Karen Dahl, MD, Division Chief, Pediatric Infectious Disease
Helen DeVos Children's Hospital, Grand Rapids, Michigan

For the week ending February 19, 2011, Helen DeVos Children's Hospital reported eight influenza A positive tests, and 4 positive influenza B tests.  Although still quite a bit of activity, it is down from our peak of 20 positive tests during the first week of February. 

RSV activity may be winding down as well; last week there were 16 positive tests but this week just 8. 

One positive adenovirus test was reported.  

At the national level, the Centers for Disease Control and Prevention continues to report elevated influenza activity in the country, widespread in 37 states for the week ending February 12. The proportion of outpatient visits for influenza-like illness was 4.5%, which is above the national baseline of 2.5%.

Karen Dahl, MD, Division Chief, Pediatric Infectious Disease
Helen DeVos Children's Hospital, Grand Rapids, Michigan

For the week ending February 5, 2011, Helen DeVos Children's Hospital reported 20 influenza A positive tests, more than twice the number seen in previous weeks. RSV activity is also picking up with five positive tests in the past week. No other viruses were reported for the week.  

At the national level, the Centers for Disease Control and Prevention reports that for the week ending January 29, influenza activity continued to increase in the country. The proportion of deaths attributed to pneumonia and influenza (P&I) was above the epidemic threshold and there were six influenza-associated pediatric deaths reported.  

Chad Afman, MD, Pediatric Otolaryngologist

I'm sure that many of you can recall the days when a tonsillectomy was as much a rite of passage for a child as a first bra or baseball glove. Then the pendulum swung the other way, and tonsillectomies were reserved for only the most severe cases. Today, more than half a million tonsillectomies are performed each year in the United States. Despite the frequency of tonsillectomies, we have just now received the first, national, evidence-based guidelines on the procedure to guide us as to when the surgery should be done.

The recommendations, from the American Academy of Otolaryngology, call for:¹

• Watchful waiting for recurrent throat infection with fewer than 7 episodes in the past year, or fewer than 5 episodes per year in the past 2 years, or fewer than 3 episodes per year in the past 3 years.
• Assessing the child with recurrent throat infection who does not meet criteria in the previous statement for other factors that might suggest a  tonsillectomy is appropriate, including:
  • Multiple antibiotic allergy/intolerance
  •  PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis)
  • History of peritonsillar abscess (collection of pus behind the tonsil)
• Asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems.
• Counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography, who also have tonsil hypertrophy and sleep-disordered breathing.

Given that tonsillectomy is one of the most common surgeries performed on kids, it is important that primary care physicians and specialists have some clarification in terms of when to recommend surgery. I think the guideline committee did a very thorough job in its assessment, reviewing and citing more than 200 high-quality papers. I also find it interesting that even after such an extensive review, the "Paradise criteria" still holds up.²

It is, thus, important that pediatricians document the infections children have had in the past. You don't necessarily have to wait an entire year; the number of prior infections should be estimated and then two additional episodes of tonsillitis be observed to confirm the frequency of illness. It is also important to ask parents if their child snores or has other signs of sleep-disordered breathing. Other signs of sleep-disordered breathing include restless sleep, pauses in breathing, coughing during sleep, and choking sounds.

Overall, we think the guidelines will lead to more watchful waiting, which is a good thing since most kids outgrow the recurrent infections that so often lead to surgery.  

Regarding tonsillar hypertrophy and sleep-disordered breathing, these guidelines support surgery as an effective treatment to improve the child's quality of life.

What are your thoughts about the new tonsillectomy guidelines? Click "Add Comment" below. 

References

1. Baugh RF, Archer SM, Mitchell RB, et al. Clinical Practice Guideline: Tonsillectomy in Children. Otolaryngology -- Head and Neck Surgery. 2011; 144(1_suppl): S1 - S30.

2. Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N. Engl. J. Med. 1984. 310 (11): 674-83. doi:10.1056/NEJM198403153101102. PMID 6700642.