Why Do Kids Like Jahi McMath Need Surgery to Remove their Tonsils for Sleep Apnea?
Date Published
Quick answer: in children, sleep apnea is most often caused by enlarged tonsils and adenoids physically narrowing the upper airway during sleep. When the child relaxes into deeper sleep, the soft tissues collapse around the airway and breathing pauses. Adenotonsillectomy -- surgical removal of the adenoids and tonsils -- is the first-line treatment for otherwise healthy children with sleep apnea, and resolves the condition in roughly 70-80 percent of cases based on the American Academy of Pediatrics clinical practice guideline. Children with obesity, Down syndrome, or craniofacial differences are more likely to have residual OSA after surgery and may need additional treatment such as CPAP or positional therapy. Diagnosis in pediatric patients should use in-lab polysomnography, not a home sleep test (AAP / AASM recommendation).
The tragic events in Oakland over recent weeks have highlighted the risks of surgery for children. Thirteen year old Jahi McMath underwent routine surgery to remove her tonsils that obstructed her airways at night. She suffered heavy bleeding and cardiac arrest on December 12, three days after complex tonsillectomy surgery.
These events have ignited a debate over the prolonging of Jahi's life even though she has severe brain damage. We won't discuss these issues or the reasons why Jahi's family elected to have the surgery. But we will discuss the diagnosis of sleep apnea in children, the surgery commonly used to treat sleep apnea in children and some of the potential complications and risks.Please speak with your child's doctor if you have concerns about your child.
What causes snoring and sleep apnea in children?
- More common causes: Enlarged tonsils or adenoids
- Dental conditions, such as a large overbite
Less common causes:
- Tumor or growth in the airway
- Birth defect, such as Down Syndrome that causes enlargement of the tongue and jaw
- Obesity
Why is surgery performed for children with sleep apnea?
- Surgery can be performed for children when sleep apnea is caused by enlarged tonsils or adenoids
- More than 530,000 children under the age of 15 have their tonsils removed each year. About 80 percent have obstructive sleep problems – snoring, irregular breathing – and the rest are because of infection, according to The American Academy of Otolaryngology-Head and Neck Surgery.
- Surgery can be a permanent solutions because tonsils don't grow back.
- A recent NIH study showed that surgery can improve some behaviors in children with sleep apnea, but surgery should not be the automatic first choice
- PAP (positive airway pressure) can also be used for children with sleep apnea instead of surgery or after surgery, if surgery doesn't work.
- Children can out grow enlarged tonsils, in some cases, with no treatment.
What are the risks of surgery for sleep apnea?
- Any surgical procedure has risks due to anesthesia or infection.
- There is a risk of bleeding in the first few days after the operation, but this is very rare. There are two times during which post-operative bleeding is most likely to occur: within the first 24 hours after surgery and six to 10 days after surgery when the scabs come off. It is estimated that 0.2% to 2.2% of patients hemorrhage within 24 hours after surgery, and 0.1% to 3.7% of patients experience post-operative bleeding six to 10 days after surgery. (from ent.about.com)
Pain during recovery is the most common side effect. If you suspect that your child has difficulty breathing at night, talk to her doctor.
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Frequently asked questions
During sleep, muscles relax and the soft tissues of the upper airway become more collapsible. Enlarged tonsils and adenoids reduce the available airway space, so the relaxed soft tissues are more likely to obstruct breathing. Children with this anatomy may snore loudly, gasp, or have witnessed breathing pauses.
Adenotonsillectomy resolves OSA in approximately 70-80 percent of otherwise healthy children with enlarged tonsils, based on AAP clinical practice guideline data. Success rates are lower in children with obesity, Down syndrome, or craniofacial conditions, where residual OSA after surgery is more common.
Typical recovery is 7-14 days with pain management, soft diet, and hydration. Pain peaks around days 3-5 then improves. Most children return to school within two weeks. Bleeding after day 5-10 is the most serious complication and is rare. Discuss recovery details with the operating surgeon.
Both the AAP and the American Academy of Otolaryngology recommend polysomnography (in-lab sleep study) before adenotonsillectomy for OSA in many cases -- especially in children with obesity, craniofacial syndromes, neuromuscular conditions, or where the snoring history is unclear. The ENT and pediatrician make the call together.
About 20-30 percent of children have residual OSA after adenotonsillectomy, particularly those with obesity or other risk factors. A follow-up polysomnogram 6-12 weeks post-op is recommended for high-risk children. Treatment options for residual OSA include weight management, positional therapy, oral appliances, or pediatric CPAP.
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