• Finnish Medical Society Duodecim. Tonsillitis and pharyngitis in children. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2007 May 30 [Various].

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society Duodecim. Tonsillitis and pharyngitis in children. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2005 Oct 30 [Various]. [1 reference]

Tonsillitis and pharyngitis

Diagnosis
Treatment

Family Practice
Otolaryngology
Pediatrics

Health Care Providers
Physicians

Evidence-Based Medicine Guidelines collect, summarize, and update the core clinical knowledge essential in general practice. The guidelines also describe the scientific evidence underlying the given recommendations.

Children with suspected or known tonsillitis and pharyngitis

Diagnosis

Culture or rapid antigen test

Note: Guideline developers considered but did not recommend assessment of clinical features as a reliable diagnostic measure.

Treatment

1. Paracetamol, naproxen, or ibuprofen for fever and pain
2. Penicillin or cephalexin
3. Isolation of infected child from daycare or school for one day after onset of antibiotic treatment

• Cure rates
• Adverse effects of treatment

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The evidence reviewed was collected from the Cochrane database of systematic reviews and the Database of Abstracts of Reviews of Effectiveness (DARE). In addition, the Cochrane Library and medical journals were searched specifically for original publications.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

1. Quality of Evidence: High

   Further research is very unlikely to change confidence in the estimate of effect

   • Several high-quality studies with consistent results
   • In special cases: one large, high-quality multi-centre trial

2. Quality of Evidence: Moderate

   Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

   • One high-quality study
   • Several studies with some limitations

3. Quality of Evidence: Low

   Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.

   • One or more studies with severe limitations

4. Quality of Evidence: Very Low

   Any estimate of effect is very uncertain.

   • Expert opinion
   • No direct research evidence
   • One or more studies with very severe limitations

Systematic Review

Not stated

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.

Basic Rules

• Antibiotics are indicated in infections caused by group A streptococci diagnosed by culture or rapid antigen test. Symptomatic treatment is indicated in other cases.
• Infectious mononucleosis presents with only mild symptoms in small children. Treatment with antibiotics is of no use, but a course of amoxicillin during the disease will provoke a red-spotted rash in almost every patient.
• Epidemics caused by streptococci should be identified and managed. Contaminated food and milk are known to cause streptococcal epidemic.

Aetiology

• Adenoviruses are the most common aetiological agents.
• Streptococcal pharyngitis is rare in children below 3 years of age.

Symptoms and Signs

• Fever and sore throat are the main symptoms associated with streptococcal infection, but clinical diagnosis is unreliable.
  • Adenoviruses and other viruses can cause exudative tonsillitis.
  • In two thirds of school-aged children with streptococcal tonsillitis there is no exudate.
• If a patient with recent onset fever and sore throat also has cough and rhinitis, a viral respiratory infection is far more probable than streptococcal infection.
• Sore throat with rash is often caused by adenoviruses or other viruses.
• Ear pain may radiate to the tonsillar region (and vice versa).
• Streptococcal pharyngitis may cause abdominal pain.

Diagnostics

• Diagnosis should be based on the detection of streptococci in pharyngeal secretions by culture or rapid antigen test (see picture 1 in the original guideline document). Bacteria other than streptococci need not be sought.
• A rapid culture method (Streptocult®) will give a result the next morning (see Finnish Medical Society Duodecim guideline "Throat Bacterial Swab."). If a rapid antigen test is used, a negative result should be verified by culture. (In children below 3 years of age streptococcal tonsillitis is so rare that a negative antigen test need not be controlled by culture.)

Treatment

• Fever and pain are best treated with paracetamol. Naproxen and ibuprofen are alternatives. Infections caused by group A streptococci should be treated with penicillin V, 70 mg/kg/day (100,000 units/kg/day), or (in patients with penicillin allergy) cephalexin, 50 mg/kg/day, in two doses for 10 days (Deeter et al., 1992) [A].
• Because of infectiousness the child should be isolated from day care or school for one day after the onset of antibiotic treatment. The length of absence from day care or school is determined by the general condition and not by the aetiological agent.

Definitions:

Levels of Evidence

1. Quality of Evidence: High

   Further research is very unlikely to change confidence in the estimate of effect

   • Several high-quality studies with consistent results
   • In special cases: one large, high-quality multi-centre trial

2. Quality of Evidence: Moderate

   Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

   • One high-quality study
   • Several studies with some limitations

3. Quality of Evidence: Low

   Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.

   • One or more studies with severe limitations

4. Quality of Evidence: Very Low

   Any estimate of effect is very uncertain.

   • Expert opinion
   • No direct research evidence
   • One or more studies with very severe limitations

None provided

Concise summaries of scientific evidence attached to the individual guidelines are the unique feature of the Evidence-Based Medicine Guidelines. The evidence summaries allow the clinician to judge how well-founded the treatment recommendations are. The type of supporting evidence is identified and graded for select recommendations (see the "Major Recommendations" field).

Appropriate diagnosis and treatment of tonsillitis and pharyngitis

Not stated

An implementation strategy was not provided.

Getting Better

Effectiveness

• Finnish Medical Society Duodecim. Tonsillitis and pharyngitis in children. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2007 May 30 [Various].

Not applicable: The guideline was not adapted from another source.

2004 Apr 21 (revised 2007 May 30)

Finnish Medical Society Duodecim - Professional Association

Finnish Medical Society Duodecim

Editorial Team of EBM Guidelines

Primary Author: Marjukka Mäkelä

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society Duodecim. Tonsillitis and pharyngitis in children. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2005 Oct 30 [Various]. [1 reference]

None available

None available

This NGC summary was completed by ECRI on August 31, 2005. This summary was updated by ECRI on March 17, 2006, and on January 8, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.