ARTICLE

Development of a Measure of Knowledge

and Attitudes About Obstructive Sleep Apnea
in Children (OSAKA-KIDS)
Elizabeth C. Uong, MD; Donna B. Jeffe, PhD; David Gozal, MD; Raanan Arens, MD; Cheryl R. Holbrook, MD;
John Palmer, MD; Claudia Cleveland, RPSGT; Helena M. Schotland, MD

Background: Primary care physicians play an impor-
tant role in screening for childhood obstructive sleep
apnea syndrome (OSAS) that, if untreated, can result in
serious complications.
Objective: To describe the development of the Obstruc-
tive Sleep Apnea Knowledge and Attitudes in Children
(OSAKA-KIDS) questionnaire for use in measuring phy-
sicians’ knowledge and attitudes about childhood OSAS
and its treatment.
Design: Cross-sectional survey to pilot administration
of the 23-item OSAKA-KIDS questionnaire, mailed to 1195
community- and academic-based physicians in Louis-
ville, Ky; Philadelphia, Pa; and St Louis, Mo.
Main Outcome Measures: Analysis of variance mea-
sured differences in knowledge and attitudes between aca-
demic- and community-based physicians and between pe-
diatricians and family practitioners. Using stepwise
multiple linear regression, we analyzed the associations
between various predictors (including specialty, prac-
tice setting, and years since medical school graduation)
and each item of knowledge and attitudes. All tests were
2-tailed.
Results: Questionnaires for 497 respondents (44% fe-
male; mean [SD] age, 45.7 [10.5] years; and mean [SD]
number of years since medical school graduation, 18.7
[11.0] years) were analyzed. The mean (SD) knowledge
score (percentage of 18 possible) was 69.6% (14.6%). In
regression analyses, more knowledge was associated with
more positive attitudes overall and more recent gradu-
ation from medical school; having a more positive atti-
tude was associated with having completed a pediatrics
residency and more knowledge about OSAS.
Conclusions: Deficits in basic knowledge about child-
hood OSAS were observed regardless of physician prac-
tice setting and specialty training. More education fo-
cusing on the diagnosis and treatment of childhood OSAS
and identifying children at risk for OSAS is recom-
mended.
Arch Pediatr Adolesc Med. 2005;159:181-186

Author Affiliations are listed at
the end of this article.
O
BSTRUCTIVE SLEEP APNEA
syndrome (OSAS) oc-
curs in 1% to 3% of chil-
dren.1-3 Compared with
adult OSAS, the cause and
characteristics of childhood OSAS are dif-
ferent,4-6 although its consequences are as
grave. Obstructive sleep apnea syndrome in
children can result in serious complica-
tions, including failure to thrive,7-9 pulmo-
nary hypertension and cor pulmonale,10-12
systemic hypertension,13 neurocognitive
deficits,14,15 and neurobehavioral dysfunc-
tion.1,16,17 Untreated OSAS has also been
shown to have a negative effect on health-
related quality of life,18 and imposes a sub-
stantial health care burden along with re-
current primary care physician contacts.19
Primary care physicians play an impor-
tant role in screening for OSAS. Recent sur-
veys have shown a 12-fold increase in the
diagnosis of adult OSAS among primary
care physicians’ practices from 1990 to
1998.20 While encouraging, gaps in knowl-
edge continue to be reported.21 Rosen et
al22 found low recognition rates of OSAS
among both community-based primary
care physicians and those in academic set-
tings (0.1% and 3.1%, respectively) com-
pared with national prevalence estimates
(9% for women and 24% for men).23
Education about sleep disorders is nec-
essary to ensure accurate diagnosis and
treatment of OSAS in adults and chil-
dren. A knowledge-based questionnaire
may be used to provide assessment prior
to and following specific educational in-
terventions. The Assessing Sleep Knowl-
edge in Medical Education (ASKME) Sur-
vey24 and the Obstructive Sleep Apnea

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 Knowledge and Attitudes (OSAKA) questionnaire25 were
developed and successfully used in educational re-
search about OSAS in adults. Obstructive sleep apnea syn-
drome in children, however, differs from the condition
in adults and little is known about the level of aware-
ness of primary care physicians regarding recognition and
appropriate management of OSAS in children. A Pedi-
atric Sleep Survey26 has been developed to assess physi-
cians’ knowledge, treatment practices, and attitudes about
pediatric sleep disorders in general. Yet only 4 of the 30
items in the survey were devoted to OSAS. The Obstruc-
tive Sleep Apnea Knowledge and Attitudes in Children
(OSAKA-KIDS) questionnaire, presented herein, was de-
veloped specifically to assess physicians’ knowledge about
childhood OSAS. In this article, we describe the devel-
opment of the OSAKA-KIDS questionnaire and the re-
sults of a pilot administration of the survey to pediatri-
cians and family practitioners in community-based
practices and academic medicine settings.
