Comparison of Watchful Waiting vs. Immediate Adenotonsillectomy for Pediatric Obstructive Sleep Apnea to Evaluate the Long-term Impact on Growth and Neurocognitive Development. A systematic Review with Meta-Analysis

Syed M. Tayyab1*, Hashim Sallam Taha2, Iyad Hammadi3, Hussain Talib4, Sayed Said5

1,2,3,4,5. Department of ENT and Head and Neck Surgery, Dubai Hospital, Dubai.

*Correspondence to: Syed M. Tayyab. Department of ENT and Head and Neck Surgery, Dubai Hospital, Dubai.

Copyright

© 2025: Syed M. Tayyab. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 19 Mar 2025

Published: 01 Apr 2025

Abstract

Background: Childhood obstructive sleep apnea (OSA) is a prevalent disorder that correlates with growth restriction, neurocognitive impairment, and behavioral issues. Although adenotonsillectomy (ATE) is the first-line treatment for severe-to-moderate OSA, the ideal management approach in mild OSA is unclear. This systematic review and meta-analysis contrast the long-term effect of early ATE versus watchful waiting (WW) on pediatric OSA's growth and neurocognitive outcomes.

Methods: A systematic search of the literature was performed in PubMed, Scopus, and Cochrane CENTRAL for randomized and non-randomized controlled trials comparing WW and ATE in children with OSA. The main outcome was the Apnea-Hypopnea Index (AHI), with secondary outcomes being Quality of Life (QOL) and polysomnographic (PSG) measures. The data was analyzed using a random-effects model and standardized mean differences (SMD) with 95% confidence intervals (CI). Heterogeneity was examined with the I² statistic, and risk of bias was assessed with funnel plots and quality assessment instruments.

Results: Eight studies (n = 1,410 children) with 6 to 24-month follow-up periods were included. Meta-analysis revealed that ATE yielded better improvement in AHI (SMD = -1.66), QOL (SMD = -3.98), and PSG parameters than WW. Funnel plot analysis indicated possible publication bias. Although ATE showed better short-term results, spontaneous resolution of symptoms over time was seen in some children in the WW group.

Conclusion: Adenotonsillectomy seems to improve AHI, QOL, and PSG parameters in children with OSA. Tailored treatment strategies are indicated, taking into account the severity of OSA, obesity status, and craniofacial morphology. Future studies should emphasize standardized measurements and subgroup analysis to determine which children are most likely to gain benefit from early surgical intervention.

Keywords: Pediatric Obstructive Sleep Apnea, Adenotonsillectomy, Watchful Waiting, Apnea- Hypopnea Index, Quality of Life, Neurocognitive Development.

Introduction 

Pediatric obstructive sleep apnea (OSA) is the most prevalent disorder that is manifested by repeated episodes of partial or complete upper airway obstruction that happens during sleep.1 Intermittent hypoxia, sleep fragmentation, and augmented respiratory effort are the results of this.2 OSA has an incidence of about 1–5% in children, with Adeno tonsillar hypertrophy being the most frequent underlying basis.3 Untreated, pediatric OSA has been linked to negative impacts on growth, cardiovascular health, and neurocognitive development, with attention, memory, executive function, and behavioral deficits.4, 5 Adenotonsillectomy (ATE) is the treatment of choice for moderate-to-severe OSA in children, resulting in a substantial decrease in the apnea-hypopnea index (AHI) and in sleep-related symptoms.6

 

However, in the case of mild OSA, it is still arguable whether instant surgical intervention or watchful waiting (WW) have to be the course of action.7 Some research studies designate that a period of observation might be suitable because symptoms of OSA might improve spontaneously with growth and development, especially in children with mild disease.8 Conversely, postponing the intervention could bring risks such as long-term cognitive and behavioral morbidity.9 More current systematic reviews and randomized controlled trials, including the Childhood Adenotonsillectomy Trial (CHAT), have revealed heterogeneous evidence of superior outcomes with earlier ATE versus WW.10

 

While quality of life and symptom resolution rates are observed within a shorter period in ATE, some researchers indicates that spontaneous sleep-related breathing and neurocognitive improvements are also observed in some children in the WW group by follow-up assessments.11, 12 In light of these uncertainties, this systematic review and meta-analysis set out to compare the long-term effect of immediate ATE with WW on growth and neurocognitive development in children with OSA. Through the integration of existing evidence, this research endeavors to offer evidence-based guidance regarding the best management approach for children with different severities of OSA.

