Chinese guideline for the diagnosis and treatment of childhood obstructive sleep apnea (2020).

Abstract

Childhood obstructive sleep apnea (OSA) is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns in children.1 OSA is one of the most serious sleep-disordered breathing (SDB) diseases in children. Because of its high prevalence and serious long-term complications, increasing numbers of families are affected by OSA. In 2012, the American Academy of Pediatrics (AAP) clinical practice guidelines reported that the prevalence of pediatric OSA was 1.2%–5.7%2; in 2010, the prevalence of pediatric OSA in Hong Kong, China was 4.8%.3 In contrast to OSA in adults, the main cause of upper airway obstruction in children is adenoid and/or tonsil hypertrophy. Obesity, craniofacial malformation, neuromuscular diseases, and other factors may also contribute to the onset of pediatric OSA.4 Without timely diagnosis and effective intervention, pediatric OSA can lead to a series of serious complications, such as maxillofacial dysplasia, behavioral abnormalities, learning disabilities, growth restriction, neurocognitive impairment, endocrine metabolic disorders, hypertension, and pulmonary hypertension; it can also increase the risk of cardiovascular events in adulthood.5-8 Therefore, early detection and early diagnosis of pediatric OSA, as well as early intervention to correct this problem, are important considerations for improving patient prognosis. There have been some controversies in the clinical diagnosis and treatment of pediatric OSA in China, which have restricted clinical diagnosis and treatment strategies, while hindering progress regarding diagnosis and treatment. The diagnosis and treatment of pediatric OSA is increasingly hampered by the absence of multi-disciplinary cooperation and guidelines. The numbers of pediatric OSA diagnosis and treatment guidelines and expert consensuses are very limited, both in China and worldwide.1, 2, 5, 9-13 The draft guideline for diagnosis and treatment of pediatric obstructive sleep apnea hypopnea syndrome issued in 2007 was mainly established on the basis of expert consensus.1 In the past 10 years, there has been a lack of multi-disciplinary evidence-based diagnosis and treatment guidelines for pediatric OSA in China. Thus, evidence-based clinical practice guidelines are urgently needed. The purpose of the present guideline is to standardize the clinical diagnosis and treatment decision-making concerning pediatric OSA in China, provide scientific evidence for the diagnosis and treatment of pediatric OSA, promote multi-disciplinary integration, guide clinical practice for relevant medical staff, and ensure the use of a scientific approach for management of pediatric OSA. This guideline is suitable for children aged 1–18 years with obstructive sleep apnea related to adenoid and/or tonsil hypertrophy, or related to obesity. The guideline is not applicable to children with central sleep apnea syndrome or hypoventilation syndrome. Moreover, they are not applicable to children with OSA who exhibit the following comorbidities: Down syndrome, severe craniofacial malformation, neuromuscular disease, chronic lung disease, sickle cell disease, metabolic disease, and/or laryngomalacia. This guideline is expected to be used by clinicians, nurses, technicians, and relevant teaching and scientific research staff engaged in sleep respiratory disease-related work in hospitals at all levels. The guideline includes 11 clinical questions and 24 recommendations for diagnosis and treatment, summarized in Table 2. Grading of evidence quality and recommendation strength is described in Table 3 by the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Regarding symptoms, the presence and frequency of snoring should be considered first. Snoring ≥ 3 nights/week merits clinical attention (1A). Further considerations should include sleep suffocation, apnea, mouth breathing, laborious breathing, restless sleep, enuresis, daytime drowsiness, attention deficit/hyperactivity, and poor academic performance (1B). For young children, mouth breathing, repeated arousal, and emotional and behavioral abnormalities should receive clinical attention (GPS). Regarding physical signs, adenoid hypertrophy, tonsil hypertrophy, adenoid face, and obesity should be considered (1B). Whether based on a single symptom/sign or a combination of multiple symptoms and signs, pediatric OSA cannot be diagnosed without the use of polysomnography (PSG). Additional diagnostic methods are recommended to improve the accuracy of diagnosis (1B). PSG is recommended for the diagnosis of pediatric OSA (1A). For hospitals with limited access to PSG, the use of clinically proven portable sleep monitoring equipment (e.g., pulse oximeter) is recommended. Other clinical information such as medical history, physical examination, and questionnaire results should be integrated for comprehensive diagnosis. If necessary, patients