METHODS
PARTICIPANTS AND PROCEDURE
The OSAKA-KIDS questionnaire and a cover letter were mailed
to a convenience sample of 1195 family physicians and pedia-
tricians at 3 sites between November 1, 2002, and March 31,
2003–academic-based pediatricians at St Louis Children’s Hos-
pital, St Louis, Mo, and Children’s Hospital of Philadelphia, Phila-
delphia, Pa, and community-based family physicians and pe-
diatricians in Louisville, Ky. A second mailing was sent 12 weeks
after the initial mailing to increase response rates. The study
was approved by the institutional review boards at all 3 sites;
return of the questionnaire implied consent. Questionnaires were
completed anonymously.
MEASUREMENT OF KNOWLEDGE
AND ATTITUDES
The OSAKA-KIDS questionnaire is a self-administered, 23-
item questionnaire that assesses physicians’ knowledge and at-
titudes regarding childhood OSAS. The OSAKA-KIDS ques-
tionnaire followed development of the OSAKA questionnaire,25
which measures physician knowledge and attitudes about OSAS
in adults, although we referred to other instruments and ex-
perts in the field during the design of the pediatric knowledge
questions.24,26,27
To establish face validity of the knowledge items, 5 experts
in pediatric sleep medicine were consulted. The experts were
asked to rate each of 30 knowledge items for relevance using a
4-point scale (1, not relevant; 2, slightly relevant; 3, relevant;
and 4, extremely relevant). Items were considered for inclu-
sion in the final questionnaire if at least 80% of the expert panel
members gave the individual items a score of 3 or 4. Modifi-
cations were made based on the experts’ feedback.
The final questionnaire included 18 knowledge items and
5 attitude items. The knowledge domains include epidemiol-
ogy, pathophysiology, symptoms, diagnosis, and complica-
tions and treatment of childhood OSAS. Items were presented
in a true-or-false format. “Don’t know” was included as a third
response choice to minimize the effect of guessing and was scored
as an incorrect response.
In addition, 5 attitude items were included pertaining to (1)
the importance of OSAS as a clinical disorder in children and
the identification of children at risk for OSAS, and (2) the phy-
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sicians’ confidence in their ability to identify children at risk
for and treat children with OSAS as well as to manage children
receiving continuous positive airway pressure therapy. These
items, drawn from the attitude items on the adult OSAKA ques-
tionnaire,25 were reworded to inquire specifically about child-
hood OSAS. Physicians were asked to rate the extent of their
agreement with each of the 5 items using a 5-point Likert scale
ranging from 1 (strongly disagree) to 5 (strongly agree). Mean
attitude scores were computed for each of the 2-item impor-
tance and 3-item confidence subscales as well as for the 5-item
overall attitudes scale.
DEMOGRAPHIC VARIABLES
The OSAKA-KIDS questionnaire also included questions about
age, gender, year of medical school graduation, and type of resi-
dency training completed.
