10.14639/0392-100X-N0670
The primary goal of the present study was to compare breathing difficulties resulting from OSAS to possible cognitive-behavioural problems of the child linked to their parents’ emotional-relational aspects. There is strong evidence that sleep breathing disorders are associated with behavioural alterations, a tendency towards aggressiveness, weak school performance and a clear disorder in continuous and selective attention other than vigilance status. Not all patients suffering from OSA have cognitive and/or behavioural manifestations; furthermore, the degree of dysfunction that the patient may present does not seem to be associated with the seriousness of sleep breathing disorder (SBD). It is therefore likely that genetic susceptibility associated with particular environmental factors has a role in determining phenotypic manifestations which are unique for every single patient. Questionnaires were given to parents, one regarding executive functions and one regarding parental stress: Conners’ Rating Scale Revised; Parenting Stress Index. All parents of children who suffer from moderate to severe OSA, with a McGill score of 3 to 4 and with no exclusion criteria are included in the study; behavioural and parental stress evaluation was made during hospitalisation and at 6 months after adenotonsillectomy. The results show that resolving OSAS led to important improvements in the competence and behavioural attitudes of the patient, as well as in relational and management difficulties by parents. The identification of such indicators could represent a support to surgical programming, even in nonsevere SBD. Future research will have the goal of identifying standardised risk indicators that can provide further indications for surgical treatment in children up to 5 years of age.
application/xml
1827-675X
670
5
en
Maria Laura Panatta
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
McGill score
Behavioural disorders and parental stress in children suffering from obstructive sleep apnoea syndrome: a pre- and post-adenotonsillectomy confrontation
Text.Serial.Journal
https://www.actaitalica.it/
40
OSAHS
2020-12-03
2020-02-05
2020-12-04
2020-12-04
383-389
1
Giovanni Carlo De Vincentiis
2020/12/03
10.14639/0392-100X-N0670
383
UOC Otorinolarinogoiatria, Ospedale Pediatrico Bambino Gesù, Roma, Italy
1827-675X
5
McGill score
389
Behavioural disorders and parental stress in children suffering from obstructive sleep apnoea syndrome: a pre- and post-adenotonsillectomy confrontation
https://www.actaitalica.it/article/download/670/467
40
ACTA OTORHINOLARYNGOLOGICA ITALICA 2020;40:383-389; doi: 10.14639/0392-100X-N0670




OSAHS


Behavioural disorders and parental stress in children
suffering from obstructive sleep apnoea syndrome:
a pre- and post-adenotonsillectomy confrontation
Disordini comportamentali e indice di stress genitoriale nei bambini affetti da
Sindrome dell’apnea ostruttiva nel sonno: confronto pre e post adenotonsillectomia
Emanuela Sitzia1, Federica Pianesi2, Nadia Mirante3, Giulia Marini1, Mariella Micardi2, Maria Laura Panatta1,
Alessandra Resca2, Pasquale Marsella2, Giovanni Carlo De Vincentiis1
1
 UOC Otorinolarinogoiatria, Ospedale Pediatrico Bambino Gesù, Roma, Italy; 2 UOC Audiologia e Otochirurgia, Ospedale Pediatrico
Bambino Gesù, Roma, Italy; 3 U.O.C. Pediatria Generale e Malattie Infettive, Ospedale Pediatrico Bambino Gesù, Roma, Italy


