Pediatric Pharyngitis Treatment & Management

For patients with signs of dehydration, administer adequate oral or intravenous (IV) fluids. Remember that pain may limit oral intake, complicating hydration maintenance in the patient. Rarely, small children with pharyngitis who have signs and symptoms of dehydration after refusing to drink may require hospitalization for IV hydration. Usually, even patients who require IV hydration in the emergency department (ED) consume enough oral fluids after their IV fluid bolus to allow home management with close and adequate follow-up care and good instructions for returning if the condition worsens or oral intake is poor.

For patients with group A beta-hemolytic streptococcal (GABHS) pharyngitis, the antibiotic treatment of choice is penicillin. Provided that rapid testing is available, physicians can decide, on the basis of the clinical severity of the pharyngitis, whether to initiate therapy immediately if a rapid test is positive for GABHS or to delay therapy until culture results are obtained. The issue of early versus delayed therapy has several considerations. ^[13]

Benefits of early treatment include the following:

• Therapy within 48 hours of symptom appearance appears to shorten the duration of symptoms

• Early therapy limits spread to other children

• Early therapy allows the patient and family to return to their usual routine sooner; because more than 80% of patients have culture-negative results after 24 hours of therapy, the child should remain out of school or daycare for 24 hours after starting therapy; they must also be fever free before returning

• Early therapy limits losses to follow-up

Disadvantages of early treatment include the following:

• Early therapy may lead to a higher failure rate secondary to an inability to create an immune response to the infection

• Rheumatic fever may still be prevented if antibiotic therapy is initiated within 9 days of symptom onset ^[14]

• Possible drug reactions and expenses may be avoided by refraining from immediately treating cases caused by pathogens other than GABHS (viruses in particular)

Make decisions on an individual basis, taking into account available testing, the severity of symptoms, the feasibility of arranging follow-up care, and the need for patients and their families to quickly return to their regular routine.

For patients with viral pharyngitis, care should be supportive, with antipyretics for pain and fever.

Some have also suggested that steroid use, dexamethasone in particular, may reduce pain and decrease symptom duration for both viral pharyngitis and streptococcal pharyngitis. This has been primarily shown in the adult population. In children, the length of symptoms has been shown to be minimally improved with adjunct steroid use; however, steroids might be considered in children with significant symptoms or discomfort. ^[15]

Refer to the primary care physician for follow-up care. For most patients, no specific diet is needed, but adequate fluid intake and hydration are of vital importance. Monitor the patient to prevent secondary dehydration. To limit the spread to other individuals who have not been exposed, the patient should avoid school and new contacts during the initial 24 hours after beginning antibiotic therapy for GABHS and until free of fever.

Penicillin is the typical therapy for GABHS pharyngitis, in conjunction with prevention of dehydration and supportive care for pain. Improved compliance with regimens has been noted when penicillin treatment is administered 2-3 times daily, as compared with traditional regimens comprising 4 daily doses. Treatment regimens with as few as 2 doses per day have been proved to be effective. ^[16] Administer a minimum of 20 mg/kg/day; larger children generally should receive 500 mg divided into 2 daily doses for 10 days.

Initial studies using a 5- to 7-day course of penicillin showed a decline in the number of GABHS positive follow-up throat cultures, from 53% to 18%. Subsequent 10-day courses of penicillin proved to be the most beneficial in eradicating GABHS from the pharynx. Therefore, the diagnosis and proper treatment of GABHS are of vital importance.

However, a Cochrane review of 20 studies (including 13,102 acute GABHS pharyngitis cases) that compared short duration of antibiotic therapy with standard duration of therapy for treating acute streptococcal pharyngitis in children determined that short-duration treatment resulted in shorter periods of fever and sore throat, less risk of early clinical treatment failure, and comparable rates of early bacteriologic treatment failure (or late clinical recurrence). ^[17]

The authors concluded that a 3- to 6-day regimen of oral antibiotics had an efficacy comparable with that of a standard-duration 10-day oral penicillin regimen in treating children with acute GABHS pharyngitis. ^[17] Shorter courses of antibiotics could limit antibiotic use, reduce cost, and potentially minimize antibiotic resistance; however, the long-term impact on the prevention of rheumatic heart disease is not known and requires further study.

Several other medications, including some that are more palatable and meet with better compliance, have been approved to treat GABHS pharyngitis. For example, amoxicillin has often been used in place of penicillin; however, neither has been determined to possess a significant microbiologic advantage over penicillin. One preliminary report has shown amoxicillin taken once daily to be effective.

