What are the typical symptoms and treatment options for a pediatric patient with strep throat?

Pediatric Strep Throat: Symptoms and Treatment

Children with strep throat typically present with sudden-onset sore throat, fever, pain with swallowing, and tender anterior cervical lymph nodes, and should be treated with penicillin or amoxicillin for 10 days to prevent rheumatic fever and suppurative complications. 1

Clinical Presentation in Children

Classic Symptoms (Ages 5-15 Years)

The typical presentation includes: 1

• Sudden onset of sore throat (most characteristic feature) 1
• Fever (typically 101°F to 104°F) 1
• Pain with swallowing 1
• Headache 1
• Nausea, vomiting, and abdominal pain (especially common in children) 1

Physical Examination Findings

Key findings on exam include: 1

• Tonsillopharyngeal erythema with or without exudates 1
• Tender, enlarged anterior cervical lymph nodes 1
• Palatal petechiae 1
• Beefy red, swollen uvula 1
• Scarlatiniform rash (when present) 1

Important Age-Related Differences

Children under 3 years should NOT be routinely tested for strep throat because the illness is uncommon in this age group and rheumatic fever is extremely rare. 2 When GAS does occur in toddlers, it presents differently with fever, mucopurulent rhinitis, excoriated nares, and diffuse adenopathy rather than classic exudative pharyngitis. 2 Testing may be considered only if specific risk factors exist, such as an older sibling with confirmed GAS infection. 2

Distinguishing from Viral Pharyngitis

Do NOT test for strep if viral features are present: 1, 3

• Cough 1
• Rhinorrhea (runny nose) 1
• Hoarseness 1
• Conjunctivitis 1
• Oral ulcers 1
• Diarrhea 1

These features strongly suggest viral etiology and testing is unnecessary. 3

Diagnostic Approach

When to Test

Confirm diagnosis with rapid antigen detection test (RADT) or throat culture in children 3 years and older who have: 1, 4

• Sore throat WITHOUT viral features 1
• At least 2-3 of the following: fever, absence of cough, tender anterior cervical nodes, tonsillar exudates 5

Testing Protocol

• Positive RADT is diagnostic and requires no backup culture 1
• Negative RADT in children requires backup throat culture because children have higher risk of rheumatic fever than adults 1
• Clinical features alone cannot reliably diagnose strep throat 1

Treatment Recommendations

First-Line Antibiotic Therapy

Penicillin or amoxicillin for 10 days is the treatment of choice based on effectiveness, narrow spectrum, lack of resistance, and prevention of rheumatic fever. 1

Specific dosing: 1

• Penicillin V oral: 250 mg two or three times daily for children for 10 days 1
• Amoxicillin oral: 50 mg/kg once daily (maximum 1,000 mg) OR 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
• Penicillin G benzathine IM: Single dose of 600,000 units if <60 lbs or 1,200,000 units if ≥60 lbs 1

Penicillin Allergy Alternatives

For non-anaphylactic penicillin allergy (first-generation cephalosporins): 1, 4

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

For anaphylactic penicillin allergy: 1, 4

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

Critical caveat: Macrolide resistance (azithromycin, clarithromycin) varies geographically and should be considered when selecting treatment. 4 In areas with high resistance rates, avoid macrolides. 4

Duration of Treatment

The full 10-day course is essential for penicillin and amoxicillin to prevent treatment failure, suppurative complications, and rheumatic fever. 3 Only azithromycin is given for 5 days. 1 Incomplete courses increase risk of complications. 3

Symptomatic Management

Pain and Fever Control

Use acetaminophen or NSAIDs (like ibuprofen) for moderate to severe symptoms or high fever. 1 NSAIDs are more effective than acetaminophen for pain and fever reduction. 5

NEVER use aspirin in children due to risk of Reye syndrome. 1, 3

Additional Symptomatic Measures

• Topical anesthetics (lozenges with benzocaine, lidocaine) may provide temporary relief but represent choking hazard in young children 1
• Warm salt water gargles for children old enough to gargle 1

What NOT to Use

Corticosteroids are NOT recommended for routine treatment of strep throat. 1 While they may reduce symptom duration by approximately 5 hours, the minimal benefit does not justify potential adverse effects. 1

Common Pitfalls to Avoid

1. Testing children under 3 years routinely - Only test if specific risk factors present 2
2. Testing patients with obvious viral symptoms (cough, runny nose, hoarseness) - This identifies carriers, not true infections 1, 6
3. Prescribing antibiotics without confirmatory testing - Leads to overtreatment of viral pharyngitis 6
4. Using incomplete antibiotic courses - Less than 10 days of penicillin/amoxicillin increases treatment failure risk 3
5. Using macrolides in high-resistance areas - Check local resistance patterns 4
6. Giving aspirin to children - Risk of Reye syndrome 1, 3

When to Suspect Complications

Fever persisting beyond 48-72 hours of appropriate antibiotic therapy suggests either treatment failure or development of suppurative complications (peritonsillar abscess, retropharyngeal abscess). 3 These patients require immediate evaluation and may need IV antibiotics and surgical drainage. 3