Progression of mild sleep-disordered breathing in children managed with watchful waiting.

Abstract

Purpose: To identify clinical characteristics that may be associated with persistence or progression of mild sleep-disordered breathing (SDB) in children who are observed without surgery.

Methods: This is a secondary analysis of the control arm of the Pediatric Adenotonsillectomy Trial for Snoring (PATS), which randomized 458 children aged 3.0 to 12.9 years with mild SDB (snoring with obstructive apnea-hypopnea index [oAHI] < 3 events/hour) to early adenotonsillectomy (eAT) versus watchful waiting with supportive care (WWSC). Participants were assessed at baseline and 12 months with the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder (PSQ-SRBD) scale and polysomnography (PSG). We tested for factors predictive of either (1) PSG progression defined by a 12-month oAHI ≥ 3 or (2) symptom persistence or progression defined by a 12-month PSQ-SRBD score ≥ 0.33.

Results: A total of 234 participants were observed (mean age 6.2 years, 111 [47%] female, 65 [28%] Black or African American, 37 [16%] Hispanic). Overall, only 13% (n = 20/150) progressed to an oAHI ≥ 3 on repeat PSG, whereas over half (n = 110/192, 57%) had symptom persistence/progression. Of the children with persistent or progressive symptoms, 18% (n = 16/103) progressed to oAHI ≥ 3. In unadjusted analyses, PSG progression was associated with Black race (OR 2.71, 95% CI 1.03-7.17) and higher baseline PSQ-SRBD (OR 1.74, 95% CI 1.03-3.08). Symptom persistence/progression was predicted by asthma (OR 2.70 [95% CI 1.29, 6.01]), ADHD (OR 3.73 [95% CI 1.13, 16.88]), and tobacco smoke exposure (OR 2.41 [95% CI 1.08-5.82]), while children with larger tonsils (grade III-IV) had lower odds of progression (OR 0.42 [95% CI 0.22-0.78]).

Conclusions: A high symptom burden is common after a year of WWSC for mild SDB, but only a minority of children progressed on PSG. Black race and several clinical characteristics and symptom scores were associated with higher likelihood of progression.

Trial registration: ClinicalTrials.gov Identifier: NCT0256204.

Current knowledge/study rationale: Can clinical information predict persistence or progression of mild sleep-disordered breathing in children who are observed for 1 year without adenotonsillectomy?

Study impact: Polysomnographic progression to obstructive sleep apnea occurs in a minority (13%) of those observed while symptom persistence or progression is more common (57%). Children who are Black or who have asthma, attention-deficit hyperactivity disorder, environmental tobacco exposure, and a high symptom burden could be considered stronger candidates than their peers for earlier adenotonsillectomy for symptomatic mild sleep-disordered breathing.