What is the treatment and management plan for a child with strep throat?

SOAP Note Plan for Strep Throat in a Child

Diagnostic Plan

Rapid antigen detection testing (RADT) or throat culture is essential for confirming Group A Streptococcal (GAS) pharyngitis before initiating antibiotics. 1

• Testing is indicated when clinical features suggest streptococcal infection:

  • Sudden onset of sore throat
  • Fever
  • Headache
  • Nausea/vomiting/abdominal pain
  • Tonsillopharyngeal inflammation or exudates
  • Palatal petechiae
  • Tender anterior cervical lymph nodes
  • Winter/early spring presentation
  • History of exposure to streptococcal pharyngitis

• Testing is NOT recommended when viral etiology is likely:

  • Cough
  • Rhinorrhea
  • Hoarseness
  • Oral ulcers
  • Conjunctivitis
  • Diarrhea

• Special considerations:

  • Testing generally not recommended in children <3 years unless specific risk factors exist (e.g., older sibling with GAS infection) 1
  • Post-treatment follow-up cultures not routinely needed unless symptoms persist 1
  • Testing of asymptomatic household contacts not routinely recommended 1

Therapeutic Plan

First-line Treatment (No Penicillin Allergy):

Amoxicillin is the recommended first-line treatment for children with strep throat due to excellent efficacy, safety profile, narrow spectrum, and good taste acceptance. 1

• Dosing: 50 mg/kg once daily (maximum 1,000 mg) for 10 days
• Alternative: 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days

OR

• Penicillin V (oral):

  • Children: 250 mg two or three times daily for 10 days
  • Adolescents: 250 mg four times daily or 500 mg twice daily for 10 days

• Intramuscular option (if oral compliance is a concern):

  • Benzathine penicillin G: <60 lb (27 kg): 600,000 units; ≥60 lb: 1,200,000 units (single dose)

For Penicillin-Allergic Patients:

• Non-anaphylactic allergy:

  • Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days
  • Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days

• Immediate hypersensitivity to penicillin:

  • Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days
  • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days
  • Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days

Important Therapeutic Considerations:

• The full 10-day course must be completed to prevent rheumatic fever, even if symptoms resolve earlier 1
• Be aware of increasing macrolide resistance (azithromycin, clarithromycin) which varies geographically 1
• Adjunctive therapy:
  • Acetaminophen or NSAIDs for pain/fever management 1
  • AVOID aspirin in children (risk of Reye syndrome) 1
  • Corticosteroids are NOT recommended 1

Patient/Family Education Plan

1. Medication adherence:

   • Complete the FULL course of antibiotics (usually 10 days) even if feeling better
   • Take medication at regular intervals as prescribed
   • Missing doses increases risk of treatment failure and complications

2. Disease information:

   • Strep throat is highly contagious through respiratory droplets
   • Child can return to school/daycare after 24 hours of antibiotic therapy
   • Replace toothbrush after 24 hours of antibiotic therapy to prevent reinfection

3. Prevention measures:

   • Regular handwashing
   • Avoid sharing utensils, cups, or food
   • Cover mouth/nose when coughing or sneezing

4. Warning signs requiring follow-up:

   • Persistent fever >101°F after 48 hours of antibiotics
   • Worsening throat pain or difficulty swallowing
   • Inability to take fluids
   • Development of rash
   • Persistent symptoms after completing antibiotics

5. Supportive care:

   • Encourage fluid intake to prevent dehydration
   • Soft foods and cold liquids may be more comfortable
   • Warm salt water gargles for older children
   • Throat lozenges for children old enough to safely use them

Remember that untreated strep throat can lead to serious complications including rheumatic fever, so completing the full antibiotic course is essential for preventing these potentially life-threatening sequelae.