Removing Tonsils Could Treat Behavior Problems

A surprising number of health and behavior problems -- from ADHD to sleep apnea -- can be treated by removing a child's tonsils.

Check Those Tonsils!

Annie Drohan used to stand next to her 5-year-old's bed every night and listen to her snore and breathe irregularly. "It was terrifying -- sometimes I'd count to 25 before Meghan would take her next breath," says the mom from Torrance, California. Then Meghan's teacher called to say that the kindergartner was falling asleep in class and seemed unfocused and easily distracted. "Meghan had been so bright that she'd started school early, but now her teacher wanted to hold her back a year," says Drohan. "My daughter was also gaining a lot of weight and even had trouble running around and keeping up with her friends."

Meghan's pediatrician attributed all of her symptoms -- which included frequent colds and a constant runny nose -- to allergies and prescribed antihistamines and steroid nose spray. Convinced that something else was wrong, Drohan decided to take her daughter to see Nina Shapiro, MD, a pediatric otolaryngologist at UCLA, who gave Meghan a totally different diagnosis: enlarged tonsils. "When Dr. Shapiro advised surgery, the first thing I thought of was how sick I felt after I had my own tonsils out as a kid," says Drohan. But when Meghan had the procedure last year, she was outside playing within the week. More importantly, she quickly stopped snoring and having breathing troubles, and within a couple weeks, her other symptoms -- both at home and at school -- completely disappeared.

Parents often assume that tonsillectomies are a thing of the past, but they're actually the second most common childhood surgery (following ear-tube insertions), with more than 600,000 performed every year. And 75 percent of these procedures are now done to treat nighttime breathing problems like Meghan's and related symptoms. "Unfortunately, a lot of these symptoms are easy for both doctors and parents to brush off, so a child's tonsils can get overlooked," says Marcella Bothwell, MD, a pediatric otolaryngologist at the University of Missouri, in Columbia. But getting an accurate diagnosis is essential.

Don't Ignore Snoring

Tonsils -- two masses of tissue in the back of the throat -- help trap incoming viruses and bacteria. It's common for children's tonsils and their adenoids (similar lumps of tissue high in the throat behind the nose) to become enlarged between ages 2 and 7; since young kids' throats are narrow, the swelling can partially block their airways. "Enlarged tonsils are the main cause of sleep apnea, a condition in which kids snore and momentarily stop breathing repeatedly during the night," says Dr. Shapiro. Although only about 1 percent of children have sleep apnea, about 10 percent of kids snore almost every night, according to the American Academy of Otolaryngology-Head and Neck Surgery.

But even mild snoring can have serious consequences: Children who snore regularly are about four times more likely to have symptoms of ADHD, according to research at the University of Michigan, in Ann Arbor. Any disrupted breathing at night may reduce the amount of oxygen that goes to the brain. "There are many possible symptoms, including restless sleep, difficulty waking, morning headaches, and daytime behavior problems such as irritability, hyperactivity, and an inability to focus," says Parents advisor Jodi Mindell, PhD, associate director of the Sleep Center at Children's Hospital of Philadelphia. The consequences can be long-lasting: One study found that young kids who snored were more likely to have poor academic performance in middle school.

Last year, Christina Butler began to worry about her 5-year-old, Christopher, who seemed increasingly grumpy. "He would constantly cry over little frustrations like not being able to finish a puzzle," recalls Butler, of New Vernon, New Jersey. "We knew he wasn't sleeping well because he'd thrash all over the bed." But it never occurred to her that his tonsils were to blame. "We finally took Christopher to an ear, nose, and throat doctor, who took one look down his throat and said, 'His tonsils are huge!'"

Believe it or not, big tonsils can also cause bedwetting. "When kids with nighttime breathing problems finally fall soundly asleep, they can go into such a deep sleep that they lose bladder control," says Jay Dolitsky, MD, an otolaryngologist at New York Eye and Ear Infirmary, in New York City. "I've seen children with enlarged tonsils and sleep-disordered breathing whose main symptom was that they'd started wetting the bed again after having been toilet trained for years."

What's more, the skyrocketing rate of obesity among kids is both a cause and effect of sleep apnea. "An overweight child usually has extra fat on his neck and chest that constricts his airways and makes enlarged tonsils even more of a problem," says Dr. Bothwell. "But it's a vicious cycle. A child develops sleep apnea, and because he's tired during the day, he doesn't have the energy to exercise, so he gains more weight, which makes his sleep apnea even worse."

