What is the appropriate management for a six-year-old with fever and sore throat?

Management of a Six-Year-Old with Fever and Sore Throat

Start with ibuprofen for symptom relief, then perform a rapid antigen detection test (RADT) for Group A Streptococcus, and only prescribe antibiotics if the test is positive. 1

Initial Symptomatic Treatment

• Ibuprofen is the first-line analgesic for this child, showing superior pain relief and antipyretic efficacy compared to acetaminophen, particularly after 2 hours of administration. 2, 3
• Acetaminophen (paracetamol) is an acceptable alternative with comparable safety when used at recommended doses. 2, 3
• Never use aspirin in children due to the risk of Reye syndrome. 1, 4
• Adjunctive therapy with analgesics should be used to treat moderate to severe symptoms and control high fever. 1

Diagnostic Approach

Apply the Centor criteria to assess the likelihood of bacterial pharyngitis: 3, 5

• Fever by history
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough

If the child has 0-2 Centor criteria: This suggests viral etiology—do not perform testing and do not prescribe antibiotics. Treat symptomatically with ibuprofen only. 2, 3

If the child has 3-4 Centor criteria: Perform a rapid antigen detection test (RADT) for Group A Streptococcus. 1, 3

• If RADT is positive: This confirms Group A streptococcal pharyngitis and warrants antibiotic treatment. 1
• If RADT is negative: Perform a backup throat culture in this child, as backup cultures are recommended for children and adolescents with negative RADT results due to higher risk of acute rheumatic fever in this age group. 1

Antibiotic Treatment (Only if Confirmed Group A Streptococcus)

First-line antibiotic: Penicillin or amoxicillin for 10 days. 1, 3

• These are preferred due to narrow spectrum of activity, few adverse effects, and modest cost. 1

For penicillin allergy (non-anaphylactic): 1, 3

• First-generation cephalosporin
• Clindamycin
• Clarithromycin (though note significant resistance to macrolides in some U.S. regions) 6

Do not prescribe antibiotics if the child has 0-2 Centor criteria or if testing is negative, as antibiotics do not provide meaningful symptom relief in viral pharyngitis and contribute to antimicrobial resistance. 1, 2, 3

What NOT to Do

• Do not use corticosteroids in children with sore throat, as they are not recommended for routine treatment and provide only modest benefit even in severe adult cases. 1, 2
• Do not use local antibiotics or antiseptics, as most sore throats are viral and these lack efficacy data. 2
• Do not test or treat children under 3 years old unless they have specific risk factors (such as an older sibling with confirmed streptococcal pharyngitis), because Group A streptococcal pharyngitis and acute rheumatic fever are very rare in this age group. 1
• Do not test or treat asymptomatic household contacts, as prophylaxis has not been shown to reduce subsequent infection rates. 1

Expected Clinical Course and Follow-Up

• Without antibiotics, fever and symptoms typically resolve within a few days of onset, with most cases resolving within 7-14 days. 1, 3
• Do not perform routine follow-up testing after treatment unless the child is at particularly high risk for acute rheumatic fever or has recurrence of classic symptoms. 1
• Re-evaluate the child if symptoms worsen after appropriate antibiotic initiation or persist beyond 5 days after starting treatment. 6

Key Clinical Pitfall

The most common error is prescribing antibiotics based on clinical features alone without microbiological confirmation. 1 In children, 60% or more presenting with sore throat receive antibiotics, yet only a minority have bacterial infection. 6 This six-year-old falls within the peak age range (5-15 years) for Group A streptococcal pharyngitis, but testing is still mandatory before prescribing antibiotics to avoid unnecessary treatment and antimicrobial resistance. 1, 5