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Sore throat

  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also 

    Febrile child 
    Acute pain management 
    Upper airway obstruction 
    Invasive group A Streptococcal infections: Management of Household Contacts

    Key points

    1. Most children with sore throats do not need antibiotics
    2. With the exception of scarlet-fever type rash, there are no clinical features alone that reliably discriminate between Group A streptococcal (GAS) and viral pharyngitis
    3. Antibiotic therapy is ONLY recommended for a high-risk group of children to prevent non-suppurative complications of GAS infection


    • The most common cause of sore throat in children is a viral illness
    • Group A streptococcal (GAS) pharyngitis is rare under four years of age
    • GAS can cause non-suppurative complications (acute rheumatic fever, post-streptococcal glomerulonephritis) and suppurative complications (peritonsillar abscess, retropharyngeal abscess)


    Any patient with impending airway obstruction should have minimal handling and be referred early to an experienced clinician for definitive airway management. – see Acute upper airway obstruction guideline


    • age and ethnicity
    • oral intake
    • associated viral features (cough, coryza, conjunctivitis, hoarseness, ulcers, diarrhoea, characteristic viral exanthem)
    • contacts with coxsackie virus, GAS – see Management of Household Contacts
    • high-risk groups:

      Rheumatic fever

      • Indigenous Australians
      • Maori and Pacific Islander people
      • personal history of rheumatic fever or rheumatic heart disease
      • family history of rheumatic fever or rheumatic heart disease

     Immunosuppressed children are at increased risk of suppurative complications


    Examine the throat with caution if the child has clinical signs of upper airway obstruction


    • hydration status
    • fever   
    • oral/pharyngeal ulcers (coxsackie virus)       
    • tonsillar exudates                              
    • tender anterior cervical lymphadenopathy
    • hepatosplenomegaly (EBV)
    • scarlet-fever type rash - blanching, sandpaper-like rash, usually more prominent in skin creases, flushed face/cheeks with peri-oral pallor (GAS)

    Red flags

    • unwell/toxic appearance
    • respiratory distress
    • stridor            
    • trismus
    • drooling         
    • “hot potato” voice (muffled voice associated with pharyngeal/peritonsillar pathology)
    • torticollis
    • neck swelling/fullness                                   
    • In the acutely unwell looking child consider alternative diagnosis and/or complications of GAS pharyngitis.


    Sore throat

    Supportive management: see treatment section below


    • Throat swab is NOT routinely recommended for sore throat, with the exception of the high-risk group
    • Consider other investigations if:
      • suspected suppurative complications: relevant imaging
      • hepatosplenomegaly: FBE, monospot, +/- EBV serology
    • Streptococcal serology has no role in diagnosis of GAS pharyngitis


    Supportive management is adequate for most sore throats including scarlet fever:

    • simple analgesia (see Acute pain management)
    • corticosteroids can be considered in patients with severe pain unresponsive to simple analgesia:

        dexamethasone 0.15 mg/kg (max 10 mg) PO/IV/IM as a single dose  
        prednisolone 1 mg/kg PO (max 50 mg) as a single dose

    Admission for analgesia and hydration are uncommonly required.

    Antibiotic therapy for suspected group A streptococcal pharyngitis is recommended only for high risk groups:

      Antibiotic   Route   Dose   Duration
    Phenoxymethylpenicillin PO

    <20 kg:     250 mg two times daily

    >20 kg:     500 mg two times daily

    10 days
    Amoxicillin PO   50 mg/kg once daily (max 1 g)** 10 days
      Poor compliance or oral therapy not tolerated
    Benzathine Penicillin IM

    <20 kg:      450 mg (600,000 U)

    >20 kg:      900 mg (1,200,000 U)

    Single dose
      Hypersensitivity to penicillins (exclude immediate hypersensitivity)
    Cefalexin PO   25 mg/kg twice daily (max 1 g) 10 days
      Anaphylaxis to beta-lactams
    Azithromycin PO Children:     12 mg/kg once daily (max 500 mg)

    Adults:         500 mg once daily

    5 days

    ** second line therapy for improved compliance

    Management of suppurative complications

    Disease Management
    Peritonsillar abscess (Quinsy)

    Odynophagia/Dysphagia (pooling/drooling)

     “Hot potato” voice


     Peritonsillar swelling/erythema

     Uvula deviation


    Refer to ENT for consideration of drainage


    • Amoxicillin/Clavulanic acid 25 mg/kg (maximum 1 g) IV 8 hourly

    Switch to oral therapy:

    • Amoxicillin/Clavulanic acid 22.5 mg/kg (max 875 mg) PO 12 hourly
    Retropharyngeal/Parapharyngeal abscess



     Neck swelling/tenderness

    (particularly in young infants)

     Torticollis/Neck stiffness

     Retropharyngeal bulge


    Refer to ENT


    • Lateral neck X-ray: normal X-ray does not exclude the diagnosis
    • CT with IV contrast is the imaging modality of choice.  (Should only be performed with advanced airway management available)


    • Amoxicillin/Clavulanic acid 25 mg/kg (maximum 1 g) IV 8 hourly

    Switch to oral therapy:

    • Amoxicillin/Clavulanic acid 22.5 mg/kg (max 875 mg) PO 12 hourly
    Epiglottitis/Bacterial Tracheitis

      Abrupt onset

      High grade fever

      Toxic looking


      Respiratory distress


      Muffled “hot-potato” voice

      Tripod position with neck extension

      Cervical lymphadenopathy

    **increased risk in children unimmunised to Hib**

    Minimum handling :

    • defer all invasive examination/procedures/imaging until advanced airway management available
    • early ICU/anaesthetic/ENT review


    • Ceftriaxone 50 mg/kg (max 1 g) IV/IM daily for 5 days


    • Dexamethasone 0.15 mg/kg (max 10 mg) IV/IM/PO stat, repeat in 24 hours prn.


    Consider consultation with local paediatric team when

    • systemically unwell
    • suppurative complications
    • evidence of moderate/severe dehydration
    • significant pain poorly responsive to simple analgesia

    Consider referral for Paediatric/ENT outpatient follow-up

    • 7 episodes of sore throat/tonsillitis in 1 year
    • 5 infections/year for 2 consecutive years
    • 3 infections/year for 3 consecutive years

    Consider transfer to tertiary centre when

    • evidence of acute suppurative complications eg abscess formation.
    • evidence of upper airway obstruction
    • significant comorbidities eg immunosuppression (after discussion with relevant treating team)

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Consider discharge when:

    • pain relief adequate
    • tolerating appropriate oral intake

    Parent Information Sheet

    Tonsillitis - Kids Health Info fact sheet


    Last updated May 2019