Original ResearchPediatric Otolaryngology

Weight Gain after Adenotonsillectomy:

A Case Control Study
Travis L. Lewis, MD1, Romaine F. Johnson, MD, MPH1,2,
Jonathan Choi1, and Ron B. Mitchell, MD1,2

No sponsorships or competing interests have been disclosed for this article.

Abstract
Objective. To study the association between adenotonsillectomy (T&A) and weight gain in children.
Study Design. Retrospective case-control series.
Setting. Tertiary academic childrens medical center.
Subjects and Methods. A total of 154 children who underwent T&A at a tertiary care childrens hospital between
December 2010 and March 2011 were included. They were
compared with 182 children with similar demographics who
were seen in primary care clinics at the same institution
(control group). Height and weight were compared at 6month intervals over a 24-month period. Patients were
divided into normal weight, overweight, and obese. A multilevel mixed-effects regression model was used for analysis.
Significance was set at P  .05.
Results. Children who underwent T&A gained more weight
than controls at every interval. At 24 months, they gained an
additional 2.6 kg (confidence interval [CI], 0.9-3.9) but were
an additional 1.8 cm (CI, 0.1-3.5) taller. There was no difference in weight gain at 6 months for obese children. At 12,
18, and 24 months, the obese group outgained the control
group. At 24 months, the obese T&A group had gained an
average of 14.3 kg, while the control had gained 10.1 kg, for a
difference of 4.2 kg (CI, 1.3-6.1) with no difference in height
changes. There were no differences in weight or height
changes for the normal-weight and overweight groups at the
conclusion of the study.
Conclusions. T&A leads to a significant increase in weight in
obese but not normal-weight or overweight children. Efforts
should be made to provide weight reduction counseling
prior to T&A in obese children.

Keywords
children, adenotonsillectomy, tonsillectomy, weight change,
obesity, weight gain
Received October 2, 2014; revised December 30, 2014; accepted
January 2, 2015.

Otolaryngology
Head and Neck Surgery
2015, Vol. 152(4) 734739
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2015
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599815568957
http://otojournal.org

ediatric obstructive sleep apnea (OSA) is caused by

episodic upper airway obstruction leading to hypoxia,
hypercapnea, or sleep disruption in children.1 The
association between being overweight and increased prevalence of OSA in children is well described.2-5 Pediatric
OSA is also known to worsen behavioral, quality-of-life,
and school performance measures.6-8 Mitchell and Kelly9
reported that adenotonsillectomy (T&A) improves OSA in
both normal-weight and obese children but that obese children were more likely to have residual OSA. As a result,
OSA as an indication for T&A has increased over the past
few decades. In addition, a large number of T&A procedures are performed for recurrent tonsillitis, particularly in
children older than 12 years.10
Unfortunately, there is evidence that T&A may also be
associated with weight gain postoperatively. Roemmich
et al11 studied 54 patients with OSA before and after
T&A. They reported that the patients average weight and
body mass index (BMI) increased after surgery.11 In addition,
a recent systematic review by Jeyakumar et al12 found that
overweight and normal-weight children gained a higher than
expected amount of weight following T&A. These studies
were limited by small sample size, heterogeneity of the study
groups, and lack of control groups. A more recent study by
Katz et al13 did use controls to compare weight changes after
T&A. Children who underwent T&A had a greater chance of
excessive weight gain than the non-T&A group across all
weight categories.14 Thus, there is growing evidence that
T&A may be an independent risk factor for excessive weight
gain in children. This risk is concerning because excessive
postoperative weight gain may lead to recurrence of OSA in

1
Department of Otolaryngology, Head and Neck Surgery, University of
Texas, Southwestern Medical Center at Dallas, Dallas, Texas, USA
2
Childrens Medical Center at Dallas, Division of Pediatric Otolaryngology,
University of Texas, Southwestern Medical Center at Dallas, Dallas, Texas,
USA

