Guideline Discourages Perioperative Antibiotics, Codeine for Kids Undergoing Tonsillectomy

By Will Boggs MD

February 12, 2019

NEW YORK (Reuters Health) - Children undergoing tonsillectomy should not receive perioperative antibiotics and should not receive codeine, but they should receive a single intraoperative dose of intravenous dexamethasone, according to the 2019 updated clinical-practice guideline on tonsillectomy in children from the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

"This guideline emphasizes education, counseling, and pain management for children considered for tonsillectomy," said Dr. Ron B. Mitchell from UT Southwestern and Children's Medical Center, in Dallas, Texas.

"There are several tables and handouts that are user-friendly and should be helpful to caregivers. The panel was diverse, with many stakeholders, including two consumer advocates," he told Reuters Health by email.

Dr. Mitchell and colleagues in the guideline-update group incorporated one new clinical-practice guideline, 26 new systematic reviews and 13 new randomized controlled trials in their update of the 2011 guideline on tonsillectomy in children.

Their advice appears in the February 5 issue of Otolaryngology-Head and Neck Surgery.

Among the changes from the original guideline, there is now a strong recommendation for watchful waiting for children with a recurrent throat infection.

The panel says it is an "option" to recommend tonsillectomy for recurrent throat infection with a frequency of at least seven episodes in the past year, at least five episodes per year for two years, or at least three episodes per year for three years with clear documentation of each episode along with at least one sign of significant disease (fever, cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus).

There are strong recommendations that clinicians administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy and that they should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy.

The guidelines strongly recommend against administering or prescribing perioperative antibiotics to children undergoing tonsillectomy and against administering or prescribing codeine or any medication containing codeine after tonsillectomy in children younger than 12 years.

Seven new action statements address polysomnography, obstructive sleep apnea, inpatient monitoring after tonsillectomy and outcome assessment for bleeding, and there is enhanced emphasis on patient and/or caregiver education and shared decision-making.

The clinical practice guideline has added an algorithm that incorporates all 15 of the key action statements.

"Using the best available evidence and following these key action statements, we can focus on quality improvement and optimizing patient care," Dr. Mitchell said.

The updated guideline is endorsed by the American Academy of Family Physicians, the American Academy of Sleep Medicine, The American Society of Pediatric Otolaryngology, the Infectious Diseases Society of America, the Society of Anesthesia and Sleep Medicine, The Society of Otorhinolaryngology and Head-Neck Nurses, The Society for Pediatric Anesthesia, and The Triological Society. The American Society of Anesthesiologists' Administrative Council has approved endorsement.


Otolaryngol Head Neck Surg 2019.


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