Let’s say that you have a patient who is a preschooler. The parent reports that the child snores a lot. Do you order a sleep study? And if the child demonstrates mild obstructive sleep apnea (OSA) on the sleep study, what do you do? Do you refer for surgery, or do you recommend watchful waiting?
Dr. Karen Waters and her colleagues from the University of Sydney and the University of Queensland conducted a randomized controlled trial to look at outcomes in 3-5-year-olds who underwent adenotonsillectomy. Children who had been referred for adenotonsillectomy were randomized to receive surgery immediately (within 2 months) or be on a wait list for 12 months before receiving surgery. In an article that is being early released this week in Pediatrics, the authors report on the outcomes for these 2 groups of children (10.1542/peds.2020-038588).
For both groups of children, there was a decrease in daytime napping, improved sleep scores, and improved behavioral scores, and there was no statistical difference between the two groups. There were other study outcomes as well, and you can read about them when you look at the entire study.
Based on these results, should we be recommending early surgery for these children? In an invited commentary, Drs. Jennifer Cooper and Gerry Taylor from Nationwide Children’s, and Dr. Emily Boss from Johns Hopkins say, not so fast (10.1542/peds.2021-050761). They note that, while this study was a randomized trial, the “control” group received a wait list intervention, and so we don’t really know what would have happened to this group had they continued to go without surgery. It is noteworthy that a proportion of children in the wait list intervention had some improvement in their apnea symptoms before they underwent surgery. Would they have improved enough to not warrant surgery? We don’t know the answer to that, based on this study.
There are of course other important considerations, including the inherent risks of surgery. However, I think that the results from this study are important to share when we have discussions with parents about the pros and cons of proceeding with surgery or watchful waiting.