Cephalosporins also have been used, but it is questionable whether failure rates are any better than those achieved with penicillin. Cephalosporins resist degradation by beta-lactamases and are very effective against copathogens. First- or second-generation cephalosporins are preferred. Cephalosporins used to treat pediatric pharyngitis include cephalexin, cefadroxil, cefuroxime, cefixime, cefdinir, and cefpodoxime. Macrolide antibiotics may be recommended for penicillin-allergic patients.

An update of a Cochrane review that evaluated patient outcomes on different antibiotics for group A streptococcal pharyngitis did not find clinically important differences in outcomes when comparing various classes of antibiotics against penicillin in adults and children with pharyngitis caused by GABHS. The review supports the recommendation of penicillin as a first‐choice antibiotic for GABHS pharyngitis, in light of its low cost and absence of resistance. ^[18]

As a rule, relapses or failure to improve should be treated with an antibiotic active against beta-lactamase–producing organisms (eg, a macrolide, a cephalosporin, or amoxicillin-clavulanate). The hypothesis is that colonizing pharyngeal bacteria that produce penicillinase have inactivated penicillin, resulting in treatment failure.

Findings by Hirsh et al report that despite recommendations for amoxicillin or penicillin for treatment of pharyngitis, only 52% of clinicians prescribe the recommended treatment for otitis media, sinusitis, and pharyngitis. ^{[19, 20]} A study focusing on inappropriate antibiotic prescriptions by the same team also found that pharyngitis, with 43 antibiotic prescriptions per 1000 population [95% CI, 38-49]), was the third highest diagnosis associated with the most antibiotic prescriptions behind sinusitis and otitis media. ^[21]

Corticosteroids (eg, dexamethasone) have been suggested as adjunctive therapy to decrease pain and shorten symptom duration in adults with pharyngitis. A study in children found that a single dose of oral dexamethasone (0.6 mg/kg, not to exceed 10 mg) did not decrease time to onset of clinically significant pain relief or time to complete pain relief. ^[15] However, in those children with positive rapid streptococcal test results, there was a statistically significant (but only marginally clinically significant) reduction in time to onset of pain relief.

Therefore, the use of steroids is not routinely recommended but can be considered. This position is also supported by a systematic review of pharyngitis in adult patients, which reported a slight decrease in time to resolution and amount of pain concluded that in view of the heterogeneity of the results, the use of steroids was not routinely recommended but could be offered for consideration on a patient-by-patient basis. ^[22]

In addition to adequate antibiotic therapy for patients with GABHS, administer antipyretics for pain and fever in all patients, regardless of whether the cause is bacterial or viral. Ibuprofen (10 mg/kg orally every 8 hours) or acetaminophen (15 mg/kg orally every 4-6 hours) is effective. Any such over-the-counter medications should be taken on a limited basis for a limited time (≤ 2-3 days), in accordance with package insert instructions and recommendations for dosing, delivery, and use; any questions or concerns should be referred to the primary care provider.

For patients with herpangina (stomatitis or pharyngitis), alumina-magnesia mixed with diphenhydramine hydrochloride in a 1:1 ratio can be administered orally before meals to decrease associated discomfort and to help maintain good hydration. This medication can be dosed on the basis of the diphenhydramine component (1.25 mg/kg oral swish and swallow every 6 hours as needed).

For patients with a peritonsillar abscess, needle aspiration and drainage is warranted. Retropharyngeal abscesses often require surgical drainage. An experienced pediatrician can often drain a peritonsillar abscess, but if the pediatrician is uncomfortable with the procedure, referral to an ear, nose, and throat (ENT) specialist or an ED physician is warranted.

If pharyngitis is recurrent or severe, referral to an ENT specialist for possible tonsillectomy may be considered. Parents often request such referrals if their child has had multiple episodes of pharyngitis. It should be pointed out, however, that tonsillectomy generally offers only temporary relief. Although a 50-80% reduction in GABHS pharyngitis is noted during the first 2 years after the procedure, by the third year after tonsillectomy, no difference is reported in comparison with control groups.

Because more than 90% of children clear GABHS from their pharynx within 24 hours after the initiation of antibiotic therapy, they should remain out of school or daycare for 1 day and until fever free. If symptoms persist for longer than 24-48 hours, patients should be reevaluated for the possibility that other concerns may be present, as well as for possible treatment failures.

A study by Schwartz et al reported that all children treated with amoxicillin for strep throat by 5 PM of day 1 may, if afebrile and improved, attend school on day 2. ^{[23, 24]}

Follow-up cultures are not routinely necessary unless concerns arise regarding recurrences or carrier states.