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Published on: December 6, 2016
Baseline apnea-hypopnea index threshold and adenotonsillectomy consideration in children with OSA
Saikrishna C Gourishetti1, Emily Hamburger1, Kevin D Pereira2
1Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
Insights
Adenotonsillectomy (AT) did not show significant differences in neurocognition or behavior compared to watchful waiting with supportive care (WWSC) for pediatric obstructive sleep apnea (OSA), regardless of initial severity. Treatment effects of AT alone also did not vary by obstructive sleep apnea severity.
Area of Science:
- Pediatric Sleep Medicine
- Otolaryngology
- Neurocognition and Behavior
Background:
- Adenotonsillectomy (AT) is a primary treatment for pediatric obstructive sleep apnea (OSA).
- Guidelines suggest AT for moderate to severe OSA (apnea-hypopnea index [AHI] ≥ 5), even without symptoms.
- The impact of OSA severity on treatment outcomes remains an area of investigation.
Purpose of the Study:
- To compare outcomes between AT and watchful waiting with supportive care (WWSC) in children with OSA.
- To analyze treatment differences based on baseline OSA severity, specifically an AHI ≥ 5 threshold.
- To evaluate the effect of AT alone on outcomes irrespective of AHI severity.
Main Methods:
- Secondary analysis of the Childhood Adenotonsillectomy Trial, a randomized controlled trial.
- Participants: Children aged 5-9 years with OSA randomized to AT or WWSC.
- Outcomes: Neurocognition (NEPSY), behavior, OSA symptoms, and quality of life, assessed at baseline and 7 months.
- Analysis: Two-way ANCOVA controlling for covariates, with treatment effect measured by Cohen's d.
Main Results:
- No significant difference in neurocognitive changes between AT and WWSC groups, regardless of AHI ≥ 5 threshold (Cohen's d = 0.1).
- AT group analysis showed no difference in post-treatment neurocognitive changes based on AHI threshold (Cohen's d = -0.06).
- Treatment effects on behavior, symptoms, and quality of life did not vary by AHI threshold.
Conclusions:
- Outcomes (neurocognition, behavior, symptoms, quality of life) did not differ between AT and WWSC based solely on OSA severity threshold.
- Adenotonsillectomy's effectiveness on post-treatment outcomes was consistent across different AHI severity levels.
- Baseline OSA severity (AHI ≥ 5) alone does not appear to be a significant differentiator for treatment choice outcomes in pediatric OSA.
Objectives:
Adenotonsillectomy (AT) is the first line of treatment for pediatric obstructive sleep apnea (OSA). In some treatment guidelines, children with moderate to severe OSA, defined as apnea-hypopnea index (AHI) ≥ 5, may be recommended AT regardless of symptoms. The differences in outcomes between children randomized to watchful waiting with supportive care (WWSC) or AT were compared based on baseline OSA severity threshold of AHI≥ 5.
Methods:
A secondary analysis of the Childhood Adenotonsillectomy Trial, a randomized controlled trial of children with OSA aged 5-9 years who underwent AT or WWSC, was performed. The primary outcome was the change in neurocognition measured by Developmental Neuropsychological Assessment (NEPSY). Secondary outcomes included changes in behavior, symptoms of OSA, and quality of life. Outcomes were measured at baseline and the seven-month follow-up after grouping children based on whether their AHI was greater than or equal to 5. Comparisons were performed using two-way analysis of covariance (ANCOVA) while controlling for age, sex and race. Differences in treatment effect were measured using Cohen's d.
Results:
Of the 397 children included, 203 received WWSC and 194 underwent AT. The treatment effects on post-randomization changes in neurocognition, measured by NEPSY in children with AHI ≥5 (Cohen's d = 0.1 [95% CI, -0.1 to 0.4]) was not significantly different from children with AHI <5 (Cohen's d = 0.1 [95% CI, -0.1 to 0.4]). Furthermore, among children in the AT group alone, the effects of AT on post-treatment changes in NEPSY did not differ based on AHI threshold (Cohen's d = -0.06 [95% CI, -0.3 to 0.2]). Additionally, the treatment effects on post-randomization changes in behavior, symptoms, and quality of life did not vary based on AHI threshold.
Conclusion:
The outcomes of neurocognition, behavior, symptoms, and quality of life did not differ between children with OSA randomized to WWSC or AT based on OSA severity threshold alone. Additionally, the effects of AT on post-treatment outcomes did not differ based on AHI threshold.
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