SLEEP STRATEGIES Treating childhood OSA
In most children, obstructive sleep apnea (OSA) is a curable disease that responds to surgical treatment with adenotonsillectomy. Do all children need surgery for their sleep apnea? Recent research suggests perhaps not. Some children with mild obstructive sleep apnea may “grow out of it” without having their tonsils and adenoids removed.
New research may identify children who can avoid surgery
The Childhood Adenotonsillectomy Trial (CHAT), first published in 2013, suggested to clinicians that a higher than realized number of children may grow out of their OSA (Marcus et al. N Engl J Med. 2013;368[25]:2366). This was the first study to examine the risks and benefits of early adenotonsillectomy vs. watchful waiting in children 5 to 9 years of age. When sleep studies were performed at baseline and at 7 months of follow-up, it was found that 46% of the children in the watchful waiting group had resolution of their OSA. In addition, it was noted that resolution of OSA after adenotonsillectomy was not absolute, either, as 21% in the early adenotonsillectomy group had residual OSA at 7 months postsurgery. This leads to the questions of which children should undergo surgery and how we are to identify them.
A more recent study by Chervin and colleagues published in CHEST identifies factors associated with resolution of sleep apnea in the children in the watchful waiting arm of the CHAT trial (Chest. 2015;148[5]:1204). The factors identified included baseline polysomnography characteristics of mild sleep apnea, such as lower baseline apnea/hypopnea index (AHI) and less oxygen desaturation. Figure 1 demonstrates the percentage of children in the watchful waiting group that had resolution of their OSA by their baseline AHI. The CHAT trial did not include many children with severe OSA, as median AHI was less than 5, and children with sustained desaturations were excluded. Chervin and colleagues noted that those children with a lower AHI and waist circumference profile were more likely to have resolution. Other factors that may also be associated with resolution without surgery suggested by these data include a lower waist circumference percentile and lower baseline questionnaire scores on the pediatric sleep questionnaire (PSQ). The PSQ has also been identified as a tool to help assess for likelihood of OSA. Some clinical factors may also be associated with resolution of OSA, such as the absence of loud or habitual snoring or observed apneas.
The identification of these factors, along with future research in pediatric OSA, may begin to help practitioners to identify children who can avoid surgery and help identify those who may have residual disease after surgery. While AHI improved in a large portion of children in this study, symptoms did not show as drastic an association. Only 15% had a symptomatic improvement in questionnaire scores of at least 25% (Chervin et al. previous mention). Researchers are also examining biomarkers associated with OSA. A recent study showed that increased C-reactive protein (CRP) levels were associated with residual OSA after adenotonsillectomy (Bhattacharjee et al. Sleep. 2016;39[2]:283).
Why is this important?
OSA in children is common and affects an estimated 1% to 5% of children (Marcus et al. Pediatrics. 2012;130[3]:576). In the majority of children, this is due to hypertrophy of their tonsils and adenoids. Other factors, such as obesity, craniofacial features, and genetic syndromes, can play a role. Many studies examining the effects of OSA in children have demonstrated a negative impact on attention, cognitive function, and behavior. There is often significant impact on other members of a household when a child has a sleep disorder. Longitudinal effects on how OSA in childhood impacts adulthood are still unknown.
The impact of surgery
Approximately half a million adenotonsillectomies are performed per year in the United States, with the indication primarily due to OSA increasing from being primarily for infection during the past several decades (Bhattacharyya et al. Otolaryngol Head Neck Surg. 2010;143[5]:680). Minor complications, such as throat pain and dehydration, are common. Primary (within 24 hours) and secondary (typically between 5 and 10 days postoperatively) bleeding can occur in 2% to 3 % of children. Respiratory compromise is a complication that is at increased risk when the indication for surgery is OSA and can occur in almost 10% of children (De Luca Canto et al. Pediatrics. 2015;136[4]:702). Cost of surgery and missed days of school (child) and work (parent) can all be factors. The decision for surgery rests on the parents, and they may have varying preferences as to how aggressively they want their child to be treated with surgery. While surgery is often curative, it is not 100%.
