NIH-funded clinical study may help inform decisions about this common surgical procedure
Children with sleep apnea syndrome who have their tonsils and adenoids removed sleep better, are less restless and impulsive, and report a generally better quality of life, finds a new study funded by the National Institutes of Health. However, the study found cognitive abilities did not improve compared with children who did not have surgery, and researchers say the findings don’t mean surgery is an automatic first choice.
The findings of the Childhood Adenotonsillectomy Trial (CHAT) will be presented May 21 at the American Thoracic Society 2013 meeting in Philadelphia. The study, which compared surgery to general supportive care and observation, or watchful waiting, will be concurrently published online in the New England Journal of Medicine.
“This is the first rigorous, controlled evaluation of a commonly performed treatment for childhood sleep apnea, in terms of looking at functional outcomes,” said Susan Shurin, M.D., a pediatrician and deputy director of the NIH’s National Heart, Lung, and Blood Institute (NHLBI). “This study provides additional data that can help parents and providers make more informed decisions about treating children with this disorder, and it identifies additional areas of research.”
Obstructive sleep apnea syndrome is a common disorder in which the airway becomes blocked during sleep, causing shallow breathing or breathing pauses. The sleep disturbances that result can lead to many issues in children, including learning difficulties and behavioral problems.
Enlarged or swollen tonsils are a major risk factor for pediatric sleep apnea syndrome, and surgery to remove them and the nearby adenoid can help open up blocked airways. Over 500,000 adenotonsillectomies are performed annually on children, primarily for sleep apnea. However, the extent that surgery can improve cognition and behavior previously had not been rigorously studied.
CHAT enrolled 464 children ages 5-9 years with obstructive sleep apnea syndrome from seven sleep centers across the United States and randomly assigned them into two groups. One received adenoid and tonsil surgery within a month after enrollment, while the other received supportive medical care and careful monitoring, or watchful waiting. At enrollment, both groups of children were evaluated by psychometricians—people trained to administer and interpret psychological tests—on their cognition (primarily attention and organizational skills); they were also evaluated by caregivers and teachers on behavior and quality of life, and they had sleep studies to assess their breathing and sleep parameters. After seven months, the children were reevaluated.
The researchers found no differences in cognitive skills between the two groups, but the children who underwent surgery showed improved sleep quality, behavioral regulation, and quality of life measures like being more active and experiencing less daytime sleepiness. Beneficial effects were observed even among overweight children, in whom there has been particular uncertainty about the role of surgery for sleep apnea treatment.
Overall, 79 percent of children in the surgery group had resolution of their sleep apnea after seven months, compared to 46 percent in the watchful waiting group.
“While more of the children who underwent early surgery had improvements in their sleep apnea measures, nearly half of the children without surgery also had improvements during the seven months of observation,” said senior author Susan Redline, M.D., M.P.H., of Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center, both in Boston. “This and the lack of significant cognitive decline in the watchful waiting group suggest that reassessing a child after a period of observation may be a valid therapeutic option for some children, especially those with mild symptoms.”
Redline added that these results should not be applied to children with the most severe sleep apnea syndrome or very young children, who were not included in this study.
The study was funded by NIH grants HL083075, HL083129, UL1 RR024134, and UL1 RR024989. Centers participating in CHAT are the Children’s Hospital of Philadelphia and the University of Pennsylvania School of Medicine; Boston Children's Hospital, Brigham and Women’s Hospital, and Beth Israel Deaconess Medical Center; North Carolina State University, Raleigh; University Hospitals Rainbow Babies and Children's Hospital, Cleveland; University of Michigan, Ann Arbor; University of Texas Southwestern Medical Center at Dallas; Cincinnati Children's Hospital Medical Center; Children’s Hospital at Montefiore and Montefiore Medical Center, New York City; Cardinal Glennon Children's Medical Center, St. Louis; and the University of Chicago.
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