Sore throat


  • Statewide logo

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

  • See also: 

    Febrile child guideline 
    Analgesia guideline 
    Upper airway obstruction guideline 
    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

    Sore throat

    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