Watchful Waiting for Mild Snoring in Children: Symptoms Linger Even When Sleep Studies Stay Stable

When a child snores most nights but an overnight sleep study shows only mild breathing disturbances, parents and doctors face a genuinely difficult choice: operate now, or wait and see? A new analysis of one of the largest randomized trials in pediatric sleep medicine offers the most detailed picture yet of what actually happens when families choose to wait. The findings, drawn from the Pediatric Adenotonsillectomy Trial for Snoring, known as PATS, reveal a striking disconnect between what sleep laboratories measure and what families experience at home. Only a small minority of children showed objective worsening on repeat polysomnography after a year of observation, yet more than half continued to carry a heavy burden of symptoms. The study, published in the Journal of Clinical Sleep Medicine, suggests that the decision to defer surgery deserves far more nuance than a simple wait-and-see approach often implies.

The underlying research drew on the control arm of PATS, a multicenter randomized controlled trial conducted from 2016 to 2021 at seven tertiary referral centers across the United States. The trial enrolled children aged 3.0 to 12.9 years who snored at least three nights per week and had an obstructive apnea-hypopnea index, or oAHI, below 3 events per hour, along with enlarged tonsils of Brodsky grade II or greater. Children were randomly assigned to early adenotonsillectomy or to watchful waiting with supportive care. In this secondary analysis, the researchers focused on the 234 children who did not undergo surgery, a group with a mean age of 6.2 years that included 111 girls, 65 children of Black or African American race, and 37 children of Hispanic ethnicity. The analysis was exploratory rather than prespecified, and the investigators followed observational study reporting guidelines while leveraging the rigor of the original trial’s standardized protocols.

The technical core of the study rested on two distinct definitions of progression. The first was polysomnographic: a child was considered to have progressed if the oAHI on a repeat overnight sleep study reached 3 or more events per hour at 12 months. All sleep studies were scored centrally by certified technologists blinded to each child’s clinical presentation, according to American Academy of Sleep Medicine pediatric rules. The second definition was symptomatic: a caregiver-completed Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder scale score of 0.33 or higher on the 0-to-1 range, a validated threshold indicating clinically significant symptom impact. The researchers also collected a battery of baseline measures, including the modified Epworth Sleepiness Scale for children, the OSA-18 quality-of-life instrument, behavioral inventories such as the Behavior Rating Inventory of Executive Function and the Child Behavior Checklist, physical examination findings including tonsil grade and palate position, and histories of asthma, allergies, ADHD, and environmental tobacco smoke exposure confirmed where possible by urinary cotinine assays.

The headline result on the objective side was reassuring. Of the 150 children who completed 12-month polysomnography, only 20, or 13 percent, progressed to an oAHI of 3 or greater. The mean baseline oAHI in the cohort was just 0.8 events per hour, and most children’s airway physiology remained stable or improved over the observation year. This finding aligns with earlier evidence that roughly 40 percent of children with mild-to-moderate obstructive sleep apnea show spontaneous improvement within a year without treatment, and that most children with primary snoring never develop frank apnea. For families worried that a year of observation might allow a silent slide into severe disease, the data suggest that such deterioration is the exception rather than the rule, at least over a 12-month horizon in this prepubertal, predominantly non-obese sample.

The symptomatic picture was far less comforting. Among the 192 children with follow-up questionnaire data, 110, or 57 percent, had a high symptom burden at 12 months, and the overwhelming majority of those cases, 94 percent, represented persistence of symptoms that were already elevated at baseline rather than new onset. Nearly three quarters of children whose baseline questionnaire score crossed the clinical threshold still scored above it a year later. Even more telling, among the children whose symptoms persisted or worsened and who also completed repeat sleep studies, only 18 percent had progressed objectively to an oAHI of 3 or greater. In other words, four out of five children whose breathing events remained technically mild still felt the consequences of disrupted sleep, a mismatch that echoes prior work showing that parent-reported symptom scales often mediate the behavioral benefits of adenotonsillectomy better than polysomnographic indices do.

