Diagnosis of pediatric obstructive sleep disordered breathing: beyond the gold standard.

Childhood obstructive sleep disordered breathing (OSDB), a sleep-related upper airway obstruction that degrades sleep quality, ventilation and/or oxygenation, in turn leads to a variety of daytime symptoms and morbidity. In the past, childhood OSDB was classified into primary snoring versus obstructive sleep apnea (OSA) syndrome and it was widely assumed that childhood OSA required treatment, while primary snoring did not. Pediatric polysomnography (PSG) was originally developed to distinguish primary snoring from childhood OSA. However, the late 1990s saw an explosion of new research on the daytime manifestations and long-term morbidity of childhood OSDB, which resulted in expanded, more comprehensive definitions of childhood OSDB syndromes. It is now clear that even primary snoring, in the absence of classically defined OSA, can be associated with neurobehavioral abnormalities in children. Thus, in retrospect, we realize that 'classical' childhood OSA was only a subset of a larger affected population and that children previously classified as having primary snoring may have serious neurobehavioral dysfunction. Now, in the era of the expanded definition of childhood OSDB, the role of PSG in the routine evaluation of the snoring child is controversial. Given that overnight PSG is widely regarded as the 'gold standard' for the diagnosis of OSDB in children, we review the current usage of PSG in children for the diagnosis of OSDB, its value, limitations and possibilities for future improvements.