SUMMARY
The primary goal of the present study was to compare breathing difficulties resulting from
OSAS to possible cognitive-behavioural problems of the child linked to their parents’
emotional-relational aspects. There is strong evidence that sleep breathing disorders are
associated with behavioural alterations, a tendency towards aggressiveness, weak school
performance and a clear disorder in continuous and selective attention other than vigilance
status. Not all patients suffering from OSA have cognitive and/or behavioural manifesta-
tions; furthermore, the degree of dysfunction that the patient may present does not seem to
be associated with the seriousness of sleep breathing disorder (SBD). It is therefore likely
that genetic susceptibility associated with particular environmental factors has a role in              Received: February 5, 2020
determining phenotypic manifestations which are unique for every single patient. Question-              Accepted: May 15, 2020
naires were given to parents, one regarding executive functions and one regarding parental
stress: Conners’ Rating Scale Revised; Parenting Stress Index. All parents of children who              Correspondence
suffer from moderate to severe OSA, with a McGill score of 3 to 4 and with no exclusion                 Maria Laura Panatta
criteria are included in the study; behavioural and parental stress evaluation was made dur-            U.O.C. Otorinolarinogoiatria, Ospedale Pediatrico
ing hospitalisation and at 6 months after adenotonsillectomy. The results show that resolv-             Bambino Gesù, Roma, Italy
                                                                                                        E-mail: marialaura.panatta@opbg.net
ing OSAS led to important improvements in the competence and behavioural attitudes of
the patient, as well as in relational and management difficulties by parents. The identifica-
                                                                                                        Funding
tion of such indicators could represent a support to surgical programming, even in non-
                                                                                                        None.
severe SBD. Future research will have the goal of identifying standardised risk indicators
that can provide further indications for surgical treatment in children up to 5 years of age.
                                                                                                        Conflict of interest
KEY WORDS: obstructive sleep apnea syndrome (OSAS), parental stress, excessive daily                    The Authors declare no conflict of interest.
drowsiness, Conner’s rating scale revised (CRS-R), parenting stress index, McGill score
                                                                                                          How to cite this article: Sitzia E, Pianesi F,
RIASSUNTO                                                                                                 Mirante N, et al. Behavioural disorders and
Scopo del presente lavoro è valutare la relazione esistente tra le difficoltà respiratorie legate         parental stress in children suffering from ob-
all’OSAS ed i possibili disordini neurocomportamentali correlando questi ultimi al grado di               structive sleep apnoea syndrome: a pre- and
stress genitoriale. Non tutti i pazienti affetti da OSAS presentano questo tipo di problematiche          post-adenotonsillectomy confrontation. Acta
tuttavia i disturbi di comportamento non sembrano essere associati con la severità del SBD;               Otorhinolaryngol Ital 2020;40:383-389. https://
                                                                                                          doi.org/10.14639/0392-100X-N0670
è probabile che una suscettibilità genetica associata a particolari fattori ambientali abbia
un ruolo determinante nello sviluppo fenotipico di queste manifestazioni. Sono stati utilizzati
                                                                                                        © Società Italiana di Otorinolaringoiatria
due questionari: Conners’ Rating Scale Revised; Parenting Stress Index. Sono stati arruolati            e Chirurgia Cervico-Facciale
nello studio pazienti con OSAS di grado moderato-severo, con Mc Gill score 3 o 4 in cui non
fossero presenti criteri di esclusione, la valutazione dei genitori è stata effettuata durante il ri-                  OPEN ACCESS
covero e 6 mesi dopo l’intervento di adenotonsillectomia. I risultati ottenuti hanno dimostrato
che risolvendo l’OSAS si ottengono miglioramenti nelle competenze e nel comportamento dei               This is an open access article distributed in accordance with
                                                                                                        the CC-BY-NC-ND (Creative Commons Attribution-Non-
pazienti ed inoltre si riducono le difficoltà genitoriali. L’identificazione di tali indicatori può     Commercial-NoDerivatives 4.0 International) license. The
rappresentare un supporto all’indicazione chirurgica anche in casi di DRS non severo.                   article can be used by giving appropriate credit and mentio-
                                                                                                        ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: sindrome dell’apnea ostruttiva del sonno (OSAS), stress genitoriale,                     only in the original version. For further information: https://
eccessiva sonnolenza diurna, questionario di Conner’s rivisitato (CRS-R), punteggio di McGill           creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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E. Sitzia et al.




