Tonsil and adenoid removal improves a variety of symptoms in children with moderate sleep apnea, but "watchful waiting" also helped in some ways, a new study found.
Overall, the surgery resulted in better sleep, less restlessness and impulsivity, and improved quality of life for most patients. But nearly half of children in the "watchful waiting" group also saw sleep improvements. No correlation was found between the surgery and improving attention and brain function.
"If you ask me what, as a pediatrician, I would recommend to my patients . . . with sleep apnea, I would recommend surgery, because we saw many improvements," said Carole Marcus, a physician and director of the Sleep Center at Children's Hospital of Philadelphia and the study's first author. "But if we had a family who had concerns about their child having surgery . . . we can wait and observe your child . . . . In the past, I would have really pushed for the surgery."
Marcus recalled that the operation "used to be almost universal in the '50s and '60s. Almost every child got their tonsils and adenoids taken out. At that time, the concern was infection more than sleep apnea."
As antibiotics improved, the surgery became less routine.
Still, more than 500,000 of these operations are performed on children in the United States each year, making it the second most common pediatric surgery.
The tonsils and adenoids, masses of germ-fighting tissue, are found in the nose and throat. When enlarged, the tissue can obstruct the airways of young children and cause chronic sleep disruption, or sleep apnea.
Lisa Elden, a surgeon and a study coauthor also at Children's, noted that lymph tissue diminishes over time. Most tonsil- and adenoid-removal surgeries are done when the patient is between age 5 and 7, she said.
Sleep apnea not only causes daytime sleepiness, but can also lead to attention and behavioral problems that affect learning. The condition increases the risk of obesity, diabetes, high blood pressure, and heart problems, according to the National Institutes of Health.
The NIH-funded study is the first randomized trial of the surgery, representing the gold standard in research. It was released last week at the American Thoracic Society's 2013 conference in Philadelphia and published in the New England Journal of Medicine.
The trial analyzed 453 children between the ages of 5 and 9 at six U.S. sleep centers. About one-third of patients in the trial were from Philadelphia-area medical centers; 194 children underwent surgery, while 203, the "watchful waiting" group, received medical care and monitoring.
Seventy-nine percent of patients who received the surgery reported improved sleep symptoms after seven months, compared with 46 percent of "watchful waiting" patients who saw improvement.
Overweight and obese patients reported positive results after surgery. African American children in both groups showed significantly less improvement than other subgroups.
This trial is "only the beginning," Elden said. She and her colleagues hope to see similar studies conducted, perhaps over a longer period of time and with a wider age group of children.