What are the treatment recommendations for strep throat in children?

Treatment Recommendations for Strep Throat in Children

Penicillin V or amoxicillin for 10 days is the recommended first-line treatment for Group A Streptococcal (GAS) pharyngitis in children, with amoxicillin often preferred due to better taste and once or twice daily dosing options. 1, 2

Diagnosis Considerations

Before initiating treatment, proper diagnosis is essential:

• Testing is recommended for children with signs and symptoms suggestive of GAS pharyngitis

• Clinical features to look for:

  • Sudden onset of throat pain
  • Fever
  • Tonsillar exudates
  • Tender anterior cervical lymphadenopathy
  • Absence of cough and rhinorrhea 2

• Note: GAS pharyngitis is uncommon in children under 3 years old, but testing may be considered if they have risk factors such as an older sibling with GAS infection 1

First-Line Antibiotic Treatment

For Non-Allergic Children:

• Penicillin V:

  • Dosage: 250 mg 2-3 times daily for 10 days 2

• Amoxicillin (often preferred due to better taste and convenience):

  • Dosage: 50 mg/kg once daily (maximum 1000 mg) OR
  • 25 mg/kg twice daily (maximum 500 mg per dose)
  • Duration: 10 days 2, 3

Important: A full 10-day course is necessary to prevent acute rheumatic fever, even if symptoms resolve earlier 1, 2, 3

For Penicillin-Allergic Children:

• Non-anaphylactic allergy:

  • First-generation cephalosporin for 10 days 1

• Anaphylactic allergy:

  • Clindamycin: 20-30 mg/kg/day in 3 divided doses for 10 days, OR
  • Clarithromycin: 10 days, OR
  • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 1, 2

Caution: There is significant resistance to azithromycin and clarithromycin in some parts of the US, which may affect treatment success 4

Return to School Considerations

Children with GAS pharyngitis should complete a full 24 hours of antibiotics before returning to school or daycare to minimize transmission risk 5

Adjunctive Therapy for Symptom Relief

• Pain and fever management:

  • NSAIDs or acetaminophen for moderate to severe symptoms
  • Avoid aspirin in children due to risk of Reye syndrome 1, 2

• Additional supportive measures:

  • Cold liquids, ice chips, gargling with cold water
  • Medicated throat lozenges (used every two hours)
  • Avoid hot liquids and spicy foods 2

• Not recommended: Corticosteroids are not recommended as adjunctive therapy 1

Management of Treatment Failure

If symptoms worsen or persist after 48-72 hours of antibiotic therapy:

1. Assess medication compliance

2. Consider whether the patient:

   • Is a streptococcal carrier with concurrent viral infection
   • Has a new GAS infection
   • Is experiencing true treatment failure (rare) 2

3. For confirmed treatment failure:

   • Switch to amoxicillin-clavulanate to address potential beta-lactamase producing organisms 2
   • Consider clindamycin for continued failures 2

Special Considerations

• Recurrent episodes: Consider whether the patient is experiencing multiple true GAS infections or is a chronic carrier with viral infections 1

• Carriers: GAS carriers generally do not require antimicrobial therapy as they are unlikely to spread GAS pharyngitis and are at minimal risk for complications 1

• Tonsillectomy: Not recommended solely to reduce the frequency of GAS pharyngitis 1, 4

• Post-treatment testing: Follow-up throat cultures after treatment are not routinely recommended 1

• Household contacts: Testing or empiric treatment of asymptomatic household contacts is not routinely recommended 1

By following these evidence-based recommendations, clinicians can effectively treat GAS pharyngitis in children while minimizing complications and unnecessary antibiotic use.