Prevalence of sleep apnea in children and adolescents in Colombia according to the national health registry 2017-2021.

OBJECTIVE: To describe the sociodemographic and epidemiological characteristics of diagnosis and treatment of pediatric patients with sleep apnea, both central and obstructive, in Colombia between 2017 and 2021.
METHODS: Observational, descriptive, cross-sectional, epidemiological study using the International Classification of Diseases and Related Health Problems as search terms for sleep apnea, based on SISPRO, the Colombian national health registry. Stratification by gender and age groups was performed. We also generated data of the amount of diagnostic and therapeutic procedures performed. A map of prevalence by place of residency was performed.
RESULTS: National records report 15200 cases of SA between 2017 and 2021, for an estimated prevalence of 21.1 cases by 100000 inhabitants in 2019 the year with the most cases (4769), being more frequent and in the 6 to 11 age group and in males, with a male to female ratio of 1.54:1. The number of cases declined in 2020 and 2021. The map showed a concentration of cases in the more developed departments of the country. DISCUSSION: This is the first approximation to a nation-wide prevalence of sleep apnea in Colombia which is lower to what is found in the literature worldwide, including studies performed in Latin America and in Colombia, this could reflect sub diagnosis and sub report. The fact that the highest prevalence was found in males and in the 6-11 age group is consistent with reports in literature. The decrease in cases in 2020 and 2021 could be related to the COVID-19 pandemic impact in sleep medicine services.

Introduction

Sleep apnea (SA) comprises two main clinical and polysomnographic categories: Central Sleep Apnea (CSA) and Obstructive Sleep Apnea (OSA) [1]. OSA is a respiratory sleep disorder characterized by a partial or total obstruction of the airway associated with altered sleep architecture and intermittent hypoxia [1]. In children and adolescents, a prevalence of 1 to 4% has been reported in multiple studies [2]. Some of the risk factors for OSA in this age groups are hypertrophy of the tonsils, craniofacial abnormalities, and obesity [3,4]. Untreated OSA has important cardiovascular, metabolic, and neurocognitive consequences [5-8]. Obstructive sleep disordered breathing (oSDB) comprises OSA and other problems in which the upper airway is compromised [1]. There are multiple management options for children with oSDB that range from watchful waiting to surgical removal of the tonsils or positive airway pressure devices [9,10]. Evidence of the effect of these therapeutic options on important aspects of disease such as severity, quality of life, polysomnographic values, behavioral and cognitive outcomes have been studied [11,12].

CSA happens when there is diminished, or absent respiratory effort often related to desaturation, nocturnal awakenings, and sleep fragmentation [1]. It has specific polysomnographic criteria [13]. In children and adolescents, CSA is frequently associated with other conditions such as genetic syndromes, laryngomalacia, prematurity, obesity, Arnold-Chiari malformation, among others [14,15]. CSA and OSA can occur concomitantly [16].

In Latin America, the information of the prevalence of SA in children is limited, most of the frequencies described come from questionnaire-based population studies regarding sleep disordered breathing in a specific city of a particular country. This has many limitations: these screening tools are limited in specificity, they depend on parental report which can both over and under-estimate sleep disorders, they do not replace formal clinical and polysomnographic testing [17], and each study has used different screening tools which hinders adequate comparisons.

Healthcare registries are essential to follow the local epidemiology and offer opportune diagnosis to patients [18-20]. The Integrated Social Protection Information System (SISPRO) is a set of databases developed by the Colombian Ministry of Health that collects, and storages information generated by the health and social security system [21] which is very close to universal coverage (95.23% according to the most recent figure) [22]. Through different information sources, data is obtained derived from the Individual Registry of Provision of Health Services (RIPS, for its Spanish acronym), which is mandatory for health personnel to fill out during every inpatient or outpatient medical attention this includes diagnosis using the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Data uploaded to SISPRO is subject to rigorous quality control [21].

The aim of this study was to describe the sociodemographic and epidemiological characteristics of diagnosis and treatment of pediatric patients with sleep apnea, both central and obstructive, in Colombia between 2017 and 2021.

