Sore throat

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

  • See also

    Febrile child guideline 
    Antibiotic guideline 
    Upper airway obstruction guideline

    Background to condition 

    A sore throat is a common symptom that frequently results in a medical consultation and unnecessary prescription of antibiotics. The commonest cause of a sore throat in children is a viral illness. 15 - 30% of children with a sore throat will have Group A streptococcal (GAS) pharyngitis, the peak incidence being 3-15 years of age. Bacterial causes for sore throat other than GAS are rare. 

    Currently there is controversy regarding the need for antibiotic therapy for GAS pharyngitis in a population where acute rheumatic fever (ARF) is rare. Populations at high risk of ARF (e.g. Indigenous Australians, Pacific islanders, Maori people, previous ARF) should always have antibiotic treatment and culture confirmation if available. 


    Sore throat
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    Treatment for sore throat:

    Any patient with impeding airway obstruction should be referred early to an experienced clinician for definitive airway management 

    Antibiotics for Group A streptococcal pharyngitis:

    1st line oral agent:

    Penicillin (Phenoxymethyl)         

    < 10 years: 250mg orally BD for 10 days

    > 10 years: 500mg orally BD for 10 days


    2nd line oral agent:

    Cephalexin 20 mg/kg orally BD (max 1 g per day) for 10 days


    Anaphylaxis to beta-lactam antibiotics (penicillin and cephalosporins):

    Roxithromycin 4 mg/kg (max 150mg) orally BD for 10 days


    Unable to tolerate oral medication/poor compliance

    Benzathine Pencillin G  

    <27 kg: 600,000 U IM

    ≥27 kg: 1,200,000 U IM


    Benzylpenicillin 60 mg/kg (2 g) IV 6 hourly


    1) Analgesia

    see Analgesia CPG

    2) Corticosteroids

    Consider 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

    This can be repeated the next day. 

    When to admit/consider transfers to a tertiary centre

    • Suspected upper airway obstruction
    • Systemically unwell patients
    • Evidence of acute complications e.g. abscess formation, upper airway obstruction
    • Significant comorbidity e.g. immunosuppression (after discussion with relevant treating team)




    Peritonsilllar abscess (Quinsy)


    Severe sore throat (often unilateral)

    “Hot “ potato voice

    Difficulty swallowing saliva (pooling/drooling)


    Neck swelling

    Referred ear pain


    • Benzylpenicillin 60 mg/kg
    • (max 2 g) IV 6 hourly
    • Metronidazole 15mg/kg (max 500 mg) 
    • IV stat then 7.5 mg/kg IV 8 hourly 

    Refer to ENT for surgical drainage

    Infectious mononucleosis (EBV)



    Protracted illness

    Cervical lymphadenopathy

    Fatigue and malaise

    Variable hepatosplenomegaly

    Amoxycillin-induced rash



    Consider corticosteroids 

    Consider admission if unable to tolerate oral fluids 

    Epiglottitis/Bacterial Tracheitis

    (more likely if unimmunised against H. influenzae)


    Abrupt onset

    Respiratory distress

    Absent cough with low pitched stridor

    Muffled/hoarse voice

    Tripod/sniffing position



    Maintain position of comfort with parents present 

    Defer invasive examinations/ procedures (IV) or imaging (lateral neck x-ray) in patients with severe respiratory distress due to risk of precipitating respiratory arrest 

    Early PICU/anaesthetic review 

    Antibiotics: Ceftriaxone 50 mg/kg      (max 2 g) IV 12 hourly 

    Retropharyngeal abscess/Lateral pharyngeal abscess


    Retropharyngeal abscess:

    Respiratory distress/stridor

    Dysphagia, odynophagia, drooling


    Muffled voice

    Neck mass


    Chest pain


    Lateral pharyngeal abscess:

    Above including trismus and

    swelling below the mandible

    Lateral neck x-ray initially: A normal x-ray does not exclude the diagnosis. 

    CT with IV contrast is the imaging modality of choice. This should be performed in a setting where advanced airway management is able to be performed. 

    Antibiotics: Timentin 50 mg/kg (max 3 g) IV 6 hourly 

    Refer to ENT for surgical drainage

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

    Information specific to RCH

    Any patient with suspected airway obstruction  should be referred to PICU x55211
    All patients requiring admission should be admitted under a general medical unit with ENT consultation.