What to know about sore throat in children and signs of the deadly strep throat
- Robert Bradley
- Jul 26, 2024
- 6 min read
Tonsillitis is inflammation of the tonsils most commonly caused by a viral infection or in few cases a bacterial infection. Most people that are diagnosed with tonsilitis are more likely to be suffering from tonsillopharyngitis with encompasses infection of the tonsils and pharynx.
Sore throats account for approximately 2% of all emergency department visits. Research has shown that only 15% of people who have a sore throat seek medical attention. Bacterial infection often Group A haemolytic streptococcus (GABHS) is thought to be present in meerly 5–15% of all cases.
Even though we know a vast majority of sore throats are benign a recent study showed that 64% of primary care patients presenting with tonsillitis get oral antibiotics. A cochrane review of various studies showed that antibiotics gave only modest symptom relief but did reduce the risks of Strep A complications such as rheumatic fever in those with confirmed bacterial infection.
Pathophysiology of the disease
GABHS (streptococcus pyogenes) is the infective agent responsible for the most serious complications of tonsillopharyngitis. The M protein GAHBS is associated with diseases outside the pharynx, and it is the similarity of some of those serotypes to myocardial sarcolemma antigens that is responsible for the development of rheumatic fever in some patients.
GAHBS may also release a variety of exotoxins that are responsible for illnesses such as toxic shock syndrome and necrotising fasciitis.
GAHBS can be carried asymptomatically, mostly between the ages of 3–15, where carriage rates are thought to be between 5 & 21%. In adults it is far lower, lying between 2.4 and 3.7%.
General Examination must include:
An initial ABC assessment may indicate signs of airway obstruction, respiratory difficulty and circulatory collapse. These findings should prompt the junior clinician to seek experienced help immediately.
¡Signs of upper airway obstruction:
•Snoring
•Gurgling and/or pooling of saliva
•Stridor
•Horse voice
•In complete obstruction paradoxical chest movements
It is also important to conduct a general examination of the patient as it may reveal:
•Systemic features of infection such as fever and tachycardia
•Heart murmurs found in rheumatic fever
•Neck stiffness which may indicate lymphadenopathy or rarely, retropharyngeal abscess
Hepatosplenomegaly found in infectious mononucleosis
Look for Sandpaper rash for Scarlet Fever
Rash which may be viral in origin but also consider;
Rheumatic fever erythema marginatum
Scarlet fever a rough textured macular rash with confluence in the skin folds (Pastias lines) and red cheeks with peri-oral sparing.
Look for palatal patechia
Palatal petechiae is bruising on the roof of your mouth seen in Group A beta-hemolytic streptococcal infections
Strawberry tongue
Be careful as it looks different with different skin tones as above!
This can indicate the presence of:
Kawasaki disease
Allergies. Food and drug allergies can cause a variety of symptoms, including a strawberry tongue
Scarlet fever
Toxic shock syndrome (TSS)
Vitamin deficiency.
Lymphadenopathy
Lymphadenopathy in the neck is common in both viral and GABHS infection but the presence of conjunctivitis is more specifically associated with adenoviral infection.
Tachycardia
Recognise that children with tachycardia are in at least an intermediate-risk group for serious illness.
Use the Advanced Paediatric Life Support criteria in table 1 to define tachycardia. [2013]
Table 1 Advanced Paediatric Life Support criteria for tachycardia
Less than 12 months: More than 160
12 to 24 months: More than 150
2 to 5 years: More than 140
Signs of dehydration
To assess children with fever for signs of dehydration look for:
Prolonged capillary refill time
Abnormal skin turgor
Abnormal respiratory pattern
Weak pulse
Cool extremities.
Always consider meningitis
Consider meningococcal disease in any child with fever and a non-blanching rash, particularly if any of the following features are present:
An ill-looking child
Lesions larger than 2 mm in diameter (purpura)
A capillary refill time of 3 seconds or longer
Neck stiffness
Consider pneumonia
Consider pneumonia in children with fever and any of the following signs:
Tachypnoea greater than 60 breaths per minute, age 0 to 5 months
Tachypnoea greater than 50 breaths per minute, age 6 to 12 months
Tachypnoea greater than 40 breaths per minute, age older than 12 months
Crackles in the chest
Nasal flaring
Chest in-drawing
Cyanosis
Oxygen saturation of 95% or less when breathing air.
Fever
Fever is an important part of the body’s defense against infection. Most bacteria and viruses that cause infections in people thrive best at 98.6°F (37°C).
Therefore, by increasing your body’s temperature, a fever makes it harder for the bacteria and viruses that cause infections to survive.
