A response to “What is better RME or watchful waiting for pediatric OSA”?
Last week, I wrote a post on the effects of RME or watchful waiting on paediatric Obstructive Sleep Apnoea. This attracted a lot of comments and sparked some controversy. As is customary with my blog, I always offer a blog post to anyone who offers a different perspective from mine. Dr. Dave Singh has taken me up on this offer and provided his viewpoint.
Prof Dave Singh is an Adjunct Professor in Sleep Medicine at Stanford University, USA. He is a member of the American Academy of Sleep Medicine and the World Sleep Society. He invented the first palatal expander to be FDA-cleared for the treatment of mild-moderate as well as severe obstructive sleep apnea in adults. Finally, he has published over 200 articles in the peer-reviewed medical, dental, and orthodontic literature.
Introduction
Pediatric obstructive sleep apnea (pOSA) is a complex condition. This may include differential diagnoses, such as upper airway resistance syndrome (UARS), sleep bruxism, etc. Furthermore, its management is a controversial topic. Rapid maxillary expansion (RME) is a treatment option advocated for pOSA, especially when a narrow or constricted palate is identified clinically.
RME aims to widen the upper jaw, increase the space available to accommodate the tongue and improve airflow during sleep. This treatment may be beneficial for children with pOSA or those experiencing other associated symptoms that impact their quality of life. However, the underlying mechanism(s) of pOSA correction remains elusive since the nasal airway, adenotonsillar hypertrophy, arousal index, upper airway tonicity, and childhood obesity, inter alia, contribute to phenotypic heterogeneity.
Evidence on the role of RME
In fact, opinion remains deeply divided on the efficacy of RME for treating pOSA, and a recent systematic review [1] suggested that watchful waiting (WW) might be a better option than RME. However, those conclusions were based on only one randomized clinical trial comparing RME with WW, while claiming that “gold-standard treatment adenotonsillectomy” is the preferred intervention for pOSA. In contrast, other retrospective reviews attest to persistent pOSA even after tonsillectomy [2, 3], while a recent prospective clinical trial [4] indicated that RME might, in fact, be beneficial for persistent snoring in children post-tonsillectomy.
Despite the above contentions, the basis for WW must be weighed against other evidence. One literature review [5] concluded that RME can only be considered as a last choice of treatment when other options have failed in patients with pOSA.
The review’s recommendations were based, in part, on 3 groups of retrospective studies. The first group, consisting of 8 studies examining nasal breathing, found benefits associated with RME with moderate levels of evidence. The second group, consisting of 4 studies examining pOSA, found benefits associated with RME with moderate to low levels of evidence. The third group, consisting of 4 studies examining nocturnal enuresis, found benefits associated with RME with moderate to low levels of evidence. Therefore, the recommendations of the literature review were based primarily on the quality of the studies and not on the clinical findings per se.
In contrast, another retrospective systematic review and meta-analysis [6] reported clinical outcomes from 17 studies (314 children; 7.6 ± 2.0 years old). They found that an improvement in the apnea-hypopnea index (AHI) and oxygen saturation in children undergoing RME in the short term (< 3yrs). These findings contrast starkly with the claim that spontaneous resolution of pOSA may explain the observed benefits of RME [1]. In addition, we cannot ignore quality of life issues associated with untreated pOSA during childhood through adolescence.
What did I think?
In conclusion, watchful waiting is a medical approach used when the risks or side effects of immediate treatment outweigh potential benefits or when the condition being monitored may resolve on its own without any intervention. The clinician managing pOSA must weigh the watchful waiting approach against the “do no harm” principle of medical ethics. The principle essentially means that clinicians should strive to avoid causing harm, both through actions and through omissions. Finally, additional high-quality studies on the management of pOSA and pediatric sleep-disordered breathing are still needed, as well as an examination of the potential benefits of working closely with our medical colleagues on a multi-disciplinary basis.
Conflicts of interest: None
References
- Fernández-Barriales M, Lafuente-Ibáñez de Mendoza I, Alonso-Fernández Pacheco JJ, Aguirre-Urizar JM. Rapid maxillary expansion versus watchful waiting in pediatric OSA: A systematic review. Sleep Med Rev. 2022;62:101609.
- Pomerantz J. Management of persistent obstructive sleep apnea after adenotonsillectomy. Pediatr Ann. 2016;45(5):e180-3.
- Fields CM, Poupore NS, Barengo JH, Smaily H, Nguyen SA, Angles J, Clemmens CS, Pecha PP, Carroll WW. Does REM AHI predict persistent OSA after pediatric adenotonsillectomy? Ann Otol Rhinol Laryngol. 2024:34894241227030.
- Bariani RCB, Bigliazzi R, de Moura Guimarães T, Tufik S, Moreira GA, Fujita RR. The effects of rapid maxillary expansion on persistent pediatric snoring post-tonsillectomy. Sleep Breath. 2023;27(4):1227-1235
- Eichenberger M, Baumgartner S. The impact of rapid palatal expansion on children’s general health: A literature review. Eur J Paediatr Dent. 2014;15(1):67-71.
