Watchful Waiting Appropriate for Some Kids With Mild OSA

By Anne Harding

June 10, 2020

NEW YORK (Reuters Health) - Adenotonsillectomy (ATE) should be considered for young children with moderate obstructive sleep apnea (OSA), while some children with mild OSA can benefit from watchful waiting, a new randomized trial shows.

ATE showed a small benefit based on obstructive apnea-hypopnea index (OAHI), but patients had "large improvements" in their quality of life, Dr. Johan Fehrm of Karolinska University Hospital in Stockholm and colleagues report in JAMA Otolaryngology-Head and Neck Surgery.

Some patients with mild OSA improve on their own, and may benefit from watchful waiting, but no studies to date have compared ATE to watchful waiting in children younger than 5, Dr. Fehrm and his team note.

They randomized 60 children aged 2 to 4 with OAHI scores of 2 or more but less than 10, indicating mild to moderate OSA, to ATE or watchful waiting.

At six months, OAHI score had declined in both groups, with a non-significant one-point difference favoring ATE. However, total Obstructive Sleep Apnea-18 (OSA-18) scores dropped 17 points more with ATE than with watchful waiting, a significant difference.

Among the 24 children with moderate OSA, ATE produced a 3.1-point greater improvement on OAHI than did watchful waiting (95% confidence interval, -5.7 to -0.5).

"Children with moderate OSA should be considered for early ATE, while children with mild OSA and a mild impact on quality of life may benefit from a period of watchful waiting," Dr. Fehrm told Reuters Health by email.

"I think it is important to know that there is a discrepancy between objective respiratory sleep parameters and quality of life," he added. "The decision to perform surgery should therefore be based on both these factors, as well as the clinical presentation. Both surgery and untreated OSA are associated with risks, and therefore it is important to perform more polysomnography and improve the knowledge about clinically relevant outcomes."

In an editorial accompanying the study, Dr. Cristina M. Baldassari of Eastern Virginia Medical School in Norfolk, writes, "The Karolinska Adenotonsillectomy (KATE) study is an important addition to the pediatric OSA literature."

"The findings of the KATE study, which was conducted in Sweden, may not be generalizable to other populations of children with nonsevere disease," she adds. "For example, only 4 of the children in this study were obese, and there is no mention of the race of the patients."

"In summary, young children with mild OSA who are not having sleep-related sequelae can be managed with watchful waiting. Young children with moderate OSA and those with mild disease who have poor disease-related QoL (quality of life) scores benefit from tonsillectomy," she concluded. SOURCE: and JAMA Otolaryngology - Head and Neck Surgery, online May 28, 2020