DATA ANALYSIS
All tests were 2-tailed with the level of statistical significance
set at P⬍.05. Responses to each knowledge item were catego-
rized as correct (1) or incorrect (0), and a total knowledge score
was computed for each respondent. Differences in knowledge
and attitudes by specialty (pediatrics vs family practice) and
practice setting (community vs academic) were analyzed us-
ing 1-way analysis of variance. Stepwise multiple linear regres-
sion evaluated the associations between the various predictors
(including specialty, practice setting, and years since medical
school graduation) and each of the 2 dependent variables—
knowledge and attitudes. We selected number of years since
medical school graduation as a covariate based on previous find-
ings of a negative relationship between knowledge and time since
graduation.25 In addition, we included the overall attitudes score
as a predictor of knowledge and included total knowledge as a
predictor of attitudes in the respective regression models be-
cause physicians’ knowledge and attitudes about OSAS in adults
also were shown to be correlated.25 For each significant pre-
dictor, we report the unstandardized coefficient (B), standard
error, P value, and 95% confidence interval (CI) for B.
RESULTS
Completed questionnaires were returned by 517 physi-
cians, with an overall response rate of 43%. Respon-
dents included 338 community-based physicians (pe-
diatricians and family practitioners) in Louisville (43%
of the 783 surveyed), 82 pediatricians at Children’s Hos-
pital of Philadelphia (46% of 177 surveyed), and 97 pe-
diatricians at St Louis Children’s Hospital (41% of 235
surveyed). Four physicians who trained in other special-
ties and 16 who did not indicate their specialty or year
of medical school graduation were excluded from fur-
ther analysis. The final sample included 497 respon-
dents (96% of 517 and 42% of 1195). Respondents ranged
in age from 28 to 86 years. Characteristics of the sample
are given in Table 1.
KNOWLEDGE
The mean (SD) total knowledge score (percentage of 18
possible) was 69.6% (14.6%). Responses to individual
items are listed in Table 2. At least three quarters of the
respondents correctly answered the items pertaining to
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 Table 1. Characteristics of the Sample Population* Table 2. Percentage of 497 Respondents Answering
Each Knowledge Item Correctly
No. (%) of
Characteristic Participants Correct % Responding
Question Response Correctly
Gender
Men 277 (55.7) 1. Children with obstructive sleep apnea True 86.9
Women 219 (44.1) may present with hyperactivity.
Unspecified 1 (0.2) 2. Approximately 10% of children snore True 71.0
Recruitment sites on a regular basis.
St Louis Children’s Hospital, St Louis, Mo 96 (19.3) 3. Nearly 2% of children have OSA. True 55.1
Children’s Hospital of Philadelphia, 82 (16.5) 4. Obstructive sleep apnea in children True 86.9
Philadelphia, Pa may be associated with pulmonary
Community practices in Louisville, Ky 319 (64.2) hypertension.
Specialty training 5. A polysomnogram is needed to True 71.4
Pediatrics 365 (73.4) differentiate primary snoring from
Family practice 132 (26.6) obstructive sleep apnea syndrome
Age, mean (SD), y† 45.7 (10.5) in children.
Range 28-86 6. The degree of snoring (ie, mild to False 75.9
Time since medical school graduation, 18.7 (11.0) severe) correlates with the severity
mean (SD), y of obstructive apnea in children.
Range 3-60 7. Excessive upper airway muscle tone True 68.2
loss during sleep contributes to OSA
Knowledge score
in children.
Mean percentage correct (mean score/18) 69.6 (12.53/18)
8. Enlarged tonsils and adenoids are True 85.9
Median 72.2
the most frequent contributing factor
Range 17-100
to OSA.
Attitudes, mean (SD), score 3.2 (0.6)
9. Children with suspected OSA should True 99.4
Range 1.4-5.0 have a thorough head and neck and
oropharyngeal examination.
