See also:
Febrile child guideline
Analgesia guideline
Upper airway obstruction guideline
Invasive group A Streptococcal infections: Management of Household Contacts
Key Points
- Most children with sore throats do not need antibiotics
- 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
- 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 guideline
History
- 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
Examination
Examine the throat with caution if the child has clinical signs of
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 swelling/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
Analgesia)
- 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
OR
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: 250mg two times daily
> 20 kg: 500mg two times daily |
10 days |
Amoxicillin |
PO |
50mg/kg once daily (max 1g)** |
10 days |
Poor compliance
or oral therapy not tolerated |
Benzathine Penicillin |
IM |
< 20kg: 450mg (600,000 U)
> 20kg: 900mg (1,200,000 U) |
Single dose |
Hypersensitivity
to penicillins (exclude immediate hypersensitivity) |
Cefalexin |
PO |
25mg/kg twice daily (max 1g) |
10 days |
Anaphylaxis to
beta-lactams |
Azithromycin |
PO |
Children: 12mg/kg once daily (max 500mg)
Adults: 500mg 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
Trismus
Peritonsillar swelling/erythema
Uvula deviation |
Refer to ENT for consideration of drainage
Antibiotics:
- Amoxicillin/Clavulanic acid 25 mg/kg (maximum 1 g) IV 8 hourly
Switch to oral
therapy:
- Amoxicillin/Clavulanic acid 22.5 mg/kg (max 875mg) PO 12 hourly
|
Retropharyngeal/Parapharyngeal
abscess |
Fever
Odynophagia/Dysphagia
Neck swelling/tenderness
(particularly in young infants)
Torticollis/Neck stiffness
Retropharyngeal bulge |
Refer to ENT
Investigations:
- 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)
Antibiotics:
- Amoxicillin/Clavulanic acid 25 mg/kg (maximum 1 g) IV 8 hourly
Switch to oral
therapy:
- Amoxicillin/Clavulanic acid 22.5mg/kg (max 875mg) PO 12 hourly
|
Epiglottitis/Bacterial
Tracheitis |
Abrupt onset
High grade fever
Toxic looking
Odynophagia/Dysphagia
Respiratory distress
Stridor
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
Antibiotics:
- Ceftriaxone 50mg/kg (max 1g) IV/IM daily for 5 days
Consider:
- Dexamethasone 0.15mg/kg (max 10mg) IV/IM/PO stat, repeat in 24 hours prn.
|
Follow-up
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 e.g. abscess formation.
- evidence of upper airway obstruction
- significant comorbidities e.g. 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