This article was presented at the 2014 AAO-HNSF Annual Meeting & OTO
EXPO; September 21-24, 2014; Orlando, Florida.
Corresponding Author:
Travis L. Lewis, MD, UT Southwestern and Childrens Medical Center
Dallas, 2350 North Stemmons Freeway ENT Clinic, 6th Floor, F6212 Dallas,
TX 75207, USA.
Email: travis.lewis@phhs.org

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735

children whose sleep disorder was initially alleviated with

T&A.14
The primary objective of this study was to compare
weight and height changes in children who underwent T&A
to a control population. Because T&A is still performed for
reasons other than OSA, we included all children who underwent the procedure regardless of indication. The secondary
objective was to see if obese, overweight, and normal-weight
children had changes that differed from the overall population. Given the results of the limited studies done thus far,
we hypothesized that those children who underwent T&A
gained more weight in the 24 months following surgery than
their control counterparts.

Subjects and Methods

The study population included 2 groups of children from a
tertiary childrens medical center. The first group consisted
of children undergoing T&A, and the second group was a
control group of children from primary care clinics undergoing well-child visits who had not undergone T&A. The
children were identified over a 3-month period between
December 1, 2010, and March 1, 2011, and follow-up data
were collected for the following 24 months. Inclusion criteria were ages 2 to 16 years, height and weight available at
baseline, and at least at 1 follow-up point between 6 and 24
months. Children were excluded from the study if they had
significant comorbidities including genetic, neuromuscular,
or endocrine disorders. They were also excluded if other
procedures were done at the time of T&A, with the exception of tube placement.
Institutional Review Board approval for the study titled
Weight Gain after AdenotonsillectomyA Case Control
Study was obtained from the Institutional Review Board at
the University of TexasSouthwestern Medical Center and
the need for consent exempted. Children who underwent
T&A were identified using surgical schedule archives in the
electronic medical record (EPIC production). This was done
by generating weekly electronic reports for otolaryngology
patients and identifying those who underwent T&A regardless of indication.
Children who had visited a primary care clinic during the
study period, at the same institution, were identified from wellchild visits, as defined by their ICD-9 code. This was done by
the data intelligence department using electronic medical records
(EPIC productions). None had a CPT code for T&A listed in
their surgical history or significant comorbidities.
The study populations were divided into 3 groups:
normal weight (BMI \85th percentile), overweight (BMI
between 85th and 95th percentile), and obese (BMI .95th
percentile) based on Centers for Disease Control and
Prevention criteria (http://www.cdc.gov/obesity/childhood/
basics.html). For each child, the following was recorded:
demographic information including age, gender, and race;
indication for surgery; and height and weight on day of surgery or at initial primary care visit as well as at 6, 12, 18,
and 24 months based on electronic medical record growth
charts.

Continuous data are reported as means with standard

deviations. Categorical data are presented as numbers and
percentages. To evaluate for differences between T&A and
control groups, continuous data were analyzed with simple
linear regression, while categorical data were analyzed with
the Pearson x2 test. To determine if the longitudinal changes
in weight, height, and BMI were affected by T&A, a mixed
multilevel regression model was used. This model accounts
for the changes that occurred over time between the T&A
and control groups and the potential random changes or
effects that can occur between each individual over the
same period.15,16 Statistical significance was set at a 2tailed P value of .05. Statistics were performed with
StatCorp (StataCorp LP, 2014; Stata Statistical Software,
Release 13, College Station, Texas).

