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
   

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

• maintain hydration (See Dehydration)

Admission for analgesia and hydration are uncommonly required.

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

** second line therapy for improved compliance

Management of suppurative complications

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 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