Adenotonsillectomy for Snoring and Mild Sleep Apnea in Children
Authors: Redline Susan , Cook Kaitlyn , Chervin Ronald D. , Ishman Stacey , Baldassari Cristina M. , Mitchell Ron B. , Tapia Ignacio E. , Amin Raouf , Hassan Fauziya , Ibrahim Sally , Ross Kristie , Elden Lisa M. , Kirkham Erin M. , Zopf David , Shah Jay , Otteson Todd , Naqvi Kamal , Owens Judith , Young Lisa , Furth Susan , Connolly Heidi , Clark Caron A. C. , Bakker Jessie P. , Garetz Susan , Radcliffe Jerilynn , Taylor H. Gerry , Rosen Carol L. , Wang Rui ,   Pediatric Adenotonsillectomy Trial for Snoring (PATS) Study Team, Rueschman Michael N , Tully Meg , Arnold Jean , Nicholson Michelle , Kaplan Emily , Mobley Dan , Morrical Michael , Karamessinis Laurie , Ward Michelle , Cornaglia Mary Ann , Bradford Ruth , Ciampaglia Alyssa , Groubert Hayley , Denallo Erica , Rajashari Rasal , Pyzoha Morgan , Rogers Heather , McKibben Kieran , Hicks Suzie , Carter Belinda , Boh Melodie , Swegheimer Krista , Niehaus Stacey , Herresoff Emily , Heffner Marianne , Fetterolf Judy , Geal Bill , Brand Sarah , DeWeese Braden , Johnson Libby , Brierly Kristin , Jordan Allison , Pavelka Kacee , Sands Jay , Szpara Ashley , Chambers Francesca , Vargas Laura , Eshon Constance , George Florence , Martin Mary , Sparks Vernell , Young Victoria , Stone Laura , Boykin Amy , Riggan Emily , Boswick Thomas , Bailey Michael , Stetler Amanda , Tham Addy 
Published: December 2023

ImportanceThe utility of adenotonsillectomy in children who have habitual snoring without frequent obstructive breathing events (mild sleep-disordered breathing [SDB]) is unknown.ObjectivesTo evaluate early adenotonsillectomy compared with watchful waiting and supportive care (watchful waiting) on neurodevelopmental, behavioral, health, and polysomnographic outcomes in children with mild SDB.Design, Setting, and ParticipantsRandomized clinical trial enrolling 459 children aged 3 to 12.9 years with snoring and an obstructive apnea-hypopnea index (AHI) less than 3 enrolled at 7 US academic sleep centers from June 29, 2016, to February 1, 2021, and followed up for 12 months.InterventionParticipants were randomized 1:1 to either early adenotonsillectomy (n = 231) or watchful waiting (n = 228).Main Outcomes and MeasuresThe 2 primary outcomes were changes from baseline to 12 months for caregiver-reported Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC) T score, a measure of executive function; and a computerized test of attention, the Go/No-go (GNG) test d-prime signal detection score, reflecting the probability of response to target vs nontarget stimuli. Twenty-two secondary outcomes included 12-month changes in neurodevelopmental, behavioral, quality of life, sleep, and health outcomes.ResultsOf the 458 participants in the analyzed sample (231 adenotonsillectomy and 237 watchful waiting; mean age, 6.1 years; 230 female [50%]; 123 Black/African American [26.9%]; 75 Hispanic [16.3%]; median AHI, 0.5 [IQR, 0.2-1.1]), 394 children (86%) completed 12-month follow-up visits. There were no statistically significant differences in change from baseline between the 2 groups in executive function (BRIEF GEC T-scores: −3.1 for adenotonsillectomy vs −1.9 for watchful waiting; difference, −0.96 [95% CI, −2.66 to 0.74]) or attention (GNG d-prime scores: 0.2 for adenotonsillectomy vs 0.1 for watchful waiting; difference, 0.05 [95% CI, −0.18 to 0.27]) at 12 months. Behavioral problems, sleepiness, symptoms, and quality of life each improved more with adenotonsillectomy than with watchful waiting. Adenotonsillectomy was associated with a greater 12-month decline in systolic and diastolic blood pressure percentile levels (difference in changes, −9.02 [97% CI, −15.49 to −2.54] and −6.52 [97% CI, −11.59 to −1.45], respectively) and less progression of the AHI to greater than 3 events/h (1.3% of children in the adenotonsillectomy group compared with 13.2% in the watchful waiting group; difference, −11.2% [97% CI, −17.5% to −4.9%]). Six children (2.7%) experienced a serious adverse event associated with adenotonsillectomy.ConclusionsIn children with mild SDB, adenotonsillectomy, compared with watchful waiting, did not significantly improve executive function or attention at 12 months. However, children with adenotonsillectomy had improved secondary outcomes, including behavior, symptoms, and quality of life and decreased blood pressure, at 12-month follow-up.Trial RegistrationClinicalTrials.gov Identifier: NCT02562040