Medscape: One of the most relevant recommendations in the guideline for primary care providers is the first statement, which recommends watchful waiting for recurrent throat infections if there have been fewer than 7 episodes in the previous 12 months or fewer than 5 episodes per year in the previous 2 years or fewer than 3 episodes per year in the past 3 years. So bottom line, children should be observed for at least 1 year before a referral to a surgeon to consider tonsillectomy. Is this number of episodes irrespective of the severity of the episodes? Is the intent that these episodes will have all been of sufficient intensity to warrant a visit to a healthcare provider?
Dr. Wald: To put this in perspective, and this is stated clearly in the document, the purpose of the guideline is to avoid unnecessary intervention in children who have recurrent throat infection who are very likely to have a favorable natural history and improve on their own and therefore will be benefited by avoiding surgery. There may be exceptions occasionally on the basis of either very severe or very complicated infections. But in general, I think this is a good outline and the idea is that, yes, these episodes would have been seen by a clinician and the infection would be adequately documented. A lot of this work dates back to a study that was done by Jack Paradise in the late 1970s.[2] His research used very stringent criteria that described what were termed "counting episodes." A child was considered to have had a counting episode that contributed to the number of episodes if they had, in addition to their sore throat, at least 1 of the following 4 criteria:
- A fever > 38.3° Celsius;
- Cervical adenopathy, which was defined as a lymph node in the neck that measured > 1 cm and was tender;
- Tonsillar exudates; or
- A positive test for group A streptococci.
