What is the recommended treatment for parotitis in children?

Treatment of Parotitis in Children

Immediate Management: Supportive Care is the Cornerstone

The primary treatment for parotitis in children is supportive care with hydration, pain control, and oral hygiene—antibiotics are reserved only for bacterial suppurative parotitis with systemic signs of infection. 1, 2

Supportive Measures (First-Line for All Cases)

• Maintain adequate hydration through oral fluids or intravenous fluids if the child is dehydrated, as dehydration was present in 46% of hospitalized pediatric parotitis cases 1
• Provide analgesia with acetaminophen or ibuprofen for pain and fever management 1
• Encourage good oral hygiene including frequent mouth rinses and sialagogues (lemon drops, sour candies) to stimulate salivary flow and reduce bacterial colonization 2
• Apply warm compresses to the affected parotid area for symptomatic relief 1

When to Use Antibiotics: Only for Bacterial Suppurative Parotitis

Antibiotics should be initiated only when bacterial suppurative parotitis is suspected based on fever, leukocytosis, purulent drainage, or systemic toxicity. 1, 2

Indications for Antibiotic Therapy

• Fever (present in 38% of hospitalized cases) 1
• Leukocytosis (present in 46% of hospitalized cases) 1
• Purulent drainage from Stensen's duct 2
• Significant medical comorbidities (present in 54% of hospitalized cases requiring antibiotics) 1
• Failure to improve with 24-48 hours of supportive care alone 1

Antibiotic Selection Based on Microbiology

The most common pathogens in acute bacterial suppurative parotitis are Staphylococcus aureus and anaerobic bacteria (including Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species). 2

Outpatient Oral Antibiotic Regimen

• Amoxicillin-clavulanate at standard pediatric dosing (45 mg/kg/day divided into 2-3 doses) provides coverage for S. aureus, streptococci, and anaerobes 1, 2
• All outpatients in the reviewed series were successfully treated with oral antibiotics or conservative therapy 1

Inpatient Parenteral Antibiotic Regimen

• Ampicillin-sulbactam or piperacillin-tazobactam for broad-spectrum coverage including anaerobes 2
• Add vancomycin if MRSA is suspected based on local resistance patterns or prior MRSA colonization 2
• Consider gram-negative coverage (e.g., ceftriaxone or cefepime) in hospitalized or immunocompromised patients, as gram-negative organisms including E. coli, Klebsiella, and Pseudomonas are more common in this population 2

Surgical Intervention: Reserved for Abscess Formation

Surgical drainage is required only when imaging confirms abscess formation and medical therapy has failed. 1, 2

• 15% of hospitalized pediatric parotitis patients required surgical drainage due to abscess formation 1
• Obtain imaging (ultrasound or CT) if the patient fails to improve after 48-72 hours of appropriate antibiotic therapy, to evaluate for abscess 1
• Surgery is not routinely recommended for parotitis in children beyond abscess drainage 1

Distinguishing Viral from Bacterial Parotitis

Viral Parotitis (Mumps or Other Viruses)

• Bilateral parotid swelling is more common with viral causes 3, 4
• Absence of purulent drainage, fever, and leukocytosis 5
• Self-limited course lasting 2-7 days (median 3 days) 5
• No role for antibiotics—treatment is purely supportive 5
• Mumps typically presents with bilateral parotitis 16-18 days after exposure, though only 30-40% of mumps infections produce typical parotitis 3

Bacterial Suppurative Parotitis

• Unilateral swelling is more common 1, 2
• Purulent drainage from Stensen's duct on manual compression 2
• Fever, leukocytosis, and systemic toxicity 1, 2
• Requires antibiotic therapy as outlined above 2

Recurrent Parotitis of Childhood: A Distinct Entity

Recurrent parotitis of childhood is an immunologically mediated condition that does NOT respond to antibiotics and should be managed with supportive care alone. 5, 6

Key Features of Recurrent Parotitis

• Recurrent episodes of parotid swelling (mean 8 episodes per year) without pus 5
• Biphasic age distribution with peaks at 2-5 years and at 10 years 5
• Symptoms last 2-7 days (median 3 days) per episode 5
• Diagnosis confirmed by ultrasound or sialogram showing sialectasis in 81% of cases 5
• Screen for underlying conditions: Sjögren syndrome (check ANA, anti-SSA, anti-SSB, rheumatoid factor), immunodeficiency (check immunoglobulin levels), and HIV 5, 6

Management of Recurrent Parotitis

• Supportive care only—antibiotics do not have a role 5
• Refer to pediatric rheumatology if Sjögren syndrome is suspected (positive autoantibodies, hypergammaglobulinemia, or ophthalmologic findings) 6
• Refer to immunology if hypogammaglobulinemia is detected 5

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for viral parotitis or recurrent parotitis of childhood, as 54% of patients in one series were inappropriately given antibiotics at least once 5
• Do not delay diagnosis of recurrent parotitis—70% of patients experienced diagnostic delays >1 year (maximum 8 years), often misdiagnosed as mumps (21%), "infection" (15%), or stones (11%) 5
• Do not assume mumps is the only viral cause—only 30-40% of mumps infections produce typical parotitis, and 15-20% are asymptomatic 3
• Do not overlook abscess formation—obtain imaging if the patient fails to improve after 48-72 hours of appropriate therapy 1

Inpatient vs. Outpatient Management Algorithm

Admit for Inpatient Management If:

• Age <6 months or significant medical comorbidities 1
• Dehydration requiring IV fluids 1
• Fever and leukocytosis suggesting bacterial infection 1
• Failure to tolerate oral intake or oral antibiotics 1
• Suspected abscess on clinical exam or imaging 1

Outpatient Management Appropriate If:

• No fever, leukocytosis, or systemic toxicity 1
• Able to maintain oral hydration 1
• No significant comorbidities 1
• Reliable follow-up within 24-48 hours 1