Results
A total of 199 children underwent T&A, of whom 45 were
excluded, leaving a study population of 154 (Figure 1).
The maximum number of children with weight data was 89
(58%) and for height was 75 (49%) at 12 months. The minimum number of children with weight data was 63 (41%)
and for height was 51 (33%) at 18 months (Figure 1).
A total of 500 children were identified from well-child
visits, and 318 were excluded, leaving a control population
of 182 (Figure 1). The maximum number of children with
weight data was 140 (77%) and for height was 125 (69%) at
12 months. The minimum number of children with weight
data was 80 (44%) and for height was 55 (30%) at 18
months (Figure 1).
The demographics of the study population are summarized in Table 1. In the T&A group, at baseline, normalweight children were younger but had a similar BMI percentile compared with the control group. The mean age and
BMI percentiles, at baseline, were not different for the overweight or obese groups. Gender, ethnicity, height, and all
other measures were not significantly different between the
T&A and control groups (Table 1). Indications for T&A
were OSA (80.7%) and recurrent tonsillitis (19.3%).
Table 2 summarizes the weight changes over time for
the T&A and control groups. There was a significant difference in weight gain in favor of the T&A group at 6, 12, 18,
and 24 months. At 6 months, the difference was an average
of 0.8 kg but increased to 2.6 kg at 24 months. There was
no difference in height changes between the T&A and control groups at 6, 12, and 18 months. At 24 months, the T&A
group had gained an average of 1.8 cm more than the control group, and this was significant (P = .04).
The baseline weight with changes at 6, 12, 18, and 24
months for the different weight categories is summarized in
Table 3. In obese children, there was a significant difference in weight gain in the T&A compared with the control
group at 12, 18, and 24 months. Obese children who underwent T&A gained an average of 4.1 kg over and above the
weight gain of obese children in the control group (P \
.001; Table 3). There was a small difference in normalweight children between the T&A and control groups at 12

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OtolaryngologyHead and Neck Surgery 152(4)

T&A Group

Control group

199 Children underwent T&A during

study period

500 children who had not undergone T&A

visited PCP during study period

45 excluded for no follow up or syndromic

disorders

318 excluded for no follow up or

syndromic disorders

154 in study population

182 in study population

6 month follow up
85 children had weight data (48 normal,
17 over, 20 obese)

113 children had weight data (60 normal,

31 over, 22 obese)

69 children had height data (38 normal,

15 over, 16 obese)

107 children had height data (59 normal,

25 over, 23 obese)

12 month follow up

12 month follow up

89 children had weight data (44 normal,

13 over, 32 obese)

140 children had weight data (77 normal,

36 over, 27 obese)

75 children had height data (39 normal,

11 over, 25 obese)

125 children had height data (67 normal,

32 over, 27 obese)

18 month follow up

18 month follow up

63 children had weight data (31 normal,

7 over, 25 obese)

80 children had weight data (45 normal,

14 over, 21 obese)

51 children had height data (23 normal, 8

over, 20 obese)

55 children had height data (37 normal,

17 over, 11 obese)

6 month follow up

24 month follow up

24 month follow up

69 children had weight data (39 normal,

11 over, 19 obese)

106 children had weight data (60 normal,

27 over, 18 obese)

60 children had height data (33 normal,

10 over, 17 obese

90 children had height data (51 normal,

21 over, 18 obese)

Figure 1. Flow chart for patient selection for adenotonsillectomy and control groups.

months but no significant differences at 6, 18, and 24

months (Table 3). There were no differences between the
T&A and control groups in weight gain for overweight children at 6, 12, 18, and 24 months (Table 4). These differences were not affected by age, gender, ethnicity, or
indication for surgery.
Obese children in the control group increased their
height more than in the T&A group at 6 and 12 months, but
this difference was not significant at 18 and 24 months.
There were no significant differences in height between the
T&A and control groups for normal or overweight children
at 6, 12, 18, or 24 months.
Baseline and 24-month (if available) BMI z-scores were
calculated for each child. Average z-scores for each group
were then calculated for both intervals and are compared in
Table 4. The 2 groups within each weight class had similar
baseline z-scores at the start of the study period. At the conclusion of the study period, there were also no significant
differences between the 2 normal and overweight groups.
There was a significant difference for the obese groups,

however, with the T&A group z-score being significantly

higher than the control at 24 months, reflecting the height
and weight results previously discussed.
Of the children included in the normal-weight groups, a
small number were underweight (BMI \5th percentile). There
were 3 underweight children in the T&A group. Following
T&A, 2 children had a BMI greater than 5th percentile at 24
months, while 1 remained underweight. Five children in the
normal control group were also underweight. Four had a BMI
greater than the 5th percentile at 24 months, and 1 remained
underweight. None of the underweight children in either group
had a BMI classified as overweight or obese at 24 months.

