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New Guidelines for Tonsillectomies

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. In fact, sleep-disordered breathing -- a set or problems that range from snoring to obstructive sleep apnea - is now the most common reason for tonsil removal in kids younger than 15. “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.” 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 common 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 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. Improvement in Care for Kids Having Surgery Several of the guidelines suggest ways doctors and parents can improve the care of children 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 over-prescribing.” 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.

Your Child

Should More Kids Have Their Tonsils Removed?

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Two new medical reviews suggest that more kids could benefit from having their tonsils removed if tonsillectomy guidelines were less stringent.

Currently, surgery qualifications require that a child must have many recurring throat infections within a short span of time or severe sleep disturbances, said Dr. Sivakumar Chinnadurai, a co-author of the reviews.

An evaluation of current medical evidence suggests more kids would receive significant short-term improvement in their daily life if the guidelines were relaxed, said Chinnadurai, a pediatric otolaryngologist with Vanderbilt University Medical Center in Nashville.

Chinnadural and his team found that children, who underwent a tonsillectomy even when they did not meet the guidelines, experienced nearly half as many sore throats. They also missed fewer days of school and were less likely to need extra medical care.

The benefits seemed to apply only to the first couple of years following surgery. By the third year, there was no clear benefit in terms of the number of sore throats, said Chinnadural. The benefits after the first couple of years following surgery, however, were impressive.

"The decision about whether those children should have tonsillectomy for that temporary benefit is really tied to what those children need or what they're suffering with," Chinnadurai said. Kids who miss a lot of school or need frequent trips to the doctor due to sore throats could benefit from the surgery, he said.

There's an even clearer benefit for kids whose sleep is disturbed due to inflamed tonsils, Chinnadurai said.

"In a child with a diagnosis of sleep apnea, we can see a benefit in sleep-related quality of life," he said. The kids get better sleep, and thus exhibit better everyday behavior and pay more attention in school.

Better sleep in children with sleep apnea can improve many aspects of their daily

lives.

Guidelines say a tonsillectomy to treat throat infections is justified if a child had seven or more sore throats during the previous year; five or more sore throats two years running, or three or more sore throats for three years in a row, according to the background notes.

The researchers decided to review whether the throat infection guidelines are too stringent, ruling out patients who potentially could benefit but don't meet the high threshold of recurring infections, Chinnadurai said.

There aren't strong guidelines regarding the use of tonsillectomy to treat sleep disorders, so the doctors reviewed the evidence to see whether the surgery outperformed so-called watchful waiting -- monitoring the situation.

The study results showed "there may be new evidence that supports expanding the criteria and opening up the procedure to more individuals," said Dr. Alyssa Hackett, an otolaryngologist with the Icahn School of Medicine at Mount Sinai in New York City.

"In the right child with the right indications, these are really wonderful procedures that can be life-changing for both the child and the family," said Hackett, who wasn't involved with the new research.

Although the findings were positive, Chinnadural and Hackett both warned against automatically choosing a tonsillectomy when a child has a sore throat.

"Though a tonsillectomy is low-risk, it is not risk-free, and those risks need to be weighed against the benefits for each individual child," Chinnadurai said.

"We're talking about a child who has significant sleep-related issues," Hackett said. "We don't want people to say my child snores, they need to have their tonsils out. That's not what this study says at all."

Parents should discuss the risks and benefits of a tonsillectomy with their pediatrician if they are concerned about the amount of sore throats their child has, or if sleep apnea is diagnosed.

The two reports were published online in the journal Pediatrics.

Story source: Dennis Thompson, https://consumer.healthday.com/kids-health-information-23/tonsillitis-news-669/should-more-kids-have-their-tonsils-out-718738.html

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