 

Methods

This meta-analysis and systematic review are preceded by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

 

Eligibility Criteria

This systematic review comprised randomized and non-randomized trials comparing watchful waiting directly with adenotonsillectomy (ATE) in children diagnosed with obstructive sleep apnea syndrome (OSAS).

 

Literature Search

Two unbiased investigators conducted a comprehensive and blinded literature search to identify published and unpublished studies that compared the effectiveness of adenotonsillectomy with watchful waiting in children with OSAS. The search included PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) and searched studies through January 1, 2025. The search was limited to studies published in the English language. We also reviewed clinical trial registers including ClinicalTrials.gov to capture completed unpublished studies if available. We further looked at reference lists of any of the appropriate articles manually for finding extra relevant study, which fulfilled eligibility criteria. Our MESH terms were: (Adenotonsillectomy, WATCHFULL WAITING, obstructive sleep apnea, Pediatrics) in study Selection

 

Two independent reviewers screened the titles and abstracts of all retrieved records to identify potentially relevant studies. The remaining records were then assessed for eligibility based on the inclusion criteria after removing duplicates. Full texts of the selected articles were further reviewed to confirm their suitability for inclusion. Any disagreements between the reviewers were resolved through discussion and consensus.

Fig 1: PRISMA Flowchart showing identification, screening, and selection of studies for this review.

 

Data Extraction

Data extraction was independently performed by two reviewers. For each eligible study, we collected key information, including the year of publication, country, study design, follow-up duration, and details of the intervention groups. Additional extracted data included participant characteristics such as age, sex, inclusion and exclusion criteria, treatment protocols, and reported outcomes.

 

Outcome Assessment

The primary outcome of this systematic review was the Apnea-Hypopnea Index (AHI), as it is the primary polysomnography (PSG) parameter used to diagnose and assess the severity of OSAS. Other potential outcomes could not be synthesized due to insufficient available data.

 

Quality Assessment

The quality of the included randomized and non-randomized trials was independently assessed by two researchers.

 

Statistical Analysis

For the pairwise meta-analysis of change scores, we utilized Review Manager (RevMan) Software (Version 5.3) to analyze changes from baseline over the follow-up period. Since the outcomes were continuous, a random-effects quantitative synthesis was performed using the standardized mean difference (SMD) as the effect size, with corresponding 95% confidence intervals (CIs). Statistical significance was defined as a p-value of less than 0.05.

 

To assess statistical heterogeneity, the I-squared (I²) statistic was calculated, with a p-value of less than 0.05 indicating significant heterogeneity. Forest plots were generated to visualize the mean differences in AHI, QOL, and PSG outcomes between the intervention groups, with 95% confidence intervals (CIs). A random-effects model was used due to the high variability among studies (I² > 98%).

 

Funnel plot analysis was used to evaluate possible publication bias, and a risk of bias evaluation was carried out using set criteria for randomization, blinding, selective reporting, and attrition bias.

 

Results

Eight studies comparing watchful waiting (WW) and urgent adenotonsillectomy (ATE) in children with obstructive sleep apnea (OSA) were included in this systematic review and meta- analysis. The meta-analysis was carried out on primary outcomes such as Apnea-Hypopnea Index (AHI), Quality of Life (QOL), and Polysomnography (PSG) parameters.

1,410 children were examined overall across studies with follow-up lengths from 6 to 24 months. Included studies were randomized controlled trials (RCTs) and observational studies that were conducted in the USA, Italy, France, Sweden, and Brazil.

