See also
Acute pain management
Febrile Child
Invasive group A streptococcal infections: management of household contacts
Acute upper airway obstruction
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
- Specialist advice should be sought for symptomatic patients with hypermagnesemia
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
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
|
Antibiotic |
Route |
Dose |
Duration |
|
Phenoxymethylpenicillin |
Oral |
15 mg/kg (max 500 mg) two times daily |
10 days |
|
Amoxicillin** |
Oral |
50 mg/kg (max 1 g) once daily ** |
10 days |
|
Poor compliance or oral therapy not tolerated |
|
Benzathine Penicillin |
IM |
<10 kg 450,000 units (0.9 mL)
10-
<20 kg 600,000 units (1.2 mL)
>20 kg 1,200,000 units (2.3 mL) |
Single dose |
|
Hypersensitivity to penicillins (exclude immediate hypersensitivity) |
|
Cefalexin |
Oral |
25 mg/kg (max 1 g) two times daily |
10 days |
|
Anaphylaxis to beta-lactams
|
|
Azithromycin |
Oral |
Children: 12 mg/kg (max 500 mg) once daily
Adults: 500 mg once daily |
5 days |
** 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
| 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:
- Benzylpenicillin 50 mg/kg (max 1.2 g) IV 6 hourly
Switch to oral therapy:
- Phenoxymethylpenicillin 15 mg/kg (max 500 mg) oral twice daily to complete a total of 10 days of therapy (IV + oral inclusive)
|
|
Retropharyngeal/Parapharyngeal abscess
|
|
Fever
Odynophagia/Dysphagia
Neck swelling/tenderness
(particularly in young infants)
Torticollis/Neck stiffness
Retropharyngeal bulge |
Refer to ENT for consideration of imaging and ongoing management
Investigations:
- Lateral neck X-ray: normal X-ray does not exclude the diagnosis
- CT with IV contrast is the imaging modality of choice when required. (Should only be performed with advanced airway management available)
Antibiotics:
- Amoxicillin/Clavulanic acid 25 mg/kg (max 1 g) IV 8 hourly
Switch to oral therapy:
- Amoxicillin/Clavulanic acid 22.5 mg/kg (max 875 mg) oral twice daily
|
|
Epiglottitis/Bacterial Tracheitis
|
|
Abrupt onset
Respiratory distress
High grade fever
Toxic looking
Odynophagia/Dysphagia
Stridor
Muffled “hot-potato” voice
Tripod position with neck extension
Cervical lymphadenopathy
**increased risk in children unimmunised to Hib** |
Minimal handling :
- Defer all invasive examination/procedures/imaging until advanced airway management available
- Early ICU/anaesthetic/ENT review
Antibiotics:
- Ceftriaxone 50 mg/kg (max 1 g) IV/IM daily for 5 days
Consider:
- Dexamethasone 0.15 mg/kg (max 10 mg) oral/IV/IM/ stat, repeat in 24 hours prn
|
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