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.
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.
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.
|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
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 www.nice.org.uk