What is the recommended dose and medication for strep throat in a child?

Treatment of Strep Throat in Children

For children with strep throat, penicillin V or amoxicillin remains the first-line treatment, with penicillin V dosed at 250 mg two to three times daily or amoxicillin at 50 mg/kg once daily (maximum 1,000 mg) for 10 days. 1

First-Line Treatment Options

Penicillin/Amoxicillin (First Choice)

• Penicillin V (oral):

  • Children: 250 mg two or three times daily for 10 days 1
  • Advantages: Narrow spectrum, proven efficacy, low cost, no resistance 1

• Amoxicillin (oral):

  • 50 mg/kg once daily (maximum 1,000 mg) for 10 days 1, 2
  • Alternative: 25 mg/kg twice daily (maximum 500 mg per dose) 1, 2
  • Often preferred in young children due to better taste acceptance 1

• Parenteral option:

  • Benzathine penicillin G (intramuscular):
    • <60 lb (27 kg): 600,000 units as single dose
    • ≥60 lb: 1,200,000 units as single dose 1
  • Consider for patients unlikely to complete oral therapy 1

Alternative Options for Penicillin-Allergic Patients

Non-Immediate Hypersensitivity to Penicillin

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

Immediate Hypersensitivity to Penicillin

• Clindamycin: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 1
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 1

Important Clinical Considerations

Duration of Therapy

• A full 10-day course is essential for penicillin, amoxicillin, and most alternatives to prevent:
  • Acute rheumatic fever
  • Recurrence of infection
  • Treatment failure 1
• Exception: Azithromycin is given for 5 days 1

Medication Administration

• Amoxicillin should be taken at the start of a meal to minimize gastrointestinal intolerance 2
• For oral suspensions, shake well before using and store reconstituted solution in refrigerator 2, 3

Treatment Failures and Recurrences

• For treatment failures or recurrent infections, consider:
  • Clindamycin: 20-30 mg/kg/day in three doses (maximum 300 mg per dose) for 10 days 1
  • Amoxicillin/clavulanate: 40 mg amoxicillin/kg/day in three doses for 10 days 1

Monitoring and Follow-up

• Clinical improvement should be seen within 48-72 hours of starting antibiotics
• Follow-up testing is not routinely recommended after treatment 1

Potential Pitfalls

1. Compliance issues: The 10-day duration of therapy can lead to poor adherence, especially when symptoms improve quickly. Emphasize the importance of completing the full course to prevent complications 4, 5.

2. Dosing frequency: Once-daily dosing of penicillin V has been shown to be less effective than twice-daily or four-times-daily dosing. Twice-daily dosing (500 mg) is recommended for better compliance while maintaining efficacy 6.

3. Macrolide resistance: Be aware that in some geographic regions, Group A streptococcal resistance to macrolides (like azithromycin and clarithromycin) may be present. This can lead to treatment failure when these agents are used 7, 8.

4. Antibiotic taste: Palatability affects compliance in children. Amoxicillin is often preferred over penicillin V in young children due to better taste acceptance 1, 4.

5. Shortened courses: While shorter courses of certain antibiotics have been studied, the standard 10-day course remains recommended for penicillin and most alternatives to ensure complete eradication of the organism and prevention of complications 1.