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Sore throat

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  • See also

    Acute pain management
    Febrile Child
    Invasive group A streptococcal infections: management of household contacts
    Acute upper airway obstruction

    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. 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

    Reference List

    1. eTG complete [digital].  Melbourne: Therapeutic Guidelines Limited; 2019 Jun.  Retrieved from https://www.tg.org.au (viewed 2 July 2021)
    2. RHDAustralia (ARF/RHD writing group).  The 2020Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). Retrieved from https://www.rhdaustralia.org.au/system/files/fileuploads/arf_rhd_guidelines_3rd_edition_web_updated.pdf (viewed 2 July 2021)