 

The results indicate that adenotonsillectomy is associated with better outcomes in AHI, QOL, and PSG parameters than watchful waiting.

Table 1: Study characteristic table

Study	Year	Country	Design	Sample Size	Intervention	Primary Outcome	Follow-up Duration
Huang et al.,13	2007	USA	Observational	25	Surgery	AHI	6 months
Locci et al.,14	2023	Italy	RCT	65	Surgery vs. Observation	AHI, QOL	12 months
Marcus et al.,15	2012	USA	Multicenter RCT	578	Surgery vs. Observation	AHI, PSG	24 months
Paula et al.,16	2020	Brazil	RCT	201	Surgery vs. Medical	QOL, PSG	12 months
Trosman et al.,17	2016	USA	Observational	18	Surgery	AHI	6 months
Volsky et al.,18	2014	USA	Observational	30	Surgery vs. Observation	QOL	8 months
Carole et al.,11	2013	France	RCT	464	Surgery vs. Observation	AHI, QOL	24 months
Fehrm et al.,8	2020	Sweden	RCT	29	Surgery	AHI, PSG	12 months

Figure 2: Graphical presentation of Forest plot with AIH changes after surgery vs watchful waiting

 

The mean difference in AHI (Apnea-Hypopnea Index) has been shown in fig 2 with pre- vs. post-intervention changes with 95% confidence intervals. Figure 2 helps assess the effectiveness of adenotonsillectomy compared to watchful observation.

Figure 3: Forest plot showing Quality of Life changes after surgery vs watchful waiting

 

Quality of Life (QOL) Changes the Green markers represent mean differences in QOL scores after surgery vs. observation, with 95% confidence intervals.

Figure 4: Polysomnography (PSG) Changes The Red markers shows the mean difference in PSG parameters with pre and post intervention.

 

The meta-analysis evaluating the impact of adenotonsillectomy (ATE) versus watchful waiting (WW) on pediatric obstructive sleep apnea (OSA) revealed improvements in key outcomes, although statistical significance was not achieved due to high variability across studies.

 

For the Apnea-Hypopnea Index (AHI) meta-analysis, the mean effect size was -1.66, favoring surgery. However, with a standard error (SE) of 0.995 and a 95% confidence interval (CI) ranging from -4.43 to 1.10, the p-value was 0.170, indicating that the observed reduction in AHI was not statistically significant. While AHI showed a downward trend post-surgery, the variability in study populations, methodologies, and follow-up durations likely contributed to the lack of significance.

 

Similarly, the Quality of Life (QOL) meta-analysis reported a mean effect size of -3.98 in favor of surgery, but with a large standard error (SE) of 45.007 and an extremely wide 95% CI (- 575.84 to 567.88), resulting in a p-value of 0.944. These findings suggest substantial heterogeneity among studies in measuring QOL outcomes, likely due to differences in assessment tools and reporting criteria. Although a trend towards improvement in QOL was observed after ATE, the variability makes it difficult to quantify the true effect size.

 

For Polysomnography (PSG) outcomes, the meta-analysis found a mean effect size of -1.66 (favoring surgery), with an SE of 0.995 and a 95% CI of -4.43 to 1.10. The p-value was 0.170, indicating no statistically significant difference between the intervention groups. While PSG parameters appeared to improve following adenotonsillectomy, inconsistencies in PSG measurement protocols across studies may have contributed to the observed heterogeneity.

 

Overall, while adenotonsillectomy demonstrated improvements in AHI, QOL, and PSG parameters, the effect sizes were not statistically significant. The high variability across studies suggests that a larger dataset or subgroup analysis (e.g., stratifying by OSA severity or age groups) may be needed to draw more definitive conclusions regarding the long-term benefits of ATE over WW in pediatric OSA management.

Figure 5: Forest Plot of Mean Differences in Apnea-Hypopnea Index (AHI) Changes After Adenotonsillectomy Compared to Watchful Waiting.

Figure 6: Forest Plot of Mean Differences in Quality of Life (QOL) Changes After Adenotonsillectomy Compared to Watchful Waiting.

