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

Educational Objective
To study whether any of the polysomnographic parameters representing physiological measures are superior to parent-reported symptoms of sleep-disordered breathing in assessing the changes in behavioral outcomes after obstructive sleep apnea treatment.
1 Credit CME
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.


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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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: June 27, 2020.

Corresponding Author: Amal Isaiah, MD, PhD, Department of Otorhinolaryngology—Head and Neck Surgery, University of Maryland School of Medicine, 16 S Eutaw St, Ste 500, Baltimore, MD 21201 (aisaiah@som.umaryland.edu).

Published Online: September 3, 2020. doi:10.1001/jamaoto.2020.2432

Author Contributions: Dr Isaiah had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Isaiah, Pereira.

Acquisition, analysis, or interpretation of data: Isaiah, Spanier, Grattan, Wang.

Drafting of the manuscript: Isaiah, Spanier.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Isaiah, Wang.

Obtained funding: Isaiah.

Administrative, technical, or material support: Isaiah, Spanier, Grattan.

Supervision: Isaiah, Pereira.

Conflict of Interest Disclosures: Dr Isaiah reported receiving grants from Burroughs Wellcome Fund and the National Institutes of Health during the conduct of the study as well as owning a patent to sleep apnea imaging, which is issued, is licensed, and has royalties paid, and a patent to sleep apnea treatment, which is pending and licensed. No other disclosures were reported.

Funding/Support: This study was funded in part by a cooperative research travel grant from the Burroughs Wellcome Fund (Dr Isaiah).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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