European Review for Medical and Pharmacological Sciences
Dietary habits of preschool aged children with
tonsillar hypertrophy, pre- and post-operatively
K.K. GKOUSKOU1, I.M. VLASTOS*1, I. HAJIIOANNOU3, I. HATZAKI1,
M. HOULAKIS2, G.A. FRAGKIADAKIS1
1
Technological Edutation Institute (T.E.I) of Crete, Department of Nutrition and Dietetics, Siteia (Greece)
2
Department of Otolaryngology, Agia Sophia Children Hospital of Athens (Greece)
3
Department of Otolaryngology – Head and Neck Surgery, General Hospital of Nikaia
“Agios Panteleimon”, Pireaus (Greece)
Abstract. – Background and Objectives:
Tonsillectomy has been reported to have a posi-
tive effect on weight gain of children with tonsil-
lar hypertrophy. This effect may be related to
better respiration or/and feeding, immunological
or metabolic factors. In this study we analyse
the effect of tonsillectomy on the dietary habits
of children.
Subjects and Methods: Dietary habits of
thirty 4-6 years old children were assessed be-
fore the operation and six months after it, using
24 hours dietary-recalls. In parallel, dietary
habits of eighteen healthy children of the same
age were assessed using the same method.
Results: Children with tonsillar hypertrophy
were receiving greater amounts of daily calories
overall from sugar products, soft drinks and edi-
ble fats (p = 0.01, t = 2.673). Post-operatively,
they increased the calories they were consum-
ing daily and consumed even greater amounts
of these food (p < 0.001, t = 3.527) in relation to
the control group, gaining weight significantly (p
= 0.043).
Discussion: Parents should be aware of a
possible weight increase after tonsillectomy
which can be related to an over-consumption of
products like candies and soft drinks.
Key Words:
Dietary habits, Preschool aged children, Tonsillecto-
my.
Introduction
Obstructive sleep disorders (OSD) due to ade-
notonsillar hypertrophy are a relative common
problem of preschool children affecting about 1-
3% of them1. Although an association of OSD
with some co-morbidities like hyperactivity, hy-
Corresponding Author: I.M. Vlastos, MD; e-mail: giannisvlastos@yahoo.gr
2010; 14: 1025-1030
pertension, and lower academic performance
have been well reported2,3, the effect of tonsillar
hypertrophy on growth is still an open issue.
There are several studies relating tonsillar hyper-
trophy with growth retardation4-7 whereas some
others do not show such an association8. Howev-
er, most of them agree on the positive effect of
tonsillectomy on weight gain.
Total energy intake of the children, as calculat-
ed by dietary questionnaires before and after ade-
notonsillectomy, is an important consideration in
studies examining the effect of this operation on
growth9. However, the complexity of associations
between hormonal changes, food composition
and consumption, as well as the possibility of al-
tered taste perception due to tonsillar hypertro-
phy, requires a thorough analysis of children’s di-
etary habits.
It has been reported that adults (older than 40
years of age) with history of otitis media and ton-
sillectomy showed reduced taste, liked fat food
more and had higher BMIs10. In the present arti-
cle we studied the nutritional habits of children
with OSD compared with “normal children” and
found that they have a less healthy nutrition, con-
sume more sugar products, soft drinks and fats.
By understanding the reasons of this behavior,
we may intervene more efficiently towards im-
proving the eating habits of these children.
Subjects and Methods
The study subjects were 15 boys and 15 girls,
4-6 years old (mean age 5.1 years), scheduled to
receive a tonsillectomy, due to distorted breath-
ing. Diagnosis of OSD was based on clinical cri-
teria, namely sleep disturbances due to enlarged
tonsils or adenoids. Children were living in urban
areas, were otherwise healthy (ASA score I),
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 K.K. Gkouskou, I.M. Vlastos, I. Hajiioannou, I. Hatzaki, M. Houlakis, G.A. Fragkiadakis
without any specific dietary restriction like those
related to food allergies or religious issues.
Energy and type of food intake were mea-
sured with 24-hours recalls, which has been
shown to be a reliable method for children11,12.
The parents of the children submitted two 24-
hours dietary recalls, the first one 2-4 weeks
prior to the operation and the second one 5-6
months after the operation. The enrolment of
patients into the study lasted one year with an
equal distribution of patients within the sea-
sons. The weight of each child was recorded
during the same day the dietary recalls were re-
ceived.
As a control group, 24-hours recalls were al-
so obtained twice, with a 6 months interval, by
the parents of 18 healthy preschool-age chil-
dren, without sleep obstructive disordered
breathing. Children whose data on second di-
etary recall were missing have been excluded
from the study. The choice of the patients and
the control group was in random order during
the year with a selection only so as boys and
girls to be equally distributed. In all cases food
quantities were either measured by the use of
household weighing devices or estimated in
comparison with coloured food-model pho-