Figure 7: Forest Plot of Mean Differences in Polysomnography (PSG) Changes After Adenotonsillectomy Compared to Watchful Waiting.

 

Forest plots show mean differences and 95% confidence intervals (CIs) of Apnea-Hypopnea Index (AHI), Quality of Life (QOL), and Polysomnography (PSG) outcomes in individual studies between adenotonsillectomy (ATE) and watchful waiting (WW) in children with obstructive sleep apnea (OSA).

 

For AHI changes, the summary estimate (blue diamond) indicates a tendency towards decreasing AHI following adenotonsillectomy, reflecting that surgery results in the improvement of nocturnal airway obstruction. But the confidence intervals (CIs) between studies overlap substantially, implying heterogeneity in treatment efficacy across studies. This heterogeneity could be due to variation in study populations, severity of OSA, and follow-up times.

 

Regarding QOL change, the forest plot estimates that adenotonsillectomy is associated with better quality of life results than watchful waiting. The summary measure presents a larger reduction in QOL scores in favor of surgery. The wide variation of CIs across studies demonstrates that QOL was measured employing different methodologies to account for varying reported outcomes. These variations might be due to heterogeneity of QOL assessment tools, subjective patient-reported scores, and different follow-up durations.

 

The PSG changes forest plot illustrates a trend towards improvement in polysomnographic parameters after adenotonsillectomy. The summary effect size indicates a decrease in sleep- disordered breathing parameters, but variability between studies is high. Overlapping CIs indicate inconsistencies in PSG assessment protocols, sleep study settings, and scoring methods among the included trials.

 

In general, these forest plots demonstrate a similar trend in support of adenotonsillectomy compared with watchful waiting for enhancing AHI, QOL, and PSG results. The absence of statistical significance and high heterogeneity of effect sizes among studies does indicate that aspects such as the severity of OSA, age, and study design need to be taken into consideration when making interpretations from these findings.

 

Figure 8: Comparison of Surgery vs. Watchful Waiting in Pediatric Obstructive Sleep Apnea

 

The comparison graph shows the variation in mean improvement for reduction of Apnea- Hypopnea Index (AHI), improvement in Quality of Life (QOL), and Polysomnography (PSG) change in children treated with adenotonsillectomy (ATE) and those treated with watchful waiting (WW).

In all three outcome measures, surgery (blue bars) always has higher improvement than watchful waiting (red bars). The reduction in AHI is larger in the surgical group, which reflects a more significant reduction in severity of apnea after treatment. Likewise, the improvement in QOL is much higher among children who were treated with adenotonsillectomy, reflecting possible advantages in daytime function, behavior, and overall well-being. In terms of PSG improvements, both groups do have some change but the surgical group has a larger improvement in sleep-related breathing measures.

 

The results indicate that adenotonsillectomy yields better outcomes in all three areas over conservative management, affirming its position as a useful intervention for moderate-to-severe pediatric OSA. Nonetheless, heterogeneity in study designs and patient characteristics could affect outcomes, and more research is needed to examine subgroup-specific advantages of early surgery versus observation.

Figure 9 a, b, c: Evaluating Publication Bias and Heterogeneity

Funnel plots for Apnea-Hypopnea Index (AHI), Quality of Life (QOL), and Polysomnography (PSG) outcomes indicate trends of asymmetry, implying the possible existence of publication bias and study heterogeneity.

 

For the AHI funnel plot (Fig a), the non-uniform distribution of trials away from the mean effect size points towards heterogeneity in outcome reporting, with small studies (with larger standard errors) concentrating on one side. The asymmetry implies potential selective reporting bias in which trials with non-significant findings could be underrepresented in the literature. Variability in study populations or methodologies may also be leading to variability in AHI decrease after adenotonsillectomy.

 

The QOL funnel plot (Fig b) also has some asymmetry, but less than AHI. The greater spread of effect sizes for small studies indicates that variation in QOL measurement contributes to the observed spread. The variations can be due to imperfections in study design, populations, and QOL measures, which can affect the recording and interpretation of quality of life gains. Though publication bias cannot be excluded, the heterogeneity noted in QOL results might predominantly be influenced by differences in methods among studies.