*A total of 497 participants were included in the study analyses. 10. Children with untreated OSA may have True 93.4
†Includes a total of 495 respondents as 2 respondents neglected to enter learning deficits.
their age. 11. Snoring is most frequently reported at True 50.1
ages 2 to 8 years.
12. Cardiac arrhythmias may be True 74.0
the complications and usual clinical signs and symp- associated with untreated OSA.
toms of OSAS (items 1, 4, 8, 9, 10, and 15 on the 13. Children with sickle cell disease are at True 14.5
increased risk for OSA.
OSAKA-KIDS questionnaire). Questions regarding the 14. Children younger than 2 years True 57.7
prevalence of OSAS, frequency of snoring, and popula- should have a polysomnogram prior
tions at risk for OSAS (items 6, 11, 13, 14, 16, and 17) to surgical intervention for
were answered correctly by fewer than two thirds of the presumed OSA.
respondents. Only 14% of the respondents answered the 15. Significant OSA can occur without True 82.9
snoring in children.
item concerning sickle cell disease and OSAS correctly 16. Failure to thrive is a frequent True 53.3
(item 13). Total knowledge scores were normally dis- complication of OSA.*
tributed, ranging from 17% to 100% correct. 17. Children with severe OSA may have True 61.0
Only small differences were observed in average knowl- transient worsening of respiratory
edge scores between community- and academic-based symptoms following tonsillectomy
and/or adenoidectomy.
physicians (69% vs 71%, respectively; 95% CI of the dif- 18. A cardiorespiratory monitor can False 65.6
ference, −0.4% to 4.7%) and between pediatricians and reliably detect both central and
family practitioners (70% vs 68%, respectively; 95% CI obstructive apnea in infants.
of the difference, −0.7% to 5.6%).
In the regression of knowledge on residency training, Abbreviations: OSA, obstructive sleep apnea.
practice setting, time since graduation, and attitudes to- *Will be rephrased to “Failure to thrive can be an associated finding
suggesting obstructive sleep apnea syndrome in infants and young children.”
ward childhood OSAS and its treatment, having higher
knowledge scores was associated with more positive atti-
tudes (B=0.064, SE=0.011; P⬍.001; 95% CI for B, 0.043-
0.085) and more recent graduation from medical school 5 (Table 3). The distribution of responses on the 5-item
(B=−0.001, SE=0.001; P=.039; 95% CI for B, −0.002 to attitude scale was normally distributed. In addition, 2 sub-
0.000). Attitudes accounted for 6.8% of the variance of scale scores were computed using the 2 items pertain-
knowledge scores at entry into the model at step 1, whereas ing to the importance of OSAS and its diagnosis in chil-
the number of years since graduation accounted for only dren and the 3 items pertaining to physicians’ confidence
an additional 0.8% of the variance when entered at step 2. in identifying and treating children with OSAS.
Although small, the difference in mean attitudes by
ATTITUDES practice setting was statistically significant, with physi-
cians in academic settings reporting better attitudes over-
An attitudes-toward-OSA scale score was computed us- all compared with physicians practicing in the commu-
ing the mean of all 5 items, which could range from 1 to nity (mean [SD], 3.3 [0.5] vs 3.1 [0.6], respectively; 95%

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 Table 3. Frequencies of Responses to Attitude Items*
Not Somewhat
Importance Questions Important Important
19. As a clinical disorder, OSA is: 0 (0.0) 39 (7.8)
20. Identifying children with possible OSA is: 0 (0.0) 14 (2.8)
Strongly
Confidence Questions Disagree Disagree
21. I feel confident identifying children at 11 (2.2) 110 (22.1)
risk for OSA.
22. I am confident in my ability to manage 20 (4.0) 195 (39.2)
children with OSA.
23. I am confident in my ability to manage 69 (13.9) 295 (59.4)
children receiving CPAP therapy.
Abbreviations: CPAP, continuous positive airway pressure; OSA, obstructive sleep apnea.
*A total of 497 participants were included in this study. All data are given as the number (percentage) of respondents.
