Should you have your kid's tonsils removed?

When Rachel Naud’s 10-year-old son, Tristan, had his tonsils and adenoids out in May, the days that followed were full of intense pain. A week later, he was still wincing when he swallowed. Though many of us recall tonsillectomies as an occasion to eat ice cream to soothe a sore throat, the reality is that recovery is less about cold treats and more about morphine—which can be scary for parents. “I was worried about giving it to him at first, but he really needed it,” says Naud.

Tonsils are lumps of lymphatic tissue on both sides of the back of the throat that, along with the adenoids (made up of the same tissue but located behind the nasal cavity), help support the immune system by trapping bacteria and viruses when you breathe or swallow. Ironically, although their role in the body is to help prevent infection, they often get infected themselves, which is one of the reasons kids get tonsillectomies. Tonsils and adenoids are usually taken out together because if one is problematic, chances are the other is too.

Tonsillectomies are the second most common surgical procedure children undergo and are typically performed on kids ages three to seven, says Neil Chadha, a paediatric otolaryngologist at BC Children’s Hospital in Vancouver. (Ear tube surgery is number one.) Two decades ago, even a few throat infections were enough to have doctors prepping kids for surgery. “It used to be considered something of a cure-all,” Chadha says. “But now we have more evidence-based criteria that we use to decide if it’s really the right thing to do.” To qualify for the surgery today, kids need to have had seven infections (such as tonsillitis or strep) a year, five infections a year for two years in a row or three infections a year for three years in a row.

Thirty years ago, 90 percent of tonsillectomies were done for recurrent infections, but today, infections account for just 20 percent of surgeries, while the most common reason kids have tonsillectomies is obstructive sleep apnea. Oversized tonsils and adenoids—which could be genetic or the result of an infection—can make it tough for kids to breathe at night, disrupting their sleep and leading to concentration and behavioural issues during the day. Tristan often complained about being tired and had snored nightly since he was little. “We could hear him from the next room over,” Naud says. But she didn’t realize how serious the problem was until they went for a sleep test last June. Tristan stopped breathing 16 times in the night and was diagnosed with mild sleep apnea. Still, Naud was reluctant to agree to the operation.

For many parents facing what is likely their child’s first surgery, the biggest concern is that doctors are removing a body part their children might actually need. Yes, tonsils do play a role in early immunity, Chadha says, but kids have more of the same tissue elsewhere, and tonsils and adenoids usually outlive their usefulness by the toddler stage anyway. In fact, adenoids begin to shrink after ages seven to 10, and most adults no longer have them. (Adenoids can grow back after surgery, although it happens in fewer than 10 percent of cases.)

In the end, the decision to perform a tonsillectomy is based on weighing the pros of better sleep or fewer infections with the cons of surgery. “It’s a very valid operation but not one to be taken lightly,” says Gerard Corsten, a paediatric otolaryngologist at IWK Health Centre in Halifax. “Fortunately, it’s an elective surgery, not an emergency, so you can take your time to think about it and wait if you’re not sure.”

Naud planned to take a wait-and-see approach in hopes her son would outgrow his tonsil troubles, which Chadha says can happen. But it was Tristan who made the decision to go ahead with the surgery. “He told me he was just so sick of being tired all the time,” Naud says.

Prepping for surgery Two weeks before his tonsillectomy, Tristan went to Michael Garron Hospital in Toronto for a pre-op appointment. “He was really nervous at first,” Naud says. “But they showed him where he’d go and what he’d be hooked up to, and then they went through the whole scenario with puppets. Afterwards, they gave him a Popsicle, so it was all good.”

The doctor gave Naud a list of post-procedure guidelines and warned her that the first few days would be especially tough. Although a tonsillectomy is typically a day surgery and the procedure itself takes less than an hour, the recovery can last up to two weeks. “It’s not a fun surgery for children or their parents,” Corsten says. “Kids usually feel pretty miserable for the first week.”

Although most patients are sent home the same day their procedure takes place, those with sleep apnea may be kept overnight, just so nurses can monitor their breathing. (Naud was relieved to have the professional support, with a nurse checking in every hour.) When Tristan woke up in the recovery room, he was immediately in pain as he waited for the dose of morphine he’d been given to kick in. For the first four days, Tristan’s doctor prescribed acetaminophen and liquid morphine to be given every four hours to control the pain, then cut down the recommendation to morphine only at night. Other doctors, like Sharon Cushing, staff otolaryngologist at the Hospital for Sick Children in Toronto, prefer to stick to acetaminophen and ibuprofen.

“[Choosing the right medication] is a case-by-case assessment, with the goal of keeping the child as comfortable as possible,” Cushing says. “But even with the best pain medicine, you can’t make the pain zero. I just let parents know they’ll probably have an extra-clingy child for several days.”

Naud found it really difficult to see her son in pain. “He didn’t even want to play video games,” she says. After a tonsillectomy, kids are generally home from school or daycare for one to two weeks, partly because they need time to heal and partly to reduce their risk of getting an infection. “We watched a lot of Netflix,” Naud says. She put a humidifier in Tristan’s room to keep the air moist, because every time he woke up, his mouth was dry and it hurt to swallow.

The biggest post-tonsillectomy risk is bleeding, which occurs in three to four percent of children, says Corsten. If it’s going to happen, it tends to be around days five to seven, but it could start any time up to 14 days after surgery. (After that, most children are fully healed, and the risk of bleeding is gone.) Bleeding usually stops on its own, but it may need to be cauterized, requiring a second procedure and, in very rare cases, a blood transfusion. Bleeding should always be checked by a healthcare professional. “The bleeding usually isn’t subtle,” Corsten says. “Parents will know if it’s time to go back to the hospital.”

In addition to a really sore throat, kids may develop a fever in the first few days. It’s also typical for kids’ throats to look pretty awful at first, and some may experience ear pain because of a nerve that is connected to both the ear and throat. “There might be white plaque on the back of the throat, as well as scabs, and their breath will be bad—all of which is normal,” says Corsten. Some doctors will have kids come in for a checkup two to six weeks after a tonsillectomy, although Corsten just does a follow-up call to save them a trip.

Road to recovery Naud was told not to give Tristan tomato sauce, toast, bacon, pizza or potato chips for three weeks—basically, any food that could scratch, burn or otherwise irritate the back of his throat. But, Cushing says, “the truth is, nothing a child eats will tear the tonsil bed or impair healing.” Still, most kids just naturally gravitate toward softer foods, like mac and cheese, ice cream, scrambled eggs and smoothies. “Tristan had pudding the first night in the hospital, and I don’t even know how many Popsicles,” Naud says. She relied on slushies, soups, eggs and other easy-to-swallow foods.

Now, several months later, Naud is glad they decided to go ahead with the procedure. Even before his two-week recovery period was up, she could tell Tristan was sleeping better and feeling better as a result. “When I went to check on him at night, he was purring,” she says. “It was so quiet compared to the gurgling sound he used to make when he slept. He already has more energy, and I can tell he’s feeling better, so I know it was the right thing for him.”

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