Small difference seen when compared with adenotonsillectomy

Children with mild obstructive sleep apnea (OSA) that has a moderate effect on their quality of life will probably benefit from watchful waiting rather than undergoing adenotonsillectomy (ATE).

A small randomized trial determined that there were only small differences in outcomes between children with mild OSA between the ages of 2 and 4 who underwent ATE, and those who received watchful waiting.

Results of the trial were published in JAMA Otolaryngology–Head & Neck Surgery.

According to Johan Fehrm, MD, of the Department of Otorhinolaryngology at Karolinska University Hospital in Stockholm, Sweden, and colleagues, while ATE compared with no treatment for obstructive sleep apnea is known to positively impact respiratory sleep parameters, quality of life (QoL), and behavior, its effect on children between 2 and 4 years of age is unknown.

There has been research — the CHAT trial, for example — showing that children with milder forms of OSA can get better without surgical treatment. The CHAT trial, however, included children between the ages of 5 and 9 years of age. Therefore, in this (KATE) study, the authors set out to determine whether ATE is more effective than watchful waiting in younger children with mild to moderate OSA.

The study was a single-center, prospective, randomized control trial involving 60 children, ages 2 to 4, with mild to moderate OSA (an obstructive apnea–hypopnea index [OAHI] score of 2 or greater and less than 10). Of those 60 children, 31 were randomized to watchful waiting, and 29 were randomized to ATE. The primary outcome of the trial was the difference in mean OAHI score change between the two groups, while secondary outcomes were other polysomnography parameters, score on the Obstructive Sleep Apnea-18 (OSA-18) quality of life (QoL) questionnaire, and subgroup analyses.

Fehrm and colleagues found that both groups of children saw their OAHI scores reduced at follow-up. The ATE group had a mean OAHI score decrease of −2.9 (95% CI, −4.0 to −1.9), while the watchful waiting group had a mean decrease of −1.9 (95% CI, −3.0 to −0.9). This represented a difference between the groups in mean change of −1.0 (95% CI, −2.4 to 0.5).

Additionally, 4 children in the watchful waiting group had an increased OAHI score at follow-up compared to 2 children in the ATE group, while 2 children with moderate OSA in the watchful waiting group developed severe OSA.

The authors also observed significant improvements in total OSA-18 score (−23.5; 95% CI, −31.5 to −15) in the ATE group, compared to small improvements among children in the watchful waiting group (−4.5; 95 CI, −12 to 1.5).

A subgroup analysis of children who had moderate OSA at baseline (11 in the ATE group and 13 in the watchful waiting group) showed that there was a statistically meaningful group difference in mean OAHI score change (−3.1; 95% CI, −5.7 to −0.5) in favor of ATE. For those children with mild OSA, the mean difference in mean OAHI score change was much smaller (0.7; 95% CI, −0.5 to 1.9).

“These findings suggest, in accordance with earlier recommendations from the European Respiratory Society, that otherwise healthy children with moderate OSA benefit from ATE, whereas watchful waiting could be an alternative for otherwise healthy children with mild OSA,” wrote Fehrm and colleagues.

However, they added that issues related to quality of life should be taken into account when considering surgery, and that more research is needed to confirm the results of their study.

In a commentary accompanying the study, Cristina M. Baldassari, MD, Department of Otolaryngology Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia, noted that OSA severity as determined by OAHI scores does not correlate with QoL scores in children, indicating that these scores do not reflect the effect OSA can have on a child’s quality of life.

Therefore, the improvement in OSA-18 QoL scores in children who underwent adenotonsillectomy, compared to the scores in children who were observed, suggests that QoL instruments “may be useful tools when determining treatment options for children with mild OSA,” wrote Baldassari. “Adenotonsillectomy should be considered for children with poor baseline QoL scores, because they are likely to experience significant improvement following surgery.”

  1. Young children, 2 to 4 years of age, with mild obstructive sleep apnea that has a moderate effect on their quality of life, may be candidates for watchful waiting rather than adenotonsillectomy.

  2. Issues related to quality of life should be taken into account when considering surgery in this patient population.

Michael Bassett, Contributing Writer, BreakingMED™

Fehrm reported grants from the Samaritan Foundation for Pediatric Research, from the ACTA Oto-Laryngologica Foundation, and from the Stockholm City Council during the conduct of the study.

Baldassari reported grants from CORE Otolaryngology outside the submitted work.

Cat ID: 138

Topic ID: 85,138,730,138,192,50,195,925,159