Tonsillitis in children

What is tonsillitis?

The tonsils are two pads of tissue at the back of the throat, one on each side, that form part of the immune system. Tonsillitis is when these tissues become swollen and red because of an infection. It is very common in children, and symptoms usually start to settle within 3–4 days, although they can last a little longer.

Virus or bacteria?

Most throat infections are caused by viruses and get better on their own without antibiotics. The most important bacterial cause is group A streptococcus ("strep throat"). Strep throat is most common between ages 5 and 15 and is rare in children under 3. About three in ten children with a sore throat have strep.

• Cough, runny nose, hoarseness and red eyes point more towards a viral infection.
• Sudden fever, pain on swallowing, white patches on the tonsils and swollen, tender neck glands make strep more likely; in children, stomach ache, nausea or vomiting may also occur.

Although symptoms are a useful guide, a virus cannot be reliably told apart from bacteria by appearance alone, which is why testing is done when needed.

Symptoms

• Sore throat and painful swallowing; young children may not be able to say so and may refuse food or drool.
• Fever, tiredness and headache.
• Red, swollen tonsils, sometimes with white or yellow spots of pus.
• Swollen, painful neck glands, earache and bad breath.

When to see a doctor

Examination and tests

The doctor examines the throat, tonsils, neck glands and ears. If strep is suspected, a throat swab may be taken for a rapid strep test or sent for culture. Testing is often not needed in children with clearly viral symptoms such as cough and runny nose. Basing the antibiotic decision on test results wherever possible reduces unnecessary medicine use.

Treatment and home care

When is tonsil surgery considered?

Tonsil surgery (tonsillectomy) is not needed for every throat infection. According to the 2019 American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) guideline, watchful waiting is recommended for children whose infections fall below the following thresholds. Surgery is generally discussed for throat infections documented by a doctor at this frequency:

• 7 or more in the past year.
• At least 5 a year in each of the past 2 years.
• At least 3 a year in each of the past 3 years.
• Sleep-disordered breathing: loud snoring, pauses in breathing and restless sleep caused by large tonsils, which can lead to daytime attention and behaviour problems. Some children need a sleep study (polysomnography) before a decision is made.

Other situations, such as repeated abscesses around the tonsil, are also taken into account. The decision is made after examination, weighing the child's overall health, how severe the infections are and the family's preferences.

Recovery after tonsillectomy

• Throat pain usually lasts 7–10 days, sometimes up to two weeks, and may get worse for a while after the first few days. Ear pain is also common.
• Give painkillers regularly as your doctor advises; good pain control makes drinking easier. Medicines containing codeine are not used in children under 12.
• Drinking plenty is the most important part of recovery. A white-yellowish coating where the tonsils were is normal and does not usually mean infection.
• Children usually stay off school for about two weeks and are advised to avoid strenuous sport and crowded places during this time.

Bleeding after surgery is an emergency. It can happen in the first 24 hours or later, most often around days 5–10 as the scabs come away. If there is fresh blood from the mouth or nose, your child spits or vomits blood, or is swallowing repeatedly, go to the emergency department or call emergency services (112 in Türkiye) without waiting. Sit your child leaning forward so they do not swallow the blood, and do not drive yourself. Also contact your surgeon if there is fever, refusal to drink or pain that cannot be controlled.