Which children were most likely to get worse? On the objective measure, Black race more than doubled the odds of polysomnographic progression, with an unadjusted odds ratio of 2.71, and a higher baseline symptom score raised the odds by 74 percent per standard deviation. The racial disparity is consistent with findings from the earlier Childhood Adenotonsillectomy Trial, or CHAT, and with a broader literature showing that Black children carry higher rates of sleep apnea, greater severity, and more persistent disease after surgery. The authors point to multifactorial explanations, including chronic exposure to respiratory irritants and allergens common in disadvantaged neighborhoods; notably, Black children in PATS were more likely to live in such neighborhoods. On the symptomatic side, asthma nearly tripled the odds of persistence or progression, ADHD more than tripled them, and tobacco smoke exposure raised them by nearly two and a half times, while worse sleepiness, poorer disease-specific quality of life, and greater behavioral impairment at baseline all pointed in the same direction.

One result defied expectations. Children with larger tonsils, grade III or IV on the Brodsky scale, had lower odds of symptomatic persistence or progression, with an odds ratio of 0.42. Among children with big tonsils, the proportion of caregivers reporting a high symptom inventory dropped from 69 percent at baseline to 49 percent at follow-up, while among children with smaller grade II tonsils the figure barely moved, from 75 percent to 70 percent. The authors propose several mechanisms: a possible ceiling effect in which children with large tonsils are already at maximal obstruction and have room only to improve as tonsils shrink or airways grow, versus children with smaller tonsils whose obstruction may arise from adenoid hypertrophy, diffuse airway inflammation, low pharyngeal muscle tone, or other non-tonsillar sites that a simple oral examination cannot capture. PATS did not assess adenoid size, and the finding is consistent with a long-standing literature showing that tonsil size correlates poorly with objective apnea severity.

The asthma connection deserves particular attention. Asthma and sleep-disordered breathing are known to reinforce each other bidirectionally: children with asthma are roughly twice as likely to have sleep-disordered breathing, asthma severity tracks with sleep apnea severity, and disrupted sleep worsens asthma control. Within PATS, both study arms received referral for asthma management as part of supportive care, yet at follow-up only 39 percent of children with asthma in the surgery group had high symptom scores compared with 74 percent in the observation group. Although a separate analysis of surgery’s effect on asthma symptoms did not reach statistical significance, the pattern suggests that optimizing asthma treatment alone did little to relieve sleep-related symptoms over a year of watchful waiting, lending support to earlier surgery for children whose mild snoring coexists with asthma.

How useful are these variables for prediction in practice? The honest answer is: modestly. The best multivariable model for polysomnographic progression, combining Black race, REM-sleep apnea index, and the baseline symptom score, achieved an area under the curve of only 0.70, barely better than the 0.62 achieved with clinical variables alone. For symptomatic persistence, the model pairing the baseline questionnaire score with tonsil grade performed better, reaching an AUC of 0.85, but the authors caution that the exploratory analysis was not powered to build a definitive risk calculator, and confidence intervals around several predictors were wide. The study also excluded children with severe obesity, recurrent tonsillitis, and major chronic illness, so the findings apply most directly to the prepubertal, otherwise healthy snorers who dominate typical clinic populations.

The clinical message that emerges is subtle but actionable. A single repeat sleep study a year later captures only the small minority of children whose breathing physiology objectively worsens, and it may miss the larger group whose symptoms, behavior, and quality of life remain impaired even as their apnea index stays low. For the symptomatic snoring child, the authors suggest, repeated symptom assessment and attention to behavioral and quality-of-life impacts may guide decisions better than polysomnography alone. Children who are Black, or who have asthma, ADHD, tobacco smoke exposure, or a heavy baseline symptom burden, may be stronger candidates for earlier adenotonsillectomy than their peers. As the largest controlled dataset yet assembled on this question, the analysis reframes watchful waiting not as a passive default but as a monitored strategy with identifiable risk profiles, and it sets the stage for longer, larger studies to determine which children truly benefit from waiting and which would be better served by operating sooner.

Subject of Research: Progression and symptom persistence of mild sleep-disordered breathing in children managed with watchful waiting instead of adenotonsillectomy

Article Title: Progression of mild sleep-disordered breathing in children managed with watchful waiting

Article References: 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

Image Credits: AI Generated

DOI: 10.1007/s44470-026-00082-y

Keywords: pediatric sleep apnea, sleep-disordered breathing, adenotonsillectomy, watchful waiting, polysomnography, snoring, PATS trial, asthma, ADHD, health disparities, tonsil size, Journal of Clinical Sleep Medicine