should be referred to medical institutions where PSG monitoring is available (2C). When children are diagnosed with moderate or severe OSA and clinical findings are consistent with adenoid and/or tonsil hypertrophy, adenoidectomy and/or tonsillectomy is recommended for children without surgical contraindications (1B). For children diagnosed with OSA whose clinical findings are not consistent with adenoid and/or tonsil hypertrophy, a comprehensive assessment of the upper airway (including the oral and nasal cavities) is required; further treatments are recommended (GPS). Critical evaluation of postoperative persistent OSA is recommended for obese children; supplementary treatments should be administered when necessary (1B). Children with OSA and the following characteristics are recommended to undergo postoperative monitoring: age < 3 years at the time of surgery; asthma and/or nasal diseases (e.g., allergic rhinitis or sinusitis); OAHI > 10/h and/or lowest oxygen saturation < 80%; family history of OSA (2B). For children with mild to moderate OSA, adenoid and tonsil evaluation should be performed. Until this evaluation has been completed, nasal corticosteroids or oral montelukast sodium are recommended to reduce sleep apnea events and improve symptom scores. Moreover, regular follow-up is recommended to evaluate efficacy and possible adverse reactions (1B). Regarding combination therapy, following adenoid and tonsil evaluation, nasal corticosteroids combined with oral montelukast sodium are recommended for children with mild or moderate OSA. Regular follow-up is recommended to evaluate efficacy and possible adverse reactions (2D). For children with OSA who do not respond favorably to medication or who experience recurrence after withdrawal, other treatments are recommended on the basis of comprehensive assessments of the upper airway (GPS). For children with OSA who have surgical contraindications without adenoid and/or tonsil hypertrophy, as well as children with persistent OSA after adenoidectomy and/or tonsillectomy, combined with non-surgical treatments, NPPV is recommended as an effective treatment after comprehensive assessments of the upper airway (1B). NPPV is recommended as an alternative or a perioperative complementary treatment option for children with severe OSA (GPS). For children who are receiving NPPV, adjustment of ventilator parameters under PSG monitoring is recommended. Periodic evaluation of ventilator parameters is also recommended (GPS). The application of NPPV to children with OSA may result in mild adverse reactions, such as nasal symptoms, optic irritation, and skin damage. The long-term use of NPPV may cause craniofacial abnormalities; thus, regular evaluation is recommended (GPS). Oral evaluation and oral appliance treatment are recommended for children with OSA who may exhibit oral and maxillofacial development problems, especially those with OSA who may not exhibit adenoid or tonsil hypertrophy, as well as those with persistent postoperative OSA, those who are inoperable, and those who are unable to tolerate NPPV treatment (GPS). After oral evaluation, children with OSA who require oral appliance treatment should receive maxillary expansion or mandibular anterior guidance according to the type of tooth and jaw deformity, as well as the site of airway obstruction. Maxillary arch expansion is effective for treatment of mild to moderate OSA, especially in children with middle palatal suture before bony healing (2D). Mandibular leading orthodontics is effective for children with mild to severe OSA. Treatment is recommended before puberty. Long-term treatment (> 6 months) is better than short-term treatment (1B). Recommendations: Regarding symptoms, the presence and frequency of snoring should be considered first. Snoring ≥ 3 nights/week merits clinical attention (1A). Further considerations should include sleep apnea, mouth breathing, laborious breathing, restless sleep, enuresis, daytime drowsiness, attention deficit/hyperactivity, and poor academic performance (1B). For young children, mouth breathing, repeated arousal, and emotional and behavioral abnormalities should receive clinical attention (GPS). Regarding physical signs, adenoid hypertrophy, tonsil hypertrophy, adenoid face, and obesity should be considered (1B). Whether based on a single symptom/signor a combination of multiple symptoms and signs, pediatric OSA cannot be reliably diagnosed without the use of polysomnography (PSG). Additional diagnostic methods are recommended to improve the accuracy of diagnosis (1B). Evidence summary: The guideline working group performed a qualitative analysis of 21 studies that described OSA-related symptoms and signs in children; these 21 studies included seven guidelines and three systematic reviews. The results were as follows: all 21 studies reported snoring symptoms (six reported snoring frequencies and four studies reported snoring frequencies of 3 