The Make America Healthy Again commission’s recent report on children’s health has received a lot of attention for its citation errors and focus on ultra-processed foods, smartphones, and stimulant use. But the less-discussed part on “overmedicalization” of American children stood out to us. While the report mentions surgical care only briefly, it identifies two common procedures, adenotonsillectomy and tympanostomy tube (ear tube) placement, as surgeries that “cause harm without offering benefits.” These procedures are among the most performed surgeries in children.
We are pediatric ear, nose, and throat surgeons with years of clinical and research experience. One of us (EB) leads research on how parents make decisions about elective surgeries like tonsillectomy. The other (DT) has led development of national evidence-based clinical practice guidelines aimed to ensure appropriate surgical care. We agree that these two childhood procedures are performed often enough to warrant vigilance around overuse and unnecessary surgery.
But the MAHA report presents its conclusions on surgery with tunnel vision and misinterpretation. It did not recognize proven benefits of surgery: for tonsil and adenoid removal, improved sleep, behavior, and learning; for ear tube placement, better hearing, speech, and fewer infections. In appropriately selected children, these surgeries improve quality of life and reduce both health care visits and use of antibiotics. A blanket dismissal of surgical benefits could threaten access to necessary care for children with sleep apnea or hearing loss.
The appropriate indications and expected health benefits of adenotonsillectomy and ear tube surgery for young children have been debated for decades. In 2009, President Obama suggested that financial factors might influence a surgeon’s decision to recommend tonsillectomy. In 2012, a National Summit on Overuse highlighted misuse of ear tubes for short-term ear fluid. Events like these spurred the development of evidence-based practice guidelines informed by clinical trials, experience, and patient outcomes. These guidelines clearly delineate surgical indications and emphasize shared decision-making between families and surgeons. Though still common, these surgeries have decreased in frequency over time. Meanwhile, indications have evolved and become more precise. Tonsillectomy, once used for recurrent throat infections, is now most often performed to treat obstructed breathing and sleep apnea. Ear tubes are now used to treat persistent middle ear fluid causing hearing loss and speech delay rather than infrequent, uncomplicated ear infections.
There are real, proven, and often life-changing benefits of adenotonsillectomy and ear tube surgery for many children. Performed on nearly 300,000 U.S. children each year, adenotonsillectomy is used to treat children with obstructive sleep apnea, a common condition that can lead to heart and lung strain, fatigue, hyperactivity, inattention, bedwetting, and learning delays.
The MAHA report states there is no benefit of adenotonsillectomy for sleep apnea, citing a single study that found no difference in a generic IQ screening measure. However, that same study also reported significant improvements in sleep apnea severity, behavior, and physical health in children who underwent surgery — findings that were not acknowledged in the MAHA report. More concerning, the report failed to reference many additional well-designed studies that show consistent improvements in health, sleep, behavior, learning, and quality of life after surgery. Large-scale randomized trials confirm that while some children with sleep apnea may improve without treatment, the majority continue to experience symptoms that are alleviated with surgery.
Ear tube surgery tells a similar story. Yes, overuse has occurred, especially for children with recurrent infections or transient middle ear fluid. Contemporary guidelines advise against surgery in such cases. But for children with persistent fluid and hearing loss, ear tubes provide measurable improvement. Judicious use of ear tubes also helps reduce repeated antibiotic use, a key overtreatment concern highlighted in the MAHA report.
How can we move forward, guarding against overuse while continuing to offer surgery to children who will benefit? We must better understand the real-world complexity of children undergoing surgery. Research should expand to include data beyond clinical trials and fragmented outcome measure assessment. We must also promote best practices that reduce risk and recognize that two children with the same diagnosis may have different symptom burdens, family priorities, and definitions of successful treatment.
Surgery for children should always be under scrutiny. We strive to offer surgery only when expected outcomes are favorable, risks are minimal, and disease burden justifies intervention. We applaud MAHA policymakers who focus on overuse, but we urge a comprehensive review of trials, systematic reviews, and practice guidelines. Tonsillectomy and ear tube surgery benefit many children. We know this not only from a more thorough analysis than MAHA provided, but also from clinical experience treating thousands of children.
If evidence and our experience are not enough, ask the parents. They will tell you about children who sleep soundly, hear clearly, speak precisely, perform better in school, and were changed for the better by surgery that was carefully considered and prudently delivered.
Emily Boss, M.D., M.P.H., is the director of pediatric otolaryngology and a professor of Otolaryngology-Head and Neck Surgery, Pediatrics, and Health Policy & Management at Johns Hopkins University. David Tunkel, M.D., is the director emeritus of pediatric otolaryngology and a professor of Otolaryngology-Head and Neck Surgery at Johns Hopkins University, as well as immediate past chair of the American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guidelines Taskforce. Their comments are their own and do not represent Johns Hopkins University.
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