ORCID

0000-0002-4439-8108 (Baldassari)

Document Type

Article

Publication Date

2026

DOI

10.1007/s44470-026-00082-y

Publication Title

Journal of Clinical Sleep Medicine

Volume

22

Issue

1

Pages

106

Abstract

Purpose

To identify clinical characteristics that may be associated with persistence or progression of mild sleep-disordered breathing (SDB) in children who are observed without surgery.

Methods

This is a secondary analysis of the control arm of the Pediatric Adenotonsillectomy Trial for Snoring (PATS), which randomized 458 children aged 3.0 to 12.9 years with mild SDB (snoring with obstructive apnea-hypopnea index [oAHI] <  3 events/hour) to early adenotonsillectomy (eAT) versus watchful waiting with supportive care (WWSC). Participants were assessed at baseline and 12 months with the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder (PSQ-SRBD) scale and polysomnography (PSG). We tested for factors predictive of either (1) PSG progression defined by a 12-month oAHI ≥ 3 or (2) symptom persistence or progression defined by a 12-month PSQ-SRBD score ≥ 0.33.

Results

A total of 234 participants were observed (mean age 6.2 years, 111 [47%] female, 65 [28%] Black or African American, 37 [16%] Hispanic). Overall, only 13% (n = 20/150) progressed to an oAHI ≥ 3 on repeat PSG, whereas over half (n = 110/192, 57%) had symptom persistence/progression. Of the children with persistent or progressive symptoms, 18% (n = 16/103) progressed to oAHI ≥ 3. In unadjusted analyses, PSG progression was associated with Black race (OR 2.71, 95% CI 1.03-7.17) and higher baseline PSQ-SRBD (OR 1.74, 95% CI 1.03-3.08). Symptom persistence/progression was predicted by asthma (OR 2.70 [95% CI 1.29, 6.01]), ADHD (OR 3.73 [95% CI 1.13, 16.88]), and tobacco smoke exposure (OR 2.41 [95% CI 1.08-5.82]), while children with larger tonsils (grade III-IV) had lower odds of progression (OR 0.42 [95% CI 0.22-0.78]).

Conclusions

A high symptom burden is common after a year of WWSC for mild SDB, but only a minority of children progressed on PSG. Black race and several clinical characteristics and symptom scores were associated with higher likelihood of progression.

Trial registration

ClinicalTrials.gov Identifier: NCT0256204.

Current knowledge/study rationale

Can clinical information predict persistence or progression of mild sleep-disordered breathing in children who are observed for 1 year without adenotonsillectomy?

Study impact

Polysomnographic progression to obstructive sleep apnea occurs in a minority (13%) of those observed while symptom persistence or progression is more common (57%). Children who are Black or who have asthma, attention-deficit hyperactivity disorder, environmental tobacco exposure, and a high symptom burden could be considered stronger candidates than their peers for earlier adenotonsillectomy for symptomatic mild sleep-disordered breathing.

Rights

© The Authors 2026

This article is licensed under a Creative Commons Attribution 4.0 International (CC BY 4.0) License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original authors and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

Data Availability

De-identified data (including data dictionaries) are available upon request via the National Sleep Research Resource for participants for whom there are no regulatory restrictions for data sharing (sleep data.org).

Original Publication Citation

Kirkham, E. M., Ishman, S., Garetz, S., Baldassari, C. M., Mitchell, R. B., Liu, C., Tapia, I. E., Elden, L. M., Hassan, F., Ibrahim, S., Ross, K., Cen, M., Wang, R., Redline, S., & Chervin, R. D. (2026). Progression of mild sleep-disordered breathing in children managed with watchful waiting. Journal of Clinical Sleep Medicine, 22(1), Article 106. https://doi.org/10.1007/s44470-026-00082-y

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