SDB Morbidity in Children Can Be Improved by Surgery

Surgery was found to improve quality of life in a study by Dr. Mitchell and colleagues (Arch Otolaryngol Head Neck Surg 2004). Using the OSA-18 (a validated quality of life instrument), mean total score improved for sleep disturbance, physical suffering, emotional distress, daytime problems, and caregiver concerns.

Surgery has placebo effects, he acknowledged, but if the effects were merely placebo, then the improvements in quality of life should deteriorate over time. However, follow-up of the same set of patients showed that the improvement in quality of life after surgery was maintained at two years (Mitchell R. Arch Otolaryngol Head Neck Surg 2006). In fact, the improvements in quality of life were more robust than improvements on polysomnography measures. To illustrate this point, he cited another study showing that 97% of patients had improved symptoms post-surgery, whereas only 80% of this group were improved on polysomnography.

Turning to behavioral measures of improvement following T&A, Dr. Mitchell noted, This area is much more murky than polysomnography or quality of life. These measures rely on parents’ perceptions. Not every child with sleep problems has behavioral problems.

Studies do show that behavior improves following surgery, but the extent of improvement depends on the baseline scores, he said. One study looked at a measure of hyperactivity and showed that preoperatively 10 children were severely impaired, 7 had mild impairment, and 35 were normal; following surgery, 47 were normal, 5 had mild hyperactiviity, and none were severely hyperactive. Behavioral measures require further study, he said.

Not all children with SDB have problems before surgery, and not all behavioral problems resolve post-surgery, Dr. Mitchell emphasized. Children who score way outside normal parameters on behavioral measures benefit the most from surgery.

He said that 30% to 40% of children have behavioral abnormalities preoperatively and 50% to 60% of these children normalize after surgery. As the most severely behaviorally disturbed children are most likely to benefit from T&A, documenting behavior may affect the decision to undertake surgery.

Health Care Utilization

In addition to improved sleep, improved quality of life, and improved behavior, another reason to consider surgery for children with SDB is related to economics. A recent study found a 215% elevated health care resource utilization in children with SDB compared with controls, which was mainly reflected in outpatient visits and hospital visits (Tarasiuk A. Am J Respir Crit Care Med 2007). In fact, all studies of health care utilization to date demonstrate reduced utilization, Dr. Mitchell said. One study showed that health care utilization costs were reduced by one-third after T&A, he said, and upper respiratory infections were also reduced.