tographs13.
Statistical Analysis
Quantities of food types were compared be-
tween the groups using t-test; χ2-test was used
for categorical variables (tonsillectomy group
vice control); Mann-Whitney Rank Sum test was
used for non-normally distributed continuous
outcomes (weight gain). As an indirect estima-
tion of food quality, percentages of calories re-
Table I. Characteristics of the three groups that are related to age, gender and BMI. Numbers are means expect in weight gain
where medians are reported.
Tonsillectomy group (n = 30)
Age mean 5.1
Male gender 15 (50%)
initial weight (g) 18.700
Weight after (g) 20.940
Weight gain (g) 2.400
Height before (cm) 107
Height after (cm) 110
t-test; bχ2-test; cMann-Whitney Rank Sum.
a
1026
ceived by sugar products, soft drinks and edible
fats, which are actually related to the most “taste-
ful” foods for children, were calculated for both
groups and compared with t-test.
Results
As shown in Table I, the initial characteris-
tics of the two sample groups related to age,
gender, weight and stature, where not statisti-
cally different. The only difference observed is
on the weight gain between the control group
(control group 2) and the children who have
been operated. The latter gained 700 g more, as
a mean, compared to the control group (Table
I). Weight increase in both groups is also de-
picted in Figure 1, in comparison to weight-for-
age percentiles.
The various types of food consumed before
and after tonsillectomy are presented in Table II.
Pre-operatively, as can be seen in Table 2, total
calories received by children with tonsillar hy-
pertrophy did not differ significantly, compared
to the control group (control group 1). What dif-
fered was the composition of their food, when
discrete calculations were performed for each
type of food. More specifically, percentages of
the calories received through consumption of
sugar products, soft drinks and edible fats dif-
fered significantly between the two groups (p =
0.01, t = 2.673). Furthermore, total calories re-
ceived from other type of foods, like meat, veg-
etables or legumes were less in children with ton-
sillar hypertrophy compared to the control group
(p = 0.003, t = 3.117).
Control group (n = 18) P-values
5.05 0.907a
9 (50%) 0.766b
19.440 0.384a
21.070 0.896a
1.700 0.043c
108 0.577a
111 0.575a
 Dietary habits of preschool aged children with tonsillar hypertrophy, pre- and post-operatively
Weight (gr)
Age
Figure 1. Weight increase and weight-for-age percentiles.
Post-operatively, a significant difference on
the consumption of snacks and soft drinks can be
seen between healthy children (control group 2),
and children operated due to tonsillar hypertro-
phy (Table II). More specifically, percentages of
the calories received through consumption of
sugar products, soft drinks and edible fats were
greater in children who had the operation, com-
pared to the control group (p <0.001, t = 3.527).
Total calories received from other type of foods,
like meat, vegetables or legumes did not differ
between children that had tonsillectomy, and the
control group (control group 2).
Discussion
The finding that successful treatment of OSD
has a positive effect on weight is consistent with
the findings of other studies on children4-7. The
reason of this effect is not clear yet. Several theo-
ries have been reported in the literature, like re-
duced secretion of growth hormone and insulin-
like growth factor-I in children with OSD6,14,15,
lower energy intake as a result of difficulties in
swallowing and/or increased energy expenditure
during sleep9,16.
3rd
50th
97h
Tonsillectomy
Control group
Complex and not well defined relations be-
tween sleep patterns, growth hormones secretion,
food consumption and body mass, preclude de-
tailed conclusions even in relative well designed
studies6. Since operations like tonsillectomies
can affect various parameters, the order of
changes noticed after these operations, is difficult
to be defined. For example, it is not clear if in-
sulin-like growth factor-I alteration detected after
adenotonsillectomy, is due to sleep pattern
changes or if it is caused by other factors, like al-
tered immune system responses5,6,17. It is also not
clear if weight gain after adenotonsillectomy is
due to complex metabolic changes or simply the
result of the alleviation of upper airways me-
chanical obstruction resulting in better breathing
and improved metabolism7.
Our findings, apart from the confirmation of
the significant post tonsillectomy weight gain
in children reported by other studies, indicate a
direct relationship between the obstruction
caused by tonsillar hypertrophy and food con-
sumption. More specifically, all children with
obstructed sleep disordered breathing studied
here were operated because of enlarged tonsils
and adenoids. This means that their tonsillar
and adenoid hypertrophy could have been se-
vere enough to impede food intake either di-
1027
 Table II. Dietary habits in relation to various types of foods in both groups. Food quantities are presented in calories. Their percentages in relation to total amount of calories re-
ceived are also shown in grey coloured cells.