nights/week). Additionally, attention deficit/hyperactivity, apnea, daytime sleepiness, and weight loss or gain were frequently reported, as were tonsil hypertrophy, adenoid hypertrophy. Two systematic reviews assessed the accuracy of clinical history and/or signs for diagnosis of OSA, compared with the accuracy of PSG.15, 16 Twelve original studies (n = 1058 patients) were included in a systematic review published in 200415; these included six prospective cohort studies, four retrospective case series, one cross-sectional study, and one case-control study, with sample sizes ranged from 12 to 326 cases. There was significant heterogeneity among PSG-based diagnostic criteria, such as AHI events (apnea or hypopnea) and their ranges (1–15 episodes per hour). A meta-analysis based on data from 10 studies suggested that the positive predictive value (PPV) was 55.8% (95% confidence interval [CI]: 42.1–69.6); the sensitivities and specificities of the clinical evaluation parameters were ≤ 65% in all studies.15 Methodological heterogeneity and clinical heterogeneity were evident among studies, but the results of the included studies were relatively consistent. The systematic review findings suggested that, compared with PSG, clinical symptoms and signs are not effective for diagnosis of OSA. Furthermore, 10 diagnostic tests (n = 1525 patients) were included in a systematic review published in 2012.16 Heterogeneity was observed among the included studies. Only six studies defined AHI > 1/h as the threshold for diagnosis of pediatric OSA; no study described identification of symptoms and signs, nor did any study assess the consistency between observers. The systematic review results suggested that tonsil hypertrophy and snoring were highly sensitive parameters, but were not specific for OSA; daytime sleepiness, apnea, and nocturnal dyspnea were highly specific parameters, but were not sensitive for OSA. The sensitivity and specificity ranges of the seven assessed models (using combinations of symptoms and signs) were 4%−94% and 28%−99%,16 respectively. Area under the receiver operating characteristic curve (AUROC) results indicated that symptoms and signs have poor diagnostic ability for pediatric OSA. Therefore, compared with PSG, neither a single symptom/sign nor a combination of multiple symptoms and signs can effectively diagnose pediatric OSA15, 16; other diagnostic models are needed to improve the accuracy of diagnosis. Another systematic review assessed the diagnostic value of clinical history and physical examination, compared with PSG, in pediatric SDB17; its conclusions were consistent with the findings of previous analyses. Justification: This recommendation is based primarily on the evidence of symptoms and signs that occur with greater frequency. To formulate the working group’s expert opinions based on the results of expert interviews and guidelines, some symptoms not included in the recommendations but observed in clinical practice (e.g., foaming at the mouth, prone position/head back/sitting/over-extension of the neck, and the three depression signs) are also worthy of clinical attention; these should be evaluated in clinical examinations, in combination with the above recommendations and individual child’s performance. In addition, comprehensive assessment of upper airway obstruction in pediatric OSA should be emphasized, including the presence of allergic rhinitis, nasal septum deviation, nasopharyngeal mass, laryngeal space occupation, or tumor. Children’s symptoms and signs are an important basis for the initial diagnosis of pediatric OSA, but their diagnostic accuracy is low. Diagnosis of pediatric OSA solely based on a single symptom/sign or a combination of symptoms and signs is not recommended; additional diagnostic tools should be used. In addition, this recommendation is based on the 2019 recommendations of the European Respiratory Society (ERS), which distinguish among symptoms and signs according to age. For example, the main symptoms in younger children include snoring, mouth breathing, restless sleep, and abnormal emotional behavior, while the main symptoms in older children include snoring, apnea, daytime sleepiness, attention deficit/hyperactivity, learning difficulties, and memory decline. Recommendation: PSG is the standard diagnostic method for pediatric OSA. OAHI > 1/h is recommended as the threshold value for the early detection of children with SDB who require intervention; additionally, AHI, OAI, and lowest oxygen saturation (LSaO2) are important assessments for the evaluation of pediatric OSA (1A). Evidence summary: The 2012 AAP Guideline included a systematic review of 10 diagnostic studies (from 12 publications) since 2002, all of which used standard PSG for diagnosis of pediatric OSA.2 However, the diagnostic criteria were inconsistent among studies. The key indicators for OSA diagnosis included AHI and OAI; the AHI thresholds were 1/h, 3/h, and 5/h. A systematic review