Dr. Julie Baughn

In most children, obstructive sleep apnea (OSA) is a curable disease that responds to surgical treatment with adenotonsillectomy. Do all children need surgery for their sleep apnea? Recent research suggests perhaps not. Some children with mild obstructive sleep apnea may “grow out of it” without having their tonsils and adenoids removed.

New research may identify children who can avoid surgery

The Childhood Adenotonsillectomy Trial (CHAT), first published in 2013, suggested to clinicians that a higher than realized number of children may grow out of their OSA (Marcus et al. N Engl J Med. 2013;368[25]:2366). This was the first study to examine the risks and benefits of early adenotonsillectomy vs. watchful waiting in children 5 to 9 years of age. When sleep studies were performed at baseline and at 7 months of follow-up, it was found that 46% of the children in the watchful waiting group had resolution of their OSA. In addition, it was noted that resolution of OSA after adenotonsillectomy was not absolute, either, as 21% in the early adenotonsillectomy group had residual OSA at 7 months postsurgery. This leads to the questions of which children should undergo surgery and how we are to identify them.

A more recent study by Chervin and colleagues published in CHEST identifies factors associated with resolution of sleep apnea in the children in the watchful waiting arm of the CHAT trial (Chest. 2015;148[5]:1204). The factors identified included baseline polysomnography characteristics of mild sleep apnea, such as lower baseline apnea/hypopnea index (AHI) and less oxygen desaturation. Figure 1 demonstrates the percentage of children in the watchful waiting group that had resolution of their OSA by their baseline AHI. The CHAT trial did not include many children with severe OSA, as median AHI was less than 5, and children with sustained desaturations were excluded. Chervin and colleagues noted that those children with a lower AHI and waist circumference profile were more likely to have resolution. Other factors that may also be associated with resolution without surgery suggested by these data include a lower waist circumference percentile and lower baseline questionnaire scores on the pediatric sleep questionnaire (PSQ). The PSQ has also been identified as a tool to help assess for likelihood of OSA. Some clinical factors may also be associated with resolution of OSA, such as the absence of loud or habitual snoring or observed apneas.

The identification of these factors, along with future research in pediatric OSA, may begin to help practitioners to identify children who can avoid surgery and help identify those who may have residual disease after surgery. While AHI improved in a large portion of children in this study, symptoms did not show as drastic an association. Only 15% had a symptomatic improvement in questionnaire scores of at least 25% (Chervin et al. previous mention). Researchers are also examining biomarkers associated with OSA. A recent study showed that increased C-reactive protein (CRP) levels were associated with residual OSA after adenotonsillectomy (Bhattacharjee et al. Sleep. 2016;39[2]:283).

Why is this important?

OSA in children is common and affects an estimated 1% to 5% of children (Marcus et al. Pediatrics. 2012;130[3]:576). In the majority of children, this is due to hypertrophy of their tonsils and adenoids. Other factors, such as obesity, craniofacial features, and genetic syndromes, can play a role. Many studies examining the effects of OSA in children have demonstrated a negative impact on attention, cognitive function, and behavior. There is often significant impact on other members of a household when a child has a sleep disorder. Longitudinal effects on how OSA in childhood impacts adulthood are still unknown.

The impact of surgery

Approximately half a million adenotonsillectomies are performed per year in the United States, with the indication primarily due to OSA increasing from being primarily for infection during the past several decades (Bhattacharyya et al. Otolaryngol Head Neck Surg. 2010;143[5]:680). Minor complications, such as throat pain and dehydration, are common. Primary (within 24 hours) and secondary (typically between 5 and 10 days postoperatively) bleeding can occur in 2% to 3 % of children. Respiratory compromise is a complication that is at increased risk when the indication for surgery is OSA and can occur in almost 10% of children (De Luca Canto et al. Pediatrics. 2015;136[4]:702). Cost of surgery and missed days of school (child) and work (parent) can all be factors. The decision for surgery rests on the parents, and they may have varying preferences as to how aggressively they want their child to be treated with surgery. While surgery is often curative, it is not 100%.