Introduction                                                      Last, but not least, it is opportune to consider that not all
                                                                  patients suffering from OSA have cognitive and/or behav-
In 1976, Guillelminault was the first to describe, in a sam-
                                                                  ioural manifestations; furthermore, the degree of dysfunc-
ple of 8 patients, the association between sleep breathing        tion that the patient may present does not seem to be asso-
disorders and difficulty in learning, presence of school          ciated with the severity of sleep breathing disorder (SBD).
problems and the appearance of clear mood alterations that        It is, therefore, likely that genetic susceptibility associated
were somehow connected to a more or less accentuated              with particular environmental factors has a role in deter-
daily drowsiness 1.                                               mining phenotypic manifestations that are unique for every
In the last 40 years, the literature has provided a concrete      single patient 8.
support to what was a mere observational evaluation. To-          Recent studies have confirmed the importance that frag-
day, we know that sleep breathing disorders are clinically        mented sleep has on the genesis of attentive problems,
expressed in a continuum which has its origins in primary         whereas intermittent hypoxaemia, by acting mainly on a
snoring and which its highest expression sees in obstructive      state of inflammation of the vascular area, is responsible
sleep apnoea syndrome (OSAS). Night ventilator dynamic            for alterations in the hippocampus and pre-frontal region,
in a patient suffering from obstructive sleep apnoea (OSA)        mainly modifying executive functions 9.
results in totally compromised hypopnoeic and apnoeic             As there are no sufficient studies that deal with the child’s
events, secondary to a partial or total obstruction of the res-   behaviour and parental stress in the presence of paediatric
piratory system, determining a de-structuring of sleep with       OSAS, we carried out a study to evaluate both these aspects
significant alteration of normal patterns 2.                      in a group of patients treated in our paediatric hospital.
It is now acknowledged that non-treated OSA can lead to           It is now acknowledged in the literature that excessive dai-
important consequences for the child’s health, starting from      ly drowsiness in the paediatric population suffering from
a normal postural and ponderal growth to the presence of          SBD is present in 40-50% of cases.
important cardiovascular alterations, which can lead to sys-      Our purpose is to confirm these findings, evaluating per-
temic arterial and pulmonary hypertension. Furthermore,           formance of the child to the family context and trying to
there is strong evidence that sleep breathing disorders are       understand how this factor is influenced by the patient’s
associated with behavioural alterations, a tendency towards       health and how it represents a conditioning “environmental
aggressiveness, weak school performance and a clear dis-          factor”.
order in continuous and selective attention other than vigi-
lance status 3. Neuro-behavioural manifestations can be
explained by intermittent hypoxic phenomena associated            Materials and methods
with the de-structuring of normal sleep stages, and ani-
mal models provide the plausibility that OSA contributes          Procedure
to neuro-cognitive deficits; in fact, experiments on young        All parents of children who suffer from moderate to severe
mice subjected to intermittent hypoxia during sleep high-         OSA, with a McGill score of 3 to 4 (McGill score is a pul-
light similar difficulties in conditioned learning 4.             sossimetric score which consent a diagnosis of OSAS with-
MRI and spectroscopy scans have demonstrated that ap-             out performing a regular polysomnography and indicate
noeic patients suffer from an alteration of metabolites in        priority for surgical intervention) and with no exclusion
the left hippocampus and right frontal cortex 5; in the pre-      criteria (association with other genetic syndromes, cog-
fontal cortex, OSA-mediated hypoxic damage might play a           nitive retardation, or diagnosed language disorders under
role in the development of this cerebral area, with irrevers-     treatment, certified ADHD, mild night breathing disorders,
ible consequences even if apnoeic condition is resolved 6.        previously ORL surgery) at our centre for Sleep Breath-
Many questions are yet to be answered. It is known that – in      ing Disorders of the ORL Operative Unite over a period
its initial stage – fragmented sleep is less frequent in a pae-   from September 2014 to February 2016 were invited to par-
diatric age; in particular, the microstructure of sleep in        ticipate in the study. Parents who took part in the research
EEG tracings (A1 phase and A1 index of the CAP, Cycling           signed an informed consent approved by the Institutional
Alternating Pattern) is modified, thus suggesting the non-        Review Board.
restorative nature of non-REM sleep in these patients 7.          Behavioural and parental stress evaluation was made dur-
Oxidative stress can also play a role by increasing the loss      ing hospitalisation and at 6 months after adenotonsillecto-
of neuronal elements through direct damage as well as             my, in line with the international literature 12-14 to verify the
through activation of secondary inflammatory processes            absence of rehabilitation and/or medical therapies (methyl-
and reparative events 7.                                          phenidate and psycho-stimulant generally).