CI of the difference, 0.04-0.25). The magnitude of this
difference largely reflects the difference in confidence sub-
scale scores between the 2 groups of physicians (mean
[SD], 3.0 [0.6] vs 2.7 [0.7], respectively; 95% CI of the
difference, 0.16-0.41), since importance subscale did not
differ significantly (mean [SD], 3.7 [0.7] vs 3.8 [0.8], re-
spectively; 95% CI of the difference, −0.21 to 0.08).
Statistically significant differences also were ob-
served between pediatricians and family practitioners in
the 5-item attitude scale (mean [SD], 3.3 [0.5] vs 2.9 [0.6],
respectively; 95% CI of the difference, 0.32-0.56) and the
3-item confidence subscale (mean [SD], 2.9 [0.6] vs 2.3
[0.7], respectively; 95% CI of the difference, 0.51-0.77)
but not in the 2-item importance subscale (mean [SD],
3.8 [0.7] vs 3.7 [0.9], respectively; 95% CI of the differ-
ence, −0.05 to 0.28).
In the regression analysis of attitudes, having more
positive attitudes toward childhood OSAS and its treat-
ment was associated with having completed a pediatrics
residency (B=−0.412, SE = 0.054; P⬍.001; 95% CI for B,
−0.519 to −0.305) and higher knowledge scores (B=0.952,
SE = 0.165; P⬍.001; 95% CI for B, 0.627-1.276). Resi-
dency specialty accounted for 10.9% of the variance of
attitudes at entry into the model at step 1, and knowl-
edge contributed an additional 5.6% of the variance at
entry at step 2.
COMMENT
Pediatricians and family practitioners showed deficits in
knowledge about childhood OSAS and its treatment. This
was true for both academic- and community-based phy-
sicians, emphasizing the need for more education about
childhood OSAS for physicians in both practice set-
tings. Further analysis of our data using multiple regres-
sion indicated that neither practice setting nor resi-
dency specialty (pediatrics vs family practice) were
significant predictors of knowledge about OSAS, but more
positive attitudes and being a more recent medical school
graduate, rather, were independently associated with
knowledge in this model.
Although respondents who had graduated from medi-
cal school in more recent years tended to have higher
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Very Extremely No
Important Important Important Response
174 (35.0) 195 (39.2) 87 (17.5) 1 (0.4)
141 (28.4) 232 (46.7) 108 (21.7) 1 (0.4)
Neither Agree Strongly No
Nor Disagree Agree Agree Response
130 (26.2) 232 (46.7) 14 (2.8) 0
136 (27.4) 139 (28.0) 6 (1.2) 1 (0.2)
76 (15.3) 49 (9.9) 5 (1.0) 3 (0.6)
knowledge scores overall, more focused education seems
to be needed in particular areas of care as illustrated in
Table 2. For example, the American Academy of Pedi-
atrics has recommended that all children should be
screened for snoring.28 Yet, physicians might not rou-
tinely screen children for snoring if they do not con-
sider symptoms of snoring to be common (item 2). In a
community survey of pediatricians,26 fewer than 30% of
practitioners routinely screened school-aged children and
toddlers for snoring—the age groups in which OSAS is
most prevalent.
Barely half of all respondents knew that failure to thrive
was a complication of OSAS (item 16).8,29,30 The item, how-
ever, may need to be rephrased to state that “failure to thrive
can be an associated finding suggesting OSAS in infants and
young children” rather than a “frequent” complication. In
addition, only 14% of respondents knew that children with
sickle cell disease are at increased risk for OSA, although
this association31-33 as well as complications of sickle cell
disease, including stroke,34-36 have been reported.