How is obstructive sleep apnea diagnosed in children?

Obstructive sleep apnea is diagnosed by overnight sleep study or polysomnography. Criteria for diagnosis of OSA in children can vary in the literature, but criteria used clinically are often similar to what was used in the CHAT trial: an obstructive AHI greater than 2 per hour or an obstructive apnea index (OAI) of greater than one per hour. Alternatives to an overnight sleep study have not yet been found for children. In adults, overnight oximetry, if normal, can be valuable in ruling out obstructive sleep apnea. In children, almost 50% of those screened with a normal oximetry went on to have sleep apnea during an overnight sleep study, making this an ineffective screening tool to rule out sleep apnea for most children (Brouillette et al. Pediatrics. 2000;105[2]:405). Home sleep testing has yet to be shown to be a reliable option in children but may be in the future (Tan et al. Chest;2015:148[6]:1382). Clinical history taking can be more challenging as well, as children do not typically have bed partners, and OSA is often clustered in the early morning hours in association with rapid eye movement sleep (REM), making parental observation less likely. These factors make overnight sleep studies the gold standard for diagnosis.

However, overnight sleep studies are costly, time consuming, and can be technically challenging in children depending on age and development. In certain areas, access to pediatric sleep centers can be limited. Overnight sleep studies can also be an additional economic burden to parents who are required to spend the night with their child, perhaps missing work and needing child care for other children in the family. All of this adds to the importance of identifying children who truly need to undergo a sleep study.

Can we change guidelines? Not yet.

We are not at a point where we can yet rewrite guidelines. The American Academy of Pediatrics (AAP) and the American Academy of Sleep Medicine (AASM) recommend a sleep study prior to proceeding to adenotonsillectomy in children. A repeat sleep study is recommended in children with moderate to severe OSA after adenotonsillectomy and when symptoms remain. Are there any other tools that can be used? New research may give suggestion as to which children can avoid repeating the costly and time-consuming test. In areas where sleep studies have limited availability, avoiding unnecessary testing is important.

Bottom line: More questions remain

The diagnosis and treatment of childhood OSA continue to challenge practitioners. While adenotonsillectomy is still the common treatment for OSA, it is reasonable to consider watchful waiting in some circumstances, particularly in children with mild disease. More questions still remain, however, in regards to the follow-up of these children. Practitioners still struggle with the definition of mild OSA in children (Is this an AHI less than 3, or is this an AHI less than 5? How do symptoms impact diagnosis and treatment?). Studies such as the CHAT trial are important first steps in helping to sort out the behavior of OSA in children long term. What happens to children farther out than 7 months? Additional research should help clarify these issues.

Dr. Baughn is a Consultant, Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota.

In most children, obstructive sleep apnea (OSA) is a curable disease that responds to surgical treatment with adenotonsillectomy. Do all children need surgery for their sleep apnea? Recent research suggests perhaps not. Some children with mild obstructive sleep apnea may “grow out of it” without having their tonsils and adenoids removed.

New research may identify children who can avoid surgery

The Childhood Adenotonsillectomy Trial (CHAT), first published in 2013, suggested to clinicians that a higher than realized number of children may grow out of their OSA (Marcus et al. N Engl J Med. 2013;368[25]:2366). This was the first study to examine the risks and benefits of early adenotonsillectomy vs. watchful waiting in children 5 to 9 years of age. When sleep studies were performed at baseline and at 7 months of follow-up, it was found that 46% of the children in the watchful waiting group had resolution of their OSA. In addition, it was noted that resolution of OSA after adenotonsillectomy was not absolute, either, as 21% in the early adenotonsillectomy group had residual OSA at 7 months postsurgery. This leads to the questions of which children should undergo surgery and how we are to identify them.

