Editors

JohannaNokso-Koivisto

Pharyngitis and Tonsillitis in Children

Pharyngitis in children under school age is most commonly caused by a virus.
Infections verifiably caused by group A streptococci are treated with antimicrobials. Otherwise, symptomatic treatment is sufficient.
Epidemics caused by streptococci should be identified and managed; see the article Sore throat and tonsillitis Sore Throat and Tonsillitis.

Adenoviruses are the most common aetiological agents.
Streptococcal infections rarely occur in children below 3 years of age.
Infectious mononucleosis Mononucleosis presents with only mild symptoms in small children. Treatment with antimicrobials is of no benefit for the child. A course of amoxicillin during the disease may provoke a red-spotted rash (picture 1).

Group A streptococcal infections usually present with fever and sore throat and the tonsils are coated and swollen, but clinical diagnosis is unreliable.
- Viruses may also cause exudative tonsillitis.
If the patient in addition to fever and sore throat also has cough and rhinitis, he/she most probably has a viral respiratory infection. A rash is also possible during a viral infection.

In children below 3 years of age streptococcal tonsillitis is rare.
A rapid test http://www.dynamed.com/evaluation/streptococcal-pharyngitis-testing-strategies-18#GUID-ED4ED28D-7BBB-413F-ACA5-78D5472C8741 for the detection of group A streptococci is taken from patients with a sore throat who have a fever ≥ 38°C, swollen or coated tonsils and swollen submandibular lymph nodes but no rhinitis or cough.
A negative rapid antigen test result should be verified by streptococci culture specimen only if the symptoms are prolonged.

A NSAID http://www.dynamed.com/condition/streptococcal-pharyngitis#ANALGESICS for throat pain and fever. Administering the analgesic half an hour before a meal makes eating easier.
Treatment of infections caused by group A streptococci:
- Penicillin V http://www.dynamed.com/management/antibiotics-for-streptococcal-pharyngitis#PENICILLIN, 59 mg/kg/day (in children over 6 years of age when using tablets 50 000-100 000 IU/kg/day), or, if taking penicillin is not suitable, amoxicillin, 50 mg/kg/day, divided into 3 doses for 10 days.
- In patients with penicillin allergy, cephalexin http://www.dynamed.com/management/antibiotics-for-streptococcal-pharyngitis#CEPHALOSPORINS, 50 mg/kg/day, divided into 2 doses for 10 days, is used. Shorter treatment (3-6 days) with a cephalosporin may be equally effective. A shorter course may be considered e.g. if the child has difficulties in taking a long course of antimicrobials.
- Macrolides are only used in patients with penicillin and cephalosporin allergy according to sensitivity testing.
- The dosage for a child must not exceed that of an adult.
Because of infectiousness, home care is recommended for one day after the onset of antimicrobial treatment. The total length of absence from day care or school is determined by the general condition.

van Driel ML, De Sutter AI, Thorning S, et al. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev 2021;3(3):CD004406 [PubMed]
Coutinho G, Duerden M, Sessa A, et al. Worldwide comparison of treatment guidelines for sore throat. Int J Clin Pract, published online 7 Jan 2021 http://doi.org/10.1111/ijcp.13879
[Pharyngitis]. A Current Care Guideline. Working group appointed by The Finnish Medical Society Duodecim, The Finnish Association for General Practice, The Finnish Association of Otolaryngology, The Finnish Association of Infectious Disease Specialists, and the [Finnish] Clinical Microbiologists. Helsinki: Finnish Medical Society Duodecim, 2020 (accessed 21 Aug 2020). Available in Finnish at http://www.kaypahoito.fi/hoi38020
Chiappini E, Regoli M, Bonsignori F, et al. Analysis of different recommendations from international guidelines for the management of acute pharyngitis in adults and children. Clin Ther 2011;33(1):48-58 [PubMed]