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Published on: December 6, 2016
Progression of mild sleep-disordered breathing in children managed with watchful waiting
Erin M Kirkham1, Stacey Ishman2, Susan Garetz3
1Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI, USA. ekirkham@umich.edu.
Insights
Mild sleep-disordered breathing (SDB) in children often shows persistent symptoms but rare polysomnographic progression. Black race, asthma, ADHD, and tobacco exposure are linked to increased SDB progression risk.
Area of Science:
- Pediatric Pulmonology
- Sleep Medicine
- Clinical Research
Background:
- Mild sleep-disordered breathing (SDB) in children is common.
- Predictors for SDB persistence or progression without surgery are not well-defined.
- Understanding these predictors can guide clinical management decisions.
Purpose of the Study:
- To identify clinical characteristics associated with the persistence or progression of mild SDB in children observed without surgical intervention.
- To analyze factors influencing polysomnographic (PSG) progression and symptom persistence over one year.
Main Methods:
- Secondary analysis of the control arm (watchful waiting with supportive care) from the Pediatric Adenotonsillectomy Trial for Snoring (PATS).
- Included 234 children aged 3.0-12.9 years with mild SDB (oAHI < 3 events/hour).
- Assessed baseline and 12-month PSG and Pediatric Sleep Questionnaire-SRBD scores to evaluate progression.
Main Results:
- Only 13% of children progressed to an obstructive apnea-hypopnea index (oAHI) ≥ 3 on PSG, while 57% experienced symptom persistence or progression.
- Black race and higher baseline symptom scores predicted PSG progression.
- Asthma, ADHD, and tobacco smoke exposure predicted symptom persistence/progression, while larger tonsils were protective.
Conclusions:
- A significant proportion of children with mild SDB exhibit persistent symptoms after one year of watchful waiting, though polysomnographic progression is less common.
- Clinical factors such as Black race, asthma, ADHD, and environmental tobacco exposure are associated with a higher likelihood of SDB progression.
- These findings suggest that children with these characteristics may benefit from earlier consideration for adenotonsillectomy.
Purpose:
To identify clinical characteristics that may be associated with persistence or progression of mild sleep-disordered breathing (SDB) in children who are observed without surgery.
Methods:
This is a secondary analysis of the control arm of the Pediatric Adenotonsillectomy Trial for Snoring (PATS), which randomized 458 children aged 3.0 to 12.9 years with mild SDB (snoring with obstructive apnea-hypopnea index [oAHI] < 3 events/hour) to early adenotonsillectomy (eAT) versus watchful waiting with supportive care (WWSC). Participants were assessed at baseline and 12 months with the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder (PSQ-SRBD) scale and polysomnography (PSG). We tested for factors predictive of either (1) PSG progression defined by a 12-month oAHI ≥ 3 or (2) symptom persistence or progression defined by a 12-month PSQ-SRBD score ≥ 0.33.
Results:
A total of 234 participants were observed (mean age 6.2 years, 111 [47%] female, 65 [28%] Black or African American, 37 [16%] Hispanic). Overall, only 13% (n = 20/150) progressed to an oAHI ≥ 3 on repeat PSG, whereas over half (n = 110/192, 57%) had symptom persistence/progression. Of the children with persistent or progressive symptoms, 18% (n = 16/103) progressed to oAHI ≥ 3. In unadjusted analyses, PSG progression was associated with Black race (OR 2.71, 95% CI 1.03-7.17) and higher baseline PSQ-SRBD (OR 1.74, 95% CI 1.03-3.08). Symptom persistence/progression was predicted by asthma (OR 2.70 [95% CI 1.29, 6.01]), ADHD (OR 3.73 [95% CI 1.13, 16.88]), and tobacco smoke exposure (OR 2.41 [95% CI 1.08-5.82]), while children with larger tonsils (grade III-IV) had lower odds of progression (OR 0.42 [95% CI 0.22-0.78]).
Conclusions:
A high symptom burden is common after a year of WWSC for mild SDB, but only a minority of children progressed on PSG. Black race and several clinical characteristics and symptom scores were associated with higher likelihood of progression.
Trial Registration:
ClinicalTrials.gov Identifier: NCT0256204.
Current Knowledge/Study Rationale:
Can clinical information predict persistence or progression of mild sleep-disordered breathing in children who are observed for 1 year without adenotonsillectomy?
Study Impact:
Polysomnographic progression to obstructive sleep apnea occurs in a minority (13%) of those observed while symptom persistence or progression is more common (57%). Children who are Black or who have asthma, attention-deficit hyperactivity disorder, environmental tobacco exposure, and a high symptom burden could be considered stronger candidates than their peers for earlier adenotonsillectomy for symptomatic mild sleep-disordered breathing.
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