What is the recommended treatment for a child with a sore throat?

Treatment of Pediatric Sore Throat

Ibuprofen or paracetamol (acetaminophen) are the first-line treatments recommended for relief of acute sore throat symptoms in children, with ibuprofen showing slightly better efficacy as both an analgesic and antipyretic. 1

Symptomatic Treatment

Pain Management

• First-line medications:

  • Ibuprofen: 5-10 mg/kg every 6-8 hours
  • Paracetamol (acetaminophen): 10-15 mg/kg every 4-6 hours 1, 2

• Benefits of ibuprofen vs. paracetamol:

  • Longer duration of action (6-8 hours vs. 4 hours)
  • More effective as an antipyretic
  • At least as effective as an analgesic 2

• Additional symptomatic measures:

  • Warm salt water gargles for children old enough to cooperate
  • Throat lozenges (for children old enough to safely use them)
  • Adequate hydration 3

Diagnostic Approach

When to Suspect Bacterial Pharyngitis

Use the Centor Criteria to assess likelihood of Group A Streptococcal (GAS) infection 3:

1. Tonsillar exudates
2. Tender anterior cervical lymph nodes
3. Lack of cough
4. Fever

• 0-2 criteria: Unlikely to be GAS, no testing needed
• 3-4 criteria: Testing recommended with rapid antigen detection test (RADT) and/or throat culture 3

Testing Recommendations

• Clinical scoring systems and rapid tests help target appropriate antibiotic use 1
• A strategy using clinical scores alone may lead to higher antibiotic use compared to using rapid tests or a combination of clinical scores and rapid tests 1

Antibiotic Treatment

When to Use Antibiotics

Antibiotics should only be prescribed when:

• Positive rapid strep test or throat culture
• High clinical suspicion based on Centor criteria
• Not recommended for likely viral pharyngitis (those with cough, rhinorrhea, hoarseness, oral ulcers) 3

First-Line Antibiotic Options

If bacterial pharyngitis is confirmed:

1. Amoxicillin:

   • 50 mg/kg once daily (maximum 1000 mg) OR
   • 25 mg/kg twice daily (maximum 500 mg per dose)
   • Duration: 10 days 3

2. Penicillin V:

   • Children: 250 mg 2-3 times daily
   • Adolescents: 500 mg 2-3 times daily
   • Duration: 10 days 3

For Penicillin-Allergic Patients

• Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days
• 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 3, 4

Important Considerations

• Complete the full antibiotic course (10 days for most antibiotics, 5 days for azithromycin) to prevent complications like acute rheumatic fever 3
• The 10-day duration for beta-lactams is critical for preventing rheumatic fever and ensuring bacterial eradication 3

Special Considerations

When to Consider Tonsillectomy

Consider tonsillectomy for recurrent tonsillitis based on the Paradise criteria 3:

• ≥7 well-documented, adequately treated episodes in the preceding year, OR
• ≥5 such episodes in each of the preceding 2 years, OR
• ≥3 such episodes in each of the preceding 3 years

When to Refer/Hospitalize

A child with sore throat and toxic appearance may have diphtheria or parapharyngeal/retropharyngeal abscess and should be hospitalized immediately 5

Corticosteroids

A single dose of corticosteroids (e.g., dexamethasone) may benefit children with severe symptoms or high Centor scores when used in conjunction with appropriate treatment 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Only 15-36% of children with sore throat have pharyngitis caused by GAS, yet antibiotics are prescribed in over 50% of cases 6
2. Inadequate testing: Perform appropriate testing before prescribing antibiotics 6
3. Using antibiotics for viral pharyngitis: Antibiotics should not be used in patients with likely viral pharyngitis or those with low Centor scores (0-2) 3
4. Incomplete antibiotic courses: Ensure the full course is completed to prevent complications 3
5. Inadequate pain management: Pain control is essential for the child's comfort and ability to maintain hydration 1, 2

By following these evidence-based recommendations, clinicians can effectively manage pediatric sore throat while minimizing unnecessary antibiotic use and ensuring appropriate symptom relief.