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Mild to moderate obstructive sleep apnea syndrome (OSAS) resolves spontaneously in many children in as few as 7 months, based on polysomnography results from the control arm of the Childhood Adenotonsillectomy Trial (CHAT).
Symptomatic improvement in snoring, however, was less common. Nonetheless, “watchful waiting may be a reasonable option in children with low OSAS symptom burden and, especially, little snoring, who also have low AHIs [apnea/hypopnea indexes] and do not have central obesity,” markers that were most likely to be associated with resolution, wrote Dr. Ronald D. Chervin of the University of Michigan, Ann Arbor, and his colleagues. “Without surgery, habitual snoring resolves in one-half to two-thirds of affected children within 1-3 years.”
The study enrolled 453 children, aged 5-9, with an AHI of at least 2 events per hour of sleep, or an obstructive apnea index (OHI) of at least 1. All children were recruited from pediatric sleep clinics and otolaryngology practices. The study did not include children with severe OSAS, which was defined as having an apnea/hypopnea index of greater than 30, an obstructive apnea index greater than 20, or oxygen saturation less than 90% for at least 2% of total sleep time. None of the study participants had recurrent tonsillitis, had a BMI z-score of at least 3, or were taking medication for attention-deficit/hyperactivity disorder, the investigators reported (Chest. 2015;148[5]:1204-13).
Among 453 children randomized in CHAT, 194 in the control arm had complete follow-up, remained untreated surgically, and provided data for the current analyses. Mean AHI at baseline was 6.7 (range, 1.1-29.3), mean oxygen saturation at baseline was 88.8% (range, 59%-97%), and mean score on the Pediatric Sleep Questionnaire Sleep-Related Breathing Disorder (PSQ-SRBD) scale at baseline was 0.48 (range, 0.05-0.90).
Primary endpoints based on polysomnography results at 7-month follow-up were reaching an AHI of less than 2 and an obstructive apnea index of less than 1. In addition, researchers defined “substantive resolution” of symptoms related to OSAS as a total PSQ-SRBD score of 0.33 or more at baseline that declined below 0.33 and was at least 25% below the baseline value at 7-month follow-up.
At 7 months, OSAS had spontaneously resolved by polysomnography measures in 82 of the 194 children based on achieving an AHI less than 2 and an OAI less than 1. The results did not differ by sex.
However, symptomatic improvement was less common. Of 167 children with PSQ-SRBD scores of at least 0.33 at baseline, only 25 children (15%) had scores less than 0.33 and at least a 25% reduction in PSQ-SRBD score at 7 months. Of the 25, 17 were girls and 8 were boys, indicating a higher rate of spontaneous resolution in girls than in boys (P = .033). In addition, only 20 children (12%) showed both polysomnographic and symptomatic resolution of symptoms at 7 months.
“Symptoms often matter more to patients and families than do laboratory results,” the authors wrote. “In our cohort, 34 of 147 habitual snorers (23%) were no longer habitual snorers at follow-up.”
The CHAT Study was supported by the National Institutes of Health. Dr. Chervin disclosed that he is named in or has developed, patented, and copyrighted materials owned by the University of Michigan and designed to assist with assessment or treatment of sleep disorders, including the Pediatric Sleep Questionnaire Sleep-Related Breathing Disorder scale used in this study. He also has received support for research and education from Philips Respironics and Fisher & Paykel Healthcare, and has consulted for MC3 and Zansors.
Because polysomnography is expensive, time consuming, and often unavailable, otolaryngologists will often perform an adenotonsillectomy based on a strong clinical history and parental observation in a child with snoring and chronically enlarged adenoids and tonsils. The findings of this study challenge that approach. Surgery may not be the treatment of choice for children who have a low symptom burden, little snoring, low apnea/hypopnea indexes, and no central obesity. For these children, mild OSAS resolves as they grow and a period of watchful waiting makes sense.
Admittedly, adenotonsillectomy is relatively safe, but even relatively safe surgical procedures can have complications. Further, the financial impact associated with professional fees, facility fees, medications, and parental lost time at work is substantial.
We need to better understand who requires surgery and who does not. Encouraging empirical evidence suggests anti-inflammatory agents may be effective in treating mild to moderate OSAS. As we learn more about who is affected by this disorder, new treatments will likely emerge. In the meantime, we can feel comfortable that watchful waiting can be an appropriate strategy for many children.
Dr. Ian Nathanson is a pediatric pulmonologist in Maitland, Fla. He made his comments in an editorial that accompanied the article (Chest. 2015;148[5]:1129-1130).
Because polysomnography is expensive, time consuming, and often unavailable, otolaryngologists will often perform an adenotonsillectomy based on a strong clinical history and parental observation in a child with snoring and chronically enlarged adenoids and tonsils. The findings of this study challenge that approach. Surgery may not be the treatment of choice for children who have a low symptom burden, little snoring, low apnea/hypopnea indexes, and no central obesity. For these children, mild OSAS resolves as they grow and a period of watchful waiting makes sense.
