What are the signs, symptoms, and treatment options for strep throat in children?

Strep Throat in Children: Signs, Symptoms, and Treatment

Clinical Presentation and Diagnosis

Strep throat in children typically presents with sudden onset of sore throat, fever, headache, and nausea/vomiting, along with tonsillopharyngeal inflammation, patchy exudates, palatal petechiae, and tender anterior cervical lymph nodes. 1

Key Clinical Features Suggesting Streptococcal Pharyngitis:

• Sudden onset of sore throat 1
• Age 5 to 15 years (peak incidence) 1
• Fever 1
• Headache 1
• Nausea, vomiting, or abdominal pain 1
• Tonsillopharyngeal inflammation with patchy exudates 1
• Palatal petechiae 1
• Tender anterior cervical lymph nodes 1
• Scarlatiniform rash (in scarlet fever) 1
• Presentation in winter or early spring 1
• History of exposure to streptococcal pharyngitis 1

Features Suggesting Viral (NOT Strep) Pharyngitis:

• Cough 1
• Rhinorrhea (runny nose) 1
• Hoarseness 1
• Conjunctivitis 1
• Discrete ulcerative stomatitis 1
• Diarrhea 1

Clinical features alone cannot reliably distinguish streptococcal from viral pharyngitis—microbiological testing is essential. 1

Diagnostic Testing Recommendations:

• Rapid antigen detection test (RADT) should be performed when strep throat is suspected 2
• A positive RADT is diagnostic and does not require backup culture 2
• A negative RADT in children and adolescents should be followed by throat culture 2
• Testing is generally NOT recommended in children younger than 3 years unless specific risk factors are present (such as an older sibling with confirmed infection) 1, 3
• Do not test children with clear viral symptoms (cough, rhinorrhea, hoarseness, oral ulcers) 1

Treatment

First-Line Antibiotic Therapy (No Penicillin Allergy):

Penicillin or amoxicillin for 10 days is the first-line treatment for confirmed streptococcal pharyngitis in children due to proven efficacy, safety, narrow spectrum, and low cost. 2

Oral Options:

• Penicillin V: 250 mg twice or three times daily for children; 10 days duration 1, 2
• Amoxicillin: 50 mg/kg once daily (maximum 1,000 mg) OR 25 mg/kg twice daily (maximum 500 mg); 10 days duration 1, 2

Intramuscular Option:

• Benzathine penicillin G: Single dose of 600,000 units for children <27 kg; 1,200,000 units for children ≥27 kg 1, 2

Treatment for Penicillin-Allergic Patients:

For non-anaphylactic penicillin allergy, first-generation cephalosporins are recommended; for immediate-type hypersensitivity, use clindamycin or macrolides. 2

Non-Anaphylactic Allergy:

• Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose); 10 days 1, 2
• Cefadroxil: 30 mg/kg once daily (maximum 1 g); 10 days 1, 2

Immediate-Type Hypersensitivity:

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose); 10 days 1, 2
• Azithromycin: 12 mg/kg once daily (maximum 500 mg); 5 days 1, 2
• Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose); 10 days 1, 2

Important caveat: Macrolide resistance among Group A Streptococcus varies geographically (5-8% in most U.S. areas) and may result in treatment failures. 1

Symptomatic Treatment:

Acetaminophen or NSAIDs (such as ibuprofen) should be used for moderate to severe symptoms or high fever as adjunctive therapy. 1, 2

• Acetaminophen or NSAIDs provide effective pain and fever relief 1
• Aspirin must be avoided in children due to risk of Reye syndrome 1, 2
• Corticosteroids are NOT recommended for routine use (minimal benefit of ~5 hours symptom reduction with potential adverse effects) 1
• Topical anesthetics (lozenges, sprays) may provide temporary relief but represent choking hazard in young children 1

Treatment Duration and Rationale:

The standard 10-day antibiotic course is recommended to ensure complete bacterial eradication and prevent rheumatic fever. 2

• Antibiotics rapidly improve symptoms (within 24 hours in most cases) 4
• Treatment reduces symptom duration by 1-2 days 5
• Antibiotics decrease contagiousness and allow earlier return to school 4
• Prevention of acute rheumatic fever is a critical goal, particularly in high-risk populations 1
• Suppurative complications (peritonsillar abscess, cervical lymphadenitis) are prevented 1

Note on shorter courses: While some research suggests 3-6 day courses of newer antibiotics may have comparable efficacy 6, 7, current guidelines still recommend the standard 10-day course, especially in areas where rheumatic fever prevalence remains a concern 2.

Common Pitfalls to Avoid:

• Never treat pharyngitis without confirming diagnosis through testing—clinical features alone are unreliable 2
• Do not prescribe antibiotics for viral pharyngitis—they provide no benefit and contribute to resistance 5
• Avoid broad-spectrum antibiotics when narrow-spectrum options (penicillin/amoxicillin) are effective 2
• Do not routinely perform post-treatment cultures unless symptoms persist or recur 2
• Do not routinely test or treat children under 3 years unless specific risk factors present 3

Special Considerations:

Patients with recurrent pharyngitis and positive strep tests may be chronic carriers experiencing repeated viral infections rather than true recurrent streptococcal infections. 1

• Chronic carriers do not generally require antimicrobial therapy 1
• Carriers are unlikely to spread infection or develop complications 1
• Treatment of carriers may be considered during community outbreaks or in patients with personal/family history of rheumatic fever 1

1, 2, 5, 3, 8, 9