What is the treatment for tonsillitis in a 12-year-old child?

Treatment of Tonsillitis in a 12-Year-Old Child

For acute tonsillitis in a 12-year-old, treat with supportive care (NSAIDs, hydration) for viral infections, and if bacterial infection with group A beta-hemolytic streptococcus (GABHS) is confirmed, prescribe penicillin or azithromycin as first-line antibiotics. 1, 2

Initial Assessment and Diagnosis

The diagnosis of acute tonsillitis is primarily clinical, though distinguishing viral from bacterial etiology can be challenging 1, 3. Key clinical features to document include:

• Temperature ≥38.3°C (101°F) 4
• Cervical lymphadenopathy (tender nodes or >2 cm) 4
• Tonsillar exudate 4
• Positive test for group A beta-hemolytic streptococcus 4

Important caveat: Approximately 10% of healthy children carry Streptococcus pyogenes in their tonsils without clinical signs, so microbiological screening in asymptomatic children is not indicated and does not justify antibiotic treatment 1, 3.

Medical Management

For Viral Tonsillitis (70-95% of cases):

Supportive care is the mainstay of treatment 5, 6:

• NSAIDs (ibuprofen) for pain and fever control 1, 3
• Adequate hydration 6
• Steroids (dexamethasone) may be considered for symptom relief 1, 3

For Bacterial Tonsillitis (GABHS confirmed):

First-line antibiotic therapy 1, 3, 2:

• Penicillin remains the treatment of choice for S. pyogenes tonsillitis 2
• Azithromycin (12 mg/kg once daily for 5 days) is an alternative, particularly for penicillin-allergic patients 7
• Augmented aminopenicillins (e.g., cefuroxime) have utility with increasing beta-lactamase producing bacteria 1, 2

Duration considerations: While short-term therapy (3-5 days with azithromycin or cephalosporins) is comparable to 10-day penicillin therapy for symptom reduction and primary healing, only the 10-day antibiotic course has proven effective in preventing rheumatic fever and glomerulonephritis 1, 3. Given the current incidence of rheumatic heart disease is 0.5 per 100,000 school-age children, this remains an important consideration 1, 3.

Surgical Considerations (Tonsillectomy)

Watchful Waiting is Strongly Recommended When:

Clinicians should recommend watchful waiting for recurrent throat infection if there have been:

• <7 episodes in the past year 4
• <5 episodes per year in the past 2 years 4
• <3 episodes per year in the past 3 years 4

This is a strong recommendation based on high-quality evidence showing that many children improve spontaneously without surgery, and the benefits of tonsillectomy do not extend beyond the first postoperative year 4.

Tonsillectomy May Be Considered (Option) When:

Clinicians may recommend tonsillectomy for recurrent throat infection with:

• ≥7 documented episodes in the past year, OR 4
• ≥5 episodes per year for 2 years, OR 4
• ≥3 episodes per year for 3 years 4

Each episode must be documented with sore throat PLUS one of the following:

• Temperature ≥38.3°C (101°F) 4
• Cervical adenopathy 4
• Tonsillar exudate 4
• Positive test for GABHS 4

Modifying Factors That May Favor Tonsillectomy:

Even without meeting frequency criteria, assess for: 4

• Multiple antibiotic allergies/intolerance 4
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis) 4, 1
• History of >1 peritonsillar abscess 4, 1

Critical Safety Considerations

Postoperative Pain Management (If Surgery Performed):

• Recommend ibuprofen, acetaminophen, or both for pain control 4
• MUST NOT administer or prescribe codeine or any medication containing codeine in children younger than 12 years (strong recommendation against) 4

Perioperative Antibiotics:

Clinicians should NOT administer or prescribe perioperative antibiotics to children undergoing tonsillectomy (strong recommendation against) 4

Common Pitfalls to Avoid

1. Do not perform microbiological screening in asymptomatic children - this does not justify treatment and 10% of healthy children are GABHS carriers 1, 3

2. Do not rush to tonsillectomy - randomized controlled trials show control groups have high rates of spontaneous improvement, with mean throat infection rates of only 0.3-1.17 episodes per year after observation 4

3. Document thoroughly - each episode must be contemporaneously documented with qualifying clinical features to justify surgical intervention 4

4. Educate families about the limited benefits of tonsillectomy in less severely affected children and the modest short-term benefit (1 year only) even in appropriate candidates 4