What is the treatment for a pediatric patient with swollen tonsils, possibly due to a recent respiratory infection, and a history of recurrent tonsillitis or streptococcal pharyngitis?

Treatment for Swollen Tonsils in Pediatrics

For a pediatric patient with swollen tonsils and recurrent infections, the primary treatment is medical management with antibiotics when bacterial infection is confirmed, reserving tonsillectomy only for those meeting strict Paradise criteria: ≥7 documented episodes in 1 year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years. 1, 2

Immediate Medical Management

Diagnosis and Testing

• Confirm Group A beta-hemolytic streptococcus (GABHS) infection using rapid antigen detection test or throat culture, as GABHS causes only 15-30% of pediatric pharyngotonsillitis cases 3, 4
• Each documented episode must include at least one qualifying feature: temperature >38.3°C, cervical lymphadenopathy (tender nodes or >2 cm), tonsillar exudate, or positive GABHS test 1, 2
• Viral infections account for 70-95% of tonsillitis cases and do not require antibiotics 3

Antibiotic Treatment for Confirmed GABHS

• First-line: Penicillin V 250 mg (400,000 IU) three times daily for 10 days, or amoxicillin 20-45 mg/kg/day divided every 8-12 hours for 10 days 5, 3
• Penicillin allergy: Clindamycin is the drug of choice for severe penicillin hypersensitivity 6
• Amoxicillin-clavulanate 80 mg/kg/day in three divided doses (not exceeding 3 g/day) can be considered as an alternative, though it may not provide optimal anaerobic coverage 6

Watchful Waiting Strategy

Watchful waiting is strongly recommended for patients not meeting Paradise criteria, as spontaneous improvement occurs in most cases. 1, 2

Natural History Evidence

• Untreated children experienced only 1.17 episodes in year 1.03 in year 2, and 0.45 in year 3 after observation began 1, 2
• Many children on tonsillectomy wait lists no longer meet surgical criteria by the time of surgery 1, 2
• A 12-month observation period is recommended before reconsidering tonsillectomy 1, 2

Documentation Requirements During Observation

• Primary care providers must collate all visits documenting symptoms, physical findings, test results, days of school absence, and quality of life impacts 2
• Include visits to emergency departments or urgent care centers in the documentation 1

Surgical Consideration: Tonsillectomy

Paradise Criteria for Surgery

Tonsillectomy should be considered only when ALL of the following are met 1, 2:

• Frequency threshold: ≥7 episodes in preceding year, OR ≥5 episodes/year in each of preceding 2 years, OR ≥3 episodes/year in each of preceding 3 years
• Clinical documentation: Each episode documented with qualifying features (fever >38.3°C, cervical adenopathy, tonsillar exudate, or positive GABHS test)
• Treatment history: Antibiotics administered in conventional dosage for proven or suspected streptococcal episodes
• Medical record: Contemporaneous notation in clinical record, OR if not fully documented, subsequent observation by clinician of 2 episodes with consistent patterns

Modifying Factors That May Favor Earlier Surgery

Even without meeting full Paradise criteria, consider tonsillectomy for 1, 2, 6:

• History of >1 peritonsillar abscess
• Multiple antibiotic allergies or intolerance
• PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis)
• Severe infections requiring hospitalization
• Complications such as Lemierre syndrome
• Family history of rheumatic heart disease

Modest Benefits of Surgery

• Tonsillectomy reduces sore throat episodes by only 1.4 episodes in the first year, with 1.0 episode of postoperative sore throat 1
• When considering only moderate/severe episodes, surgery provides just 0.2 fewer episodes 1
• Number needed to treat is 11 to prevent 1 sore throat per month in the first year 1
• The guideline panel concluded there is NOT a clear preponderance of benefit over harm, even for children meeting strict Paradise criteria 1

Perioperative Management

• Administer single intraoperative dose of IV dexamethasone 1
• Do NOT routinely prescribe perioperative antibiotics 1, 6

Special Consideration: Obstructive Sleep-Disordered Breathing

If the patient has concurrent symptoms of airway obstruction (snoring, mouth breathing, pauses in breathing), this changes the treatment algorithm entirely 7:

• Grade 3 tonsillar hypertrophy with clinical obstructive symptoms provides sufficient indication for tonsillectomy without requiring polysomnography in otherwise healthy children 7
• In this scenario, recurrent tonsillitis serves as an additional supporting factor, and watchful waiting is NOT appropriate 7
• Document obstructive symptoms including struggling to breathe, daytime sleepiness, inattention, poor concentration, or hyperactivity 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for viral pharyngitis - this promotes bacterial resistance and unnecessary side effects 3, 8
• Do not rush to surgery - the natural history favors spontaneous improvement in most cases 1, 2
• Do not delay surgery when obstructive symptoms are present - watchful waiting only applies to infectious indications without obstruction 7
• Do not rely on clinical impression alone - overestimation of GABHS infection occurs in 80-95% of cases by experienced clinicians 8