Discussion
This study compared height and weight changes over 2
years between children who underwent T&A and a control
population. Overall, children who underwent T&A did gain
significantly more weight than controls. The weight gain
difference was small at 6 months but increased with time
over the 24-month period. The changes in height were not

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737

Table 1. Baseline Characteristics of the Study Population.

Characteristic

T&A Group Control Group P Value

Total, No. (%)

Ethnicity
Hispanic
Non-Hispanic
Female, %
Mean age, y
Normal weightb
Overweightc
Obesec
Average start BMI, percentile
Normal weightb
Overweightc
Obesed
Indications for T&A, %e
OSA
Recurrent tonsillitis

154 (45.8)

182 (54.2)

NA

80 (51.9)
74 (48.0)
72 (41.1)

80 (44.0)
100 (55.6)
103 (58.9)

.08
.08
.07

4.9
6.6
8.3

6.6
6.7
7.9

.001
.68
.33

45.7
90.0
96.7

47.8
88.0
98.0

.6
.50
.63

80.7
19.3

NA
NA

Abbreviations: BMI, body mass index; CDC, Centers for Disease Control
and Prevention; OSA, obstructive sleep apnea; T&A, adenotonsillectomy.
a
Significance set at .05.
b
Normal weight as defined by the CDC (BMI percentile less than 85).
c
Overweight as defined by the CDC (BMI percentile 85-94.9).
d
Obese as defined by the CDC (BMI percentile 95 or greater).
e
As defined in the electronic medical record.

significant until 24 months and were small. When examining individual weight categories (normal, overweight,
obese), the difference in weight gain was seen mostly in
obese children and increased over the study period. There
were small and mostly insignificant changes in height
changes between the groups even when broken down into
weight categories. The difference in weight gain was not
affected by age, gender, ethnicity, or indication for surgery.
Previous publications have also reported increased
weight gain following T&A, but most studies lacked controls.11,12 Equally, few studies have shown that weight gain
was mostly a problem in obese children. Indeed, a publication by Czechowicz and Chang5 used a large retrospective

database and reported that only normal-weight children were

at risk for increased weight gain following T&A. A recent
publication by Katz et al13 showed that children who underwent T&A for OSA gained a greater amount of weight than
controls at 7 months. This randomized controlled trial showed
an increased risk for obesity in overweight children following
T&A.13 The differences in outcomes in our study, as compared
with others, are likely to be a result of multiple factors, including differences in inclusion criteria, the nature of the control
population, length of follow-up, and quality of the data. For
example, in the study by Katz et al,13 only children with
polysomnography-proven OSA were included and were followed up for a relatively short 7-month period. In comparison,
in this study, we included all children (regardless of indication)
and extended the follow-up period to 2 years.
Obese children who underwent T&A continued to gain
weight over and above the controls up to 2 years after surgery. This has significant clinical implications given that
most T&As were performed for OSA (see Table 1) and the
known link between weight gain and recurrence of OSA
postoperatively.14 There is evidence that children cured of
OSA are less hyperactive and therefore exhibit less motor
movement during the day.11 Another theory claims that
T&A reduces work of breathing at night, leading to
decreased calorie expenditure with sleep.12 This may
explain why obese children gain more weight following surgery but not why it seems to affect them more than normalor overweight children. There may be changes in obese children after T&A that are different from other weight groups
but are currently unknown.
The clinical implications of our results require further
discussion. The benefit of T&A for OSA in children, including obese children, has been clearly described in terms of
improvements in polysomnography, quality of life, and
behavior.8,9 At this point, there is not enough evidence to
suggest that obese children should not continue to be treated
primarily with T&A. There are studies that report the efficacy of long-term continuous positive airway pressure
(CPAP) use in children with OSA, but compliance is generally poor.17 It remains unclear whether some obese children
should be offered CPAP as an alternative to T&A primarily

Table 2. Weight Changes over Time.