A more recent study by Chervin and colleagues published in CHEST identifies factors associated with resolution of sleep apnea in the children in the watchful waiting arm of the CHAT trial (Chest. 2015;148[5]:1204). The factors identified included baseline polysomnography characteristics of mild sleep apnea, such as lower baseline apnea/hypopnea index (AHI) and less oxygen desaturation. Figure 1 demonstrates the percentage of children in the watchful waiting group that had resolution of their OSA by their baseline AHI. The CHAT trial did not include many children with severe OSA, as median AHI was less than 5, and children with sustained desaturations were excluded. Chervin and colleagues noted that those children with a lower AHI and waist circumference profile were more likely to have resolution. Other factors that may also be associated with resolution without surgery suggested by these data include a lower waist circumference percentile and lower baseline questionnaire scores on the pediatric sleep questionnaire (PSQ). The PSQ has also been identified as a tool to help assess for likelihood of OSA. Some clinical factors may also be associated with resolution of OSA, such as the absence of loud or habitual snoring or observed apneas.

The identification of these factors, along with future research in pediatric OSA, may begin to help practitioners to identify children who can avoid surgery and help identify those who may have residual disease after surgery. While AHI improved in a large portion of children in this study, symptoms did not show as drastic an association. Only 15% had a symptomatic improvement in questionnaire scores of at least 25% (Chervin et al. previous mention). Researchers are also examining biomarkers associated with OSA. A recent study showed that increased C-reactive protein (CRP) levels were associated with residual OSA after adenotonsillectomy (Bhattacharjee et al. Sleep. 2016;39[2]:283).

Why is this important?

OSA in children is common and affects an estimated 1% to 5% of children (Marcus et al. Pediatrics. 2012;130[3]:576). In the majority of children, this is due to hypertrophy of their tonsils and adenoids. Other factors, such as obesity, craniofacial features, and genetic syndromes, can play a role. Many studies examining the effects of OSA in children have demonstrated a negative impact on attention, cognitive function, and behavior. There is often significant impact on other members of a household when a child has a sleep disorder. Longitudinal effects on how OSA in childhood impacts adulthood are still unknown.

The impact of surgery

Approximately half a million adenotonsillectomies are performed per year in the United States, with the indication primarily due to OSA increasing from being primarily for infection during the past several decades (Bhattacharyya et al. Otolaryngol Head Neck Surg. 2010;143[5]:680). Minor complications, such as throat pain and dehydration, are common. Primary (within 24 hours) and secondary (typically between 5 and 10 days postoperatively) bleeding can occur in 2% to 3 % of children. Respiratory compromise is a complication that is at increased risk when the indication for surgery is OSA and can occur in almost 10% of children (De Luca Canto et al. Pediatrics. 2015;136[4]:702). Cost of surgery and missed days of school (child) and work (parent) can all be factors. The decision for surgery rests on the parents, and they may have varying preferences as to how aggressively they want their child to be treated with surgery. While surgery is often curative, it is not 100%.

How is obstructive sleep apnea diagnosed in children?

Obstructive sleep apnea is diagnosed by overnight sleep study or polysomnography. Criteria for diagnosis of OSA in children can vary in the literature, but criteria used clinically are often similar to what was used in the CHAT trial: an obstructive AHI greater than 2 per hour or an obstructive apnea index (OAI) of greater than one per hour. Alternatives to an overnight sleep study have not yet been found for children. In adults, overnight oximetry, if normal, can be valuable in ruling out obstructive sleep apnea. In children, almost 50% of those screened with a normal oximetry went on to have sleep apnea during an overnight sleep study, making this an ineffective screening tool to rule out sleep apnea for most children (Brouillette et al. Pediatrics. 2000;105[2]:405). Home sleep testing has yet to be shown to be a reliable option in children but may be in the future (Tan et al. Chest;2015:148[6]:1382). Clinical history taking can be more challenging as well, as children do not typically have bed partners, and OSA is often clustered in the early morning hours in association with rapid eye movement sleep (REM), making parental observation less likely. These factors make overnight sleep studies the gold standard for diagnosis.

However, overnight sleep studies are costly, time consuming, and can be technically challenging in children depending on age and development. In certain areas, access to pediatric sleep centers can be limited. Overnight sleep studies can also be an additional economic burden to parents who are required to spend the night with their child, perhaps missing work and needing child care for other children in the family. All of this adds to the importance of identifying children who truly need to undergo a sleep study.

