The telltale signs a child may need his tonsils out are pretty common. How many does yours have?

child coughing
Credit: Tara Donne

When my son, Patrick, was 3, he started snoring. We thought it was cute at first. Then, as he got older his snoring got louder, and we noticed that he seemed chronically stuffed up and he breathed through his mouth during the day. Our pediatrician told us that he probably had seasonal allergies, but we took him to an ear, nose, and throat specialist just to be sure. His diagnosis: enlarged adenoids (or in the doctor's words, "Holy smokes! Those are some huge adenoids!"). We worried that this signaled tonsil problems—and possible surgery—since big adenoids can lead to swollen tonsils too. Fortunately, antibiotics cleared up most of Patrick's symptoms and the snoring slowly got better as he got older. His adenoids gradually continued to shrink, and that meant quieter nights—and a less stuffy kid.

We were relieved that he didn't have to have his tonsils or adenoids removed, but nearly 600,000 other kids (mostly between ages 3 and 8) need this surgery every year. Tonsils (those little bumps on both sides in the back of the throat) and adenoids (hidden up in the throat between the nose and mouth) often cause some trouble, but thankfully they aren't considered to be the bad guys they were in the old days. Fifty years ago, between 1 and 2 million kids had their tonsils and adenoids removed annually. "Back in the 1950s and 1960s, doctors just didn't think that tonsils served much of a purpose," says Brian Wiatrak, M.D., a pediatric ear, nose, and throat specialist at The Children's Hospital of Alabama, in Birmingham. "Children who had frequent sore throats were getting their tonsils removed without a specific cause."

Research has shown that many of those surgeries may not have been necessary. Tonsils and adenoids are little glands that trap a lot of germs and prevent your child from getting sick, so they're the first line of defense against illnesses. Sometimes, though, they become overwhelmed by the foreign invaders and get infected themselves. When that happens, it's known as tonsillitis and adenoid infection.

Young children are more likely to have issues related to the size of their tonsils than older kids or adults are. That's because the glands enlarge in the first five to seven years of life and they're crammed into a relatively small space in a child's throat. So if they get bigger as the result of an infection, that space gets even tighter. If you think your child may have a problem with his tonsils, these common warning signs can help you identify what's really going on.

He Has Trouble Focusing at School

If your child is having problems like hyperactivity, inattention, or poor performance in class—or if he's moody, frustrated, tired, and generally cranky, you may be thinking ADHD. However, it could be his tonsils. In fact, it's very common for kids with tonsil problems to be misdiagnosed when their symptoms don't seem to be physical. Enlarged tonsils and adenoids can block your child's airway when he's sleeping, causing sleep apnea, a condition in which he briefly stops breathing and wakes up repeatedly during the night.

Surprisingly, 60 to 80 percent of all tonsillectomies are now done because kids' tonsils are obstructing their airway and creating sleep problems. How to tell whether this could be the case? "Your child may be a restless sleeper. You might notice that he'll snore loudly and then suddenly gasp and move around a little bit," says Scott Manning, M.D., division chief of otolaryngology at the Seattle Children's Hospital. That's because the muscles around the tonsils and adenoids are relaxing, and they collapse around the tonsil tissues. If your child's tonsils are large, the airway becomes blocked, causing him to startle and wake up very briefly. Once his tonsils are removed, your kid will sleep better and be able to focus more during the day. One study at the University of Kansas School of Medicine, in Kansas City, for example, found that many children who seemed to have ADHD actually had large tonsils and sleep apnea. After they had surgery, their apparent ADHD symptoms significantly improved.

She Snores a Lot

Sometimes a child's naturally large tonsils and adenoids can partially obstruct her airway while she's sleeping—causing snoring but not actual sleep apnea. "The tendency to have obstructed breathing can be hereditary," says Dr. Manning. If you or your husband snored a lot as a kid, your child may be following suit. When she's sleeping, the muscles of her throat relax, and the amount of space for airflow around her large tonsils is reduced. So you'll hear your child snoring, but you won't hear the startled gasp or see her moving around several times a night, as a child with apnea would.

She'll also seem well rested when she wakes up.

The good news is that your child's tonsils and adenoids will naturally shrink as she gets older (usually around the tween years), so her snoring may fade away over time. If it doesn't, but she has no other signs of tonsil or adenoid issues, it could be that she was simply born with excess tissue in her throat and is naturally prone to snoring.

