This pre-referral guideline covers recurrent tonsillitis in children from 1–16 years of age.

Initial work-up

• History and physical examination.
• Most sore throats are due to a viral infection.
• The only clinically important bacterial pathogen is group A B-hemolytic streptococcus (GABHS).
• GABHS is likely if the following are present:
• Tender and enlarged tonsillar cervical lymph nodes, inflammation of the tonsils and the rest of the pharynx, unilateral signs or a generalised erythematous (scarlatiniform) rash.
• Throat swab for culture.

Pre-referral treatment

• Viral – supportive management.
• Bacterial – broad spectrum antibiotics i.e. oral phenoxymethylpenicillin 250mg (500 mg >10 years)  12 hourly. Erythromycin 15 mg/kg (max 500 mg) 8 hourly or roxithromycin  2.5 mg/kg (max 150 mg) 12 hourly for those with penicillin allergy.
• If the throat swab does not grow GABHS – may stop the antibiotics. If GABHS is grown – continue antibiotics for a total of 10 days.

When to refer

• 7 infections in 1 year
• >2 weeks missed from school
• 5 infections/ year for 2 consecutive years
• 3 infections/year for 3 consecutive years

Referral form (pdf)

Parent handout (pdf)

Resources

Kids Connect (RCH Primary Care Liaison)

Kids Health Info (Parent fact sheets online)

Contact information

References

Paediatric Handbook Ear, Nose and Throat Conditions, Chapter 21 (pp312-324); Robert Berkowitz and Michael Marks; Seventh Edition, Blackwell Publishing. By the staff of the Royal Children's Hospital, Melbourne, Australia