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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)Ìý 12 hourly. Erythromycin 15 mg/kg (max 500 mg) 8 hourly or roxithromycinÌý 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)

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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