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Original Investigation
September 3, 2020

Predictors of Behavioral Changes After Adenotonsillectomy in Pediatric Obstructive Sleep Apnea: A Secondary Analysis of a Randomized Clinical Trial

Author Affiliations
  • 1Department of Otorhinolaryngology—Head and Neck Surgery, University of Maryland School of Medicine, Baltimore
  • 2Department of Pediatrics, University of Maryland School of Medicine, Baltimore
  • 3Department of Neurology, University of Maryland School of Medicine, Baltimore
  • 4Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
JAMA Otolaryngol Head Neck Surg. Published online September 3, 2020. doi:10.1001/jamaoto.2020.2432
Key Points

Question  Are polysomnographic parameters superior to parent-reported symptoms of upper-airway obstruction in predicting posttreatment behavioral outcomes in children with obstructive sleep apnea (OSA)?

Findings  In this secondary analysis of the Childhood Adenotonsillectomy Trial involving 453 children, parent-reported symptoms of upper-airway obstruction were better indicators of most changes in children’s behavior than were polysomnographic parameters.

Meaning  Results of this secondary analysis suggest that most treatment-related behavioral changes in children with OSA were mediated by the changes in parent-reported sleep-disordered breathing severity alone.

Abstract

Importance  Adenotonsillectomy (AT) is associated with improved behavior in children with obstructive sleep apnea (OSA). However, it is unknown whether polysomnographic parameters are superior to the parent-reported severity of sleep-disordered breathing (SDB) in predicting behavioral changes after AT.

Objective  To ascertain whether polysomnographic parameters vs parent-reported severity of SDB are better predictors of treatment-related behavioral changes in children with OSA.

Design, Setting, and Participants  This ad hoc secondary analysis of the Childhood Adenotonsillectomy Trial (CHAT) downloaded and analyzed data from January 1 to January 31, 2020. Children aged 5 to 9 years with a polysomnographic diagnosis of OSA were enrolled in the CHAT and subsequently randomized to undergo either early AT or watchful waiting with supportive care. All outcome measures were obtained at baseline and at follow-up (7 months after randomization).

Interventions  Early AT vs watchful waiting with supportive care.

Main Outcomes and Measures  Postrandomization changes between the baseline and follow-up periods were derived from (1) T scores in 4 validated behavioral assessments (Conners Global Index parent and teacher versions, Behavior Rating Inventory of Executive Function metacognition index, and Child Behavior Checklist of total, internalizing, and externalizing behavior subscales); (2) 8 aggregated polysomnographic parameters representing the severity of obstruction, hypoxemia, sleep quality, and structure; and (3) the parent-reported severity of SDB measured by the Pediatric Sleep Questionnaire–Sleep-Related Breathing Disorder (PSQ-SRBD) scale. The treatment-related changes in each of the behavioral outcomes attributable to changes in SDB severity (represented by the subjective PSQ-SRBD score and objective polysomnographic parameters) were measured and compared using mediation analysis.

Results  A total of 453 children were assessed at baseline, of whom 234 were girls (52%) and the mean (SD) age was 6.6 (1.4) years. The postrandomization changes in 7 of 8 behavioral outcome measures between the baseline and follow-up periods were partially mediated by the changes in PSQ-SRBD scores (range of nonzero causally mediated effects, 2.4-3.5), without contribution from any of the polysomnographic parameters.

Conclusions and Relevance  This secondary analysis of a national randomized clinical trial found that most treatment-related behavioral changes in children with OSA were mediated by the changes in parent-reported SDB severity alone. These findings suggest that polysomnographic parameters provide clinicians with limited means to predict the improvement in neurobehavioral morbidity in OSA.

Trial Registration  ClinicalTrials.gov Identifier: NCT00560859

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