Drowsy Diagnosis

As kids get older, their tonsils naturally tend to shrink and their airways get wider -- so doctors will only consider removing big tonsils if they're causing specific problems. If your pediatrician suspects that your child has sleep apnea, he'll do a physical exam of her tonsils and neck, and may order an x-ray to determine the size of her airway. If her tonsils are enlarged, the next step is to see an otolaryngologist, who may first recommend an overnight sleep study (done in a specialized lab at a hospital or sleep center) to monitor your child's nighttime breathing.

How it works: You'll arrive a couple hours before your child's normal bedtime, and a technician will attach sensors to his skin. These sensors will measure his heart rate, breathing rate, leg and eye movements, and brain waves while he sleeps in a bed all night. (Centers usually have a cot in the room for parents.) "Most kids don't have any trouble falling asleep in the lab -- it's usually the parents who are awake and nervous," says Dr. Mindell.

If your insurance plan doesn't cover a sleep study, your doctor may ask you to film your child yourself. "I often have parents make a videotape of their child sleeping, and most of the time I can tell by watching it whether a child has enlarged tonsils that are causing sleep apnea," says Dr. Bothwell.

Twenty-five percent of all tonsillectomies are still done to treat chronic sore throats, although doctors are less likely to remove tonsils for this reason than they used to because most infections can be easily treated with antibiotics. "Thirty years ago, doctors were quick to opt for surgery. Now we think kids don't really benefit unless they have at least seven throat infections in one year," says Dr. Dolitsky.

A Truly Quick Fix

Tonsillectomies are actually an ancient operation: The first one reported was done in A.D. 30 by the Roman surgeon Celsus, who described tearing the tonsils out with a hook. Thankfully, we've come a long way since then. Today, there are two different types of tonsillectomy: the traditional approach, in which the whole tonsils (and usually adenoids) are removed, and a newer procedure, the subtotal tonsillectomy, in which the surgeon leaves a little tissue behind to protect the throat muscles, blood vessels, and nerves. "This technique is usually less painful and kids recover faster -- typically within four or five days instead of seven to 10," says Joseph Bernstein, MD, a pediatric otolaryngologist at the New York University School of Medicine, in New York City.

There are also new methods for removing tonsils. The Harmonic Scalpel and the Coblator use ultrasonic and radio-frequency energy to dissolve tonsils. A study published this year found that kids who underwent a total tonsillectomy with the Coblator reported less discomfort over a 10-day period than those who had surgery with other methods. "We were amazed by how quickly Christopher bounced back after the coblation," says Butler. "We gave him lots of ice cream, but by the next evening, he didn't need any pain medication and was eating regular food."

You might have to stock your freezer with pints of Haagen-Dazs for a week, but the 15-minute surgery will probably have a major impact on your child's life. Tonsillectomy will cure sleep apnea in almost 90 percent of kids, according to a recent study at the University of Michigan Health System. The 22 kids in the study who'd previously been diagnosed with ADHD all saw an improvement in their symptoms; a year later, half had no associated behavior problems at all. "Parents are always shocked at what a difference surgery makes, but even after four to six weeks, kids are more alert and better able to focus," says Dr. Dolitsky.

"Meghan is like a different child since the operation -- she's reading on a third-grade level, she's lost about 10 pounds, she no longer needs allergy drugs, and she's playing on her school's soccer team," says Drohan. "Now that she's sleeping well at night, she just seems happier -- and that's what really matters."

Surgery Specifics

  1. How to prepare your child: If she's under 3, she's probably too young to understand what's going on, but she can pick up on your anxiety. If she's between 3 and 6, she'll likely be scared. "It's best to be honest and say, 'You're going to have an operation. Your throat will hurt afterward, but we'll give you medicine to make it hurt a lot less,'" suggests Dr. Joseph Bernstein. Reassure her that many kids have gone to the hospital for the same reason and you'll be with her the whole time.
  2. What happens at the hospital: Your child usually can't eat solid food or drink on the morning of surgery. You'll be able to sit next to him and hold his hand in the operating room while he inhales the anesthesia; in about 30 seconds, he'll be asleep and the surgeon will ask you to leave the room. "Most hospitals will make sure that you're in the recovery room when your child wakes up, so he'll feel like he's never been separated from you," says Dr. Nina Shapiro.
  3. The road to recovery: Your child may be able to go home just 90 minutes after surgery. Doctors usually advise giving your child acetaminophen with codeine as needed every four hours while she's awake. Kids will resume a normal diet within three days but should avoid foods with sharp edges for a couple of weeks. Your child should be ready to return to school within a week. Doctors advise avoiding strenuous activities for two weeks. About 5 percent of kids experience bleeding from the surgery site and may need additional care.

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