How Large Tonsils Affect the Sleep of Children

Snoring and sleep apnea may affect growth and behavior

Children often have enlarged tonsils, but how might these large tonsils affect sleep? Snoring and sleep apnea may often result, and this can have important consequences on growth and behavior. Discover the impact of large tonsils and whether treatment with surgery may be required.

young girl snoring while she sleeps
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Large Tonsils May Affect Breathing

The upper airway of children may be compromised by large tonsils or adenoids. The back of the mouth and throat are proportionately smaller in children and have increased muscle tone compared to adults. The lymphoid tissue of the tonsils and adenoids grows in most children between the age of 2 and 6 years. In those who do not have room to spare, this growth may cause a narrowing that compromises the passage of air. This may lead to snoring or even sleep apnea in these children. The vast majority of children with large tonsils or adenoids never develop sleep apnea, however.

How to Determine the Size and Impact of Tonsils

The degree of enlargement is assessed with a scale that attempts to objectively judge the size of the tissues and the risk for sleep-disordered breathing. This Brodsky scale grades the size of the palatine tonsils from 1+ to 4+. At the largest classification, the tonsils are touching in the midline of the throat. When these tissues reach a critical threshold, as determined by a doctor, there may be associated changes that lead to additional problems.

The disrupted airflow may lead to vibration (such as snoring) that causes swelling and redness within the tissues. There may also be recurrent infections. Other anatomic variations that may be associated with a narrowed airway, such as a short neck or small jaw, may also make things worse.

Unfortunately, untreated snoring and sleep apnea can have significant impacts on the health of children. Poor sleep may disturb the release of growth hormone and cause children to be shorter. In addition, children who do not sleep well are more likely to have behavioral problems like attention deficit hyperactivity disorder (ADHD). These effects can be serious and may prompt treatment.

Removing Tonsils With Tonsillectomy Surgery May Help

If you are concerned about snoring or recurrent infection in your child, your doctor may evaluate the size of the tonsils. If these are determined to be enlarged, they may be removed with a surgery called tonsillectomy. This procedure has a low degree of risk and may be extremely helpful when it is needed.

Some parents will choose to wait until further growth occurs to improve the size of the airway. If there are no impacts on sleep, growth, and behavior, this may appropriate. When problems are occurring, it may be important to explore treatment options.

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  1. American Academy of Pediatrics. Sleep apnea detection. Updated November 26, 2012.

  2. Shah UK. Enlarged tonsils and adenoids in children. Merck Manual. Updated February, 2019.

  3. Kumar DS, Valenzuela D, Kozak FK, et al. The reliability of clinical tonsil size grading in children. JAMA Otolaryngol Head Neck Surg. 2014;140(11):1034-7. doi:10.1001/jamaoto.2014.2338

  4. Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: Tonsillectomy in children (update)-executive summary. Otolaryngol Head Neck Surg. 2019;160(2):187-205. doi:10.1177/0194599818807917

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