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Adenotonsillectomy: Watching/Waiting Comparable to Watchful Waiting for Children with Mild Sleep-Disordered Breathing

by Linda Kossoff •

CLINICAL QUESTION

How does early adenotonsillectomy compare with watchful waiting and supportive care 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, although there were improved secondary outcomes.

BACKGROUND: Affecting 6% to 17% of children, SDB carries potential health and quality-of-life risks if left untreated. Adenotonsillectomy is the first-line treatment, but there are limited data addressing the benefits of surgery, and the effect of adenotonsillectomy on behavioral and health outcomes in these children is not known.

STUDY DESIGN: Randomized clinical trial.

SETTING: Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass.

SYNOPSIS: Researchers analyzed a geographically and racially diverse sample of 458 children (50% female, mean age 6.1 years) with snoring and an obstructive apnea-hypopnea index (AHI) <3 who were enrolled at multiple U.S. academic sleep centers from June 29, 2016, to Feb. 1, 2021. Participants were randomized in adenotonsillectomy (n = 231) and watchful waiting (n = 237) groups. Overall, 395 children (86%) completed 12-month follow-ups. Adenotonsillectomy compared with watchful waiting resulted in no statistically significant differences in improvement in the two primary outcomes of executive function and attention at 12-month follow-up. Adenotonsillectomy did result in greater improvements in several key secondary outcomes, including behavioral problems, symptom burden, daytime sleepiness, and quality of life. Decrease in blood pressure and lowered progression of AHI to greater than three events were also seen. Authors stated that findings did not support adenotonsillectomy for improving cognition, but that differences may have been observed with additional follow-up. Study limitations included the inability to mask caregivers to the intervention, potentially influencing outcome assessments.

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.