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Sharp rise in children’s throat infections - is tonsillitis to blame?

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“Children admitted to hospital with throat infections have increased by 76% over the past 10 years,” reports BBC News.

The headline is prompted by research that was looking at the association between whether a change in hospital admissions for throat infections and the decline in the amount of tonsillectomies (surgery to remove the tonsils). In previous decades, tonsillectomies were one of the most commonly performed types of surgery in children with a history of tonsillitis (inflammation of the tonsils, usually due to infection).

But medical opinion shifted, as evidence showed that in many cases the potential benefits of tonsillectomies were outweighed by the risks of complications, some of which – while uncommon – can be serious (such as post-operative infection and excessive bleeding).

The current study aimed to look at whether this reduction had been followed by an increase in the severity of tonsillitis and its complications, such as abscesses (pus-filled swellings) around the tonsils.

It looked at national hospital data for England between 1999 and 2010 to identify admissions for acute throat infections and abscesses around the tonsils. Although the rate of admissions for acute throat infections did increase in this period, the length of stay decreased, with half of children admitted and discharged on the same day.

The rate of admission for abscesses around the tonsils did not increase in this time, which suggested that the rate of complications of tonsillitis have not increased.

The researchers conclude that the reduction in tonsillectomies does not appear to be linked to increased severity of acute throat infections or rates of admission for tonsil abscesses.

Instead, they suggest that the rise in admissions for acute throat infections may have been because of changes in the health service, such as the increasing use of admissions to short stay observation wards and changes in the way data was recorded.

When is a tonsillectomy  needed?

Surgery for tonsillitis is now usually only recommended if a child has five or more episodes of sore throat due to tonsillitis in one year and the episodes of tonsillitis are disabling and are disrupting normal activities, such as school work.

Where did the story come from?

The study was carried out by researchers from Imperial College London and St George’s Hospital, London. The research was commissioned by the National Institute for Health Research Service Delivery and Organisation programme.

The study was published in the peer-reviewedmedical journal, Archives of Disease in Childhood.

The results of the study were covered appropriately by the BBC.

What kind of research was this?

This was a time-trend study, looking at how admissions for acute throat infections and tonsillectomy rates in children changed between 1999 and 2010.

The researchers report that acute throat infections (including tonsillitis) are among the most common reasons for children to present to their GP.

They say that evidence from systematic reviews and randomised controlled trials in children has suggested that tonsillectomy produces only modest reductions in throat infections, and this reduction is mainly in those who children are most severely affected.

The potential benefits need to be weighed up against the potential complications associated with the surgery, such as bleeding and infection. Also a tonsillectomy can impact on a child’s quality of life as it can cause post-operative pain.

These findings have led to a reduction in tonsillectomy, with the UK reportedly having among the lowest rates in Europe. The researchers wanted to investigate whether as the tonsillectomy rates decreased, rates of admissions for tonsillitis and its complications (such as abscesses) have increased.

This type of study is useful for identifying trends in different events over time, but it can be difficult to say definitively what factors are responsible for any changes seen.

What did the research involve?

The researchers analysed national data collected by hospitals in England to identify hospital admissions primarily for acute throat infections or abscesses around the tonsils, and tonsillectomy surgeries in children aged up to 17 years old. The figures were adjusted to give standardised rates for the age distribution of children in England in 2004 (midway through the study period), to allow the figures to be compared across years.

The researchers calculated the rates of these events in different age groups each year between 1999 and 2010. They also looked at how long the children stayed in hospital, as a measure of how severe their condition was. They compared the yearly rates to see if there had been any changes over time.

What were the basic results?

Overall, there were 193,973 admissions for acute throat infections or abscesses around the tonsils among children aged 17 years or younger between 1999/2000 and 2009/10.

The researchers found that admissions for acute throat infection in children increased from 107.3 per 100,000 in 1999/2000 to 188.4 per 100,000 in 2009/10 – an increase of 76%. The average (median) length of the admission reduced from a day to under a day over this period.

Admissions for abscesses around the tonsils remained broadly stable, at 9.6 per 100,000 in 1999/2000 to 8.7 per 100,000 in 2009/10.

The rates of tonsillectomy decreased from 367.4 per 100,000 children between 1999/2000 to 293.6 per 100,000 in 2009/10, with some fluctuations in between.

How did the researchers interpret the results?

The researchers concluded that admissions for acute throat infections among children have increased markedly in the past decade, but hospital stays are short. Admissions for abscesses around the tonsils have not increased. The researchers suggest that this illustrates that declining tonsillectomy rates do not appear to have resulted in increased admissions for more severe acute throat infections or abscesses around the tonsils.

They say that until more research can be done, it seems reasonable to continue with the current practice of performing tonsillectomy only if a child has severe recurrent episodes of tonsillitis.

Conclusion

The current study illustrates that while rates of tonsillectomy in the NHS in England have gone down in the past decade, the rates of complications of tonsillitis (abscesses) have not increased in children and adolescents. Although the rate of admissions for acute throat infections has increased, the severity of these infections on admission does not appear to have changed and may have reduced.

The study is reported to be the first to look at the rates of tonsillectomies and acute throat infections in children in England. The study was large, and includes national data, but there are some limitations, which the authors acknowledge:

  • Some data may be incorrectly recorded or coded.
  • Length of hospital stay is only a proxy measure for severity of throat infection, and the data source does not include in-depth clinical information about each case.
  • It is not possible to identify multiple admissions for the same child, so the number of admissions may overestimate the number of children affected.
  • The data only covers NHS activity, and some tonsillectomies may be performed in the private sector.
  • It is not possible to say for certain that changes in the rates are directly attributable to any given factor.

Overall, these figures give an idea of how acute throat infections in children have changed over time. This sort of analysis is helpful to monitor what the effect of changes in provision of tonsillectomy may have. The authors recommend further studies that follow individual patients over time to further study the trends in acute throat infection and tonsillectomy in children.

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