of 10 studies was published in 201216; the results showed that the diagnostic thresholds used for diagnosis of pediatric OSA by PSG were inconsistent, such that six studies used AHI > 1/h and two studies used AHI > 5/h. In a 2016 Chinese diagnostic trial (n = 1115 patients),18 PSG was applied to children who met the diagnosed criteria of American Thoracic Society (ATS) (AHI > 5/h or OAI > 1/h) and who were between the International Classification of Sleep Disorders (ICSD) and ATS thresholds (OAHI ≥ 1/h, while AHI ≤ 5/h and OAI ≤ 1/h), as well as children who met the ICSD criteria for primary snoring (OAHI < 1/h). The mean and longest durations of obstructive apnea were significantly longer in children between ICSD and ATS thresholds than in the ICSD primary snoring group (P < 0.01); moreover, LSaO2 was lower in children between ICSD and ATS thresholds than in the primary snoring group (P < 0.05). Children between ICSD and ATS thresholds had obvious nocturnal symptoms, their daytime behavior was affected, and their PSG parameters were similar to those of children with OSA. Therefore, OAHI ≥ 1/h should be regarded as the diagnostic threshold of pediatric OSA; this approach is more conducive to the early identification of children with SDB who require intervention. A 2005 cross-sectional study (n = 48 patients) explored the value of PSG in the differential diagnosis of snoring in children.19 The results showed that the mean SaO2, lowest SaO2, and the SaO2 < 95% times were significantly different between children with AHI < 1/h and those with AHI ≥ 5/h (P < 0.01), while there was no significant difference in snoring index or total number of snoring sounds; thus, AHI ≥ 1/h was more suitable for the diagnosis of OSA in children. A 2016 cross-sectional survey in China (n = 99 participants) analyzed the sleep-breathing parameters of healthy children.20 OAI and OAHI were similar between children aged 3−5 years and those aged 6−14 years (OAI, 0.08 ± 0.12/h and 0.07 ± 0.14/h, respectively; OAHI, 0.18 ± 0.21/h. Justification: This recommendation is based on available evidence, as well as the 2017 ERS Guideline.21 It is consistent with the International Classification of Sleep Disorders-Third Edition (ICSD-3) (Table 4).22 OAHI > 1/h was used as the diagnostic threshold for pediatric OSA. This recommendation emphasizes the importance of obstructive factors in the diagnosis of pediatric OSA. Central respiratory events in pediatric OSA are presumably associated with long-term obstructive apnea and hypoventilation. This recommendation is made with the presumption that obstructive factors constitute the root cause of pediatric OSA; these factors lead to a series of pathophysiological changes in children with OSA. Therefore, OAHI should be used as the main objective indicator for the diagnosis of OSA, rather than AHI. Recommendations: The severity of OSA is recommended to be graded based on PSG findings. The suggested grades are as follows (2B): mild, 1/h < OAHI ≤ 5/h; moderate, 5/h < OAHI ≤ 10/h; severe, OAHI > 10/h. The severity of OSA is not recommended to be graded on the basis of tonsil size (1B). Evidence summary: A 2011 systematic review (20 studies) assessed tonsil size and PSG value for pediatric OSA severity rating.25 The results showed an association between subjective tonsil size and objective OSA severity in 11 of the 20 studies, but revealed no association in the remaining nine studies. No difference was observed between high quality (score 3.22) and low quality (score 2.36) studies. Thus, a weak correlation was recorded between the severity of objective OSA and the size of children’s tonsils. High-quality studies showed no association between subjective tonsil size and objective OSA severity. Some studies used clinical parameters to assess the severity of pediatric OSA. The results suggested no correlation between tonsil size and AHI or ODI.26 In preschoolers, a weak correlation has been observed between adenoid size and OSA severity; adenoid hypertrophy is considered the main cause of OSA in preschoolers with normal weight.27 For OSA severity classification, standards have been inconsistent among studies, but most are based on obstructive AHI values of 5/h, 10/h, or 15/h.28-30 Some studies have referred to SpO2 and total sleep time.29 In 2014, the Australasian Sleep Association Guideline recommended OAHI as the standard for classification of pediatric OSA severity.23 OAHI < 1.2/h was regarded as normal, 1.2/h ≤ OAHI < 5/h as mild abnormality, 5/h ≤ OAHI < 10/h as moderate abnormality, and 10/h ≤ OAHI < 30/h as severe abnormality. The 2007 Draft Guideline of the Chinese Medical Association used AHI or OAI as the criteria for OSA severity classification in children.1 Specifically, 5/h ≤ AHI ≤ 10/h or 1/h ≤ OAI ≤5/h and LSaO2 saturation between 0.85 and 0.91 were considered indicative of mild abnormality, while 10/h < AHI ≤ 20/h or 5/h < OAI ≤ 10/h and LSaO2 saturation between 0.75 and 0.84 