Can we change guidelines? Not yet.

We are not at a point where we can yet rewrite guidelines. The American Academy of Pediatrics (AAP) and the American Academy of Sleep Medicine (AASM) recommend a sleep study prior to proceeding to adenotonsillectomy in children. A repeat sleep study is recommended in children with moderate to severe OSA after adenotonsillectomy and when symptoms remain. Are there any other tools that can be used? New research may give suggestion as to which children can avoid repeating the costly and time-consuming test. In areas where sleep studies have limited availability, avoiding unnecessary testing is important.

Bottom line: More questions remain

The diagnosis and treatment of childhood OSA continue to challenge practitioners. While adenotonsillectomy is still the common treatment for OSA, it is reasonable to consider watchful waiting in some circumstances, particularly in children with mild disease. More questions still remain, however, in regards to the follow-up of these children. Practitioners still struggle with the definition of mild OSA in children (Is this an AHI less than 3, or is this an AHI less than 5? How do symptoms impact diagnosis and treatment?). Studies such as the CHAT trial are important first steps in helping to sort out the behavior of OSA in children long term. What happens to children farther out than 7 months? Additional research should help clarify these issues.

Dr. Baughn is a Consultant, Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota.

In most children, obstructive sleep apnea (OSA) is a curable disease that responds to surgical treatment with adenotonsillectomy. Do all children need surgery for their sleep apnea? Recent research suggests perhaps not. Some children with mild obstructive sleep apnea may “grow out of it” without having their tonsils and adenoids removed.

New research may identify children who can avoid surgery

The Childhood Adenotonsillectomy Trial (CHAT), first published in 2013, suggested to clinicians that a higher than realized number of children may grow out of their OSA (Marcus et al. N Engl J Med. 2013;368[25]:2366). This was the first study to examine the risks and benefits of early adenotonsillectomy vs. watchful waiting in children 5 to 9 years of age. When sleep studies were performed at baseline and at 7 months of follow-up, it was found that 46% of the children in the watchful waiting group had resolution of their OSA. In addition, it was noted that resolution of OSA after adenotonsillectomy was not absolute, either, as 21% in the early adenotonsillectomy group had residual OSA at 7 months postsurgery. This leads to the questions of which children should undergo surgery and how we are to identify them.

A more recent study by Chervin and colleagues published in CHEST identifies factors associated with resolution of sleep apnea in the children in the watchful waiting arm of the CHAT trial (Chest. 2015;148[5]:1204). The factors identified included baseline polysomnography characteristics of mild sleep apnea, such as lower baseline apnea/hypopnea index (AHI) and less oxygen desaturation. Figure 1 demonstrates the percentage of children in the watchful waiting group that had resolution of their OSA by their baseline AHI. The CHAT trial did not include many children with severe OSA, as median AHI was less than 5, and children with sustained desaturations were excluded. Chervin and colleagues noted that those children with a lower AHI and waist circumference profile were more likely to have resolution. Other factors that may also be associated with resolution without surgery suggested by these data include a lower waist circumference percentile and lower baseline questionnaire scores on the pediatric sleep questionnaire (PSQ). The PSQ has also been identified as a tool to help assess for likelihood of OSA. Some clinical factors may also be associated with resolution of OSA, such as the absence of loud or habitual snoring or observed apneas.

The identification of these factors, along with future research in pediatric OSA, may begin to help practitioners to identify children who can avoid surgery and help identify those who may have residual disease after surgery. While AHI improved in a large portion of children in this study, symptoms did not show as drastic an association. Only 15% had a symptomatic improvement in questionnaire scores of at least 25% (Chervin et al. previous mention). Researchers are also examining biomarkers associated with OSA. A recent study showed that increased C-reactive protein (CRP) levels were associated with residual OSA after adenotonsillectomy (Bhattacharjee et al. Sleep. 2016;39[2]:283).

Why is this important?