384
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Post-surgery questionnaires were filled-in during a routine       Ethical approval
check-up at 6 months after surgery.                               All procedures performed in studies involving human par-
A psychologist handed out the questionnaires and explained        ticipants were in accordance with the ethical standards of
them to parents, who then filled them in autonomously in          the institutional and/or national research committee (Os-
the waiting room. The PSI questionnaire was completed by          pedale Pediatrico Bambino Gesù Ethical Committee) and
mothers and not fathers.                                          with the 1964 Helsinki declaration and its later amend-
In order to avoid missing data, the psychologist checked          ments or comparable ethical standards.
that all questionnaires were properly completed.
The study was carried out in compliance with the Helsinki         Results
declaration.
                                                                  Overall, 50 children of age ranging from 28 months to 82
Observation questionnaires                                        months were found eligible (68% boys) (average: 44; ±
Questionnaires were given to parents, one regarding execu-        SD:10.3).
tive functions and one regarding parental stress. During the      Abandonment rate was 0%. All children chosen, in fact, under-
same evaluation meeting, children underwent non-struc-            went evaluation before surgery and at 6 months after surgery.
tured qualitative behavioural observation.                        Mothers who filled in the questionnaire were asked about
Conners’ Rating Scale Revised: (CRS-R: C. Keith Con-              their educational and economic level; 18% had secondary
ners) 10: this is a structured questionnaire composed of 80       school diploma, a little over half had a high school diploma
questions which investigated problematic or psycho-path-          (52%), while the remaining 30% had a degree. Their socio-
ological behaviours during developmental age, from 3 to           economical level was similar to their educational level, i.e.
17. There are three versions of the questionnaire, one for        20% had a low level, a little more than half (54%) had me-
                                                                  dium level and about one-quarter of mothers had a high
parents (CPRS-R), one for teachers (CTRS-R) and a self-
                                                                  social economic level (26%) (Tab. I).
report for adolescents from 12 to 17 (YSR-R).
                                                                  As shown in Table II by Conners’ scales, the most signifi-
There are 14 areas of investigation: 1) Oppositivity 2)
                                                                  cant items, with p < 0.01, were: oppositivity (p = 0.0008),
Cognitive disorders 3) Hyperactivity-Impulsiveness 4)
                                                                  hyperactivity (p = 0.001), perfectionism (p = 0.003), rest-
Anxiety-Shyness 5) Perfectionism 6) Social Issues 7) Psy-
                                                                  lessness/impulsiveness (p = 0.0003), emotional instability
chosomatic traits 8) ADHD index 9) CGI – Restlessness/
                                                                  (p = 0.0005) and general difficult behaviour (p = 0.0008).
Impulsiveness 10) Emotional Instability 11) CGI – Total
                                                                  In particular, there was an increase in 24% of children
12) DSM IV – Lack of Attention 13) DSM IV – Hyperac-
                                                                  with standard oppositivity post-surgery, compared to pre-
tivity/Impulsiveness 14) DSM IV-Total.
                                                                  surgery evaluation (from 62% of sample to 86%); in the
The questionnaire includes 0-4 multiple choice. In our
                                                                  hyperactivity subscale, there was an increase in 20% of
study, we used the parental version.
Parenting Stress Index (Richard Abidin) 11: this is a mul-
tiple choice questionnaire with a score between 0 and 4,          Table I. Socio-demographic characteristics of sample (N = 50).
composed of 36 questions, which investigates parental                                                                   N            (%)
stress meant as discrepancy perceived by parents among             Gender
the resources available and the need to maintain a parental        Male                                                34            (68)
role.                                                              Pre-surgery chronological age, months
Specifically, it investigates four areas: 1) Parental distress;
                                                                   (average, ± SD)                                     44          (± 10,3)
2) Dysfunctional child-parent interaction; 3) Difficult child;
                                                                   Post-surgery chronological age, months
4) Defensive response.
                                                                   [(average, ± DS)                                    50          (± 10,3)
                                                                   Education
Statistical analysis of data
                                                                   Secondary School Diploma                            9             (18)
Categorical data are transcribed as numbers and percentage,
                                                                   High School Diploma                                 26            (52)
while continuous data are transcribed as average and ± SD.
                                                                   Degree                                              15            (30)
As these are ordinal data, statistical analysis was elaborated
                                                                   Socio-economic level
with Wilcoxon Test for paired data. A value of p < 0.05
was considered significant, and a value of p < 0.01 as even        Low                                                 10            (20)
more significant. Statistical elaboration was carried out          Medium                                              27            (54)
with STATA 14 statistical software.                                High                                                13            (26)