While adenotonsillectomy remains the treatment of
choice for most cases of childhood OSAS,28 more edu-
cation is needed to help physicians identify groups of chil-
dren at risk for operative complications and persistent
OSAS.37-39 Risk factors include young age, failure to thrive,
cor pulmonale, the presence of neuromotor disease, cra-
niofacial anomalies, chromosomal abnormalities, a his-
tory of prematurity, and obesity.37,38 Although 86% of re-
spondents recognized adenotonsillar hypertrophy as a
frequent cause of OSAS (item 8), only 61% knew that tran-
sient worsening of respiratory symptoms can occur af-
ter surgery (item 17) and that children younger than 2
years are particularly vulnerable to postsurgical compli-
cations (item 14).
Childhood OSAS is a fairly new and growing field of
interest in pediatric research. As further research in this
area is conducted, we can expect that some of the knowl-
edge items included in this OSAKA-KIDS questionnaire
might become outdated. As new knowledge becomes
available, it will be necessary to revise, delete, or add new
items to the questionnaire, and new versions of the mea-
sure will be made available to researchers and medical
educators interested in its use.
WWW.ARCHPEDIATRICS.COM
 While more than half of all respondents considered
childhood OSAS as a clinical disorder and identification
of children with OSAS to be at least important (Table 3),
fewer respondents reported confidence in their abilities
to treat children with OSAS. This finding is similar to ob-
servations made by previous investigators.26 This lack of
confidence was particularly true for managing children
on continuous positive airway pressure therapy, which
the American Academy of Pediatrics has recommended
as an option for children with OSAS who are not candi-
dates for, or do not respond to, surgery.28 A greater em-
phasis on treating children with OSAS in medical edu-
cation is clearly needed.
Whereas attitudes and the number of years since medi-
cal school graduation were predictors of knowledge in
the multivariate analysis, residency specialty and knowl-
edge predicted respondents’ attitudes toward OSAS and
its treatment. In univariate tests, we noted that between-
groups differences in the overall attitudes score seemed
to be driven by differences in the confidence subscale
score, since no statistically significant differences were
observed for the importance subscale. Thus, academic-
based physicians were more confident in identifying and
treating childhood OSAS compared with community-
based physicians. While this may be related to proxim-
ity of academic physicians to university sleep facilities
and specialists, it also may be related to specialty train-
ing rather than practice setting, since pediatricians also
reported higher confidence compared with family prac-
titioners and all the family practitioners were practicing
in the community. Regardless of any between-groups dif-
ference in confidence, an emphasis on treating children
with OSAS in medical education would help boost phy-
sicians’ confidence in these abilities.
There are several limitations to the study. The cross-
sectional design limits our ability to make causal infer-
ences about the associations reported herein. This study
was a first step in developing and pilot testing a new mea-
sure of physicians’ knowledge and attitudes toward OSAS
in children. As such, the questionnaire was adminis-
tered to a convenience sample of physicians at 3 collabo-
rating sites, and the results may not be representative of
the knowledge and attitudes of pediatricians in other areas
of the country. In addition, although there were pedia-
tricians at all 3 sites, only the Louisville site included phy-
sicians who were not pediatricians, and all the community-
based physicians were from the Louisville site. Thus,
regardless of the large sample size, the sample was not a
representative, population-based sample of pediatri-
cians and family practitioners. Moreover, the survey re-
sponse rate was only 43%, which further limits the gen-
eralizability of our findings owing to selection bias.
Despite these limitations, this study demonstrated that
more education in sleep is needed, both in the under-
graduate and postgraduate medical education settings.
In 1978, the American Sleep Disorders Association re-
ported that less than 10% of medical schools provided
adequate education in the area of sleep medicine.40 Fif-
teen years later, a national survey of US medical schools
found less than 2 hours of total teaching time allocated
to sleep and sleep disorders.41 The American Sleep Dis-
orders Association Taskforce 2000 reported that physi-
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cians received, on average, 2.1 hours of education about
sleep medicine after 4 years of medical education.42 Even
less attention is given to pediatric sleep during medical
school, with an average of 0.38 clinical teaching hours
devoted to the area of pediatric sleep disorders–the least
of any topic surveyed.41 Mindell et al27 reported that 46%
of pediatric residency training programs surveyed did not
offer instruction in pediatric sleep disorders and that pe-
diatricians seemed most informed about sleep issues re-
lated to development and sleep hygiene but lacked knowl-
edge about the diagnosis of specific sleep disorders.
