Intranasal Corticosteroids for Childhood OSA Syndrome: The Jury Is Still Out

We have read with great interest, the article by Tapia et al1Tapia I.E. Shults J. Cielo C.M. et al.A trial of intranasal corticosteroids to treat childhood OSA syndrome.Chest. 2022; 162: 899-919Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar in CHEST (October 2022) that demonstrated that the administration of intranasal corticosteroids (INCS) to children with mild-to-severe OSA syndrome does not result in a significant decrease in obstructive apnea-hypopnea index (OAHI) or in neurobehavioral, symptom, or polysomnography changes at 3 and 12 months of treatment compared with placebo. The authors propose that their findings do not favor the use of INCS in children with OSA syndrome. We appreciate the important findings presented in the paper by Tapia et al1Tapia I.E. Shults J. Cielo C.M. et al.A trial of intranasal corticosteroids to treat childhood OSA syndrome.Chest. 2022; 162: 899-919Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and wish to comment on some study characteristics that could possibly modify interpretation of the results. The use of INCS has been suggested for children with mild-to-moderate OSA syndrome, and the beneficial effect on upper airway obstruction has been attributed to a reduction in the size of the adenoids, which increases rapidly in children with snoring early in life and does not change thereafter.2Papaioannou G. Kambas I. Tsaoussoglou M. Panaghiotopoulou-Gartagani P. Chrousos G. Kaditis A.G. Age-dependent changes in the size of adenotonsillar tissue in childhood: implications for sleep-disordered breathing.J Pediatr. 2013; 162: 269-274.e264Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar, 3Kaditis A. Alonso Alvarez M.L. Boudewyns A. et al.Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management.Eur Respir J. 2016; 47: 69-94Crossref PubMed Scopus (454) Google Scholar, 4Demain J.G. Goetz D.W. Pediatric adenoidal hypertrophy and nasal airway obstruction: reduction with aqueous nasal beclomethasone.Pediatrics. 1995; 95: 355-364Crossref PubMed Google Scholar, 5Alexopoulos E.I. Kaditis A.G. Kalampouka E. et al.Nasal corticosteroids for children with snoring.Pediatr Pulmonol. 2004; 38: 161-167Crossref PubMed Scopus (104) Google Scholar In the current study, it is not specified whether participants had adenoidal hypertrophy or at least chronic nasal obstruction. In a multicenter, retrospective study, less than 7 years of age and normal weight were favorable predictors of mild OSA syndrome resolution after a 12-week regimen of INCS and oral montelukast.6Kheirandish-Gozal L. Bhattacharjee R. Bandla H.P.R. Gozal D. Antiinflammatory therapy outcomes for mild OSA in children.Chest. 2014; 146: 88-95Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar Of note, in the clinical trial by Tapia et al,1Tapia I.E. Shults J. Cielo C.M. et al.A trial of intranasal corticosteroids to treat childhood OSA syndrome.Chest. 2022; 162: 899-919Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar one-third of the subjects were obese, and more than one-half of the subjects were overweight or obese. Moreover, most children were more than 7 years old (mean age was 8.2 years in the INCS arm and 8.1 years in the placebo arm); approximately one-quarter of them had more than 10 episodes/h at baseline on the OAHI. These three participants’ characteristics may have modified the effect of INCS adversely on the OAHI. Another point that needs to be clarified is the percentage of patients with OAHI score of more than 5 episodes/h who had mild OSA syndrome at 3 months after treatment with INCS or placebo. Children with OAHI scores of less than 5 episodes/h, but without OSA syndrome-associated morbidity or impaired quality of life, do not necessarily need treatment; thus, adenotonsillectomy can be avoided. Although results of the clinical trial by Tapia et al1Tapia I.E. Shults J. Cielo C.M. et al.A trial of intranasal corticosteroids to treat childhood OSA syndrome.Chest. 2022; 162: 899-919Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar do not favor INCS use for pediatric OSA syndrome and given that they are prescribed widely in clinical practice to avoid adenotonsillectomy, we propose that targeted treatment of nonobese 2- to 6-year-old children with mild-to-moderate OSA syndrome and adenoidal hypertrophy should be further explored. The jury for INCS in pediatric OSA syndrome is still out. None declared. A Trial of Intranasal Corticosteroids to Treat Childhood OSA SyndromeCHESTVol. 162Issue 4PreviewIn children with OSAS, treatment with INCS did not result in significant polysomnography, neurobehavioral, or symptom changes at 3 and 12 months of treatment. Twelve months of INCS treatment resulted in a statistically significant but not clinically relevant OAHI reduction. Full-Text PDF