved in the selection of peer reviewers or any editorial decisions regarding this manuscript.
Ethical Approval
This study was conducted in accordance with the Helsinki Declaration of 1964 and its later amendments. Ethical approval was obtained from the Biomedical Research Ethics Board of Hanoi Medical University (Approval Number: 794/GCN-HĐĐĐNCYSH-ĐHYHN). The participants’ parents/caregivers/legal guardians provided informed consent for their child to participate in this study.
Footnotes
Prior presentation: This manuscript has not been previously presented or published.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request. However, the data are not publicly accessible due to privacy and ethical restrictions.