Seeing 8-year-old Jacob Burkholder full of energy as he arrives home from a day at school is a relief to his mom. She said his snoring at night used to rob him of sleep.
"I mean you could hear it through the walls. It was very loud," said Jenni Burkholder.
She said the cause turned out to be swollen tonsils.
"You could not see any space between. They touched almost," Burkholder said.
That's when Jacob's schoolwork started to suffer.
"His father and I, we noticed the issues he starting to have at school with being forgetful and his appearance, looking really tired, bags under the eyes," she said.
Jacob's little brother Joshua, also snored, just not as loudly as Jacob.
"I would stay awake all night," said Joshua.
So both boys had their tonsils out.
Tonsillectomies are more common than any other surgery of childhood aside from ear tubes and circumcision.
"In the United States right now we do about 600,000 tonsillectomies per year, more in kids," said Dr. Scott Manning.
Even that is down two thirds from thirty or forty years ago according to Dr. Manning. He is Chief of Pediatric Ear Nose and Throat, Otolaryngology, at Seattle Children's.
He said the reason for 80 percent of tonsillectomies is obstructed breathing during sleep. And the remainder?
"Twenty percent is for recurrent infection, some of which is usually strep throat," he said.
Recently the American Academy of Otolaryngology published the first ever guideline for doctors and parents on the surgery. It concludes that a tonsillectomy should be considered after at least seven sore throats in a year, 5 sore throats in a two year stretch, or at least three a year for three years. The guideline recommends that doctors and parents decide together if a tonsillectomy would help a child with sleep issues. Dr. Manning tells what doctors look for in a young patient.
"It's a combination of genetic tendency, low tone during deep sleep, and big tonsils, and sometimes being overweight, a problem in our society, more and more in kids now," he said.
The guideline also said tonsillectomies that improve sleep may reverse bedwetting, growth delay, poor school performance and behavior problems.
There's something else the new guidance emphasizes; parents should keep close tabs on a child's pain after surgery, and treat the pain until it's all gone.
Both of the Burkholder boys sleep better now. And Jacob has another benefit.
"He seems to be doing well in school, paying a little bit more attention," said his mother.
Joshua's improved sleep is putting his learning back on track.