1028
PREOPERATIVELY POSTOPERATIVELY

Tonsillectomy Control group Tonsillectomy Control group (six

group (n = 30) (n = 18) P-values group (n = 30) months later) (n = 18) P-values
Mean of calories (SD) Mean of calories (SD) Mean of calories (SD) Mean of calories (SD)
FOOD Mean of percentages (SD) Mean of percentages (SD) Mean of percentages (SD) Mean of percentages (SD)

Bread-Cereal-Rice 273 (116) 310 (192) 0.398 275 (133) 311 (162) 0.4
19 (8) 21 (14) 0.545 19 (9,7) 20 (9,8) 0.779
Potatoes 134 (134) 207 (219) 0.157 136 (135) 214 (214) 0.124
9 (9.6) 13 (13.1) 0.311 9 (8.8) 13 (13.1) 0.173
Pasties 83 (137) 164 (179) 0.075 89 (136) 170 (171) 0.078
6 (9.5) 11 (11.8) 0.112 6 (9.9) 10 (9.1) 0.222
Legumes 11 (38) 26 (61) 0.320 7 (36) 25 (49) 0.136
1 (2.2) 2 (4.3) 0.227 0.5 (2,5) 2 (3.5) 0.131
Vegetables 34 (37) 37 (48) 0.811 41 (46) 35 (46) 0.634
3 (2.9) 2 (3.3) 0.864 3 (3.4) 2 (2.6) 0.279
Red meat 117 (95) 111 (105) 0.828 124(94) 125 (103) 0.967
8 (6.7) 7 (7) 0.807 8 (6.5) 9 (8.2) 0.761
White meat 67 (76) 88 (103) 0.422 77 (85) 96 (120) 0.519
5 (5.9) 5 (6.1) 0.819 5 (5.7) 6 (7.9) 0.604
Eggs 23 (46) 31 (44) 0.548 27(43) 28 (39) 0.913
1 (2.7) 2 (3.2) 0.347 2 (2.9) 2 (2.9) 0.802
Cheese-Milk 85 (94) 95 (76) 0.709 68 (80) 111 (86) 0.091
6 (6.4) 6 (5.6) 0.938 5 (5,9) 7 (6.3) 0.192
Fish 45 (93) 54 (99) 0.741 46 (94) 54 (99) 0.779
3 (5.6) 4 (6.5) 0.704 3 (5.6) 3 (5.6) 0.843
Subtotals
Sugar products- 217 (150) 146 (124) 0.098 217 (152) 140 (99) 0.066
Soft drinks 15 (10.3) 9 (8.2) 0.05 15 (10.4) 9 (6) 0.03
Edible fats
345 (145) 264 (121) 0.054 364 (144) 156 (103) 0.08
24 (9.2) 17 (8.1) 0.012 25 (10.5) 17 (7.7) 0.008
Calories received from 562 (201) 411 (168) 0.01 581 (194) 397 (136) < 0.001
sugar products, soft
drinks and fats
K.K. Gkouskou, I.M. Vlastos, I. Hajiioannou, I. Hatzaki, M. Houlakis, G.A. Fragkiadakis

Calories from the rest 873 (247) 1114 (280) 0.003 892 (237) 1172 (383) 0.003
types of food
Total calories 1435 (265) 1525 (324) 0.3 1472 (291) 1569 (441) 0.363
 Dietary habits of preschool aged children with tonsillar hypertrophy, pre- and post-operatively
rectly or indirectly by impeding breathing dur-
ing eating. The finding of increased consump-
tion of sugar products and soft drinks can be
explained in this way. More specifically, par-
ents being aware of their children’s situation
and detecting a possible inadequate caloric in-
take may provide the rest of the calories in the
form of soft drinks and candies, as an easier
and more pleasant form of food to consume.
This is consistent with previous studies show-
ing that quite often children consume what they
enjoy or prefer18. Continuing this type of diet
the first few months after the operation may
well result in the weight increase detected in
this study19 although sweet drink intake by chil-
dren has not been linked to obesity in recent
meta-analysis20.
Of course the above hypothesis may simplify
the problem by neglecting the complexity of hor-
monal aspects of appetite and metabolism. More-
over, alternation of sensory/hedonic experiences
has been connected with diseases that can affect
the interaction of taste with cranial nerves V, VII
and IX10. Arsenault et al21 have shown that chil-
dren with severe otitis media have significantly
higher intakes of sweets and lower intakes of
vegetables, whereas Chapo et al.22 have shown
the same in adults with a history of otitis media
and adenotosnillectomy.
Our results in infants, in combination with the
results of Chapo et al22 in adults possibly indi-
cate permanent effect of tonsil hypertrophy and
tonsillectomy on food preferences. Parents
should be aware of the possibility of a signifi-
cant weight increase after adenotonsillectomy,
thus taking care of the dietary habits of their
children not to exceed current recommendations
especially in relation to sugar products, soft
drinks and edible fats.
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