1. Watchful waiting for recurrent throat infection

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.

Strong recommendation

High Quality Evidence (systematic reviews of randomized controlled trials that fail to show clinically important advantages of surgery over observation alone (as stated in Statement 1)⁵;

Grade C, observational studies showing improvement with watchful waiting)^6,7

2. Recurrent throat infection with documentation

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 beta-hemolytic streptococcus.

Conditional Recommendation

Moderate Quality Evidence (systematic review of randomized controlled trials with limitations in the consistency with the randomization process regarding recruitment and follow-up; some observational studies)^8,9

3a. Tonsillectomy for recurrent infection with modifying factors

Clinicians should assess the child with recurrent throat infection who does not meet criteria in Key Action Statement 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.

Strong recommendation

High Quality Evidence (systematic review of randomized controlled trials with limitations for PFAPA; observational studies for all other factors)^10-16

3b. Role of ASOT in decision making

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,

Strong recommendation (against)

High Quality Evidence (randomized controlled trials)¹⁷

4. Tonsillectomy for obstructive sleep-disordered breathing

Clinicians should ask caregivers of children with obstructive sleepdisordered breathing (oSDB) and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis,

asthma, and behavioral problems.

Strong recommendation

High Quality Evidence (randomized controlled trials, systematic reviews, and before-and-after observational studies)^18-21

5. Indications for polysomnography

Before performing tonsillectomy, the clinician should refer children

with obstructive sleep-disordered breathing (oSDB) for polysomnography (PSG) 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.

Strong recommendation

High Quality Evidence (observational studies with consistently applied reference standard; and  one systematic review of observational studies on obesity)^22-25

6. Additional recommendations for polysomnography

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

Strong recommendation

High Quality Evidence (a randomized controlled trial, observational and case-control studies)^26,27

7. Tonsillectomy for obstructive sleep apnea

Clinicians should recommend tonsillectomy for children with obstructive sleep apnea (OSA) documented by overnight polysomnography (PSG).

Strong recommendation

High Quality Evidence (randomized controlled trial, observational before-and-after studies, and meta-analysis of observational studies showing substantial reduction in the prevalence of sleep-disordered breathing and abnormal PSG after tonsillectomy)^28-29

8. Education regarding persistent or recurrent obstructive sleep-disordered breathing

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

Strong recommendation

High Quality Evidence (randomized controlled trial, systematic reviews, and before-andafter observational studies)³⁰

9. Perioperative pain counseling

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.

Strong recommendation

High Quality Evidence (randomized controlled trials and observational studies)^31-34

10. Perioperative antibiotics

Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy

Strong recommendation (against)

High Quality Evidence (randomized controlled trials and systematic reviews, showing no benefit in using perioperative antibiotics to reduce posttonsillectomy morbidity)^35-37

11. Intraoperative steroids

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

Strong recommendation

High Quality Evidence (randomized controlled trials and multiple systematic reviews, for preventing postoperative nausea and vomiting (PONV); randomized controlled trials and systematic review for decreased pain and shorter times to oral intake)^38,39

12. Inpatient monitoring for children after tonsillectomy

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

Strong recommendation

High Quality Evidence (observational studies on age, meta-analysis of observational studies regarding complications)^40-42

13. Postoperative ibuprofen and acetaminophen

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

Strong recommendation

High Quality Evidence (based on systematic review and randomized controlled trials)^43,44

14. Outcome assessment for bleeding

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).

Strong recommendation

High Quality Evidence (based on observational studies with a preponderance of benefit over harm.)^45,46