were considered indicative of moderate abnormality; AHI > 20/h or OAI > 10/h and LSaO2 saturation < 0.75 were considered indicative of severe abnormality. Justification: The purpose of the severity rating in this recommendation is to guide the assessment of prognostic risk for pediatric OSA; “mild OSA”, “moderate OSA”, and “severe OSA” are established as indicated in Table 4. Notably, existing systematic reviews of tonsil size did not show an association with AHI or ODI. Uniform grading standards of OSA severity are not available; previous studies have used values established in systematic reviews, other original studies, and published guidelines (Table 4).21-23 This recommendation uses 1/h < OAHI ≤ 5/h, 5/h < OAHI ≤ 10/h, and OAHI > 10/h as criteria for pediatric OSA severity rating. Long-term follow-up of children with OSA is difficult; there remains a lack of cohort studies, both in China and globally, regarding the correlation between graded diagnosis of pediatric OSA and long-term effects on diseases and complications (e.g., changes in cognition, metabolism, cardiopulmonary function, and cardiovascular health). Therefore, long-term follow-up and cohort analysis of children with OSA is an important future research goal. Recommendations: PSG is recommended for the diagnosis of pediatric OSA (1A). For hospitals with limited access to PSG, the use of clinically proven portable sleep monitoring equipment (e.g., pulse oximeter) is recommended. Other clinical information such as medical history, physical examination, and questionnaire results should be integrated for comprehensive diagnosis. If necessary, patients should be referred to medical institutions where PSG monitoring is available (2C). Evidence summary: The systematic review produced by the Steering Group included 13 studies (n = 1633 patients). Of these 13 studies, seven used pulse oximeters (n = 1450 patients) and six used portable sleep monitoring devices (n = 183 patients). Seven studies did not provide original data for descriptive analysis; of the remaining six studies, three used pulse oximeters (n = 1019 patients) and three used watch-PAT devices (n = 114 patients). The combined sensitivity and specificity of OSA diagnosis using PSG were 75.0% (95% CI: 53.0%–89.0%) and 88.0% (95% CI: 70.0%–96.0%), respectively. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 6.2 (95% CI: 2.5–15.4) and 0.3 (95% CI: 0.1–0.7), respectively. The cumulative area under the receiver operating characteristic curve was 0.89 (95% CI: 0.86–0.91, P = 0.000). In 2013, a systematic review of 33 studies (n = 1064 patients; AMSTAR2 = 7.5) reported a comparison of PSG with 40 other diagnostic methods.31 One pulse oximeter and two portable sleep monitoring devices were compared with PSG (sample size ranged from 21 to 57) in studies published from 1995 to 2003. Two studies (both using OSA diagnostic criteria AHI > 1/h) reported sensitivities of 66.7% and 100%, whereas they reported specificities of 66.7% and 62.5%. Justification: This recommendation continues to support PSG as a standard diagnostic method for pediatric OSA. However, standard PSG monitoring involves equipment limitations, as well as a complex technical process, requirement for specialized personnel, and high cost. Therefore, clinicians are recommended to use pulse oximeters and other portable monitoring equipment to support the findings of clinical examinations when PSG monitoring is unavailable. Objective assessment and preliminary diagnosis of sleep breathing characteristics are recommended to obtain more objective diagnostic evidence before initiation of clinical treatment in children with OSA; this approach supports comprehensive assessment and individual treatment. It is also consistent with the 2012 AAP Guideline and 2014 Australasian Sleep Association Guideline.2, 23 If use of the above portable equipment reveals severe OSA, affected patients should be referred to a medical institution with the ability to perform PSG, prior to treatment. In addition, the retrieval evidences of the above recommendations of the is not limited to the equipment type of evidence, but sleep monitoring III–IV level equipment have various kinds and the clinical question mainly focused on simple alternative diagnostic tools such as the diagnostic accuracy of pulse oximeter. For the method of pulse oxygen monitoring, the McGill oxygen score (Table 5) could be used.32, 33 For children who do not meet the s the McGill oxygen score (e.g., children with SaO2 < 0.90 fewer than three times and more than three clusters of SaO2 decrease events, or children with SaO2 < 0.90 more than three times and stable baseline SaO2 > 0.95), PSG is recommended to facilitate a clear diagnosis. Recommendation: The PSQ and OSA-18 alone are not recommended to be used as diagnostic tools for pediatric OSA. A combination of medical history, physical examination, and sleep monitoring findings are recommended to increase the specificity