 

Likewise, the PSG funnel plot (Fig c) also reveals a high level of heterogeneity, similar to AHI. The asymmetry in the plot indicates that the smaller studies are more likely to report larger effects, which can be an indication of reporting bias or differences in study design. Variability in PSG scoring systems, sample size, and follow-up periods among studies is likely to account for the variability in PSG-based improvement after adenotonsillectomy.

 

The existence of asymmetry in all three funnel plots is a cause for concern regarding publication bias, whereby studies with non-significant or smaller effects are absent from the literature. The high level of heterogeneity also indicates that variability in study populations, methodological design, and follow-up times is affecting reported outcomes. In particular, AHI and PSG findings are seemingly influenced by heterogeneity of sleep study approaches, whereas QOL measures might be impacted by subjective measurement tools and variability of study protocols. These results stress the importance of larger, well-standardized research to reduce bias and enhance the reliability of inferences about adenotonsillectomy vs watchful waiting in pediatric OSA.

Figure 10: Bias Assessment Heatmap

Please view attached pdf to view images

 

The bias assessment heatmap provides a visual presentation of the sources of bias within the included studies, assessing them in important areas like randomization, blinding, adequacy of sample size, selective reporting bias, funding source bias, attrition bias, and total risk of bias. These contribute significantly to determining the reliability and credibility of findings in this systematic review and meta-analysis.

Of the included studies, few (Trosman et al.,17 Carole et al.,11 Fehrm et al.,8 and Paula et al.,16) utilized randomization, which serves to reduce selection bias. Still, some other studies omitted randomization, introducing an allocation bias potential, in which the treatment allocation may have been affected by non-random factors. The lack of blinding in all studies is the other prominent limitation, since detection bias risk increases, which suggests that participants or assessors were affected by their knowledge of what intervention was delivered. Though challenging in surgery research, a lack of blinding lowers the internal validity of evidence.

 

In terms of sample size adequacy, Carole et al.,15 and Marcus et al.,11 both used large sample sizes, which lessened the chances of small-study effects and increased the generalizability of their results. Trosman et al.,17 and Fehrm et al.,8 used small sample sizes, such that their results were less representative of the larger pediatric OSA population.

 

Selective reporting bias was high risk in Trosman et al.,17 Huang et al.,13 and Locci et al.,14 indicating that some results might have been selectively reported, epphasizing significant outcomes at the expense of non-significant results. However, Carole et al. and Paula et al. presented more inclusive reporting, minimizing selective bias.

 

One of the major concerns was funding source bias since the majority of studies did not disclose their funding sources, thus raising questions on whether industry sponsorship had an effect on study outcomes. Carole et al. was solely an industry-funded study, thus leaving open the potential for funding bias, whereas Marcus et al. and Paula et al. were funded by academia, thus minimizing the potential for financial conflicts to result in biased study outcomes.

 

Attrition bias was also assessed, with Huang et al.,13 being high in attrition bias, reflecting a large number of participant dropouts that may have affected the reliability of the end results. The majority of the other studies had moderate to low attrition bias, reflecting greater participant retention throughout the follow-up duration.

 

The highest risk of bias was noted in Trosman et al.,17 Huang et al.,13 and Locci et al.,14 mostly because of selective reporting and lack of randomization. In contrast, Carole et al.,15 and Paula et al.,16 had the lowest total risk of bias, thus making their results more trustworthy and generalizable to the general population.

 

Although adenotonsillectomy seems to be of value in pediatric OSA, the absence of blinding in all the studies is a serious limitation, with the risk of bias when measuring outcomes. The heatmap offers an instant self-check to assess the reliability of the included studies, informing future sensitivity analyses or possible exclusions in meta-analysis to ensure sound and unbiased conclusions.

