HEALTH

Back when I was a kid, tonsils were routinely yanked at the first sign of trouble. Everyone I knew had their tonsils removed and I, with tonsils intact, envied them. I thought going to a hospital, wearing a plastic bracelet, eating Jell-O and making paper hats with kind nurses sounded like a blast.

In spite of suffering through years of tonsillitis, I had a doctor less inclined towards surgery. Perhaps he was just ahead of his time, because today the pendulum has swung the other way, says Johnna MacCormick, ENT (ear, nose and throat) surgeon at the Children's Hospital of Eastern Ontario in Ottawa. Now most doctors prefer to wait things out or try antibiotics over surgery when it comes to treating throat ailments.

That would seem to be a sensible approach, given that close to 90 percent of kids' sore throats are minor viral infections that generally run their course in a few days. But that doesn't mean they don't hurt. Sore throats can cause mild discomfort to blazing pain, complete with high fever, depending on the cause and area of infection. Some kids, however, are more stoic than others, so how can a parent tell when it's serious?

"A typical sore throat is called pharyngitis," explains MacCormick, adding that it may accompany a cold or flu. "Tonsils look large and red - everything is red." It's usually viral, she says, and will go away on its own in a day or so.

Strep Search

If the sore throat persists, however, it could be strep (a bacterial infection officially called A beta-hemolytic streptococcus - but let's just call it strep). Strep is usually accompanied by swollen glands and a high fever but no cough. It's most prevalent in kids older than three. In any case, finding out if it's strep requires a trip to the doctor. "Strep can only be diagnosed by a throat swab. You can't judge it by looking," stresses MacCormick. Antibiotics should only be taken when a throat swab reveals strep, she says, noting the purpose of the medication isn't necessarily to treat the infection. "Antibiotics only shorten the course by one day," she explains. Rather, this approach is used to prevent strep-related complications, such as rheumatic fever, ear infections, abscesses and other secondary infections. Scarlet fever is a different strain of strep throat with an added toxin in the bacteria that produces a fine, red rash, mostly on the groin and elbows. It's usually no more serious than regular strep.

A confusing aspect of this infection is that up to 25 percent of kids can be strep carriers while remaining healthy. While some doctors treat the infection anyway, Saul Greenberg, attending physician at Toronto's Hospital for Sick Children, believes it's not necessary. "They're not more likely to have recurrent strep throat than others, and there's debate about whether they're infecting others. And good bacteria that combat strep also exist in the throat, and antibiotics destroy it as well." If the child is otherwise healthy, he says, let sleeping strep lie.

The Take on Tonsils

Tonsillitis is another all-too-common infection for kids. The majority of cases are viral, but it can be caused by strep bacteria. A throat swab is still required to determine the source of the infection and, therefore, whether it should be treated with antibiotics. A tonsillectomy (removing the tonsils) is the last resort these days if a child gets "a significant amount of tonsillitis," explains MacCormick- such as six or seven times in one year. Doctors and parents also need to seriously consider other factors - such as how much school the child is missing and how frequently antibiotics are prescribed - before surgery is given the go-ahead.

For ten-year-old Stephanie Vacca of Maple, Ontario, regular bouts of tonsillitis and the subsequent removal of her tonsils are a distant memory. But her mother, Lilly Vacca, remembers all too clearly those exhausting months.

At around age four, Stephanie began suffering chronic tonsillitis due to the strep bacteria. She rarely complained of a sore throat, instead telling her mom of stomach aches, headaches and fever - not uncommon symptoms, according to Greenberg. Vacca would wait a few days, then take Stephanie to the doctor, who routinely diagnosed strep tonsillitis. "She would be on antibiotics for two weeks," explains Vacca. "But then she would get it again shortly after, month after month." Vacca agonized about the effect of seemingly constant courses of antibiotics on her daughter, especially after a few allergic reactions. And it pained her to see Stephanie so sick. "She had black circles under her eyes," Vacca recalls. "She'd snore because she had to sleep in a funny position to get air."

After six months of this, the Vaccas were referred to an ENT who said Stephanie's tonsils and adenoids should come out. Adenoids are sometimes described as "the tonsils that we can't see," and are situated at the passage that connects the nose and the throat. Tonsil and adenoid problems often go together, explains MacCormick, but a problem with one doesn't necessarily mean a problem with the other. For Stephanie, however, the infections were linked. For the first few weeks after the surgery, with her daughter in such pain, Vacca wondered what she'd agreed to. Then, suddenly, she recalls, "Stephanie bounced back." But when Vacca found herself in the middle of the night running to her daughter's room because she couldn't hear her snoring, she knew things had really changed. "She was sleeping so quietly," Vacca recalls, laughing.

Sore = Snore?

Snoring was the indicator for the Wells family, in London, Ontario, that something was wrong with five-year-old Julia. "She was a wicked snorer, so we figured it was her adenoids or her tonsils," says mom Gabriella, noting that Julia also seemed to have strep throat more frequently than other kids. It turns out they were right. Oversized adenoids were obstructing Julia's breathing. Wells was willing to have them removed, but her doctor was more cautious, suggesting that Julia's body would grow into them - and eventually out of them. Sure enough, after a growth spurt, "a few months ago we noticed we didn't hear Julia snore any more," says Wells, adding that she now appreciates her doctor's wait-and-see attitude.

Snoring is a good indicator of enlarged tonsils or adenoids, confirms MacCormick. In fact, she says, "tonsils are removed more frequently because they're causing obstruction, not infection." At the extreme, these enlarged tonsils and/or adenoids cause sleep apnea, a serious disorder in which the sleeper stops breathing temporarily only to start again with a snort.

Disappearing Act

No one knows why some kids are more prone to throat problems than others, although children exposed to tobacco smoke have a higher likelihood of getting a sore throat - tobacco smoke irritates any mucous membrane, explains Greenberg - as do preschoolers in group daycare. "All infections are much more common due to daycare exposure," he notes. Kids are simply in closer and greater contact with other kids, and infections get passed around along with the toys and books.

But a predisposition to chronic sore throats doesn't mean a lifetime of poor health. "It doesn't mean a weak immune system," assures MacCormick. And keep in mind that tonsils and adenoids aren't always bad guys. "They're also the first line of defence against infection," she explains, and, as such, should be preserved when possible.

Parents of sore throat sufferers take heart. MacCormick notes that many children outgrow their propensity for throat problems between the ages of eight and 13. Why? Tonsils get smaller around this age, and adenoids almost disappear. Adults rarely have adenoids. "That's why we try not to be aggressive with surgery. Mother Nature often takes care of things on her own."

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Soothing a Sore Throat

OK, so it's not strep or tonsillitis. But your child is nonetheless behaving as though the end is near. Between the kitchen and the bathroom, you're sure to find something to help ease the pain.

Lozenges are a quick and easy comforter for school-aged children. Or better still, says Saul Greenberg, attending physician at Toronto's Hospital for Sick Children, give kids over four hard candy such as LifeSavers. "It doesn't have to be medicated," he explains. Anything that will moisten the throat and induce saliva production will soothe. Try to get kids older than seven or eight to gargle with a solution of an eighth of a teaspoon of salt dissolved in a glass of warm water. Be sure to give all kids plenty of fluids, as well as ice cream or Popsicles: The cold acts as a temporary anaesthetic, and just feels good going down. Acetaminophen will bring down a fever, but is unnecessary if the fever is below 101 degrees F (38.3 degrees C) or if the child is comfortable.

October 2000