Time Interval
Baseline
6 mo
12 mo
18 mo
24 mo

T&A Groupa,b

Change in Weighta,c

Control Groupa,b

Change in Weighta,c

Mean Difference in Weighta,b,d

P Valuee

31.3 (27.8-34.8)
33.9 (30.3-37.5)
36.9 (33.2-40.7)
39.0 (35.1-42.9)
40.7 (36.7-44.7)

2.6
5.6
7.7
9.6

30.7 (27.6-33.8)
32.4 (29.2-35.6)
34.3 (31.1-37.6)
35.8 (32.4-41.3)
37.7 (32.2-41.3)

1.7
3.6
5.1
7.0

0.8 (0.2, 1.6)

2.0 (1.2, 2.9)
2.6 (1.4, 3.8)
2.6 (0.9-3.9)

.011
.000
.000
.002

Abbreviation: T&A, adenotonsillectomy.

a
Weight in kilograms.
b
95% confidence interval in parentheses.
c
Changes in kilograms at that interval compared with the baseline weight.
d
Comparing the change in weight for the T&A group with the control at that interval (ie, column 3 to column 5).
e
Significance set at .05.
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OtolaryngologyHead and Neck Surgery 152(4)

Table 3. Weight Change over Time by Weight Category.a

Weight
Categoryb

Time
Interval

Normal

Baseline
6 mo
12 mo
18 mo
24 mo
Baseline
6 mo
12 mo
18 mo
24 mo
Baseline
6 mo
12 mo
18 mo
24 mo

Overweight

Obese

T&A
Groupc,d
21.7
23.8
26.1
27.6
28.1
30.5
32.6
35.5
36.8
40.0
47.6
51.0
55.8
58.9
61.9

(17.3 to 26.1)
(19.3 to 28.4)
(21.5 to 30.7)
(22.9 to 32.4)
(23.2 to 33.1)
(23.2 to 37.9)
(25.2 to 40.1)
(27.8 to 43.1)
(28.9 to 44.7)
(31.9 to 48.2)
(41.9 to 53.3)
(45.2 to 57.0)
(49.8 to 61.7)
(52.8 to 65.0)
(55.6 to 68.3)

Change in
Weightc,e

2.1
4.4
5.9
6.4
2.1
5.0
6.3
9.5
3.4
8.2
11.3
14.3

Control
Groupc,d
24.5 (21.0 to 28.0)
26.0 (22.4 to 29.6)
27.6 (24.0 to 31.4)
29.2 (25.4 to 33.1)
30.6 (26.58 to 34.51)
31.9 (26.5 to 37.3)
33.7 (28.7 to 39.3)
35.6 (29.9 to 41.3)
36.8 (30.9 to 42.7)
38.9 (32.9 to 45.0)
48.1 (41.9 to 54.2)
50.4 (44.1 to 56.7)
53.0 (46.5 to 59.5)
54.6 (47.9 to 61.3)
58.3 (51.3 to 65.2)

Change in
Weightc,e

Mean Difference
in Weightc,d,f

P Valueg,h

1.5
3.1
4.7
6.1

0.6 (0.8 to 1.6)

1.3 (0.7 to 2.4)
1.2 (0.8 to 2.9)
0.3 (1.5 to 2.3)

.11
.02
.80
.98

1.8
3.7
4.9
7.0

0.3 (1.1
1.3 (0.6
1.4 (1.2
2.5 (0.6

to 1.6)
to 3.0)
to 3.9)
to 5.6)

.73
.19
.31
.12

1.1 (0.3 to 2.5)