 

Table 2: Random effects meta-analysis

Outcome	Random- Effects Mean Difference	Heterogeneity (I²)	Interpretation
AHI (Apnea- Hypopnea Index)	-1.66	98.92% (High)	Significant variation in effect sizes across studies, suggesting different populations or methodologies.
QOL (Quality of Life)	-3.98	98.80% (High)	Large variations in QOL measures  due to different scoring systems or patient demographics.
PSG (Polysomnography)	-1.66	98.92% (High)	High variability suggests inconsistent PSG parameter effects across studies.

 

The random-effects meta-analysis examined the impact of adenotonsillectomy (ATE) versus watchful waiting (WW) on Apnea-Hypopnea Index (AHI), Quality of Life (QOL), and Polysomnography (PSG) outcomes in children with obstructive sleep apnea (OSA). The results indicate a trend toward improvement across all three outcome measures following surgery; however, high heterogeneity (I² > 98%) suggests substantial variability in effect sizes across studies, limiting statistical certainty.

 

For AHI, the random-effects mean difference was -1.66, indicating a reduction in apnea severity following adenotonsillectomy. However, the high heterogeneity (I² = 98.92%) suggests significant variation in effect sizes across studies, likely due to differences in study populations, OSA severity, and follow-up durations. This variability implies that while adenotonsillectomy generally reduces AHI, its impact may differ depending on individual patient characteristics.

 

Likewise, the QOL meta-analysis had a mean difference of -3.98 in favor of improved quality of life after surgery. Yet, the heterogeneity was still high (I² = 98.80%), with significant differences in QOL measurement across studies. The difference might be due to variation in the QOL measuring tools, variations in patient outcomes, and variations in follow-up periods. The findings indicate that adenotonsillectomy has a beneficial effect on QOL, yet the magnitude of improvement can differ significantly between different populations and methods of measurement.

 

For PSG measures, the mean difference was -1.66, once more demonstrating a trend towards improvement after surgery. The high heterogeneity (I² = 98.92%) indicates that the impact of adenotonsillectomy on PSG results is variable between studies. Differences in PSG scoring systems, sleep study procedures, and sample sizes could have caused the observed variations. Although the results point towards improvement in objective measures of sleep, inconsistency between studies identifies the importance of standardized methods of PSG assessment in future studies.

 

The outcomes of this meta-analysis indicate that adenotonsillectomy is correlated with AHI, QOL, and PSG improvement. Nevertheless, high heterogeneity (I² > 98%) shows that the effect sizes are significantly diverse among studies, probably due to variations in population characteristics, study design, and outcome measures used. These results highlight the importance of subgroup analysis to identify which children with OSA will benefit most from early surgery. Also, future research needs to strive towards more standardized testing protocols to limit heterogeneity and enhance the reliability of findings about the efficacy of adenotonsillectomy in the treatment of pediatric OSA.

 

Discussion

This meta-analysis and systematic review compared the long-term outcomes of watchful waiting (WW) versus immediate adenotonsillectomy (ATE) in pediatric obstructive sleep apnea (OSA) children with regard to the main outcomes of Apnea-Hypopnea Index (AHI), Quality of Life (QOL), and Polysomnography (PSG) measures. The results indicate that adenotonsillectomy offers improvements in AHI, QOL, and PSG parameters but were not statistically significant because of extreme heterogeneity between studies (I² > 98%). The subsequent discussion discusses these results in light of current literature and possible clinical implications.

 

The AHI reduction in our meta-analysis had a mean difference of -1.66 in favor of surgery over watchful waiting. But it was not statistically significant (p = 0.170), with extreme heterogeneity (I² = 98.92%). The findings are consistent with the Childhood Adenotonsillectomy Trial (CHAT) by Marcus et al., carried out in 201311, which presented significant improvement in AHI in the adenotonsillectomy group vs. WW at 7-month follow-up. But CHAT also showed that children in the WW group had some spontaneous improvement of OSA severity, supporting the contention that mild cases can remit spontaneously.

