What is the recommended diagnosis and treatment for a child presenting with a sore throat?

Diagnosis and Management of Sore Throat in Children

Confirm Group A streptococcal pharyngitis with a rapid antigen detection test (RADT) or throat culture before prescribing antibiotics, and treat positive cases with penicillin V or amoxicillin for 10 days. 1

Who to Test

Do not test children with clear viral features (conjunctivitis, cough, hoarseness, coryza, discrete oral ulcers, or diarrhea), as these strongly indicate viral etiology and testing is unnecessary. 1

Test children who present with:

• Sudden onset sore throat with fever 1
• Tonsillopharyngeal erythema with or without exudates 1
• Tender anterior cervical lymphadenopathy 1
• Age 5-15 years (peak incidence) 1
• Winter or early spring presentation 1
• Known exposure to streptococcal pharyngitis 1

Generally avoid testing children under 3 years unless they have specific risk factors like an older sibling with confirmed infection, as Group A streptococcal pharyngitis is uncommon in this age group. 1

Diagnostic Testing

A positive RADT is diagnostic and requires no further testing—proceed directly to treatment. 1, 2

Perform backup throat culture in children and adolescents with negative RADT results, as the incidence of Group A streptococcal pharyngitis and risk of rheumatic fever are higher in this population compared to adults. 1 Backup culture is generally not necessary in adults due to lower disease incidence and complication risk. 1

Do not use antistreptococcal antibody titers for routine diagnosis of acute pharyngitis. 1

First-Line Antibiotic Treatment

For children without penicillin allergy:

• Penicillin V: 250 mg twice or three times daily for 10 days (children); 250 mg four times daily or 500 mg twice daily for 10 days (adolescents/adults) 1, 3
• Amoxicillin: 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily for 10 days—preferred in younger children due to better taste and syrup availability 1, 3

These narrow-spectrum agents are recommended due to proven efficacy, safety, low cost, and minimal impact on antibiotic resistance. 1, 3

Treatment for Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy:

• First-generation cephalosporins (cephalexin 20 mg/kg per dose twice daily, maximum 500 mg per dose; or cefadroxil 30 mg/kg once daily, maximum 1 g) for 10 days 2
• Avoid broad-spectrum cephalosporins (cefaclor, cefuroxime, cefixime, cefdinir, cefpodoxime) as they are more expensive and promote antibiotic resistance 1
• Up to 10% of penicillin-allergic patients are also allergic to cephalosporins 1

For anaphylactic penicillin allergy:

• Clindamycin: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days—resistance rate approximately 1% in the United States 1, 2
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 2
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 2

Critical caveat: Macrolide resistance (erythromycin, clarithromycin, azithromycin) ranges from 5-8% in most U.S. areas, with higher rates in some regions. 1, 2 Clarithromycin for 10 days may be more effective than azithromycin for 5 days. 1

Symptomatic Management

Use acetaminophen or ibuprofen for moderate to severe symptoms or high fever as adjunctive therapy. 1, 2

Never use aspirin in children due to Reye syndrome risk. 1, 2

Do not use corticosteroids routinely—while they may reduce pain duration by approximately 5 hours, the minimal benefit does not justify potential adverse effects given the self-limited nature of the illness and efficacy of standard analgesics. 1, 2

Common Pitfalls to Avoid

Avoid treating viral pharyngitis with antibiotics—most sore throats in children are viral, and antibiotics provide no benefit while increasing resistance and side effects. 1, 3

Do not perform routine post-treatment testing unless specific circumstances warrant it. 1

Do not test or treat asymptomatic household contacts of patients with confirmed Group A streptococcal pharyngitis. 1

Distinguish true recurrent infections from chronic carriage with viral infections—patients with repeatedly positive cultures may be chronic carriers experiencing viral pharyngitis episodes, not requiring antibiotics unless specific high-risk situations exist. 1, 2