Reducing fever will not reduce risk of febrile convulsion (most common 6 months to 3 years old)
Seizure cause unknown
No increase risk of death in childhood/adulthood with febrile seizure
1 in 50 may go on to be diagnosed with epilepsy later in life
In children older than 6 months do not use height of body temperature alone to identify those with serious illness.
Do not use duration of fever to predict the likelihood of serious illness. However, children with a fever lasting 5 days or longer should be assessed for signs of Kawasaki disease.
Kawasaki disease:
Management of fever
Drink plenty
Rest plenty
Room temperature is comfortable
If possible open window but avoid a draft
Wear light weight clothing and bedding
Do not use hot water bottle or electric blankets
Paracetamol if not contraindicated QDS (only if child distressed)
Ibuprofen if not contraindicated TDS (only if child distressed)
Don’t wake them up at night!
Never give aspirin! Linked to Reye’s syndrome
Febrile Convulsions-should I be worried?
Pediatricians are frequently taught that a rapid rise in temperature is responsible for causing a febrile seizure; yet there are no clinical data to support this hypothesis.
The few experimental data are based on hyperthermia-induced seizures in animals and are of no clear relevance to naturally occurring fevers and accompanying seizures. Further, the experimental findings are not consistent across studies.
By contrast, there is substantial evidence indicating that the height of temperature plays a role in eliciting a febrile seizure.
Although febrile seizures are now recognized as benign and, in general, a disorder that should not be treated with chronic anticonvulsant therapy, an understanding of how fevers lead to febrile seizures may be useful for evaluating the appropriateness and efficacy of treatments that involve intermittent therapy given at the time of fever.
Check the NICE (2013) Traffic Light System for Identifying risk of serious illness
Add up the Fever Pain Score to assess risk of bacterial infection for tonsillitis
Modified feverPAIN score 2022 DECEMBER
Fever (during previous 24 hours)
Purulence (pus on tonsils)
Attend rapidly (within 3 days after onset of symptoms)
Severely Inflamed tonsils
No cough or coryza (inflammation of mucus membranes in the nose)
Each of the FeverPAIN criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause.
FOR A SCORE OF 3 OR MORE=ANTIBIOTICS
2= NONE OR PROVIDE A DELAYED PRESCRIPTION
0–1=NONE
Another useful tool is the CENTOR SCORE
FOR A SCORE OF 3 OR MORE=ANTIBIOTICS
2= NONE OR PROVIDE A DELAYED PRESCRIPTION
0–1=NONE
SO WHAT ABOUT THE ANTIBIOTICS?
When a clinical decision has been made to treat a child with antibiotics please prescribe:
‒ SORE THROAT: a 5-day course of phenoxymethylpenicillin
‒ SCARLET FEVER: a 10-day course of phenoxymethylpenicillin
‒ For children with penicillin allergy, prescribe:
‒ SORE THROAT: a 5-day course of clarithromycin
‒ SCARLET FEVER: a 10-day course of clarithromycin
Watch out for that Amoxicillin rash with Glandular Fever!
Amoxicillin and glandular fever rash
It is associated with acute Epstein-Barr virus infection. It is recognised that in the context of acute glandular fever, some antibiotics, notably ampicillin and amoxicillin, may lead to severe, generalised rashes that involve the extremities. The pathophysiology of the rash is unknown.
Preventing the spread of Strep Throat!
¡Management of Contacts
Contacts will be identified by HPTs. HPTs will advise on who requires prophylaxis. For information, the following individuals who are close contacts of cases are recommended for antibiotic prophylaxis due to higher risk of severe outcomes;
Pregnant women from ≥37 weeks gestation;
Neonates and women within the first 28 days of delivery
Older household contacts (≥75 years);
Individuals who develop chickenpox with active lesions either seven days prior to onset in the iGAS case or within 48 hours after commencing antibiotics by the iGAS case, if exposure is ongoing.
Close contact is defined as:
Prolonged contact with the case in a household-type setting during the 7 days before onset of symptoms and up to 24 hours after initiation of appropriate antimicrobial therapy in the index case.
If you or your child has a strep A infection, you should stay away from nursery, school or work for 24 hours after you start taking antibiotics. This will help stop the infection spreading to other people.
REMEMBER THOSE RED FLAGS!
There are a number of red flag symptoms and signs that should prompt the clinician to consider a more serious cause for a sore throat, including:
Significant systemic upset
Severe pain
Stridor
Severe neck stiffness
Inability to swallow / drooling of saliva
Patient holding a tripod position
Returning patients should always be seen by a different clinician preferably a senior
A patient with signs of potential or partial airway obstruction such as stridor, inability to swallow and holding a tripod position must be assessed urgently by a senior anaesthetist.
In this situation the patient must not be moved unnecessarily or have any painful procedures undertaken, such as cannulation or blood gas sampling, until specialist support arrives.
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