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Randomized Controlled Trial
. 2025 Jun 1;179(6):600-609.
doi: 10.1001/jamapediatrics.2025.0023.

Adenotonsillectomy and Health Care Utilization in Children With Snoring and Mild Sleep Apnea: A Randomized Clinical Trial

Jessie P Bakker  1 , Fang Zhang  2 , Raouf Amin  3 , Cristina M Baldassari  4 , Ronald D Chervin  5   6 , Susan L Garetz  5   7   6 , Fauziya Hassan  6   8 , Sally Ibrahim  9 , Stacey L Ishman  10 , Erin M Kirkham  7 , Ariel Linden  11 , Ron B Mitchell  12   13 , Kamal Naqvi  14 , Carol L Rosen  15 , Kristie Ross  9 , Ignacio E Tapia  16 , Lisa R Young  16 , Phoebe K Yu  17 , Susan Redline  1 , Rui Wang  1   2   18
Affiliations
Randomized Controlled Trial

Adenotonsillectomy and Health Care Utilization in Children With Snoring and Mild Sleep Apnea: A Randomized Clinical Trial

Jessie P Bakker et al. JAMA Pediatr. .

Abstract

Importance: The literature indicates that health care utilization (HCU) of children with untreated moderate-to-severe obstructive sleep apnea is greater than that of matched controls before diagnosis, and treatment is associated with a decline in HCU not observed in those who remain untreated. Research on this topic has been limited to retrospective analyses and observational cohort studies; little is known about HCU among the many children with snoring and mild sleep-disordered breathing (SDB).

Objective: To determine whether adenotonsillectomy in comparison with watchful waiting with supportive care is associated with fewer health care encounters and prescriptions.

Design, setting, and participants: This randomized clinical trial, Pediatric Adenotonsillectomy Trial for Snoring (PATS), was a 12-month, parallel-arm trial conducted from 2016 to 2022 in tertiary care centers in the United States. Participants were recruited from otolaryngology, sleep, pulmonary, or general pediatric clinics; aged 3 to 13 years; diagnosed with mild SDB; had a tonsillar hypertrophy grade of 2 or more; and had a body mass index z score less than 3. Children referred from a clinician outside of the local electronic medical record system were excluded. Data analysis was conducted from June 2022 to April 2024.

Intervention: Early adenotonsillectomy.

Main outcomes and measures: Evaluation of HCU was a prespecified secondary aim of PATS. Total encounters and total prescriptions over the 12 months after randomization were analyzed.

Results: Among 459 children who were randomized, the analytic sample included 381 children, after excluding those referred from outside the local electronic medical record system. The median (IQR) age was 6 (4-8) years; 192 participants (50%) were female and 189 (50%) male. Adenotonsillectomy was associated with a 32% reduction in total health care encounters (mean difference, -1.25 per participant per year; 95% CI, -1.96 to -0.53) and a 48% reduction in prescriptions (mean difference, -2.53 per participant per year; 95% CI, -4.12 to -0.94). The difference in encounters was primarily driven by fewer office visits and outpatient procedures rather than by reduced hospitalizations or urgent care visits.

Conclusions and relevance: This study found that adenotonsillectomy was associated with reduced all-cause HCU in children with mild SDB, supporting early intervention for children with mild SDB. Future research focused on the cost effectiveness of adenotonsillectomy for pediatric SDB is warranted.

Trial registration: ClinicalTrials.gov Identifier: NCT02562040.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bakker’s employment at Brigham and Women’s Hospital ended in February 2024, and she reported employee ownership of shares from Philips and Signifier Medical Technologies and consulting fees from Koneksa Health and Apnimed outside the submitted work. Dr Zhang reported grants to their institution from Pfizer and GlaxoSmithKline outside the submitted work. Dr Chervin reported personal fees from UpToDate as an author and editor outside the submitted work and having had a patent for copyrighted material licensed to MAPI, serving as an unpaid officer (president elect) and board member for the International Pediatric Sleep Association, and being named in patents and copyrighted material owned by the University of Michigan and designed to help in diagnosis and treatment of sleep disorders. Dr Hassan reported being a consultant for Eli Lilly outside the submitted work. Dr Ishman reported work on a clinical trial from Nyxoah, grants from Inspire Medical, and personal fees from Ethicon during the conduct of the study. Dr Kirkham reported grants from National Institute of Heart, Lung and Blood Institute of the National Institutes of Health (1 K23 HL153897-01A1) during the conduct of the study and author royalties from UpToDate outside the submitted work. Dr Ross reported grants to their institution from Astra Zeneca, GlaxoSmithKline, and Sanofi Regeneron and advisory board fees from Boehringer Ingelheim outside the submitted work. Dr Young reported authorship fees from Wolter Kluwers UpToDate and advisory board fees from Boehringer Ingelheim outside the submitted work. Dr Redline reported being an unpaid board member for the Alliance of Sleep Apnea Partners and National Sleep Foundation. No other disclosures were reported.

Comment on

  • The Butterfly Effect of Adenotonsillectomy.
    Lam DJ. Lam DJ. JAMA Otolaryngol Head Neck Surg. 2025 May 1;151(5):431-432. doi: 10.1001/jamaoto.2025.0117. JAMA Otolaryngol Head Neck Surg. 2025. PMID: 40094645 No abstract available.

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