Where a Child Lives Shapes Whether They Get a Sleep Test Before Tonsil Surgery

For children with suspected obstructive sleep apnea, the polysomnogram is the diagnostic gold standard: an overnight recording of brain waves, breathing, oxygen saturation, and limb movements that tells clinicians whether a snoring child is merely noisy at night or genuinely struggling to breathe during sleep. Yet according to a commentary published in the Journal of Clinical Sleep Medicine by Madeleine Grigg-Damberger of the University of New Mexico School of Medicine, whether an American child actually receives this test depends less on the severity of their symptoms than on where they live, what insurance they carry, and the color of their skin. Writing about new analyses of polysomnography use among children enrolled in Medicaid, Grigg-Damberger argues that the geography of pediatric sleep medicine in the United States is a patchwork, and that the children most likely to benefit from objective testing are often the least likely to get it.

The commentary, published in October 2026, draws attention to research examining geographic and racial and ethnic patterns of polysomnography use among Medicaid-enrolled children between 2017 and 2019, a body of work led by investigators including C. Christine McLaughlin, Jamie L. Hawke, Emily F. Boss, and their colleagues. Medicaid covers roughly forty percent of American children, making it the single largest payer of pediatric care in the country, and an ideal lens through which to observe how diagnostic practice varies when financial barriers at the point of care are nominally removed. What those data reveal is not a smooth national distribution of sleep testing but stark regional and demographic gradients that persist even among children who share the same insurance coverage.

The clinical stakes are considerable. Obstructive sleep apnea in children affects an estimated one to five percent of the pediatric population, and its consequences extend far beyond disrupted nights. Chronic intermittent hypoxia and fragmented sleep during critical developmental windows are associated with behavioral problems, impaired attention and learning, cardiovascular strain, and metabolic dysfunction. The standard treatment for most children is adenotonsillectomy, the surgical removal of the adenoids and tonsils, which resolves airway obstruction in the majority of cases. Clinical practice guidelines from the American Academy of Pediatrics and the American Academy of Otolaryngology recommend polysomnography before surgery in most circumstances, particularly for children under three, those with obesity, craniofacial anomalies, neuromuscular disease, or other risk factors for perioperative respiratory complications.

The rationale for preoperative testing is grounded in physiology and surgical safety. The apnea-hypopnea index measured during a polysomnogram quantifies how many times per hour a child’s airflow collapses or diminishes, and children with severe obstruction face elevated risks of postoperative respiratory events, including oxygen desaturation, airway obstruction during anesthesia recovery, and the need for unplanned intensive care admission. Studies of children undergoing adenotonsillectomy have repeatedly identified preoperative polysomnographic severity as one of the strongest predictors of these complications, alongside young age, obesity, and cardiac findings. Knowing a child’s baseline severity allows anesthesiologists and surgeons to plan appropriate monitoring, choose the right postoperative setting, and anticipate trouble before it happens in the recovery room.

Yet the commentary makes clear that adherence to this testing paradigm is anything but uniform. Children enrolled in Medicaid, and children from Black, Hispanic, and other minoritized racial and ethnic groups, are consistently less likely to undergo polysomnography before adenotonsillectomy than privately insured white children, and regional variation compounds these disparities. In some parts of the country, preoperative sleep testing is routine; in others, it is the exception. The result is a system in which two children with identical symptoms and identical surgical indications may receive fundamentally different workups depending on their zip code and their family’s background.

The drivers of this variation are multifactorial, and Grigg-Damberger’s commentary situates the new utilization data within a decade of accumulated evidence. Access to pediatric sleep laboratories is geographically concentrated: accredited facilities cluster around academic medical centers and large metropolitan hospitals, leaving families in rural areas and smaller communities facing long travel distances, waiting lists that stretch for months, and the logistical burden of overnight stays far from home. For a parent working an hourly job without paid leave, an overnight sleep study two hundred miles away is not a neutral inconvenience; it can be an insurmountable barrier. Where sleep laboratories are scarce, clinicians may reasonably default to operating on clinical judgment alone, a practice the guidelines permit in uncomplicated cases but which can miss severe disease in children who look deceptively healthy by day.

Racial and ethnic disparities add a second, more troubling layer. Prior studies of tonsillectomy utilization among Medicaid-insured children have documented that Black children are less likely to receive the surgery at all despite comparable or greater disease burden, and surveys of families suggest that caregiver willingness to consider surgery varies with trust in the medical system, the quality of counseling received, and prior experiences of care. Children from minoritized groups also carry a higher baseline prevalence of severe sleep-disordered breathing, driven in part by higher rates of obesity and asthma, which makes under-testing particularly consequential: the children at greatest perioperative risk are precisely those least likely to have that risk quantified before they reach the operating room.

The commentary also engages with a genuine clinical debate: whether routine polysomnography before adenotonsillectomy is always necessary, or whether selective testing is a defensible way to conserve scarce laboratory capacity. Some investigators have argued that for the typical healthy child with clear-cut tonsillar hypertrophy and classic symptoms, surgery without a sleep study is reasonable and that mandatory testing introduces delay and cost without changing outcomes. Others counter that clinical signs correlate poorly with objective severity, that snoring frequency in young children predicts cognitive and behavioral problems better than the apnea-hypopnea index itself, and that skipping the test systematically disadvantages children whose symptoms are dismissed or whose families lack the advocacy needed to push for referral. The disagreement is not merely academic; it determines how scarce testing resources should be allocated and whether the current pattern of underuse in vulnerable populations should be read as clinical pragmatism or as inequity.

What makes the new utilization data so striking is that they emerge from a population in which insurance itself should not be the limiting factor. Medicaid removes the out-of-pocket cost barrier that private deductibles can create, yet disparities persist, which points to structural and systemic explanations: the uneven distribution of pediatric sleep medicine infrastructure, referral patterns that differ by practice setting, differences in how symptoms are perceived and communicated across cultural and linguistic lines, and the cumulative effect of fragmented care for children who move between providers. Grigg-Damberger’s framing, borrowed from the real estate mantra, is deliberate: location, location, location. A child’s address predicts their access to diagnosis in ways that clinical guidelines have not yet overcome.

The path forward, as the commentary implies, requires both measurement and infrastructure. Telemedicine-based sleep assessment, home sleep apnea testing adapted for children, and expanded training for pediatric sleep technologists could extend diagnostic capacity beyond academic centers. Quality measures that track preoperative testing rates by region and by demographic group would make the disparities visible to payers and health systems in a way that individual clinicians cannot easily see. And the underlying research, published in the Journal of Clinical Sleep Medicine, provides the kind of population-level evidence that policy interventions demand. Until then, the overnight sleep study that should precede most pediatric tonsil surgeries will remain, for too many American children, a test determined not by the severity of their disease but by the accident of where they were born.

Subject of Research: Geographic and racial/ethnic disparities in pediatric polysomnography use among US Medicaid-insured children

Article Title: Location, location, location: wide geographic and racial/ethnic variations in pediatric polysomnography in US Medicaid children

Article References: Grigg-Damberger, M. (2026). Location, location, location: wide geographic and racial/ethnic variations in pediatric polysomnography in US Medicaid children. Journal of Clinical Sleep Medicine, 22(1), Article 184. https://doi.org/10.1007/s44470-026-00170-z

Image Credits: AI Generated

DOI: 10.1007/s44470-026-00170-z

Keywords: polysomnography, pediatric sleep apnea, Medicaid, adenotonsillectomy, health disparities, sleep-disordered breathing, tonsillectomy, geographic variation, Journal of Clinical Sleep Medicine, obstructive sleep apnea, pediatric otolaryngology, health equity