Wheezing in a 10-Year-Old with Acute Pharyngitis
The wheezing in this 10-year-old is most likely a viral-induced bronchospasm unrelated to bacterial pharyngitis, and should be treated with inhaled albuterol as the primary bronchodilator, while the pharyngitis itself requires diagnostic testing to determine if Group A Streptococcal (GAS) infection is present before considering antibiotics.
Immediate Management of Wheezing
Administer albuterol via metered-dose inhaler with spacer (2-4 puffs every 20 minutes for up to 3 doses) as first-line therapy for acute wheezing. 1, 2, 3
- Albuterol is safe and effective in children 2 years and older, with the MDI-spacer delivery method being equally efficacious to nebulization and easier to administer 2, 3, 4
- Dosing: 2-4 puffs (90 mcg per puff) every 20 minutes for up to 3 treatments, then reassess 1
- If using nebulization, the dose is 2.5 mg (0.083% solution) every 20 minutes for up to 3 doses 1
Diagnostic Approach to the Pharyngitis
Do not assume the wheezing is caused by the pharyngitis—these are likely separate processes. 5
- Test for GAS pharyngitis only if viral features are absent (no cough, rhinorrhea, hoarseness, or oral ulcers) 5, 6
- The presence of wheezing and cough strongly suggests a viral etiology for both the pharyngitis and wheezing, making GAS testing unnecessary 5
- If testing is pursued, use rapid antigen detection test (RADT) with high sensitivity (80-90%) and specificity (90-95%) 7, 6
Antibiotic Treatment (Only if GAS Confirmed)
If RADT is positive for GAS, treat with penicillin or amoxicillin for 10 days. 5, 8, 6
- First-line: Amoxicillin 50 mg/kg once daily (maximum 1000 mg) OR 25 mg/kg twice daily (maximum 500 mg/dose) for 10 days 5, 8
- Penicillin-allergic (non-anaphylactic): Cephalexin 20 mg/kg/dose twice daily (maximum 500 mg/dose) for 10 days 5, 8
- Penicillin-allergic (anaphylactic): Clindamycin 7 mg/kg/dose three times daily (maximum 300 mg/dose) for 10 days 5, 8, 6
- The full 10-day course is mandatory to prevent acute rheumatic fever—do not shorten the duration 5, 8, 6
Symptomatic Treatment
Provide ibuprofen or acetaminophen for pain and fever control regardless of antibiotic use. 5, 6
- Ibuprofen or acetaminophen at standard pediatric doses for moderate to severe symptoms 5
- Never use aspirin in children due to Reye syndrome risk 5
- Do not use corticosteroids as adjunctive therapy for pharyngitis 5
Critical Clinical Pitfalls
Do not prescribe antibiotics without confirming GAS infection—the wheezing and viral features make bacterial pharyngitis unlikely. 5, 6
- Wheezing with pharyngitis in a child strongly suggests viral etiology (rhinovirus, respiratory syncytial virus, or other respiratory viruses) 5
- Antibiotics will not improve viral wheezing and expose the child to unnecessary adverse effects and resistance 6, 9
- If wheezing persists despite albuterol treatment, consider alternative diagnoses (asthma, anatomic abnormalities) but this requires bronchoscopy evaluation, not antibiotics 5
When to Reassess
If wheezing does not improve after 3 albuterol treatments or worsens, consider hospital admission or alternative diagnoses. 5, 1
- Persistent wheezing despite bronchodilator therapy may warrant flexible bronchoscopy to evaluate for anatomic abnormalities (tracheomalacia, vascular rings), though this is rare 5
- If pharyngitis symptoms worsen or fail to improve within 48-72 hours of antibiotic initiation (if GAS-positive), reassessment is warranted 7, 6