Admittedly, adenotonsillectomy is relatively safe, but even relatively safe surgical procedures can have complications. Further, the financial impact associated with professional fees, facility fees, medications, and parental lost time at work is substantial.
We need to better understand who requires surgery and who does not. Encouraging empirical evidence suggests anti-inflammatory agents may be effective in treating mild to moderate OSAS. As we learn more about who is affected by this disorder, new treatments will likely emerge. In the meantime, we can feel comfortable that watchful waiting can be an appropriate strategy for many children.
Dr. Ian Nathanson is a pediatric pulmonologist in Maitland, Fla. He made his comments in an editorial that accompanied the article (Chest. 2015;148[5]:1129-1130).
Because polysomnography is expensive, time consuming, and often unavailable, otolaryngologists will often perform an adenotonsillectomy based on a strong clinical history and parental observation in a child with snoring and chronically enlarged adenoids and tonsils. The findings of this study challenge that approach. Surgery may not be the treatment of choice for children who have a low symptom burden, little snoring, low apnea/hypopnea indexes, and no central obesity. For these children, mild OSAS resolves as they grow and a period of watchful waiting makes sense.
Admittedly, adenotonsillectomy is relatively safe, but even relatively safe surgical procedures can have complications. Further, the financial impact associated with professional fees, facility fees, medications, and parental lost time at work is substantial.
We need to better understand who requires surgery and who does not. Encouraging empirical evidence suggests anti-inflammatory agents may be effective in treating mild to moderate OSAS. As we learn more about who is affected by this disorder, new treatments will likely emerge. In the meantime, we can feel comfortable that watchful waiting can be an appropriate strategy for many children.
Dr. Ian Nathanson is a pediatric pulmonologist in Maitland, Fla. He made his comments in an editorial that accompanied the article (Chest. 2015;148[5]:1129-1130).
Mild to moderate obstructive sleep apnea syndrome (OSAS) resolves spontaneously in many children in as few as 7 months, based on polysomnography results from the control arm of the Childhood Adenotonsillectomy Trial (CHAT).
Symptomatic improvement in snoring, however, was less common. Nonetheless, “watchful waiting may be a reasonable option in children with low OSAS symptom burden and, especially, little snoring, who also have low AHIs [apnea/hypopnea indexes] and do not have central obesity,” markers that were most likely to be associated with resolution, wrote Dr. Ronald D. Chervin of the University of Michigan, Ann Arbor, and his colleagues. “Without surgery, habitual snoring resolves in one-half to two-thirds of affected children within 1-3 years.”
The study enrolled 453 children, aged 5-9, with an AHI of at least 2 events per hour of sleep, or an obstructive apnea index (OHI) of at least 1. All children were recruited from pediatric sleep clinics and otolaryngology practices. The study did not include children with severe OSAS, which was defined as having an apnea/hypopnea index of greater than 30, an obstructive apnea index greater than 20, or oxygen saturation less than 90% for at least 2% of total sleep time. None of the study participants had recurrent tonsillitis, had a BMI z-score of at least 3, or were taking medication for attention-deficit/hyperactivity disorder, the investigators reported (Chest. 2015;148[5]:1204-13).
Among 453 children randomized in CHAT, 194 in the control arm had complete follow-up, remained untreated surgically, and provided data for the current analyses. Mean AHI at baseline was 6.7 (range, 1.1-29.3), mean oxygen saturation at baseline was 88.8% (range, 59%-97%), and mean score on the Pediatric Sleep Questionnaire Sleep-Related Breathing Disorder (PSQ-SRBD) scale at baseline was 0.48 (range, 0.05-0.90).
Primary endpoints based on polysomnography results at 7-month follow-up were reaching an AHI of less than 2 and an obstructive apnea index of less than 1. In addition, researchers defined “substantive resolution” of symptoms related to OSAS as a total PSQ-SRBD score of 0.33 or more at baseline that declined below 0.33 and was at least 25% below the baseline value at 7-month follow-up.
At 7 months, OSAS had spontaneously resolved by polysomnography measures in 82 of the 194 children based on achieving an AHI less than 2 and an OAI less than 1. The results did not differ by sex.
However, symptomatic improvement was less common. Of 167 children with PSQ-SRBD scores of at least 0.33 at baseline, only 25 children (15%) had scores less than 0.33 and at least a 25% reduction in PSQ-SRBD score at 7 months. Of the 25, 17 were girls and 8 were boys, indicating a higher rate of spontaneous resolution in girls than in boys (P = .033). In addition, only 20 children (12%) showed both polysomnographic and symptomatic resolution of symptoms at 7 months.
