Progression of mild sleep-disordered breathing in children managed with watchful waiting

Abstract Purpose To identify clinical characteristics that may be associated with persistence or progression of mild sleep-disordered breathing (SDB) in children who are observed without surgery. Methods This is a secondary analysis of the control arm of the Pediatric Adenotonsillectomy Trial for Snoring (PATS), which randomized 458 children aged 3.0 to 12.9 years with mild SDB (snoring with obstructive apnea–hypopnea index oAHI < 3 events/hour) to early adenotonsillectomy (eAT) versus watchful waiting with supportive care (WWSC). Participants were assessed at baseline and 12 months with the Pediatric Sleep Questionnaire–Sleep-Related Breathing Disorder (PSQ-SRBD) scale and polysomnography (PSG). We tested for factors predictive of either (1) PSG progression defined by a 12-month oAHI ≥ 3 or (2) symptom persistence or progression defined by a 12-month PSQ-SRBD score ≥ 0.33. Results A total of 234 participants were observed (mean age 6.2 years, 111 47% female, 65 28% Black or African American, 37 16% Hispanic). Overall, only 13% ( n = 20/150) progressed to an oAHI ≥ 3 on repeat PSG, whereas over half ( n = 110/192, 57%) had symptom persistence/progression. Of the children with persistent or progressive symptoms, 18% ( n = 16/103) progressed to oAHI ≥ 3. In unadjusted analyses, PSG progression was associated with Black race (OR 2.71, 95% CI 1.03–7.17) and higher baseline PSQ-SRBD (OR 1.74, 95% CI 1.03–3.08). Symptom persistence/progression was predicted by asthma (OR 2.70 95% CI 1.29, 6.01), ADHD (OR 3.73 95% CI 1.13, 16.88), and tobacco smoke exposure (OR 2.41 95% CI 1.08–5.82), while children with larger tonsils (grade III–IV) had lower odds of progression (OR 0.42 95% CI 0.22–0.78). Conclusions A high symptom burden is common after a year of WWSC for mild SDB, but only a minority of children progressed on PSG. Black race and several clinical characteristics and symptom scores were associated with higher likelihood of progression. Trial registration ClinicalTrials.gov Identifier: NCT0256204. Brief summary Current knowledge/study rationale Can clinical information predict persistence or progression of mild sleep-disordered breathing in children who are observed for 1 year without adenotonsillectomy? Study impact Polysomnographic progression to obstructive sleep apnea occurs in a minority (13%) of those observed while symptom persistence or progression is more common (57%). Children who are Black or who have asthma, attention-deficit hyperactivity disorder, environmental tobacco exposure, and a high symptom burden could be considered stronger candidates than their peers for earlier adenotonsillectomy for symptomatic mild sleep-disordered breathing.