Sleep-Disordered Breathing, Behavior, and Cognition in Children Before and After Adenotonsillectomy

Abstract

Objectives: Most children with sleep-disordered breathing (SDB) have mild to moderate forms, for which neurobehavioral complications are believed to be the most important adverse outcomes. To improve understanding of this morbidity, its long-term response to adenotonsillectomy, and its relationship to polysomnographic measures, we studied a series of children before and after clinically-indicated adenotonsillectomy or unrelated surgical care.Methods: We recorded sleep and assessed behavioral, cognitive, and psychiatric morbidity in 105 children 5.0 to 12.9 years old: 78 were scheduled for clinically-indicated adenotonsillectomy, usually for suspected SDB, and 27 for unrelated surgical care. One year later, we repeated all assessments in 100 of these children.Results: Adenotonsillectomy subjects, in comparison to controls, were more hyperactive on wellvalidated parent rating scales (p<0.001), inattentive on cognitive testing (p=0.003), sleepy on Multiple Sleep Latency Tests (p=0.002), and likely to have DSM-IV-defined Attention-Deficit/ Hyperactivity Disorder as judged by a child psychiatrist (p=0.03). In contrast, one year later, the two groups showed no significant differences in the same measures. Adenotonsillectomy subjects had improved substantially (p≤0.01) in all measures and control subjects in none. However, polysomnographic assessment of baseline SDB and its subsequent amelioration did not clearly predict either baseline neurobehavioral morbidity or improvement in any area other than sleepiness.Conclusions: Children scheduled for adenotonsillectomy often have mild to moderate SDB and significant neurobehavioral morbidity --including hyperactivity, inattention, Attention-Deficit/ Hyperactivity Disorder, and excessive daytime sleepiness --all of which tend to improve by one year after surgery. However, the lack of better correspondence between SDB measures and neurobehavioral outcomes suggests the need for better measures or improved understanding of underlying causal mechanisms.

A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea

“…[22][23][24][25][26][27][28][29][30] The plausibility of the obstructive sleep apnea syndrome contributing to cognitive deficits is supported by research showing impaired learning in juvenile rats exposed to intermittent hypoxemia 3 and by imaging studies showing cerebral neuronal injury in children with the syndrome. 30 Previous studies have shown differences in the cognitive function of children with the obstructive sleep apnea syndrome, as compared with controls.…”

“…19,27,31 However, baseline cognitive scores of children with the obstructive sleep apnea syndrome fell within the normal range, a finding similar to that in the current study. Cognitive and behavioral abnormalities have been shown to be reduced after adenotonsillectomy in some, [24][25][26][27]29 but not all, 30 nonrandomized studies, with inconsistency in the reported effect after treatment. 25,29,32 Previous studies have been limited by small samples, lack of randomization or appropriate controls, heterogeneous study groups, and sole reliance on parent questionnaires rather than including neuropsychological testing.…”

Prenatal and Neonatal Risk Factors for Sleep Disordered Breathing in School-Aged Children Born Preterm

“…(6)(7)(8)(9)(10)(11)(12) Identification of children at high risk for SDB and its associated morbidities is particularly important given the growing body of evidence that treatment with adenotonsillectomy may improve quality of life and neurocognitive function. (5,(13)(14)(15)(16)(17) Preterm infants are especially vulnerable both to SDB and its sequelae. In a Finnish cohort study, very low birth weight infants were shown to have a two-fold risk of SDB as young adults.…”

Current Treatment of Selected Pediatric Sleep Disorders

“…Studies have identified and reported post-therapy AHI and/or oxygen saturation and other respiratory measures, sleep EEG analysis such as sleep stages, spindles, arousals, and spectral analysis, various neurocognitive and/or behavioral measures, parental and teacher report of improvement or satisfaction, academic performance, and more recently serologic markers [5][6][7][8] such as C-Reactive Protein, and other physiological tests [7,9] as evidence of treatment effect. Interestingly, these outcomes do not necessarily show symmetry at baseline or in response to intervention ; for example, in children treated by adenotonsillectomy, hyperactivity, inattention, cognitive function, and other neurobehavioral morbidities all tended to be improved a year after treatment, but little correlation has been seen between some of these variables and polysomnographic measures before or after surgery, though esophageal pressure monitoring as a more sensitive measure of breathing abnormalities may offer some promise in this regard [10,11].…”

“…Smaller or uncontrolled studies suggest that adenotonsillectomy may improve OSA-related deficits in attention, memory, performance, and/ or behavior [10,11,24,25]. The Childhood Adenotonsillectomy Trial (CHAT) was recently undertaken to assess neuropsychological and health outcomes in children randomized to receive early AT (eAT) as compared to Watchful Waiting with Supportive Care (WWSC) [18].…”