Jan. 3, 2011 -- Most children who get repeated throat infections probably don’t need surgery to remove their tonsils and would improve in time with careful monitoring, according to new clinical guidelines on tonsillectomies in children.
The new guidelines also suggest, however, that removal of the tonsils, or tonsillectomy, may improve problems tied to poor sleep, including bed-wetting, slow growth, hyperactive behavior, and poor school performance.
“We used to think that only if you were an air traffic controller did it matter if you slept well or not, and now we know that’s not the case,” says Amelia F. Drake, MD, chief of the division of pediatric otolaryngology at the University of North Carolina School of Medicine in Chapel Hill.
More than half a million tonsillectomies are performed each year on children in the U.S., making it the second most common surgery in this age group, just behind procedures to place tubes in the ears to relieve recurrent ear infections.
Despite the fact that it is a mainstay of American medicine, experts have long disagreed about how useful or appropriate tonsillectomies may be.
The new guidelines, published Monday by the American Academy of Otolaryngology - Head and Neck Surgery, are the first set of official recommendations on tonsillectomy published in the U.S. The guidelines aim to give doctors and parents more information about when tonsillectomy may be warranted and to help minimize the risks and pain of this procedure in young patients.
“I thought they were very comprehensive,” says Drake, who reviewed the new recommendations but was not involved in drafting them. “This is an area where improvements and refinements can have a huge impact. This is medicine at its core.”
New Criteria for Removing Tonsils
The guidelines update a set of clinical indicators for tonsillectomies published in 2000 by the American Academy of Otolaryngology, which suggested that doctors could consider taking out the tonsils if a child had at least three cases of swollen and infected tonsils in a year.
The new guideline, however, says that kids should have at least seven episodes of throat infection, such as tonsillitis or strep throat in a year, or at least five episodes each year for two years, or three episodes annually for three years, before they become candidates for surgery, and that those infections should be documented by a doctor, rather than just reported by parents.
The idea, experts said, was to reserve surgery only for the most severely affected, because the surgery can rarely have serious complications including infections and serious bleeding.
“Children who have fewer episodes really aren’t going to see a lot of benefit,” says Jack L. Paradise, MD, professor emeritus of pediatrics at the University of Pittsburgh School of Medicine.
“There aren’t many kids, overall, who meet those stringent criteria,” Paradise says.
What’s more, Paradise and other experts stress that even children who satisfy the guidelines shouldn’t get an automatic green light for surgery.
“I’m not sure, if I had a child that met all the criteria, that I’d automatically subject the child to the consequences of that,” Paradise says, “Post-operatively, it’s a very painful procedure.”
Changing Attitutes to Tonsillectomies
The tonsils are cone-shaped lumps of tissue embedded in the throat, and they are believed to play a role in how the body responds to infections, though experts aren’t exactly sure how.
But in the early part of the 20th century, the tonsils were blamed as the “focus of infection” in the body, and doctors began taking them out as a way to promote good health.
The operation became so routine, for example, that entire classrooms of youngsters would get their tonsils taken out at school.
But by the 1970s, many experts were questioning how effective and appropriate it was to subject kids to a painful operation that could have rare but serious complications -- all for what new research suggested had begun to suggest were minimal improvements in the risk of sore throats.
At the same time, however, doctors were starting to become more aware of the myriad problems tied to sleep disordered breathing in children, a spectrum of problems that can range from snoring to obstructive sleep apnea.
And more tonsils began to be taken out as a way to open up the airway and improve sleep.
As sleep improves, research suggests behavior, growth, school performance, and even bed-wetting does, too.
“I’ve seen kids like this,” says Drake. “Kids are so tired that their brains can’t hear the signal from their bladders that it’s time to go, and you take the tonsils out and the problem resolves.”
That benefit, Drake acknowledges, is still controversial.
In fact, a study published in December in the Journal of Urology which followed a group of more than 300 children -- 257 who were undergoing tonsillectomies and 69 who were having surgeries for other reasons -- found no difference in the rates of bed-wetting before or after surgery in either group.
Still, doctors say the idea isn’t all that far-fetched.
“Not wetting the bed requires a level of neurological control that’s upset by a lot of different things,” Paradise says. “I’m quite willing to believe that anything that upsets a child’s equilibrium could have an effect on that, including poor sleep.”
Improvement in Care for Kids Having Surgery
Several of the guidelines suggest ways doctors and parents can improve the care of kids having tonsillectomies.
One of the strongest recommendations is against the use of antibiotics just before or just after surgery.
“They are commonly given, and there’s no evidence that antibiotics offer any benefit,” says study researcher Reginald F. Baugh, MD, professor and chief of otolaryngology at the University of Toledo Medical Center in Ohio. “You run the risk of allergic reactions and there are the harms of overprescribing.”
In drafting the statement that advises doctors to counsel parents about the importance of pain management in kids after surgery, Baugh says the panel that reviewed the evidence behind the guidelines was alarmed to learn that many parents don’t give medications to control pain after the procedure.
“That was one thing we really learned, about the importance of telling parents about the need to give pain meds in these kids,” Baugh says.