What is the recommended dose of amoxicillin for children post-operative tonsillectomy (T) and adenoidectomy (A)?

Amoxicillin Should Not Be Administered to Children After Tonsillectomy and Adenoidectomy

Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. 1

Evidence Against Antibiotic Use Post-T&A

The 2019 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guideline for tonsillectomy in children provides a strong recommendation against the use of perioperative antibiotics, including amoxicillin, for children undergoing tonsillectomy 1. This recommendation is based on high-quality evidence from multiple randomized controlled trials and systematic reviews.

The guideline explicitly states in Key Action Statement 10: "Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy" with a strong recommendation against this practice 1.

Rationale for Avoiding Antibiotics

• No proven benefit in reducing post-operative pain, bleeding, or other complications
• Potential risks of antibiotic use include:
  • Allergic reactions (2% risk per course for beta-lactams like amoxicillin)
  • Gastrointestinal upset and diarrhea
  • Promotion of antibiotic resistance
  • Anaphylaxis risk (0.01% to 0.05% for penicillins) 1

Recommended Post-T&A Management

Instead of antibiotics, the guidelines recommend:

1. Pain management: Ibuprofen and/or acetaminophen should be used for post-tonsillectomy pain control (strong recommendation) 1

2. Intraoperative steroids: A single intraoperative dose of intravenous dexamethasone should be administered (strong recommendation) 1

   • Typical dose: 0.5 mg/kg (though doses from 0.15 to 1.00 mg/kg have been studied)
   • Maximum dose range: 8 to 25 mg 1
   • Benefits: Reduces post-operative nausea and vomiting, decreases throat pain, and shortens time to resumption of oral intake

3. Inpatient monitoring: For children <3 years old or with severe OSA (AHI ≥10 obstructive events/hour or oxygen saturation nadir <80%) 1

Research Evidence

Multiple studies have demonstrated that routine antibiotic use does not improve outcomes after tonsillectomy:

• A 2013 study showed that antibiotics (amoxicillin with clavulanic acid) for 5 days post-tonsillectomy did not reduce throat pain, time to normal diet resumption, or fever compared to no antibiotics 2

• Another study in 2013 found no difference in postoperative pain between patients receiving single-dose preoperative cephalothin versus those receiving additional oral amoxicillin/clavulanate for 7 days 3

Common Pitfalls to Avoid

1. Prescribing antibiotics "just to be safe": This practice is not supported by evidence and contributes to antibiotic resistance

2. Using codeine for pain control: Clinicians must not administer or prescribe codeine after tonsillectomy in children younger than 12 years (strong recommendation against) 1

3. Inadequate pain management: Proper pain control with ibuprofen and/or acetaminophen is essential for recovery

4. Overlooking the need for inpatient monitoring in high-risk children (age <3 years or severe OSA)

Conclusion

Based on the most recent and highest quality evidence from the 2019 AAO-HNS guidelines, amoxicillin or any other antibiotic should not be administered to children after tonsillectomy and adenoidectomy. Instead, focus should be placed on appropriate pain management with ibuprofen and/or acetaminophen, administration of a single intraoperative dose of dexamethasone, and proper monitoring of high-risk patients.