Association of adverse childhood experiences with the diagnosis and severity of obstructive sleep apnea
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Citation
Abstract
BACKGROUND: Obstructive Sleep Apnea (OSA) is a very common disease characterized by brief episodes of airway collapse and low oxygen during sleep. Many years of research on OSA have shown that social determinants of health, such as race, income, zip code, and parental education level lead to varied levels of disease prevalence and severity among different populations. It has been shown very clearly that low-income African-American children have the highest prevalence and most severe outcomes of OSA. However, there is one very important component of health that has not been evaluated in conjunction with OSA: childhood trauma.
To assess for childhood trauma, physicians often use the Adverse Childhood Experiences (ACE) QUESTIONNAIRE. This series of questions has been used in numerous medical specialties, including primary care, oncology, pulmonology, general surgery, and obstetrics/gynecology, for decades to evaluate patients for childhood trauma before the age of 18. This survey not only allows clinicians to provide trauma-informed care to their patients, but also serves as a reminder to address both the social and physical aspects of disease when treating a patient, as trauma has been shown to have detrimental effects on long-term health. Over two decades of research have shown that an increased number of ACEs before the age of 18 leads to worse outcomes in a wide variety of diseases, many of which are some of the leading causes of morbidity and mortality in the United States. However, no studies to date have used the ACE questionnaire to evaluate disease and surgical outcomes in the field of otolaryngology (ENT), one of the medical specialties in which patients with OSA are treated and followed. Given the prevalence of OSA nationwide among adults and children, it is crucial to begin examining whether childhood trauma leads to worse disease outcomes in OSA.
OBJECTIVE: To conduct a comprehensive literature review of research done on both pediatric OSA and the effects of childhood trauma on disease outcomes for some of most common causes of morbidity and mortality in the United States. An additional objective is to show, using data from the Kids Inpatient Database, associations between various demographic factors and diagnosis with OSA requiring an adenotonsillectomy.
METHODS: For the literature review, a PubMed search was conducted on both aforementioned topics using various keywords and MeSH terms to narrow down the search. Reference lists of relevant papers were also used to find other relevant papers. For the empirical data, the Kids’ Inpatient Database, a national database created by the Healthcare Cost and Utilization Project and Agency for Healthcare Research and Quality, was used. There have been many version of this database, but the most recent version from 2016 was used for this study. Due to the COVID-19 pandemic-related restrictions, we were not able to administer the ACE Questionnaire to patients with obstructive sleep apnea as originally planned.
RESULTS: The literature review on pediatric OSA showed that the main risk factors for developing severe OSA are adenotonsillar hypertrophy, African-American race, low socioeconomic status/low income, and obesity. Other important risk factors include preterm birth, male sex, and craniofacial anomalies. The literature review on childhood trauma showed that adults over the age of 18 who endorsed more adverse experiences on the ACE questionnaire consistently had worse disease outcomes in chronic illnesses such as ischemic heart disease, chronic obstructive pulmonary disease, and some cancers. The results from the Kids Inpatient Database showed that Black children had the highest odds of developing OSA and requiring a tonsillectomy. Additionally, the Kids Inpatient Database shed light on the odds of having a tonsillectomy based on income quartile, showing that children of higher income quartiles are more likely to receive surgery.
CONCLUSIONS: Many years of research have shown both that social determinants of health such as income, race, and socioeconomic status are associated with severity of obstructive sleep apnea, and that increased childhood trauma is often associated with worse disease outcomes in a wide variety of chronic illnesses. However, a very important next step in research on these topics is to combine them to assess whether increased childhood trauma also correlates with increased severity of OSA.