He Always Seems to Have Strep Throat

When tonsils are infected and enlarged, it hurts to swallow. Tonsillitis is frequently caused by a virus, and your child usually won't need more than lots of fluids and rest. But tonsillitis can also be caused by the strep-throat bacteria (you'll probably see white spots on your child's tonsils).

Doctors today will only consider removing your child's tonsils if he's had four or five positive strep tests in one year or six or seven over the course of a couple years. And keep in mind that even once his tonsils are out, your child won't be immune to strep. "When kids get recurrent strep throat, it's usually because the strep bacteria have become permanently colonized in the tonsils themselves and then occasionally erupt," explains Dr. Wiatrak. "But after their tonsils are gone, kids can still catch strep from other infected kids."

She Has Recurring Ear Infections

Even if your child's tonsils are perfectly healthy, she can still have issues with her adenoids, which sit right next to the opening of the ear, at the back of the nose. "If the adenoids are chronically infected—and some kids are just unlucky that way—they're basically a gathering place for bacteria, and will cause kids to continue to get ear infections," says John McClay, M.D., a pediatric ear, nose, and throat specialist at the Children's Medical Center of Dallas.

In fact, if your child is getting ear infections so frequently that you're considering having ear tubes placed, your doctor may suggest an adenoidectomy in addition to the tubes. "If your child has already had one set of tubes and your doctor thinks she needs a second set, that's also a sign that her adenoids may be the culprit," Dr. McClay explains. A peek in your child's nose with a flexible fiber-optic scope can tell the doctor whether the adenoids are enlarged and infected.

He Always Breathes Through His Mouth

When his tonsils and adenoids are enlarged, your child may feel as though his nose is plugged, so he'll start breathing more through his mouth. Then it's a chain reaction: As he breathes through his mouth for extended periods—you'll see and hear this even during the day—the saliva in his mouth can quickly dry out. "The dryness creates a welcoming environment for bacteria that increases his risk of getting cavities," says John Rutkauskas, D.D.S., chief executive officer of the American Academy of Pediatric Dentistry in Chicago.

The bottom line? Keep an eye out for potential problems, talk to your kid's doctor, and listen to your instincts. Those pesky "seasonal allergies" might actually be something more. If you catch the early warning signs of tonsil or adenoid trouble, your child will breathe a lot easier, and so will you.

The Low-down on Surgery

If your child has a tonsillectomy, chances are the surgeon will remove the adenoids too. That's because if large or infected tonsils are causing problems, then the adenoids usually are as well. But the reverse doesn't hold true: If the adenoids are troublesome (causing ear infections, for example), the tonsils might not be. And because the recovery time for tonsil removal is longer, doctors will usually leave tonsils alone during an adenoidectomy.

After surgery, a natural scab will form over the site. So watch for bleeding that occurs within the first two weeks of surgery—that's a sign the scab isn't forming properly. Keeping your child hydrated will help keep the mucous lining moist and prevent the scab from drying up and falling off prematurely.

Give your child plenty of liquids and offer her soft foods like pudding or Jell-O. "Scratchy" foods like toast or crackers can irritate her throat, so hold off on those. And skip hot drinks too.

Kids can be in a significant amount of pain for up to ten days post-op, so medicate accordingly. A new study from the University of California, Irvine, shows that many parents don't do this—even though 86 percent of parents described their child's pain as significant and their physician had encouraged them to use prescription acetaminophen with codeine. Almost a quarter of kids got either no medication or just one dose in their first day at home and three or fewer doses in the entire two weeks after surgery. But being pain-free can reduce the risk of complications, says study coauthor Zeev Kain, M.D. There's no need to fear that your child will become dependent on the drug.

After the doctor's sure your child is healed from the surgery (healing can take up to two weeks), keep her active while maintaining a healthy diet. "Kids with very large tonsils can't breathe well through their nose, and that affects their sense of taste," explains Brian Wiatrak, M.D. "After having surgery, they can eat more easily and smell and taste food better." If your child was overweight to begin with (possibly contributing to sleep apnea), it's important to keep this in mind.

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Originally published in the March 2010 issue of Parents magazine.

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