of questionnaire-based diagnosis (2D). Evidence summary: In total, eight studies were included in a comparison of diagnostic accuracy between OSA-related questionnaires or scales and PSG (OSA-18: four studies, n = 1047 patients; PSQ: four studies, n = 472 patients). The PSQ questionnaire here specifically refers to the sub-questionnaire of sleep-related breathing disorders, which cover the three major symptoms of pediatric OSA: sleep snoring, drowsiness, and hyperactivity. Four studies did not provide original data for descriptive analysis. The remaining four studies revealed the following respective combined sensitivity, specificity, PLR, NLR, and AUROC values for PSQ (n = 307 patients) and OSA-18 (n = 743 patients) in the diagnosis of pediatric OSA: 77% (95% CI: 55%–90%), 61% (95% CI: 38%–80%), 2.0 (95% CI: 1.2–3.3), 0.38 (95% CI: 0.19–0.76), and 0.75 (95% CI: 0.71–0.78, P = 0.000). A systematic review (AMSTAR2 = 10) published in 2014 investigated the accuracy of PSG in diagnosis of SDB in children by comparing multiple physical examinations and questionnaires among four subgroups: questionnaire, questionnaire + physical examination, questionnaire + physical examination + other diagnostic methods, and physical examination + other diagnostic methods.17 Of the 11 included diagnostic tests, three assessed PSQ vs. PSG (n = 102 patients), PSQ + physical examination vs. PSG (n = 61 patients), and OSA-18 + physical examination + other diagnostic methods vs. PSG (n = 527 patients). The results suggested that the diagnostic accuracy of questionnaire-based assessment was insufficient to replace PSG or other objective examinations as an independent approach. Justification: The 2012 AAP Guideline2 and 2014 Australasian Sleep Association Guideline23 clearly emphasize the importance of clinical symptoms and questionnaires/scales in the preliminary diagnosis of OSA. For quantitative assessments of clinical symptoms, questionnaires are simple, convenient, and non-invasive. In 2011, a total of 6404 sleep assessment tools were available worldwide, including 183 children’s sleep disorders questionnaire and scales. Unfortunately, few screening tools have been evaluated for reliability and validity.34 In terms of the questionnaires that have been scientifically validated and widely used in China, this recommendation mainly advocates the use of two questionnaires, PSQ and OSA-18. The PSQ has been translated into Portuguese,35 Spanish,36 Chinese37, 38 and other versions; its reliability and validity have been confirmed. As a current approach to investigate the quality of life in children with OSA, the OSA-18 has been widely used; this questionnaire covers five dimensions (18 items): sleep disorder, physical symptoms, emotional distress, daytime conditions, and the degree of influence on guardians. However, current evidence suggests that the diagnostic accuracy of the questionnaire is low; thus, it cannot replace PSG or other objective examinations as an independent diagnostic tool. This questionnaire should be used in combination with other clinical diagnosis tools, including PSG (if necessary). Recommendations: When children are diagnosed with moderate or severe OSA and clinical findings are consistent with adenoid and/ or tonsil hypertrophy, adenoidectomy and/or tonsillectomy is recommended for children without surgical contraindications (1B). For children diagnosed with OSA whose clinical findings are not consistent with adenoid and/or tonsil hypertrophy, a comprehensive assessment of the upper airway (including the oral and nasal cavities) is required; further treatments are recommended (GPS). Evidence summary: The results of qualitative studies are made as follows: 1) Seventy-seven studies were retrieved regarding surgical indications in children with OSA; these included 10 guidelines (recommendations are shown above), 3 systematic reviews, and 64 original studies. 2) The systematic reviews and original studies mainly discussed surgical efficacy, surgical methods, and complications related to adenoidectomy and/or tonsillectomy in children with OSA (inclusion criteria were pediatric OSA with adenoid and/or tonsil hypertrophy). 3) Two studies had a minimum age of 1 year in patients who underwent surgery, while 13 studies had a minimum age of 2 years; the remaining studies had a minimum age of 3 years. 4) The shortest course of OSA in children ranged from 3 to 6 months in patients who underwent surgery. Justification: Tonsillectomy and/or adenoidectomy are currently first-line treatments for pediatric OSA, especially in children with moderate to severe OSA, following comprehensive assessments of the upper airway (including nasal, nasopharyngeal, oropharyngeal, laryngopharyngeal, and laryngeal cavities) via endoscopy or imaging, in combination with fulfillment of clinical examination criteria for adenoidectomy and/or tonsillectomy without surgical contraindications (based on 2012 AAP Guideline).2 Furthermor