- Camacho M, Chang ET, Song SA, Abdullatif J, Zaghi S, Pirelli P, Certal V, Guilleminault C. Rapid maxillary expansion for pediatric obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope. 2017;127(7):1712-1719.
Emeritus Professor of Orthodontics, University of Manchester, UK.
Amid the turmoil of the original responses to the prior post, it is refreshing to read a professional response and rebuttal.
To the point of some of the literature cited, I will share my opinion that pediatric OSA research must include three things in order to be valid.
The first is polysomnography (PSG) tests, to confirm the presence or absence of OSA. Questionnaires may indicate a susceptibility to OSA, or a probability. However, IMO, PSG is necessary to concretely establish the presence or absence of OSA. IMO without PSG, the research must frequently be discounted or disregarded.
The second is that, a control group must be used. Children grow and things change. We cannot be certain a claimed benefit of treatment wouldn’t have occurred anyway just through normal growth, without a control group. The author does list some research that meets these two requirements.
The third condition especially applies for research on children, PSG must be from at least 3 time points. Before and after treatment points are obvious, as that confirms the presence or absence of OSA. However, a time point sufficiently later is also required to assure that there is a long term difference.
Consider, perhaps palatal expansion in some research might achieve a reduction in AHI scores on a PSG immediately post treatment. However, if 6 months, or a year, or two years later the AHI scores are the same, it would appear that pediatric expansion could be declared ineffective when considered over that time frame.
There is a prior orthodontic analogy that applies here. By now we are all aware of research showing that functional appliances may achieve greater mandibular anterior displacement in the short run. However, when we look at the third and later time point at growth cessation, there is no difference in mandibular growth between the treated and control groups.
In this case, the author does not present research that fills all criteria, PSG for the diagnosis, a control group to compare what happens without treatment, and a sufficiently later time point to establish that the benefits of expansion, if any, are are not just short lived and temporary.
Thanks both Dave and Robert for your insightful opinions. I may add that an important piece of the decision process is that we should not, as dentists, suggest WW as an alternative. Such a suggestion would be a medical advice and completely out of our scope of practice – legal consequences could ensue. If we were to identify signs and symptoms of OSA that may imply high risk of the disease we should refer for proper medical diagnosis.
In a patient with a palatal constriction the decision to intervene or not at that given time is within our scope of practice.
I agree that to imply a meaningful effect long-term data should be provided – including QoL and other patient oriented outcomes. The focus on AHI as the only meaningful outcome can be articulated as a naive oversimplification of a very complex chronic disease.
Great discussion. I really appreciate the thoughtful approach to this topic. As a practicing orthodontist, I definitely lean toward the early intervention. The young kids tolerate the expanders very nicely, so management is a breeze. With 3D printed metal appliances now available, we are able to avoid separators, band fitting and alginate imps- the three things kids hate the most about going to the Orthodontist. And we save 2 appointments. Its scan, then deliver all the way.
We focus on the orthodontic benefits of RME and explain thoroughly that we are not diagnosing or treating pOSA. We screen the kids with the Pediatric Screening Questionnaire that has some validity (Thanks Dr. Flores-Mir for turning me on to that!). When they score too highly, we refer them to an ENT or a Pediatric Neurologist in our area. Teamwork is the key. Parents generally truly appreciate our explanation and our approach. Many have reported a life-changing effect for their kids. Many, not all, have been able to avoid T and A. It keeps us connected to the medical world without practicing medicine. Its one of the most fulfilling part of my ortho practice.
“..medical advice and completely out of our scope of practice – legal consequences could ensue.”
Dave, Robert , Carlos, and John have all given sensible advice. As has the AAO white paper on sleep apnea, which carefully explains that sleep apnea is a medical condition. However, there are some signs that some American practitioners need to heed this advice. I experienced confirmation of this problem when recently completing an ACP comprehensive medical history with a new personal physician. There was a question on sleep apnea with the notation that a physician diagnosed the condition. This was the only question that had that caveat. We can safely say that it is a red flag. Another potentially more ominous sign was on a malpractice insurance application form about treating patients for OSA without a physician’s referral. The carrier will most likely inform anyone answering yes that the policy does not cover any procedures outside their legal scope of practice. A scenario could develop where a practitioner is involved in a malpractice/negligence case and is also found guilty of practicing medicine without a valid license, a criminal felony, or a misdemeanor in every state. This will most likely also raise the level of malpractice/negligence to a criminal status. And it gets worse: no liability insurance. Talk about jumping from the frying pan into the fire. I recognize this scenario is highly unlikely, but it only needs to happen once to potentially ruin a career.
I have included links with information you may find interesting:
Journal of Clinical Medicine–#17 ranking:
https://www.mdpi.com/2077-0383/9/3/888
The other link is to the Mayo Clinic’s patient portal on pediatric OSA. I suggest following each pull-down menu:
https://www.mayoclinic.org/diseases-conditions/pediatric-sleep-apnea/symptoms-causes/syc-20376196