NICE has published Referral Advice - A guide to appropriate referral from general to specialist services, which deals with 11 common complaints. Last month we covered psoriasis. In this issue we reproduce the advice on recurrent episodes of acute sore throat in children aged up to 15 years.

The referral advice is set out in consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred.

For a summary of the consensus statements click here

Sore throat in the under-15s

Most children have isolated episodes of acute sore throat (acute tonsillitis, acute pharyngitis), which can last up to 10 days and usually resolve spontaneously. In some children this may be coupled with systemic features such as fever, lethargy, malaise and vomiting.

If recurrent, sore throat may interfere with school attendance, education and behaviour.

Findings on examination include redness and swelling of the tonsils or pharyngeal lymphoid tissue, with or without exudate. The child may also have swollen and tender cervical lymph nodes.

The definition of recurrence is arbitrary; here recurrence is defined as five or more episodes in the previous 12 months.

The diagnosis of recurrence does not depend on the underlying cause (viral, bacterial), or on the severity of the symptoms.

Primary care

Advice should be given on keeping a ïsore throat diaryÍ in order to establish any pattern of recurrence and the impact on the childÍs day-to-day activities. Clinical management aims to reduce the severity and duration of individual episodes and prevent complications such as quinsy (peritonsillar abscess).

Drug treatment options for the individual episode include analgesia (excluding aspirin) and antibiotics.

For most patients, antibiotics have little effect on the extent and duration of symptoms.

Paradoxically, children treated early with an antibiotic may be at increased risk of further infection and may re-attend more often. An antibiotic should be given, however, if the child has:

  • features of marked systemic upset secondary to the acute sore throat
  • unilateral peritonsillitis
  • a history of rheumatic fever
  • an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency).

In those in whom an antibiotic is initially withheld, the position should be reviewed if the symptoms are worsening after several days. Reasons for prescribing or withholding an antibiotic should be discussed.

There is no evidence to support the routine use of throat swabs.

Specialist services

These are in a position to:

  • confirm or establish the diagnosis
  • provide management advice
  • assess the need for, and if necessary, undertake surgery
  • treat complications.
Referral Advice
Almost all children with recurrent sore throat can be managed in primary care. However, children should be referred to a specialist service if:
they have, or are suspected of having, a quinsy
the swelling is causing acute upper airways obstruction
the swelling is interfering with swallowing, causing dehydration and marked systemic upset
they have a history of sleep apnoea, daytime somnolence and failure to thrive
they have had five or more episodes of acute sore throat in the preceding 12 months documented by the parent or clinician, and these episodes have been severe enough to disrupt the childÍs normal behaviour or day-to-day activity
they have guttate psoriasis which is exacerbated by recurrent tonsillitis

there is suspicion of a serious underlying disorder such as leukaemia

The starring system developed by NICE to identify referral priorities
Arrangements should be made so that the patient:
is seen immediately1
is seen urgently2
is seen soon2
has a routine appointment2
is seen within an appropriate time depending on his or her clinical circumstances (discretionary)

1 within a day
2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.

Reproduced with kind permission from: Referral Advice - A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001.

The complete document can be downloaded from the NICE website

Guidelines in Practice, September 2002, Volume 5(9)
© 2002 MGP Ltd
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