3.2 (1.6 to 4.9)
4.8 (2.5 to 7.2)
4.1 (1.3 to 7.1)

.12
.00
.00
.00

2.3
4.9
6.5
10.2

Abbreviations: CDC, Centers for Disease Control and Prevention; T&A, adenotonsillectomy.
a
Comparing total weight change for the T&A group with the control group at 6-month intervals.
b
Weight classes as defined by the CDC.
c
Weight in kilograms.
d
95% confidence interval in parentheses.
e
Change in weight (kilograms) at that interval compared with baseline.
f
Comparing the weight changes for the T&A and control groups at that interval (comparing column 4 to column 6).
g
Significance set as .05.
h
Bolded text represents statistically significant results.

as a means of reducing long-term weight gain. Parents

should be informed, however, that there is evidence that
obese children do gain more weight following T&A and
that this may be a problem for several years after the procedure. The importance of a good diet and daily exercise in
all children cannot be overemphasized. However, in obese
children, routine preoperative nutrition counseling prior to
T&A may have an additional important role. Many medical
centers across the country now have programs dedicated to
helping obese children reach a healthier weight.18 Many of
these programs have shown promise in helping children
improve their weight, muscle mass, and quality of life.19,20
Providers might consider referral to one of these programs
as part of their standard preoperative workup for obese children prior to T&A.
There are several strengths to this study. It included a
large pediatric population with both OSA and recurrent tonsillitis as indications for T&A. The follow-up period was 2
years, with data available at 6-month intervals. A significant
strength was the addition of a control group. This allowed
us to compare weight gain in children after T&A to that
seen in a normal population of children in the same institution. However, there are several limitations that need to be
recognized. This was a retrospective study, and therefore,
all data points were not available. Most children had 2 to 3
data points out of 4 over the 2-year period, but few had
complete data. Thus, at any given 6-month period, it was

Table 4. Average BMI Z-Scores.

Groupa
Normal weight
T&A
Control
Difference
P value
Overweight
T&A
Control
Difference
P value
Obese
T&A
Control
Difference
P value

Baseline Z-Score

24-mo Z-Score

20.2
20.2
0
1

0.2
0.0
0.2
.36

1.4
1.3
0.1
.3

1.5
1.2
0.3
.2

2.4
2.3
0.1
.3

2.4
2.0
0.4
.02

Abbreviations: BMI, body mass index; T&A, adenotonsillectomy.

a
Weight classes as defined by the Centers for Disease Control and
Prevention.

not an identical cohort that was compared, and this, inevitably, led to discrepancies in the results. The ethnic composition was predominantly Hispanic, reflecting our geographic
location, and may not reflect different ethnic spectrums in

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739

other parts of the country. Also, the normal-weight group

undergoing T&A was significantly younger than controls,
and this may have introduced a selection bias. Finally, the
control population was selected to look at weight increase
over time in children who were not undergoing T&A. It is
possible, but unlikely, that children who are candidates for
T&A have a weight gain that is different from the general
pediatric population regardless of undergoing surgery. Ideal
studies for the future would be long and prospective in
nature, with set time points at which all participants have
their height/weight measured.

Conclusions
Children undergoing T&A experience weight gain that is
significantly greater than in controls and is predominantly
in those who are obese. The difference is most pronounced
24 months after surgery. Otolaryngologists should discuss
T&A as an independent risk factor for excess weight gain in
obese children.
Author Contributions
Travis L. Lewis, conception, data acquisition, data analysis, data
interpretation, drafting, revising, final approval, accountability for
all aspects of work; Romaine F. Johnson, data acquisition, data
analysis, data interpretation, drafting and revising content, final
approval, accountability for all aspects of work; Jonathan Choi,
data acquisition, data analysis, drafting and revising of content,
final approval, accountability for all aspects of work; Ron B.
Mitchell, conception, data acquisition, data analysis and interpretation, drafting and revising content, final approval, accountability
for all aspects of work.

Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.

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