Risk Factors, Symptom Burden, and Treatment Response in Pediatric REM-Predominant OSA: Evidence From the Childhood Adenotonsillectomy Trial.

OBJECTIVE

To evaluate whether children with rapid eye movement (REM)-predominant obstructive sleep apnea (OSA) are less likely to achieve disease resolution following different management strategies compared with those with non-REM-predominant OSA.

METHODS

We performed a secondary analysis of the Childhood Adenotonsillectomy Trial. Children aged 5.0-9.9 years with OSA were randomized to adenotonsillectomy (AT) or watchful waiting. REM-predominant OSA was defined as a REM-AHI to NREM-AHI ratio of ≥ 2. The primary outcome was OSA resolution at 7-month follow-up.

RESULTS

Among 382 children (48.2% male; median age 6.75 years), 55.8% had REM-predominant OSA. Black race and obesity were associated with a higher prevalence of this subtype. REM-predominant OSA group exhibited increased daytime sleepiness (difference, 10%; 95% CI, 1%-17%), higher AHI (difference, 1.37; 95% CI, 0.67-2.22), and lower oxygen saturation nadirs (difference, -2.00; 95% CI, -3.00 to -2.00) compared with the non-REM-predominant OSA group. However, PSQ-defined symptom burden (difference, -1%; 95% CI, -9% to 7%) and OSA-18-defined quality-of-life impairment (difference, 3%; 95% CI, -6% to 12%) did not differ significantly between groups. At the 7-month follow-up, children in the REM-predominant OSA group who underwent watchful waiting were significantly less likely to experience spontaneous resolution than those in the non-REM-predominant OSA group (aOR, 0.52; 95% CI, 0.28-0.97). However, no significant difference was observed in the OSA resolution rate between the two groups who underwent AT (aOR, 0.75; 95% CI, 0.34-1.66).

CONCLUSIONS

REM-predominant OSA was associated with greater daytime sleepiness and PSG severity but was not associated with significantly greater parent-reported symptom burden or worse disease-specific quality of life. Children with REM-predominant OSA were less likely to experience spontaneous resolution after watchful waiting, underscoring the prioritization of AT.

LEVEL OF EVIDENCE: 3. Trial Registration: ClinicalTrials.gov Identifier: NCT00560859.