This guideline predominantly addresses indications for tonsillectomy in children based on obstructive and infectious causes. The evidence that supports tonsillectomy for orthodontic concerns, dysphagia, dysphonia, secondary enuresis, tonsilliths, halitosis, and chronic tonsillitis is limited and generally of lesser quality, and a role for shared decision making is present.

· Clinicians should recommend watchful waiting for recurrent throat infection if there have been<7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years.

· Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.

· Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy.

· Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess.

· Clinicians should not order ASOT. The determination of the antistreptolysin-O titer (ASOT) and other streptococcal antibody titers does not have any value in acute and recurrent tonsillitis / pharyngitis.

· Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems.

· Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses.

· The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB.

· Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography.

· Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management.

· The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery.

· Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index  >10 obstructive events/hour, oxygen saturation nadir <80%, or both).

· Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding).

· The guideline group made a strong recommendation against prescribjng perioperative antibiotics to children undergoing tonsillectomy.

· Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and  1 of the following: temperature >38.3 C, cervical adenopathy, tonsillar exudate, or positive test for group A betahemolytic streptococcus