See also

Acute pain management
Febrile Child
Invasive group A streptococcal infections: management of household contacts
Acute upper airway obstruction

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
   

Background

• 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)

Assessment

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

History

• Age and ethnicity
• Oral intake
• Associated viral features (cough, coryza, conjunctivitis, hoarseness, ulcers, diarrhoea, characteristic viral exanthem)
• Contacts with coxsackie virus, GAS - see Invasive group A streptococcal infections: management of household contacts
• High-risk groups:
• Rheumatic fever
  • Aboriginal and Torres Strait Islander people
  • 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 suppuratives complications

Examination

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

Assess

• 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 stiffness/fullness

                             
In the acutely unwell looking child consider alternative diagnosis and/or complications of GAS pharyngitis

Management

*Supportive management: see treatment section below

Investigations

• 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

Treatment

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) oral/IV/IM as a single dose

OR

prednisolone 1 mg/kg (max 50 mg) oral as a single dose

• Maintain hydration (See Dehydration)

Admissions for analgesia and hydration are not commonly required

Antibiotic therapy for suspected group A streptococcal pharyngitis

Antibiotic therapy is recommended only for high risk groups.  Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines

** second line therapy for improved oral adherence

Management of suppurative complications

Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines

 Consider consultation with local paediatric team when

• Systemically unwell
• Suppurative complications are present
• There is evidence of moderate/severe dehydration
• There is significant pain poorly responsive to simple analgesia

Consider consultation with paediatric/ENT outpatient follow-up when

• 7 episodes of sore throat/tonsillitis in 1 year
• 5 infections/year for 2 consecutive years
• 3 infections/year for 3 consecutive years
• Recommendations may differ, please refer to local referral guidelines

Consider transfer to tertiary centre when

• There is evidence of acute suppurative complications eg abscess formation
• There is evidence of upper airway obstruction
• Significant comorbidities are present, eg immunosuppression (after discussion with relevant treating team)

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• Pain relief is adequate
• Tolerating appropriate oral intake

Parent Information

Kids Health Info: Tonsillitis  
Australian Commission on safety and Quality in Health Care: Sore Throat: Should I take antibiotics?

Last updated July 2021