“Symptoms often matter more to patients and families than do laboratory results,” the authors wrote. “In our cohort, 34 of 147 habitual snorers (23%) were no longer habitual snorers at follow-up.”
The CHAT Study was supported by the National Institutes of Health. Dr. Chervin disclosed that he is named in or has developed, patented, and copyrighted materials owned by the University of Michigan and designed to assist with assessment or treatment of sleep disorders, including the Pediatric Sleep Questionnaire Sleep-Related Breathing Disorder scale used in this study. He also has received support for research and education from Philips Respironics and Fisher & Paykel Healthcare, and has consulted for MC3 and Zansors.
Mild to moderate obstructive sleep apnea syndrome (OSAS) resolves spontaneously in many children in as few as 7 months, based on polysomnography results from the control arm of the Childhood Adenotonsillectomy Trial (CHAT).
Symptomatic improvement in snoring, however, was less common. Nonetheless, “watchful waiting may be a reasonable option in children with low OSAS symptom burden and, especially, little snoring, who also have low AHIs [apnea/hypopnea indexes] and do not have central obesity,” markers that were most likely to be associated with resolution, wrote Dr. Ronald D. Chervin of the University of Michigan, Ann Arbor, and his colleagues. “Without surgery, habitual snoring resolves in one-half to two-thirds of affected children within 1-3 years.”
The study enrolled 453 children, aged 5-9, with an AHI of at least 2 events per hour of sleep, or an obstructive apnea index (OHI) of at least 1. All children were recruited from pediatric sleep clinics and otolaryngology practices. The study did not include children with severe OSAS, which was defined as having an apnea/hypopnea index of greater than 30, an obstructive apnea index greater than 20, or oxygen saturation less than 90% for at least 2% of total sleep time. None of the study participants had recurrent tonsillitis, had a BMI z-score of at least 3, or were taking medication for attention-deficit/hyperactivity disorder, the investigators reported (Chest. 2015;148[5]:1204-13).
Among 453 children randomized in CHAT, 194 in the control arm had complete follow-up, remained untreated surgically, and provided data for the current analyses. Mean AHI at baseline was 6.7 (range, 1.1-29.3), mean oxygen saturation at baseline was 88.8% (range, 59%-97%), and mean score on the Pediatric Sleep Questionnaire Sleep-Related Breathing Disorder (PSQ-SRBD) scale at baseline was 0.48 (range, 0.05-0.90).
Primary endpoints based on polysomnography results at 7-month follow-up were reaching an AHI of less than 2 and an obstructive apnea index of less than 1. In addition, researchers defined “substantive resolution” of symptoms related to OSAS as a total PSQ-SRBD score of 0.33 or more at baseline that declined below 0.33 and was at least 25% below the baseline value at 7-month follow-up.
At 7 months, OSAS had spontaneously resolved by polysomnography measures in 82 of the 194 children based on achieving an AHI less than 2 and an OAI less than 1. The results did not differ by sex.
However, symptomatic improvement was less common. Of 167 children with PSQ-SRBD scores of at least 0.33 at baseline, only 25 children (15%) had scores less than 0.33 and at least a 25% reduction in PSQ-SRBD score at 7 months. Of the 25, 17 were girls and 8 were boys, indicating a higher rate of spontaneous resolution in girls than in boys (P = .033). In addition, only 20 children (12%) showed both polysomnographic and symptomatic resolution of symptoms at 7 months.
“Symptoms often matter more to patients and families than do laboratory results,” the authors wrote. “In our cohort, 34 of 147 habitual snorers (23%) were no longer habitual snorers at follow-up.”
The CHAT Study was supported by the National Institutes of Health. Dr. Chervin disclosed that he is named in or has developed, patented, and copyrighted materials owned by the University of Michigan and designed to assist with assessment or treatment of sleep disorders, including the Pediatric Sleep Questionnaire Sleep-Related Breathing Disorder scale used in this study. He also has received support for research and education from Philips Respironics and Fisher & Paykel Healthcare, and has consulted for MC3 and Zansors.
FROM CHEST
Key clinical point: Advise parents that moderate obstructive sleep apnea syndrome can spontaneously resolve in children with a low baseline apnea/hypopnea index and a normal waist circumference, or if they have a low Pediatric Sleep Questionnaire and snoring score.
Major finding: After 7 months, 82 of 194 children no longer met polysomnographic criteria for OSAS; 25 of 167 children with baseline PSQ scores of at least 0.33 still had symptoms after 7 months.
Data source: A prospective cohort study of 194 children, aged 5-9 years.
Disclosures: The study was supported by the National Institutes of Health; Dr. Chervin disclosed that he is named in or has developed, patented, and copyrighted materials owned by the University of Michigan and designed to assist with assessment or treatment of sleep disorders, including the Pediatric Sleep Questionnaire Sleep-Related Breathing Disorder scale used in this study.