Adenotonsillectomy beneficial for children with mild sleep apnea: JAMA

USA: Adenotonsillectomy, compared with watchful waiting fails to significantly improve executive function or attention at 12 months in children with mild sleep-disordered breathing (SDB), says a recent study in the Journal of the American Medical Association (JAMA). However, it led to improved secondary outcomes including symptoms, blood pressure, and behaviour.

Surgical removal of the tonsils and adenoids in children with snoring and mild breathing problems during sleep appears to improve their sleep, quality of life, and blood pressure a year after surgery, a clinical trial supported by the National Institutes of Health has found. The study, funded by the National Heart, Lung, and Blood Institute (NHLBI), part of NIH, is believed to be the first large, randomized trial to address the effects of adenotonsillectomy on children with mild sleep-disordered breathing (SDB). Adenotonsillectomy is among the most common surgical procedures in children, and mild SDB is an issue for a large proportion of these patients. 

“Our data suggest that for children with no symptoms other than snoring, it's reasonable to monitor them over time without proceeding to surgery,” said study leader Susan Redline, M.D., M.P.H., of Brigham and Women’s Hospital and Harvard Medical School, both in Boston. “However, for children who are having issues with disturbed sleep, daytime sleepiness, and behavioral problems, our data suggest that surgery may be a very reasonable option.”

SDB refers to breathing disturbances during sleep that can range from loud snoring to sleep apnea. SDB affects 6-17% of typically developing children in the United States. Some research indicates that if left untreated, the condition may increase the risk for behavioral problems, reduced quality of life, and cardiovascular diseases, including heart disease and high blood pressure. Researchers and parents are showing increasing interest in how sleep problems such as sleep apnea might also affect brain development, cognition, and academic performance.

Adenotonsillectomy, or removal of enlarged tonsils and adenoids, is a standard treatment for children with moderate to severe SDB and is aimed at reducing snoring and improving breathing in those with the condition. However, data are unclear whether the surgery is beneficial for children with mild forms of SDB.

The Pediatric Adenotonsillectomy Trial for Snoring (PATS) was a randomized clinical trial that involved 459 children and adolescents with mild SDB who were enrolled at seven academic sleep centers in the United States between 2016 to 2021. The participants were ages 3 to 12, racially diverse, and followed for a year. The study did not include children with moderate to severe SDB.

During the trial, half the participants received an adenotonsillectomy and the other half received supportive care without surgery, which included standardized education on healthy sleep and lifestyle and referral for untreated allergies or asthma. Researchers then evaluated neurodevelopmental, behavioral, health, and sleep-related outcomes in these groups, using measurements of attention and executive function, which includes a set of cognitive skills that help children manage everyday activities. Sleep outcomes were measured by polysomnography, a standard sleep test that measures breathing, heart rate, eye movement, and other factors.

At the end of the study period, cognition and attention improved in both groups, but improvement was not significantly greater in the children who were treated with surgery compared to the group who did not receive surgery. However, the secondary results of the study did show several beneficial changes in the surgery group. These included less daytime sleepiness, reduced SDB, less snoring, fewer behavioral problems, better quality of life, and lower blood pressure. The children treated with surgery were also less likely to show disease progression into full-blown sleep apnea, the researchers said.

Researchers plan to explore the long-term impacts of surgery in this population and note the need to develop improved screening tools that better identify which children are most likely to benefit from adenotonsillectomy.

“It is clear that adenotonsillectomy can help some children with mild sleep-disordered breathing. However, it may not be appropriate for everyone,” said Marishka Brown, Ph.D., director of the National Center on Sleep Disorder’s Research within the NHLBI. “Parents with concern over their children's nighttime breathing should discuss options with their paediatrician to develop a plan of action.”

Reference:

Redline S, Cook K, Chervin RD, et al. Adenotonsillectomy for Snoring and Mild Sleep Apnea in Children: A Randomized Clinical Trial. JAMA. 2023;330(21):2084–2095. doi:10.1001/jama.2023.22114.