What medications can be given to a 2-year-old with fever, hand foot mouth disease, and acute tonsillitis (AT) or pharyngitis?

Management of Fever, Hand-Foot-Mouth Disease, and Acute Tonsillitis/Pharyngitis in a 2-Year-Old

For a 2-year-old with fever, hand-foot-mouth disease (HFMD), and acute tonsillitis/pharyngitis, the primary treatment should focus on supportive care with acetaminophen or ibuprofen for fever and pain management, while antibiotics should be reserved only for confirmed Group A Streptococcal (GAS) pharyngitis. 1, 2, 3

Fever and Pain Management

• Acetaminophen is recommended as first-line antipyretic and analgesic therapy at a dose appropriate for the child's weight 1, 4
• Ibuprofen is an effective alternative that may provide slightly better pain relief than acetaminophen for sore throat symptoms 1
• Aspirin should be strictly avoided in children due to the risk of Reye syndrome 1
• Pain management is essential regardless of antibiotic decision, with particular attention during the first 24 hours of illness 1, 5

Hand-Foot-Mouth Disease Management

• HFMD is a self-limited viral illness caused by enteroviruses that typically resolves within 7-10 days 2, 3
• Treatment is primarily supportive:
  • Ensure adequate hydration, which may be challenging due to painful oral lesions 6, 3
  • Cold liquids, popsicles, or ice cream can help soothe oral discomfort 3
  • Avoid spicy, salty, or acidic foods that may irritate oral lesions 6
• No specific antiviral therapy is indicated for routine HFMD 2, 3

Acute Tonsillitis/Pharyngitis Assessment

• Determine if the pharyngitis is likely viral or bacterial:

  • HFMD is characterized by fever and maculopapular rashes on hands, feet, and oral cavity, suggesting viral etiology 2, 3
  • Presence of cough, rhinorrhea, hoarseness, or oral ulcers strongly suggests viral etiology 1, 7
  • GAS pharyngitis typically presents with sudden onset of sore throat, fever, headache, tender cervical lymph nodes, and tonsillar exudate without cough or rhinorrhea 1, 7

• Testing for GAS is generally not recommended in children younger than three years unless specific risk factors exist (such as a sibling with GAS pharyngitis), as GAS infection is uncommon in this age group 1

Antibiotic Decision Algorithm

1. If clinical features strongly suggest viral etiology (as in HFMD with pharyngitis):

   • Avoid antibiotics 1, 2
   • Focus on supportive care 3

2. If GAS pharyngitis is suspected:

   • Perform rapid antigen detection test (RADT) or throat culture 1
   • If positive, treat with antibiotics 1
   • If negative RADT in children, confirm with throat culture 1

Antibiotic Selection (Only if GAS Confirmed)

• First-line: Amoxicillin 50 mg/kg once daily (maximum 1g) for 10 days 1
• For penicillin allergy:
  • Non-type I hypersensitivity: Cephalexin 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
  • Type I hypersensitivity: Clindamycin 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1
  • Alternative: Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days 1

Important Considerations and Pitfalls

• Avoid unnecessary antibiotic use for viral infections like HFMD, as this can contribute to antibiotic resistance 2, 8
• Be aware that HFMD and viral pharyngitis can coexist, and the presence of characteristic HFMD rash strongly suggests a viral etiology 2, 3
• Monitor for rare but serious complications of HFMD, including meningitis and encephalitis 2, 6
• Ensure caregivers understand the expected course of illness and when to seek further medical attention (worsening symptoms, inability to drink fluids, severe lethargy) 3

Follow-up Recommendations

• If symptoms worsen or fail to improve within 48-72 hours, reassessment is necessary 5
• Signs of treatment failure include worsening condition, persistence of symptoms beyond 48 hours after starting appropriate treatment, or recurrence of symptoms within 4 days of completing treatment 5