Finally, knowledge did not differ significantly by type
of residency training or practice setting. Perhaps the
knowledge scores of both pediatricians and family prac-
titioners reflected similar training (or lack thereof) in pe-
diatric OSAS. Comparisons with physicians having resi-
dency training in a specialty very different from pediatric
primary care (eg, in surgery or radiology) would con-
tribute to the variance in knowledge scores to better dis-
criminate between pediatricians and other specialists. Fu-
ture research should include administration of the
OSAKA-KIDS in addition to other questionnaires, for ex-
ample, measures about other sleep disorders and the
OSAKA questionnaire,25 which measures knowledge and
attitudes toward OSAS in adult patients, to determine the
discriminant validity of the OSAKA-KIDS measure. Ad-
ditionally, the predictor variables included in our mul-
tivariate regression analyses accounted for only a small
proportion of the variance of knowledge and attitudes
in the respective regression models. Variables not mea-
sured herein account for the large, unexplained part of
the variance of knowledge and attitudes, and identify-
ing these factors could be explored in future research.
Further study also might include the OSAKA-KIDS mea-
sure to evaluate the effectiveness of educational inter-
ventions focusing on OSAS in children to change phy-
sicians’ knowledge and attitudes toward childhood OSAS.
CONCLUSIONS
Despite recent advances and improving educational trends
in pediatric sleep medicine, this study demonstrated defi-
cits in pediatricians’ and family practitioners’ basic knowl-
edge about childhood OSAS regardless of practice set-
ting. More focused education regarding diagnosis and
treatment of childhood OSAS and the identification of
particular groups at risk for OSAS seems warranted. Im-
proving physician knowledge will be needed to im-
prove childhood OSA–related screening and subse-
quent treatment practices. To our knowledge, no
childhood OSA educational programs for primary care
providers or medical trainees have been developed, imple-
mented, and evaluated longitudinally. We believe that
the OSAKA-KIDS questionnaire could be useful in evalu-
ations of the effectiveness of educational interventions
to improve physicians’ knowledge and attitudes about
OSAS in children.
Accepted for Publication: September 27, 2004.
Author Affiliations: Division of Allergy and Pulmonary
Medicine, Department of Pediatrics (Dr Uong) and the
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 Division of Health Behavior Research, Departments of
Medicine and Pediatrics (Dr Jeffe), Washington University
School of Medicine, St Louis, Mo; Division of Pediatric
Sleep Medicine, Kosair Children’s Hospital Research
Institute, University of Louisville School of Medicine,
Louisville, Ky (Drs Gozal and Holbrook); Division of
Pulmonary Medicine, Children’s Hospital of Philadelphia,
University of Pennsylvania School of Medicine (Drs Arens
and Palmer); Sleep Diagnostic Service, St Louis Children’s
Hospital, St Louis (Ms Cleveland); and the Division of
Sleep Medicine, Department of Medicine, University of
Pennsylvania School of Medicine, Philadelphia
(Dr Schotland).
Correspondence: Elizabeth C. Uong, MD, Division of
Allergy and Pulmonary Medicine, St Louis Children’s
Hospital, One Children’s Pl, Room 5S30, St Louis, MO
63110 (Uong_e@kids.wustl.edu).
Funding/Support: This work was supported in part by
grants HL-65270 and HS13145 from the National Insti-
tutes of Health, Bethesda, Md, and the Kentucky Chal-
lenge for Excellent Research Trust, Louisville.
Disclaimer: No off-label or investigational agents were
used in this study.
Acknowledgment: We thank the expert panel members
for their invaluable insight and comments about items
on the OSAKA-KIDS questionnaire and the physicians
who took the time to respond to our survey.
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