 

A more recent systematic review by Tsikopoulos et al., (2024)12 similarly reported variable AHI reductions following adenotonsillectomy, but highlighted that age, obesity, and baseline OSA severity influenced treatment response. Our study's findings are consistent with this, suggesting that AHI outcomes are not universally improved, likely due to patient-specific factors such as BMI, craniofacial structure, and follow-up duration.

 

The QOL meta-analysis demonstrated a mean effect size of -3.98 favoring adenotonsillectomy, but with a wide confidence interval (-575.84 to 567.88) and high heterogeneity (I² = 98.80%). While trends indicate that children undergoing surgery experience improved sleep quality, behavior, and overall well-being, the variability in QOL assessment tools across studies limits the ability to draw definitive conclusions.

 

Previous studies, such as Aurora et al. (2017)6 and Mitchell et al. (2004),19 found significant QOL improvements in children undergoing adenotonsillectomy, particularly in domains such as sleep disturbance, physical health, and cognitive functioning. However, a study by Lee et al., (2015)20 suggested that while early surgical intervention provides rapid symptom relief, long- term QOL outcomes between ATE and WW groups may converge, particularly in children with mild OSA.

 

The PSG meta-analysis found sleep parameter improvements, but like AHI, the mean difference of -1.66 was not statistically significant. PSG measures like oxygen saturation, arousal index, and sleep efficiency were variably reported between studies and had high heterogeneity (I² = 98.92%).

 

Bandyopadhyay et al., (2020)4 reported large PSG improvements after adenotonsillectomy in non-obese children, and Li et al. (2022)21 observed that the changes in PSG parameters were more evident in younger children with severe baseline OSA. This indicates that subgroup analyses by obesity status, age, and OSA severity can further enhance our knowledge of which patients benefit most from surgery.

 

Clinical Implications

The results of this meta-analysis offer clinicians treating pediatric OSA valuable information, especially in mild-to-moderate disease. Though adenotonsillectomy can be seen to have advantages in the reduction of AHI, QOL improvement, and changes on PSG, the high level of heterogeneity in effect sizes indicates that surgical therapy should be individualized according to each patient's characteristics. Some important conclusions arise from this analysis:

1. Subgroup Analysis Needed: Future studies should focus on stratifying patients by obesity status, craniofacial abnormalities, and baseline OSA severity to better identify which populations benefit most from early surgery.

2. Watchful Waiting as an Alternative: Given that some children in the WW group demonstrated spontaneous improvement, non-surgical management should be considered in mild cases, especially if symptoms do not significantly impact daily functioning.

3. Standardized QOL and PSG Assessments: The lack of uniformity in QOL measurement tools and PSG protocols across studies underscores the need for standardized assessment criteria in future research to enhance comparability.

4.   Long-Term Follow-Up is Critical: Studies with longer follow-up durations (beyond 24 months) are needed to assess whether early surgical intervention leads to sustained neurocognitive and growth benefits.

 

Limitations and Future Directions

Several limitations in our meta-analysis should be considered:

• High heterogeneity (I² > 98%) across studies, likely due to differences in study design, inclusion criteria, and outcome assessment tools.

• Small sample sizes in some studies, which may have limited the statistical power to detect significant effects.

• Potential publication bias, as suggested by the asymmetry in funnel plots, indicating that studies with non-significant results may be underreported.

 

To address these issues, future research should prioritize large-scale, multicenter randomized controlled trials (RCTs) with standardized methodologies, longer follow-up periods, and subgroup analyses based on patient-specific characteristics.

 

Conclusion

This meta-analysis highlights the potential benefits of adenotonsillectomy in improving AHI, QOL, and PSG parameters, but emphasizes that the variability in treatment effects necessitates a personalized approach to clinical decision-making. While immediate surgery may be beneficial for children with moderate-to-severe OSA, watchful waiting remains a viable option in mild cases, particularly where spontaneous improvement is possible. Future studies should focus on identifying patient subgroups that derive the most benefit from early surgical intervention and implementing standardized QOL and PSG assessment tools to reduce heterogeneity and improve the reliability of evidence.

 

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