Predictors of positive airway pressure therapy adherence in children: a prospective study

Abstract

Study objectives: Children with obstructive sleep apnea are increasingly being treated with positive airway pressure (PAP), particularly if they have underlying medical conditions. Although PAP is an effective treatment, its use is challenging due to poor adherence. We hypothesized that demographic, psychosocial, and polysomnographic parameters would be related to PAP adherence. We therefore prospectively collected data potentially pertaining to PAP adherence, and correlated it with PAP use.

Methods: Fifty-six patients and their parents completed a series of psychosocial questionnaires prior to PAP initiation. Objective adherence data were obtained after 1 and 3 months of PAP use.

Results: The population was primarily obese; 23% had neurodevelopmental disabilities. PAP adherence varied widely, with PAP being worn 22 ± 8 nights in month-1, but mean use was only 3 ± 3 h/night. The greatest predictor of use was maternal education (p = 0.002 for nights used; p = 0.033 for mean h used/night). Adherence was lower in African American children vs other races (p = 0.021). In the typically developing subgroup, adherence correlated inversely with age. Adherence did not correlate with severity of apnea, pressure levels, or psychosocial parameters other than a correlation between family social support and nights of PAP use in month-3.

Conclusions: PAP adherence in children and adolescents is related primarily to family and demographic factors rather than severity of apnea or measures of psychosocial functioning. Further research is needed to determine the relative contributions of maternal education, socioeconomic status and cultural beliefs to PAP adherence in children, in order to develop better adherence programs.

Keywords: CPAP; maternal education; obstructive sleep apnea.

Figure 1. Flow diagram of subject enrollment

Sixty-nine consecutive children were approached, of whom 9 declined (2 because of distance, 5 because of the burden of the study visits, 1 for no stated reason, and 1 because of severe parental illness). Thus, 60 children were enrolled. Four children were subsequently excluded: one child with Down syndrome developed pneumonia one week after enrollment and underwent tracheotomy; one child with nasopharyngeal stenosis underwent surgery; one adolescent was institutionalized for behavioral problems without his PAP equipment; and one child moved away after consenting but before entering the study. Thus, data are presented on 56 subjects.

Figure 2. Positive airway pressure nightly use for month-1

The number of nights/month that positive airway pressure therapy was used during month-1 is shown for individual subjects (expressed as a percentage of total subjects)

Figure 3. Correlation between positive airway pressure use and age for month-1

The correlation between mean nightly positive airway pressure (PAP) use and age is shown for month-1. There was no significant correlation.

Figure 4. Maternal education and number of nights with positive airway pressure use (month-1)

The number of nights that positive airway pressure (PAP) was used at each level of maternal education is shown for month-1. There was a significant correlation between maternal education and nights PAP was used. HS, high school; grad, graduate; PG, postgraduate.

Figure 5. Maternal education and hours of PAP use per night (month-1)

The mean hours per night of positive airway pressure (PAP) use per night at each level of maternal education is shown for month-1. There was a significant correlation between maternal education and minutes of PAP use. HS, high school; grad, graduate; PG, postgraduate.