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Predictors of Behavioral Changes After Adenotonsillectomy in Pediatric Obstructive Sleep Apnea: A Secondary Analysis
Amal Isaiah1,2, Adam J Spanier2, Lynn M Grattan3,4
1Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore.
Insights
Parent-reported sleep-disordered breathing severity, not polysomnography, predicts behavioral improvements after adenotonsillectomy in children with obstructive sleep apnea.
Area of Science:
- Pediatric Sleep Medicine
- Behavioral Pediatrics
- Otolaryngology
Background:
- Adenotonsillectomy (AT) improves behavior in children with obstructive sleep apnea (OSA).
- Predictors of behavioral change after AT, specifically polysomnographic parameters versus parent-reported severity, remain unclear.
Purpose of the Study:
- To determine if polysomnography or parent-reported sleep-disordered breathing (SDB) severity better predicts behavioral changes post-AT in children with OSA.
Main Methods:
- Secondary analysis of the Childhood Adenotonsillectomy Trial (CHAT) involving 453 children (5-9 years) with OSA.
- Compared changes in behavioral outcomes (validated assessments) with changes in polysomnographic parameters and parent-reported SDB (Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder scale).
- Mediation analysis was used to compare the predictive power of subjective and objective SDB measures on behavioral changes.
Main Results:
- Behavioral improvements in 7 of 8 outcome measures were significantly mediated by changes in parent-reported SDB severity alone.
- Polysomnographic parameters did not contribute to predicting behavioral changes after treatment.
- Causally mediated effects ranged from 2.4 to 3.5 for parent-reported SDB severity.
Conclusions:
- Parent-reported SDB severity is a stronger predictor of treatment-related behavioral changes than polysomnographic parameters in children with OSA.
- Clinical utility of polysomnography for predicting neurobehavioral improvements post-AT is limited.
- Findings emphasize the importance of subjective symptom reporting in managing OSA-related behavioral issues.
Importance:
Adenotonsillectomy (AT) is associated with improved behavior in children with obstructive sleep apnea (OSA). However, it is unknown whether polysomnographic parameters are superior to the parent-reported severity of sleep-disordered breathing (SDB) in predicting behavioral changes after AT.
Objective:
To ascertain whether polysomnographic parameters vs parent-reported severity of SDB are better predictors of treatment-related behavioral changes in children with OSA.
Design, Setting, And Participants:
This ad hoc secondary analysis of the Childhood Adenotonsillectomy Trial (CHAT) downloaded and analyzed data from January 1 to January 31, 2020. Children aged 5 to 9 years with a polysomnographic diagnosis of OSA were enrolled in the CHAT and subsequently randomized to undergo either early AT or watchful waiting with supportive care. All outcome measures were obtained at baseline and at follow-up (7 months after randomization).
Interventions:
Early AT vs watchful waiting with supportive care.
Main Outcomes And Measures:
Postrandomization changes between the baseline and follow-up periods were derived from (1) T scores in 4 validated behavioral assessments (Conners Global Index parent and teacher versions, Behavior Rating Inventory of Executive Function metacognition index, and Child Behavior Checklist of total, internalizing, and externalizing behavior subscales); (2) 8 aggregated polysomnographic parameters representing the severity of obstruction, hypoxemia, sleep quality, and structure; and (3) the parent-reported severity of SDB measured by the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder (PSQ-SRBD) scale. The treatment-related changes in each of the behavioral outcomes attributable to changes in SDB severity (represented by the subjective PSQ-SRBD score and objective polysomnographic parameters) were measured and compared using mediation analysis.
Results:
A total of 453 children were assessed at baseline, of whom 234 were girls (52%) and the mean (SD) age was 6.6 (1.4) years. The postrandomization changes in 7 of 8 behavioral outcome measures between the baseline and follow-up periods were partially mediated by the changes in PSQ-SRBD scores (range of nonzero causally mediated effects, 2.4-3.5), without contribution from any of the polysomnographic parameters.
Conclusions And Relevance:
This secondary analysis of a national randomized clinical trial found that most treatment-related behavioral changes in children with OSA were mediated by the changes in parent-reported SDB severity alone. These findings suggest that polysomnographic parameters provide clinicians with limited means to predict the improvement in neurobehavioral morbidity in OSA.
Trial Registration:
ClinicalTrials.gov Identifier: NCT00560859.
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