Methods

We conducted an observational, descriptive, cross-sectional study. The data of the population with a principal diagnosis of Sleep Apnea (ICD 10 code G47.3: Sleep Apnea: Central and Obstructive), publicly available in RIPS. We obtained information for the whole country, in the period from January 1st, 2017, and December 31st, 2021.

The principal diagnosis (Sleep Apnea) corresponds to the disease that caused the signs and symptoms for which the patient consults to the health institution or independent health provider. It is important to clarify that the SISPRO database does not allow for the differentiation between OSA and CSA since the ICD-10 code G47.3, Sleep Apnea, includes both OSA and CSA.

First consults seen in the period and previously confirmed cases were analyzed. Patients aged 0 to 17 years, male and female, were included and stratified by developmental age groups (less than 1 year, 1–5, 6–11, 12–18). Cases of diagnostic impression were excluded since they are not considered confirmed SA cases. SISPRO contains information of the patients that required a consult for a principal diagnosis of SA trough the Colombian Healthcare System. Variables of interest such as department of residence and attention, type of insurance, number of new and repeated cases, use of diagnostic and therapeutic procedures (surgical and non-surgical) were described.

A descriptive analysis was developed, calculating proportions for qualitative variables and measures of central tendency for quantitative variables. Contingency tables were used for bivariate descriptive analysis. Prevalence and incidence rates were calculated using as denominators the projected and retro projected population of the 2018 Colombian national census [23]. Statistical analysis was performed using R studio (version 4.1.2, 2018). And the software QGIS (2009) was used to design a prevalence map.

This approach is similar to the ones proposed in other studies that have used data from SISPRO to estimate the prevalence of other diseases in Colombia [24-30].

Ethical considerations and data availability:

The study protocol was reviewed and approved by the Research and Ethics Committee of Hospital Universitario San Ignacio and Pontificia Universidad Javeriana, both located in Bogota, Colombia. (FM-CIE-0473-21). The study was classified as no risk research and conducted in agreement with the Helsinki Declaration and Resolution 008430 of 1993 issued by the Colombian Ministry of Health. Data collected for analysis came from SISPRO, the Colombian national health registry [21]. Data is fully anonymized in the source, before being accessed by researchers. Thus, a waiver for informed consent was obtained. The raw data is available publicly or under request at https://www.sispro.gov.co.

Results

During the five years evaluated, we identified a total of 15.099 registries and a total of 9737 children and adolescents in SISPRO with a principal diagnosis of SA; 5463 children were newly diagnosed with SA in this period. 2019 was the year with the most cases (2996 new and repeated cases) (Table 1 and Fig 1). For all age groups, the highest prevalence was found in 2019 which was also the year with the most cases (4769 cases), this would provide the most precise prevalence estimation of our data of 21.1 cases by 100000 inhabitants in children and adolescents. 2017 was the year with the lowest prevalence (8.8 by 100000 inhabitants) (Table 2). There was a steady increase of cases reported between 2017 and 2019 and a significant decrease in 2020 and 2021 (Table 1 and Fig 1). Newly diagnosed cases were lowest in 2021 (837) and highest in 2019 (1773).

Table 1

New and repeated cases of sleep apnea in children and adolescents, Colombia, 2017–2021.

Cases / Year	2017	2018	2019	2020	2021	Total
New cases	843	965	1.773	1.045	837	5463
Repeated cases	395	1.029	1.223	844	783	4274
Total	1.238	1.994	2.996	1.889	1.620	9737

Fig 1

Cases of sleep apnea in children and adolescents in Colombia between 2017 and 2021.

Table 2

Prevalence of sleep apnea in children and adolescents, Colombia, 2017–2021.

Year	2017			2018			2019			2020			2021			Total
Age (years)	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total	Female	Male	Total
< 1	-	-	-	-	-	-	-	-	-	-	-	-	2.9	2.0	2.5	2,9	2,0	2,5
1 to 5	3.3	3.8	3.5	5.7	6.5	6.1	11.4	17.6	14.6	10.0	15.0	12.6	10.3	13.9	12.1	40,7	56,9	49,0
6 to 11	13.0	16.3	14.7	20.1	29.6	24.9	27.9	40.4	34.3	15.3	22.1	18.8	11.9	17.8	14.9	88,1	126,1	107,5
12 to 17	7.3	10.2	8.7	9.7	15.2	12.5	12.1	21.6	16.9	7.0	13.7	10.4	7.1	10.1	8.6	43,1	70,7	57,1
Total	7.7	9.9	8.8	11.5	16.8	14.2	16.5	25.5	21.1	10.2	16.1	13.2	9.3	13.2	11.3	55,1	81,5	68,6