                                                                                                                                        385
E. Sitzia et al.




Table II. Pre-post-surgery confrontation, results of Conners’ test (entire sample).
                                                                      Pre                    Post           P value*
                                                           N                     (%)    N           (%)
 Opposition
 Average                                                   31                    (62)   43          (86)    0.0008
 Borderline                                                14                    (28)   4            (8)
 Pathological                                              5                     (10)   3            (6)
 Inattention/ Cognitive disorders
 Average                                                   40                    (80)   42          (84)    0.2674
 Borderline                                                6                     (12)   5           (10)
 Pathological                                              4                      (8)   3            (6)
 Hyperactivity
 Average                                                   32                    (64)   42          (84)    0.0014
 Borderline                                                 9                    (18)   7           (14)
 Pathological                                               9                    (18)   1            (2)
 Anxiety/Shyness
 Average                                                   42                    (84)   43          (86)     0.40
 Borderline                                                4                      (8)   5           (10)
 Pathological                                              4                      (8)   2            (4)
 Perfectionism
 Average                                                   32                    (64)   42          (84)     0.003
 Borderline                                                10                    (20)   6           (12)
 Pathological                                               8                    (16)   2            (4)
 Social issues
 Average                                                   48                    (96)   50          (100)    0.16
 Borderline                                                1                      (2)   0             (-)
 Pathological                                               1                     (2)    0            (-)
 Psycho-somatic disorders
 Average                                                   37                    (74)   44          (88)     0.02
 Borderline                                                8                     (16)   5           (10)
 Pathological                                              5                     (10)   1            (2)
 ADHD
 Average                                                   34                    (68)   40          (80)     0.038
 Borderline                                                10                    (20)   6           (12)
 Pathological                                              6                     (12)   4            (8)
 Restlesness/impulsiveness
 Average                                                   29                    (58)   40          (80)    0.0003
 Borderline                                                11                    (22)   9           (18)
 Pathological                                              10                    (20)   1            (2)
 Emotional instability
 Average                                                   33                    (66)   45          (90)    0.0005
 Borderline                                                12                    (24)   2            (4)
 Pathological                                              5                     (10)   3            (6)
 General behavioural issues
 Average                                                   32                    (64)   42          (84)    0.0008
 Borderline                                                10                    (20)   7           (14)
 Pathological                                              8                     (16)   1            (2)

                                                                                                              continues 


386
                                                                                                                              OSAS and parental stress




Table II. Pre-post-surgery confrontation, results of Conners’ test (entire sample) (follows).
                                                                      Pre                                   Post                       P value*
                                                            N                     (%)                N                (%)
    DSM-IV inattention
    Average                                                 38                    (76)              43                (86)               0.02
    Borderline                                              8                     (16)              4                  (8)
    Pathological                                            4                      (8)              3                  (6)
    DSM-IV hyperactivity/impulsiveness
    Average                                                 37                    (74)              44                (88)               0.01
    Borderline                                              9                     (18)              6                 (12)
    Pathological                                            4                      (8)              0                  (-)
    DSM-IV ADHD combined
    Average                                                 37                    (74)              42                (84)               0.05
    Borderline                                              9                     (18)              6                 (12)
    Pathological                                            4                     (8)                2                (4)
*
    Wilcoxon test for paired data



children in the standard (pre-post-surgery: 64% vs. 84%);                           Discussion
during follow-up, children with problems of perfectionism
                                                                                    For a long time, the scientific literature has given impor-
were statistically decreased (pathological pre-post: 16%
                                                                                    tance to the link between sleep disorders and behaviour,
vs. 4%); almost all children with pathological restlessness/
                                                                                    focusing on the child’s functional abilities in terms of at-
impulsivity went back to standard/borderline (from 20% to
                                                                                    tention, restlessness, memory and learning ability 12,13,15,16.
2%). A similar outcome resulted in sub-scale “general dif-
                                                                                    Parental stress related to child care for children suffering
ficult behaviour” (from 16% to 2%); lastly, emotional insta-
                                                                                    from SBD were not seen.
bility also improved, ranging from 66% to 90% of children.
                                                                                    The present study confirmed the previous literature data re-
Sub-scales with p < 0.05 and p ≥ 0.01 were as follows: psycho-
                                                                                    garding functional competence in children suffering from
somatic problems (p = 0.02), ADHD, DSM-IV inattention                               SBD improve significantly after adenotonsillectomy. The in-
(p = 0.02) and hyperactivity/impulsiveness (p = 0.01) (Tab. II).                    novative part of our study is having observed the emotional
The DSM-IV ADHD combined parameter resulted in bor-                                 behaviour by parents towards the problems of apnoeic pa-
derline statistical significance (p = 0.05) (Tab. II).                              tients together with children’s executive functions. Breathing
More specifically, children with psychosomatic problems                             disorders result in parental stress and preoccupation, so much
decreased from 10% to 2%, with an increase of 12% in                                so that children negatively influence their sleep-wake rhythm,
children with no ADHD (from 68% to 80% post-surgery).                               thus altering their parental competence. This parental dys-
A similar increase was also seen for subscale DSM-IV in-                            functionality acts as environmental phenomenon which nega-
attention, with a decrease of 10% at 6 months. Lastly, no                           tively influences already critical behavioural attitudes.
pathological result was found for subscale DSM-IV hyper-                            Behavioural improvements mainly focus on three areas:
activity/impulsiveness in post-surgery (8% of pathological                          Oppositivity, Hyperactivity, Perfectionism, Restlessness/
children at the beginning vs. 0% in post-surgery).                                  impulsiveness, Emotional Instability and General Difficult
Table III shows the results obtained with the PSI question-                         Behaviour.
naire on parental stress, in this case related to mothers. The                      From the anamnesis of parents pre- and post-surgery, there
area with p < 0.01 was on total stress, ranging from 62% of                         was evidence that children had a net improvement in op-
parents to 78% in post-surgery.                                                     positive-provocatory behaviours, which in school age can
Significant improvement was also seen in the parental                               lead to learning disorders.
distress subscale (p = 0.1), with a 16% increase in moth-                           Qualitative analysis of results is also very interesting, as
ers with normal values post-surgery compared to baseline                            parents report that their children are “easier to deal with
(from 58% to 74%) (Tab. III).                                                       in shopping centres” (Item 13 CRS), less “perfectionist”
Lastly, there are no significant differences between pre- and                       (Item 5 CRS), more “active“ and less “tired” or “they move
post-surgery in the other subscales (Tab. III).                                     as in slow motion” (Item 73 CRS).