OSA in children is common and affects an estimated 1% to 5% of children (Marcus et al. Pediatrics. 2012;130[3]:576). In the majority of children, this is due to hypertrophy of their tonsils and adenoids. Other factors, such as obesity, craniofacial features, and genetic syndromes, can play a role. Many studies examining the effects of OSA in children have demonstrated a negative impact on attention, cognitive function, and behavior. There is often significant impact on other members of a household when a child has a sleep disorder. Longitudinal effects on how OSA in childhood impacts adulthood are still unknown.

The impact of surgery

Approximately half a million adenotonsillectomies are performed per year in the United States, with the indication primarily due to OSA increasing from being primarily for infection during the past several decades (Bhattacharyya et al. Otolaryngol Head Neck Surg. 2010;143[5]:680). Minor complications, such as throat pain and dehydration, are common. Primary (within 24 hours) and secondary (typically between 5 and 10 days postoperatively) bleeding can occur in 2% to 3 % of children. Respiratory compromise is a complication that is at increased risk when the indication for surgery is OSA and can occur in almost 10% of children (De Luca Canto et al. Pediatrics. 2015;136[4]:702). Cost of surgery and missed days of school (child) and work (parent) can all be factors. The decision for surgery rests on the parents, and they may have varying preferences as to how aggressively they want their child to be treated with surgery. While surgery is often curative, it is not 100%.

How is obstructive sleep apnea diagnosed in children?

Obstructive sleep apnea is diagnosed by overnight sleep study or polysomnography. Criteria for diagnosis of OSA in children can vary in the literature, but criteria used clinically are often similar to what was used in the CHAT trial: an obstructive AHI greater than 2 per hour or an obstructive apnea index (OAI) of greater than one per hour. Alternatives to an overnight sleep study have not yet been found for children. In adults, overnight oximetry, if normal, can be valuable in ruling out obstructive sleep apnea. In children, almost 50% of those screened with a normal oximetry went on to have sleep apnea during an overnight sleep study, making this an ineffective screening tool to rule out sleep apnea for most children (Brouillette et al. Pediatrics. 2000;105[2]:405). Home sleep testing has yet to be shown to be a reliable option in children but may be in the future (Tan et al. Chest;2015:148[6]:1382). Clinical history taking can be more challenging as well, as children do not typically have bed partners, and OSA is often clustered in the early morning hours in association with rapid eye movement sleep (REM), making parental observation less likely. These factors make overnight sleep studies the gold standard for diagnosis.

However, overnight sleep studies are costly, time consuming, and can be technically challenging in children depending on age and development. In certain areas, access to pediatric sleep centers can be limited. Overnight sleep studies can also be an additional economic burden to parents who are required to spend the night with their child, perhaps missing work and needing child care for other children in the family. All of this adds to the importance of identifying children who truly need to undergo a sleep study.

Can we change guidelines? Not yet.

We are not at a point where we can yet rewrite guidelines. The American Academy of Pediatrics (AAP) and the American Academy of Sleep Medicine (AASM) recommend a sleep study prior to proceeding to adenotonsillectomy in children. A repeat sleep study is recommended in children with moderate to severe OSA after adenotonsillectomy and when symptoms remain. Are there any other tools that can be used? New research may give suggestion as to which children can avoid repeating the costly and time-consuming test. In areas where sleep studies have limited availability, avoiding unnecessary testing is important.

Bottom line: More questions remain

The diagnosis and treatment of childhood OSA continue to challenge practitioners. While adenotonsillectomy is still the common treatment for OSA, it is reasonable to consider watchful waiting in some circumstances, particularly in children with mild disease. More questions still remain, however, in regards to the follow-up of these children. Practitioners still struggle with the definition of mild OSA in children (Is this an AHI less than 3, or is this an AHI less than 5? How do symptoms impact diagnosis and treatment?). Studies such as the CHAT trial are important first steps in helping to sort out the behavior of OSA in children long term. What happens to children farther out than 7 months? Additional research should help clarify these issues.

Dr. Baughn is a Consultant, Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota.