Tonsillitis in Children: Symptoms, Treatment, Antibiotics and When Tonsils Are Removed

Tonsils are two lumps of lymph tissue at the back of the throat that help the body fight germs. Tonsillitis is infection and inflammation of the tonsils. It is very common in school-aged children and teenagers, and usually clears up on its own within a week. The main task is to identify the few cases that need antibiotics, and to recognise complications.

Causes

• Viral infections (most cases): cold viruses, adenovirus, influenza, Epstein-Barr virus (glandular fever) and others
• Bacterial infection: the most important is group A Streptococcus ("strep throat")

It is hard to tell the two apart by looking alone, though some clues help.

Symptoms

• Sore throat, pain on swallowing, refusing food or drink
• Red, swollen tonsils, sometimes with white or yellow patches
• Fever, headache, tiredness
• Tender swollen glands in the neck
• Bad breath, hoarse voice
• Abdominal pain and vomiting in younger children
• Ear pain (referred from the throat)

Features suggesting viral cause: cough, runny nose, hoarseness, mouth ulcers, conjunctivitis and diarrhoea.

Features suggesting strep: sudden sore throat with fever, white patches on the tonsils, tender neck glands and no cough, usually in children aged 5-15.

A throat swab or rapid strep test confirms strep throat where available.

Home care

• Pain relief: paracetamol, as per weight. Use our paracetamol dose calculator. Ibuprofen can also help if advised and when dengue is not suspected. Never use aspirin in children.
• Fluids: cool or warm drinks, ice lollies, and plenty of rest. Avoid very hot, acidic or spicy food.
• Soft foods: porridge, soups, mashed vegetables, curd and banana.
• Salt-water gargles for older children who can gargle without swallowing, and lozenges for those over 6 years.
• Humid air and a rest from school.
• Encourage hand-washing, and do not share cups, plates or toothbrushes. Replace the toothbrush after recovery.

Avoid unproven herbal remedies in small children, as some contain unsafe ingredients.

Do children need antibiotics?

Viral tonsillitis does not respond to antibiotics. Using them unnecessarily causes side effects and resistant bacteria. Doctors prescribe antibiotics when strep throat is confirmed or likely, to:

• Reduce the length of illness slightly
• Reduce spread
• Prevent rheumatic fever and other complications

Treatment: penicillin V (or amoxicillin) for 10 days is the standard. If allergic to penicillin, alternatives are used. Finish the whole course, even if the child feels better after two or three days. Amoxicillin should not be used for suspected glandular fever because it can cause a rash.

When to see a doctor

• Sore throat with fever lasting more than 2-3 days
• Difficulty swallowing or inability to drink fluids
• White patches on tonsils, or a sore throat without cough in school-age children
• A rash, joint pain or swelling after a sore throat
• Repeated episodes, snoring or breathing pauses during sleep
• Age under 3 years with high fever or with significant symptoms

Emergency signs

Go to hospital immediately if the child:

• Has difficulty breathing, noisy breathing or cannot open the mouth fully
• Drools and cannot swallow saliva
• Has a muffled "hot potato" voice, and swelling on one side of the throat (possible peritonsillar abscess)
• Has a stiff neck, severe headache or drowsiness
• Shows signs of dehydration, such as very little urine or dry mouth

Complications

• Peritonsillar abscess (quinsy), a pocket of pus beside the tonsil
• Ear and sinus infections
• Rheumatic fever weeks after untreated strep throat, causing joint pain, fever, rash and, importantly, damage to heart valves. It remains a concern in South Asia. Prompt treatment of strep throat prevents it.
• Post-streptococcal glomerulonephritis, a kidney inflammation causing dark urine and swelling
• Scarlet fever, a rash caused by strep toxins

When is tonsillectomy considered?

Removal of the tonsils (tonsillectomy) by an ENT surgeon may be considered if:

• Infections are frequent and severe: for example 7 or more episodes in 1 year, 5 or more per year for 2 years, or 3 or more per year for 3 years, each well documented
• There is repeated peritonsillar abscess
• Enlarged tonsils cause sleep apnoea, loud snoring, or breathing and feeding difficulty
• Chronic tonsillitis does not improve with treatment

Tonsillectomy is a significant operation with pain, bleeding risk and a recovery period of 1-2 weeks, so it is not recommended for occasional sore throats.

Prevention

• Hand-washing, covering coughs and avoiding sharing utensils
• Keeping sick children home until recovered
• Good nutrition and sleep
• Avoiding smoke exposure
• Keeping up to date with vaccines, which prevent some throat infections such as diphtheria. See childhood vaccination

For general advice on fever see fever in children, and for coughs and colds see cough and cold in children.

References

• NICE guideline NG84: sore throat (acute) antimicrobial prescribing
• Infectious Diseases Society of America: clinical practice guideline for group A streptococcal pharyngitis
• American Academy of Otolaryngology: clinical practice guideline on tonsillectomy in children
• World Health Organization: rheumatic fever and rheumatic heart disease