For Kids, Sleep Study Needed to Parse out the Kind of Snoring That Means Surgery

Mild obstructive sleep apnea (OSA) was not easily distinguishable from primary snoring in children without polysomnography, analysis of randomized clinical trial data showed.

The only clinical and demographic factors significantly more commonly associated with mild OSA than primary snoring were Black race (OR 2.08), obesity (OR 1.80), and high urinary cotinine levels above of 5 μg/L (OR 1.88), reported researchers led by Ron Mitchell, MD, of Children’s Medical Center of Dallas and the University of Texas Southwestern Medical Center in Dallas.

Following multivariate adjustment, obesity remained the only significant predictor of increased OSA risk (aOR 1.67, 95% CI 1.01-2.75) in the multicenter, single-blind PATS trial analysis published in JAMA Otolaryngology–Head & Neck Surgery.

Obstructive sleep-disordered breathing (oSDB) in pediatric patients is commonly caused by adenotonsillar hypertrophy. For the more severe end of the spectrum diagnosed as OSA, adenotonsillectomy remains a first-line treatment; but for patients on the more mild end of the spectrum, classified as primary snoring with an apnea-hypopnea index (AHI) score of ≤1, there are still questions as to whether surgery is beneficial.

“The debate remains about whether all children with oSDB should undergo polysomnography prior to adenotonsillectomy or whether testing should be limited to high-risk groups. The reliance on the AHI to inform treatment decisions and provide long-term prognostic information remains controversial,” the group wrote. “Patient-centered outcomes such as quality of life and symptoms are arguably just as important as the results of objective physiological tests. The value of objective testing vs subjective report to predict long-term outcomes for the healthy growth and development of children with mild oSDB is an open question.”

The new data suggests that settling those questions of who to test won’t be so simple.

“This [study] tells me that the patient is more complex than one study, or one piece of information, or one quality-of-life measurement,” commented Amy Whigham, MD, MS-HPEd, of Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tennessee.

No short list of factors will tell the whole story, she told MedPage Today. “And so we have to take all the factors into account. For parents and referring physicians like pediatricians, it’s good for us to see that an exam of looking at tonsils and history is not always correlative with what our objective data shows.”

Whigham also noted that for patients and caregivers who are apprehensive about a surgical approach like adenotonsillectomy, observation can be a useful step to ensure that intervention is absolutely necessary.

“Sometimes we have a referral for a patient that the pediatrician is convinced needs an adenotonsillectomy, or a dentist sees huge tonsils, or they get an x-ray and think that they need to be referred to have an immediate tonsillectomy,” she said. “In reality, when we’re trying to flesh out some of these details about how the child is functioning [and] their quality of life, getting a sleep study taken can put a whole picture together” and lead to a different treatment decision.

The trial was conducted at six academic sleep centers from June 2012 to January 2021. Patient caregivers answered questionnaires for symptom scoring, and all patients received a full-night polysomnography. Patients also had their urinary cotinine levels evaluated to test their environmental tobacco smoke exposure.

In order to be included, participants needed to be ages 3 to 12.9 years, have tonsillar hypertrophy with at least 25% of their airway obstructed, and snore at least 3 nights per week as reported by their caregivers.

A total of 459 participants were included in the study. Of them, 50.1% were female and 19.2% were obese. The average patient age was 6 years. The cohort comprised 51.5% white patients, 26.4% Black patients, 16.4% Hispanic patients, and 5.7% with another race or ethnicity.

The majority of patients (67.8%) were diagnosed as having primary snoring, while 32.2% were diagnosed with mild OSA. Just over 61% of patients had either a grade III or IV tonsillar size, and 36.5% had a grade III or IV Friedman palate position score.

Researchers acknowledged that all the patients included in the study were identified as candidates for adenotonsillectomy, potentially risking selection bias. Other potential limitations included the fact that children who reported primary snoring symptoms alone might have been underrepresented and that traditional mild OSA parameters include an AHI score of 1-5, whereas this study utilized an AHI range of 1-3.

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