CLINICAL QUESTION
How does adenotonsillectomy compare with watchful waiting and supportive care for neurodevelopmental, behavioral, health, and polysomnographic outcomes in children with mild sleep-disordered breathing (SDB)?
BOTTOM LINE
Compared with watchful waiting, adenotonsillectomy did not significantly improve executive function or attention at 12 months in children with SDB, although those who received the surgery had improved secondary outcomes.
COMMENT: The long-awaited results of the Pediatric Adenotonsillectomy Trial for Snoring (PATS) have been published! The PATS study was specifically designed to assess the effectiveness of early adenotonsillectomy compared to watchful waiting in children with mild sleep-disordered breathing (habitual snoring + obstructive apnea index < 1 and obstructive AHI < 3). The study also included children as young as age 3 (as compared to the Childhood Adenotonsillectomy Trial (CHAT), which didn’t assess children younger than 5). There was no significant difference in the primary outcome measures, which assessed executive function and attention. There was, however, significant improvement with adenotonsillectomy in secondary outcome measures, including behavioral problems, sleepiness symptoms, quality of life, and blood pressure reduction. —Sarah Bowe, MD EdM
BACKGROUND: Sleep-disordered breathing affects 6% to 17% of children, with higher prevalence in those from racial minority or low-income backgrounds. Adenotonsillar hypertrophy is the most recognized risk factor for pediatric SDB, so adenotonsillectomy is the first-line SDB treatment in otherwise healthy children. There are limited data addressing the benefits of surgery.
STUDY DESIGN: Randomized clinical trial.
SETTING: Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass.
SYNOPSIS: Researchers for the PATS study enrolled 459 children with snoring and an obstructive apnea–hypopnea index (AHI) <3 at seven U.S. academic sleep centers from June 29, 2016, to Feb. 1, 2021. Participants were randomized 1:1 to early adenotonsillectomy (n = 231) or watchful waiting with supportive care (n = 228). Primary study outcomes were the Behavior Rating Inventory of Executive Function and an objective test of attention, the Go/No-Go (GNG) task. Secondary outcomes included changes in neurodevelopmental, behavioral, quality of life, sleep, and health outcomes. Twelve-month follow-up visits were completed for 394 children (86%). There were no statistically significant differences in change between the two groups in executive function or attention. Behavioral problems, sleepiness, symptoms, and quality of life improved more with adenotonsillectomy than with watchful waiting. Adenotonsillectomy was associated with a greater 12-month decline in blood pressure levels and lowered progression of the AHI to >3 events. Findings do not provide support for adenotonsillectomy in children with mild SDB with the goal of improving cognition. Study limitations included an inability to mask caregivers to the intervention.
CITATION: Redline S, Cook K, Chervin RD, et al. Adenotonsillectomy for snoring and mild sleep apnea in children: a randomized clinical trial. JAMA. 2023;330:2084–2095.
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