Regarding age groups, SA was more frequent in children between 6 and 11 years of age in all of the years evaluated. The lowest prevalence was consistently found in the less than 1 year old group, probably because primary apneas of the newborn have a different code in the ICD-10. During the five years of observation, 490 cases of other apneas of the newborn (ICD-10 P28.4) and 81 cases of primary sleep apneas of the newborn (ICD-10 P28.3).

In the 1–5 and in the 6–11 years group the lowest prevalence was found in 2017, and in the 12–17 group the lowest prevalence was found in 2021. (Tables 1 and 2). Prevalence was greater in males, with a male to female ratio of 1.54: 1 in the five year period. The group with the highest prevalence during the time of study were the 6 to 11 years old males in 2019 (40.4 per 100000 inhabitants).

The analysis of the type of insurance of patients with SA (Table 3) showed that the majority belonged to the contributory regime (72.9%), followed by the subsidized regime (21.3%), special regimes (3%), and complementary plans (0.7%).

Table 3

Type of insurance of children and adolescents with sleep apnea, Colombia, 2017–2021.

Insurance	2017	2018	2019	2020	2021	Total
Contibutory	678	741	1.296	732	601	3.700
Subsidized	156	159	363	242	233	1083
Special	3	50	52	31	30	150
Not applicable / uninsured	5	14	61	22	31	132
Complementary plans	2	0	1	17	15	34
Total	839	962	1.766	1.042	909	5.074

A prevalence by department of residence analysis was performed for 2019 (Fig 2). We found an ample range of frequencies varying from 0 cases in San Andrés, Amazonas, Guainia and Guaviare to 243.5 per 100000 in Risaralda and 54.6 per 100000 in Bogota, the country’s capital city. Remarkably, the prevalence in Risaralda (the department with the highest prevalence) was 4.5 times the one of Bogotá (the second highest prevalence) this is related to population density which is 8 times higher in Bogotá than in Risaralda [23].

Fig 2

Prevalence of sleep apnea in children and adolescents by department, Colombia, 2019.

“Elaborated by the authors. Map shapes/layers reprinted from https://www.datos.gov.co/Mapas-Nacionales/Departamentos-y-municipios-de-Colombia/xdk5-pm3f under a CC BY license, covered by Law 1712 of 2014 of the Colombian Ministry of Information and Communication Technologies, 2022”.

Tables 4 and 5 show the SA related diagnostic and therapeutic procedures to which children and adolescents in SISPRO had performed. 2019 was the year with the highest number of diagnostic procedures executed. In total, 2845 Polisomnographies, 449 capnographies 1225 nasolaringoscopies and 213 transthoracic echocardiographies were carried out in the five years. Only polysomnography is regarded as a procedure for SA diagnosis, the other three procedures (Capnography, Nasolaringoscopy and transthoracic echocardiography) can aid the diagnosis and/or management of pediatric SA patients. Regarding therapeutic procedures, 882 and 855 amigdalectomies and adenoidectomies were performed, respectively. Only 41 patients had positive airway pressure therapy (PAP) initiated.

Table 4

Diagnostic procedures performed in children and adolescents with sleep apnea, Colombia 2017–2021.

Diagnostic procedure	Age group	Year
		2017	2018	2019	2020	2021	Total
Polisomnography	< 1	0	0	0	0	6	6
	1 to 5	50	92	221	106	190	630
	6 to 11	308	266	431	139	261	1369
	12 to 17	199	154	234	85	195	840
	Total	557	512	886	330	652	2845
Capnography	< 1	0	0	0	2	10	12
	1 to 5	3	24	49	24	39	136
	6 to 11	28	41	55	29	60	206
	12 to 17	6	18	28	18	28	95
	Total	37	83	132	73	137	449
Nasolaryngoscopy	< 1	0	0	0	0	3	3
	1 to 5	1	12	68	78	68	224
	6 to 11	11	83	222	145	140	593
	12 to 17	5	68	142	101	96	405
	Total	17	163	432	324	307	1225
Transthoracic ecocardiography	< 1	0	0	0	1	4	5
	1 to 5	4	20	27	18	26	93
	6 to 11	4	12	24	8	27	75
	12 to 17	1	5	11	9	14	40
	Total	9	37	62	36	71	213

Table 5

Diagnostic procedures performed in children and adolescents with sleep apnea, Colombia 2017–2021.

Therapeutic procedures	Age group	Year
		2017	2018	2019	2020	2021	Total
PAP therapy	< 1	0	0	0	0	0	0
	1 to 5	0	0	1	0	2	2
	6 to 11	0	0	2	4	4	7
	12 to 17	2	1	21	20	18	32
	Total	2	1	24	24	24	41
Amigdalectomy	< 1	0	0	0	0	0	0
	1 to 5	1	7	56	21	17	102
	6 to 11	62	194	247	79	28	610
	12 to 17	26	59	64	14	7	170
	Total	89	260	367	114	52	882
Adenoidectomy	< 1	0	0	0	0	0	0
	1 to 5	3	10	55	22	17	107
	6 to 11	72	215	232	60	26	604
	12 to 17	24	54	47	11	8	144
	Total	99	279	334	93	51	855

Discussion

This is the first approximation to a nation-wide prevalence of SA analyzing data from all the regions of Colombia. When comparing the estimated prevalence of SA in children and adolescents in our study (21.1 by 100000 inhabitants in 2019) is lower than the ones reported in the aforementioned questionnaire-based studies worldwide [2,17,31].

Since most prevalence population studies have been performed for sleep disordered breathing and not a formal diagnosis of SA, comparisons are limited with previous literature. In general, these studies have a higher sensitivity but lower specificity when compared with the analysis performed from health registries such as SISPRO. Nevertheless, this prevalences do appear to be higher than our study. This could reflect sub diagnosis and sub report of SA in Colombia, since the patients from the questionnaire studies might have not consulted and given a formal diagnosis within the Colombian Healthcare system and therefore, are not part of the SISPRO data.

We must highlight that healthcare coverage in Colombia is almost universal (95.23%) [22], and SISPRO is a strong healthcare registry with constant quality controls [21], this is important since it allows us to infer that there are few patients with SA as a principal diagnosis that are not being counted in the study. Our findings reinforce the necessity of strengthening SA early detection, appropriate evaluation, and management in Colombia. Since the patients in our study were given a principal diagnosis of SA by a healthcare professional, they should have undergone diagnostic testing confirming SA. Multiple strategies exist for pediatric SA diagnosis and validation and standardization is further required for both children and adult studies [32].

The findings of age-related higher prevalence of SA in the 6 to 11 years age group and in males comes in accordance with the described in other studies [33]. This has been reported in relation to hypertrophy of the tonsils and adenoid tissue which narrows the airway [34], this is also supported with our study’s finding that 1737 children with SA in Colombia have been managed with ENT surgery in the five years. The approach to SA diagnosis and treatment goes beyond sleep studies and requires a multidisciplinary strategy [35]. Multiple management strategies exist for pediatric SA [9,12], some of them have important variations such as tonsillectomy versus tonsillotomy for oSDB [36]. Health registries such as SISPRO are limited in the information they provide regarding variations in diagnostic and therapeutic procedures such as the ones presented in our study.

The changes in prevalence through the five years analyzed are quite remarkable. Between 2017 and 2019 there was a clear tendency of increasing number of cases, diagnostic and therapeutic procedures; making 2019 the year with the highest and most reliable/closest to reality measure of prevalence calculated to date (21.1 by 100000 inhabitants). Then, the number of cases significantly decreased in 2020 and 2021, this could be in evident relation to the COVID-19 pandemic effect on sleep medicine services worldwide [37]. Sleep clinics had to close temporarily to focus human and infrastructure resources in the pandemic. Also, the number of diagnostic procedures and particularly polysomnography diminished remarkably [37]. A communication was made by sleep specialists in Colombia to guide sleep medicine services nationwide during the pandemic [38].

The ample differences in prevalence between geographic regions could obey to difficulties in healthcare services access by patients. Some of the departments with the lowest prevalence have in common a low population density and less urban development. The graphic prevalence distribution could also show a concentration of sleep medicine services in principal and developed cities, which could hinder access to diagnosis of SA to patients residing far from city centers this could reflect on the importance of validating and including other strategies other than conventional polysomnography such as portable polysomnography [39,40], bio-impedance [41], heart rate variability monitoring [42] and peripheral arterial tonometry [43] as alternatives for children residing far from sleep medicine services. The fact that most of the patients belong to the contributory regime, may reflect inequity in access a sleep medicine services. This could lead to sub diagnosis in the most vulnerable, underserved part of the Colombian population leaving them at risk for the untreated SA health and quality of life consequences; this same pattern has been found in other SISPRO registry studies in Colombia [24,30,44]. Also, our findings suggest low usage of capnography in polysomnographic studies which is recommended as per American Academy of Sleep Medicine manuals [45].

Acknowledging the limitations of our study, it is important to clarify that this study provides an estimated and not a real prevalence of SA in Colombia since the study design was not developed as a census. This prevalence depends on adequate diagnosis and registry of information in RIPS by every healthcare provider in the country. SISPRO registers the principal and related diagnosis, SA could be selected by providers as a related diagnosis of some of the SA associated comorbidities such as obesity, adeno-tonsillar hypertrophy, Down syndrome, craniofacial abnormalities and cardiovascular disease. The measurement of the prevalence of SA in relation to some of the listed diseases could be a proposal for future studies with a similar methodology.

Another limitation inherent to the way that SISPRO manages ICD-10 diagnostic categories is that our study comprises both OSA and CSA which, differ in diagnostic criteria [1]. Nevertheless, reports have been consistent in the fact that the CSA only accounts for approximately 5% of all SA cases in children [46]. Also, SA diagnosis has evolved in time and many physicians worldwide currently use the 3rd version of the International Classification of Sleep Disorders (ICSD III) [1] and not the ICD-10 criteria, nevertheless, we consider this limitation unlikely to result in significant bias, since the patients diagnosed by ICSD criteria should have also been included in SISPRO by the healthcare providers using an ICD-10 code. Also, due to the nature of the data available in SISPRO, our study does not allow for evaluation of other important aspects of disease such as severity; given the fact that most of the children in the registry were not reported to have initiated PAP therapy or had surgery performed we suspect most cases would be mild or moderate in severity. For future prevalence estimations and to strengthen the current public health data bases, sleep medicine services should standardize and properly inform diagnostic categories to RIPS, ideally healthcare registries should allow for further differentiation between OSA and CSA. Further studies (e.g. multicenter nationwide studies) are required to best resolve these limitations inherent to the use of healthcare registries to address complex diseases sucha as sleep apnea.

Conclusion

This study estimates the prevalence of SA in Colombia based on the healthcare system’s registry during five years. When comparing it to other studies performed to date it suggests sub diagnosis and sub registry of SA nationwide. There was a decrease in SA diagnosis in 2020 and 2021 related to the COVID-19 pandemic. This data calls upon early detection, adequate evaluation and management of this disease that consumes a great quota of resources.

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Reviewer #1: Introduction

- line 57, Obstructive sleep-disordered breathing (oSDB) is a condition that encompasses breathing problems when asleep, due to an obstruction of the upper airways, ranging in severity from simple snoring to obstructive sleep apnoea syndrome (OSAS). It affects both children and adults. In children, hypertrophy of the tonsils and adenoid tissue is thought to be the commonest cause of oSDB. As such, tonsillectomy - with or without adenoidectomy - is considered an appropriate first-line treatment for most cases of paediatric oSDB. In otherwise healthy children, without a syndrome, of older age (five to nine years), and diagnosed with mild to moderate OSAS by PSG, there is moderate quality evidence that adenotonsillectomy provides benefit in terms of quality of life, symptoms and behaviour as rated by caregivers and high quality evidence that this procedure is beneficial in terms of PSG parameters. At the same time, high quality evidence indicates no benefit in terms of objective measures of attention and neurocognitive performance compared with watchful waiting. Furthermore, PSG recordings of almost half of the children managed non-surgically had normalised by seven months, indicating that physicians and parents should carefully weigh the benefits and risks of adenotonsillectomy against watchful waiting in these children. This is a condition that may recover spontaneously over time. For non-syndromic children classified as having oSDB on purely clinical grounds but with negative PSG recordings, the evidence on the effects of adenotonsillectomy is of very low quality and is inconclusive.Low-quality evidence suggests that adenotonsillectomy and CPAP may be equally effective in children with Down syndrome or MPS diagnosed with mild to moderate OSAS by PSG. please discuss and cite doi:10.1002/14651858.CD011165.pub2

- line 65, an interesting systematic review analyzed the correlation between changes in behavior and cognitive outcomes after AT were according to the scores post-AT in almost all studies. After comparing the AT group and control group, only one study had no difference that reached significance at one year post-AT. In another study, it did not show any significant improvement in terms of all behavioural and cognitive outcomes. The questionnaires on sleep-related quality of life after AT (PSQ-SRBD or ESS or OSA-18 or KOSA) may improve with positive changes in sleep parameters (AHI, ODI and SpO2). Furthermore, there is a significantly higher decrease in OSAS symptoms than the pre-AT baseline score. please discuss and cite doi:10.3390/children8100921

Methods

Please apply the latest strobe guidelines, consort model and equator.

Discussion

- To assess whether partial removal of the tonsils (intracapsular tonsillotomy) is as effective as total removal of the tonsils (extracapsular tonsillectomy) in relieving signs and symptoms of oSDB in children, and has lower postoperative morbidity and fewer complications. For children with oSDB selected for tonsil surgery, tonsillotomy probably results in a faster return to normal activity (four days) and in a slight reduction in postoperative complications requiring medical intervention in the first week after surgery. This should be balanced against the clinical effectiveness of one operation over the other. However, this is not possible to determine in this review as data on the long-term effects of the two operations on oSDB symptoms, quality of life, oSDB recurrence and need for reoperation are limited and the evidence is of very low quality leading to a high degree of uncertainty about the results. please discuss and cite doi:10.1002/14651858.CD011365.pub2

Reviewer #2: Dear author,

I appreciate the fact that your article first focused on the analysis of the prevalence in the pediatric population of sleep apnea in Colombia. It is definitely a good starting point for the study of this pathology now widely spread and of great interest to the general population. It is evident, when reading the article, the difficulties encountered in data collection and the diversity of methods used for the diagnosis of sleep apnea.

My advice is to prefer standard diagnostic tools for apnea such as polysomnography or pulse oximetry (preferred method in pediatric age). This would also allow a better differential diagnosis between central and obstructive apneas. You could try to conduct a nationwide multicenter study rather than the Colombian registry analysis to circumvent this problem. Therefore, you could use the data you collected on posing about the lack of standard methods for the study of apnea and not just subdiagnosis.

I wish you a good continuation of your work.

**********

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Reviewer #1: No

Reviewer #2: No

**********

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29 Jul 2022

Dr. Kuo-Cherh Huang

Academic Editor

PLOS ONE

PONE-D-22-09943

Prevalence of sleep apnea in children and adolescents in Colombia according to the national health registry, 2017-2021

Dear Dr. Kuo-Cherh Huang

Academic Editor

PLOS ONE

We thank the reviewers and the journal’s editorial team for their valuable comments. Please find attached a revised version of the manuscript. Below you can find a point-by point response to the reviewers’ comments.

We look forward your response.

Kind regards,

The authors

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RESPONSE: Thank you for the observation. We have reviewed the PLOS ONE style requirements. We have made corrections in file naming and in the manuscript following the style templates.

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RESPONSE: We provided additional details regarding participant consent. We included a new Ethical considerations and Data availability statement sub heading in the revised manuscript as follows: The study protocol was reviewed and approved by the Research and Ethics Committee of Hospital Universitario San Ignacio and Pontificia Universidad Javeriana, both located in Bogota, Colombia. (FM-CIE-0473-21). The study was classified as no risk research and conducted in agreement with the Helsinki Declaration and Resolution 008430 of 1993 issued by the Colombian Ministry of Health. Data collected for analysis came from SISPRO, the Colombian national health registry [17]. Data is fully anonymized in the source, before being accessed by researchers. Thus, a waiver for informed consent was obtained. The raw data is available publicly or under request at https://www.sispro.gov.co

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RESPONSE: Thank you for the comment. We have updated the Cover letter with a Data Availability Statement. Data collected for analysis came from SISPRO, the Colombian national health registry. Data in SISPRO is fully anonymized irreversibly before being accessed by researchers. The raw data is available publicly or under request at https://www.sispro.gov.co . We have attached a supplement with the data set underlying the results. We also included the SISPRO website within the manuscript in which interested researchers could gain access to the information.

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RESPONSE: Thank you for the comment. We have included a full ethics statement in the Methods section of the revised manuscript file including the full name of ethics committee that approved the study and waived the requirement of informed consent since data is irreversibly anonymized at the primary source (SISPRO).

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RESPONSE: Thank you for the comment. The figures were elaborated directly by the authors and are not subject to copyright. We used the software QGIS (2009) which is an open access, open code geographical data system. The shapes/layers used to elaborate the map come from a public domain, open access and free use data available at https://www.datos.gov.co/Mapas-Nacionales/Departamentos-y-municipios-de-Colombia/xdk5-pm3f

This public domain is covered by Law 1712 of 2014 of transparency and access to national public information of Colombia which states that citizens (e.g., the authors) can access this public data freely and without restrictions and can be used by third parties. We have updated the figure caption of the copyrighted figure as follows: “Elaborated by the authors. Map shapes/layers from https://www.datos.gov.co/Mapas-Nacionales/Departamentos-y-municipios-de-Colombia/xdk5-pm3f under a CC BY license, covered by Law 1712 of 2014 of the Colombian Ministry of Information and Communication Technologies, 2022.”

Additional Editor Comments:

Dear Dr. Waich

We appreciate your submission to PLOS ONE. Both reviewers have provided a variety of important concerns and helpful suggestions. Please respond carefully to their suggestions. In particular, please pay attention to the critical point raised by Reviewer 2 as regards the diversity of methods used for the diagnosis of sleep apnea in your study.

Kuo-Cherh Huang

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Introduction

- line 57, Obstructive sleep-disordered breathing (oSDB) is a condition that encompasses breathing problems when asleep, due to an obstruction of the upper airways, ranging in severity from simple snoring to obstructive sleep apnoea syndrome (OSAS). It affects both children and adults. In children, hypertrophy of the tonsils and adenoid tissue is thought to be the commonest cause of oSDB. As such, tonsillectomy - with or without adenoidectomy - is considered an appropriate first-line treatment for most cases of paediatric oSDB. In otherwise healthy children, without a syndrome, of older age (five to nine years), and diagnosed with mild to moderate OSAS by PSG, there is moderate quality evidence that adenotonsillectomy provides benefit in terms of quality of life, symptoms and behaviour as rated by caregivers and high quality evidence that this procedure is beneficial in terms of PSG parameters. At the same time, high quality evidence indicates no benefit in terms of objective measures of attention and neurocognitive performance compared with watchful waiting. Furthermore, PSG recordings of almost half of the children managed non-surgically had normalised by seven months, indicating that physicians and parents should carefully weigh the benefits and risks of adenotonsillectomy against watchful waiting in these children. This is a condition that may recover spontaneously over time. For non-syndromic children classified as having oSDB on purely clinical grounds but with negative PSG recordings, the evidence on the effects of adenotonsillectomy is of very low quality and is inconclusive.Low-quality evidence suggests that adenotonsillectomy and CPAP may be equally effective in children with Down syndrome or MPS diagnosed with mild to moderate OSAS by PSG. please discuss and cite doi:10.1002/14651858.CD011165.pub2

RESPONSE: Thank you for the comment, we have added additional data in the revised manuscript regarding oSDB and the evidence of the effect of adenotonsillectomy and other management options in PSG values and other aspects of disease in children. We have discussed and cited the recommended reference.

- line 65, an interesting systematic review analyzed the correlation between changes in behavior and cognitive outcomes after AT were according to the scores post-AT in almost all studies. After comparing the AT group and control group, only one study had no difference that reached significance at one year post-AT. In another study, it did not show any significant improvement in terms of all behavioural and cognitive outcomes. The questionnaires on sleep-related quality of life after AT (PSQ-SRBD or ESS or OSA-18 or KOSA) may improve with positive changes in sleep parameters (AHI, ODI and SpO2). Furthermore, there is a significantly higher decrease in OSAS symptoms than the pre-AT baseline score. please discuss and cite doi:10.3390/children8100921

RESPONSE: Thank you for the comment, we have discussed and cited the recommended reference. Also, we added a sentence regarding the evidence of adenotonsillectomy and other therapeutical procedures to treat OSA improving PSG values, symptoms and quality of life of children with OSA.

Methods

Please apply the latest strobe guidelines, consort model and equator.

RESPONSE: Thank you for the comment. Since our study is observational, we have applied the latest STROBE guidelines.

Discussion

- To assess whether partial removal of the tonsils (intracapsular tonsillotomy) is as effective as total removal of the tonsils (extracapsular tonsillectomy) in relieving signs and symptoms of oSDB in children, and has lower postoperative morbidity and fewer complications. For children with oSDB selected for tonsil surgery, tonsillotomy probably results in a faster return to normal activity (four days) and in a slight reduction in postoperative complications requiring medical intervention in the first week after surgery. This should be balanced against the clinical effectiveness of one operation over the other. However, this is not possible to determine in this review as data on the long-term effects of the two operations on oSDB symptoms, quality of life, oSDB recurrence and need for reoperation are limited and the evidence is of very low quality leading to a high degree of uncertainty about the results. please discuss and cite doi:10.1002/14651858.CD011365.pub2

RESPONSE: Thank you for the comment, we have discussed and cited the recommended reference. We added a sentence regarding the different therapeutic options existing for pediatric SA and that some have variations such as intracapsular vs. extracapsular adenotonsillectomy since these specific data does not tend to appear in health registries such as SISPRO.

Reviewer #2: Dear author,

I appreciate the fact that your article first focused on the analysis of the prevalence in the pediatric population of sleep apnea in Colombia. It is definitely a good starting point for the study of this pathology now widely spread and of great interest to the general population. It is evident, when reading the article, the difficulties encountered in data collection and the diversity of methods used for the diagnosis of sleep apnea.

My advice is to prefer standard diagnostic tools for apnea such as polysomnography or pulse oximetry (preferred method in pediatric age). This would also allow a better differential diagnosis between central and obstructive apneas. You could try to conduct a nationwide multicenter study rather than the Colombian registry analysis to circumvent this problem. Therefore, you could use the data you collected on posing about the lack of standard methods for the study of apnea and not just subdiagnosis. I wish you a good continuation of your work.

RESPONSE: Thank you for the comment and review. We added new sentences throughout the revised manuscript regarding the diversity of diagnostic methods for SA. Since the patients in our study were given a confirmed principal diagnosis of SA by a healthcare professional, they should have undergone polysomnographic testing confirming SA (central and/or obstructive).

We agree with the reviewer on the limitations that are inherent to the use of a healthcare registries methodology to collect data and that are reflected in the discussion section of the manuscript. We agree with the reviewer in that a nationwide multicenter study could allow for a better differential diagnosis between central and obstructive apneas, our study would also invite healthcare authorities to start discriminating between central and obstructive sleep apneas in the national health registry. We expect this first analysis to invite researchers to design and perform studies with different methodologies such as a nationwide multicenter study proposed by the reviewer, we have added further insight in this matter in the discussion section of the revised manuscript.

In the future, a prospective study is proposed to include patients diagnosed with sleep apnea using PSG as a diagnostic method to achieve greater precision between central and obstructive sleep apnea.

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

RESPONSE: Thank you for the comment, we have uploaded the updated figure files to PACE digital diagnostic tool.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

8 Aug 2022

Prevalence of sleep apnea in children and adolescents in Colombia according to the national health registry, 2017-2021

PONE-D-22-09943R1

Dear Dr. Waich,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Kuo-Cherh Huang

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear author the paper is improved and could be accepted. Well done. Really interesting, will add several informations to the literature

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

22 Aug 2022

PONE-D-22-09943R1

Prevalence of sleep apnea in children and adolescents in Colombia according to the national health registry 2017-2021

Dear Dr. Waich:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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on behalf of

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PLOS ONE