Adenotonsillectomy for Children with Mild Sleep-Disordered Breathing: Who Benefits?

To examine clinically-meaningful benefit that may be achieved by early adenotonsillectomy (eAT) vs. watchful waiting with supportive care (WWSC) in children with mild sleep-disordered breathing (MSDB, snoring but little or no obstructive sleep apnea), and to identify baseline demographic, symptom, physical exam, historical, or polysomnographic features that may predict such benefit.

Secondary analysis of participants (aged 3.0-12.9 years) in the 12-month multi-center randomized clinical trial of eAT vs. WWSC for MSDB, the Pediatric Adenotonsillectomy Trial for Snoring (PATS). Meaningful benefit was defined as a composite outcome of clinically-significant change in at least 2 of 4 domains - behavior, quality of life, subjective sleepiness, and blood pressure - each of which had shown greater improvement 12 months after AT versus WWSC in PATS.

Among 363 participants, the mean age was 6.6 (SD 2.3) years, 199 (55%) were > 5 years old at enrollment, and 185 (51%) were male. A total of 115 (65%) vs. 73 (39%) in the eAT vs. WWSC arms, respectively, experienced clinically-meaningful improvement on ≥2 domains (p < 0.01). Among variables explored for effect modification - including demographics, health factors, symptoms and signs, and polysomnographic data - only a high Mallampati score of III or IV vs. I or II showed predictive value (OR 4.16, 95% CI [1.22, 15.6], p = 0.027).

Clinically-meaningful positive outcomes occur more often after eAT vs. WWSC for children with MSDB. However, many clinical features accessible prior to AT, with the intriguing exception of a high Mallampati score, may not help to identify which children stand to benefit.

Pediatric Adenotonsillectomy for Snoring (PATS); HYPERLINK "https://clinicaltrials.gov/study/NCT02562040;" https://clinicaltrials.gov/study/NCT02562040; Registration number: NCT02562040.