                                                                                                                                                  387
E. Sitzia et al.




Table III. Pre-post PSI test confrontation.
                                                        Pre                                        Post                           P value*
                                                N                 (%)                    N                    (%)
    Parental distress
    Average                                    29                 (58)                   37                   (74)                 0.01
    Borderline                                 17                 (34)                   10                   (20)
    Pathological                               4                   (8)                   3                     (6)
    Parent/ disfunctional child interaction
    Average                                    38                 (76)                   40                   (80)                 0.542
    Borderline                                 10                 (20)                   9                    (18)
    Pathological                               2                   (4)                   1                     (2)
    Difficult child
    Average                                    25                 (50)                   29                   (58)                 0.122
    Borderline                                 16                 (32)                   15                   (30)
    Pathological                                9                 (18)                   6                    (12)
    Total stress
    Average                                    31                 (62)                   39                   (78)                 0.004
    Borderline                                 12                 (24)                   7                    (14)
    Pathological                               7                  (14)                   4                     (8)
    Defensive response
    Average                                    28                 (56)                   32                   (64)                 0.132
    Borderline                                 17                 (34)                   14                   (28)
    Pathological                               5                  (10)                    4                    (8)
*
    Wilcoxon test for paired data



As for parental behaviour, the perception of their children         cognitive-behavioural problems of the child linking them
improved, especially the idea that their child was “more            to their parents’ emotional-relational aspect.
agitated”, and the fact that he/she had a tendency to cry           The results obtained demonstrated that resolving OSAS
more than other kids (Item 25 PSI) was dramatically de-             brings about important improvements in the competence
creased, and the same thing can be said with the feeling that       and behavioural attitude of the patient, in addition to rela-
their children woke up “in a bad mood” (Item 26 PSI), or            tional and management difficulties by parents.
that sleep and food rhythms were more difficult to manage           The identification of such indicators could represent a sup-
(Item 31 PSI).                                                      port to surgical programming, even in non-severe SBD.
Food-wise, many parents referred that lack of appetite – a          Future research needs to identify standardised risk indica-
typical occurrence – changed into a suitable food behav-            tors that can provide further indications on surgical treat-
iour.                                                               ment in children up to 5 years of age.
For what concerns criticalities, we observed that non-Ital-         It would be interesting to monitor whether behavioural and
ian parents had problems filling-in the questionnaire; fur-         relational improvements are maintained in the family for
thermore, during the first test, the lack of awareness of chil-     periods longer than 6 months after surgery, and if the areas
dren’s behaviours changed during post-surgery test, which           that did not undergo changes in the first 6 months improve
led to a clearer precision in filling-in the questionnaire.         after a longer time span.
An advantage was that evaluations were not “operator-
mediated”, thus avoiding a possible influence in the test
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