Is watchful waiting an alternative to adenotonsillectomy in children with mild to moderate obstructive sleep apnoea?

UNLABELLED: Adenotonsillectomy (ATE) has traditionally been the first-line treatment for obstructive sleep apnoea (OSA) in children. Increasing evidence suggests that many children with mild to moderate OSA may improve without surgery. This mini-review examines whether watchful waiting is a safe and effective alternative to ATE in otherwise healthy children with mild to moderate OSA. We searched PubMed from inception to January 2026 for randomised controlled trials (RCTs) comparing ATE with watchful waiting in children aged 1-16 years with OSA or sleep-disordered breathing confirmed by polysomnography or a validated symptom score. Two reviewers independently screened and extracted data. Results were analysed qualitatively. Five RCTs (seven published reports; n = 1287 children; mean age 6.1 years) met inclusion criteria. Spontaneous OSA resolution occurred in 44-55% of children managed with watchful waiting, compared with 57-79% following ATE. ATE produced statistically greater reductions in the apnoea-hypopnoea index in four of five trials, but between-group differences were modest. The largest and most consistent effects of ATE were seen for OSA symptom scores. CONCLUSION: Watchful waiting is a reasonable option for young, nonobese children with mild OSA, given the relatively high rates of spontaneous resolution. ATE remains appropriate for children with moderate to severe OSA. Shared decision-making, individualised care and close follow-up are essential when watchful waiting is chosen. WHAT IS KNOWN: • Otherwise healthy children with obstructive sleep apnoea due to adenotonsillar hyperplasia are usually managed with adenotonsillectomy. • Young, non-obese, Caucasian children with more mild obstructive sleep apnoea, however, showed a surprisingly high probability of spontaneous resolution of the disease in one study. WHAT IS NEW: • High rates of spontaneous resolution of obstructive sleep apnoea were observed in four independent studies, ranging from 44% to 55%. • Watchful waiting for several months may, thus, be a reasonable management option in a particular low-risk group of children with obstructive sleep apnoea.