Acute pharyngitis in children and adolescents: Symptomatic treatment

INTRODUCTION — Symptomatic relief for children and adolescents who have been diagnosed with acute pharyngitis will be reviewed here. The evaluation of sore throat in children, the diagnosis and differential diagnosis of group A streptococcal tonsillopharyngitis in children, and the symptomatic treatment of acute pharyngitis in adults are discussed separately. (See "Evaluation of sore throat in children" and "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis" and "Symptomatic treatment of acute pharyngitis in adults".)

CAUSES OF ACUTE PHARYNGITIS — In children and adolescents, acute pharyngitis is usually caused by a viral infection or group A Streptococcus (table 1). (See "Evaluation of sore throat in children", section on 'Common conditions'.)

Other causes of sore throat in children, including life-threatening causes, are discussed separately (table 2). (See "Evaluation of sore throat in children", section on 'Causes'.)

GENERAL MANAGEMENT

Patient or caregiver counseling — Counseling for the patient or caregiver of a patient who has been diagnosed with acute pharyngitis includes education about:

●Expected course of illness – Throat pain caused by infections usually lasts a few days and should improve steadily without worsening.

In a 2013 meta-analysis of six randomized trials and one observational study (344 children), sore throat lasted between two to seven days among children who received control, placebo, or over-the-counter treatment; sore throat resolved by day 3 in approximately 60 to 70 percent of cases [1]. The duration of symptoms was similar in children with and without group A streptococcal (GAS) tonsillopharyngitis.

●Indications for reevaluation – Indications for reevaluation in children and adolescents with acute pharyngitis include:

•Difficulty breathing or drooling (may indicate upper airway obstruction) (see "Emergency evaluation of acute upper airway obstruction in children", section on 'Infection')

•Inability to maintain hydration (see "Clinical assessment of hypovolemia (dehydration) in children", section on 'Clinical assessment')

•Worsening pain or pain that persists for >3 days without improvement (see 'Worsening or persistent pain' below)

●Indications for antibiotics and potential harms of inappropriate use – Antibiotics generally are indicated for laboratory-documented bacterial pharyngitis. They are not helpful in viral pharyngitis and may be associated with adverse effects including diarrhea, allergy, increased bacterial resistance, unnecessary expense, etc. (See "Patient education: What you should know about antibiotics (The Basics)".)

●Pain management – Management of throat pain is discussed below. (See 'Our approach' below.)

●Safety and efficacy of over-the-counter medications versus complementary and alternative therapies – Over-the-counter medications for the treatment of acute pharyngitis or other inflammatory conditions (not limited to acute pharyngitis) must demonstrate safety and efficacy in clinical studies before approval by the US Food and Drug Administration. In contrast, manufacturers of alternative products can claim efficacy and safety without providing the rigorous documentation of safety and efficacy.

Treat underlying cause as indicated

●Viral infections – Viral causes of acute pharyngitis that may require antiviral therapy include:

•Influenza A or B viruses (see "Seasonal influenza in children: Management", section on 'Antiviral therapy')

•Herpes simplex virus type 1 (herpetic gingivostomatitis) (see "Herpetic gingivostomatitis in young children", section on 'Management of gingivostomatitis')

•Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, coronavirus disease 2019 [COVID-19]) (see "COVID-19: Management in children", section on 'Outpatient therapy for select children')

•HIV (see "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach")

Other viruses that cause pharyngitis generally do not require antiviral therapy in immunocompetent children and adolescents. These include adenoviruses, enteroviruses, rhinoviruses, coronaviruses, and parainfluenza viruses 1, 2, and 3 [2]. (See "Diagnosis, treatment, and prevention of adenovirus infection", section on 'Treatment' and "Hand, foot, and mouth disease and herpangina", section on 'Management' and "Parainfluenza viruses in children", section on 'Treatment' and "The common cold in children: Management and prevention", section on 'Sore throat'.)

●Bacterial infections – Antimicrobial therapy should be provided for patients with laboratory-documented bacterial pharyngitis/tonsillitis. Antibiotic therapy helps to prevent complications and the spread of infection [3].

Antimicrobial treatment of bacterial pharyngitis is discussed separately:

•GAS pharyngitis (see "Treatment and prevention of streptococcal pharyngitis in adults and children")

For patients with GAS tonsillopharyngitis, early initiation of antibiotic therapy appears to modestly reduce the duration of symptoms, but antibiotics are less effective in reducing pain than other interventions (eg, systemic analgesic agents) [3-6] (see 'Systemic analgesia' below)

•Group C and G streptococcal pharyngitis (see "Group C and group G streptococcal infection", section on 'Treatment')

•Arcanobacterium hemolyticum (see "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis", section on 'Other bacterial infections')

•Neisseria gonorrhoeae (see "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Pharyngeal infection')

•Treponema pallidum (secondary syphilis) (see "Syphilis: Treatment and monitoring", section on 'Treatment of early syphilis')

•Oral anaerobes (acute necrotizing ulcerative gingivitis, also called Vincent angina and trench mouth) (see "Gingivitis and periodontitis in children and adolescents", section on 'Acute necrotizing ulcerative gingivitis')

•Yersinia enterocolitica or Yersinia pestis (see "Yersiniosis: Infection due to Yersinia enterocolitica and Yersinia pseudotuberculosis")

•Francisella tularensis (see "Tularemia: Clinical manifestations, diagnosis, treatment, and prevention", section on 'Treatment')

•Corynebacterium diphtheriae (see "Clinical manifestations, diagnosis, and treatment of diphtheria", section on 'Treatment')

●Fungal infections – Although oropharyngeal candidiasis usually occurs in infants, it may occur in older children and adolescents (eg, after a course of systemic antibiotics). Topical or systemic antifungal therapy should be provided for patients with oral candidiasis. Antifungal treatment of oropharyngeal candidiasis is discussed separately. (See "Candida infections in children", section on 'Oropharyngeal candidiasis'.)

Supportive care — General supportive measures that can be suggested for most patients with infectious pharyngitis include [7-10]:

●Getting adequate rest

●Consuming an adequate volume of fluids

●Avoiding cigarette smoke (including secondhand smoke) and other respiratory irritants

●Avoiding acidic foods and beverages (particularly for those with oral or pharyngeal ulcers)

●Eating a soft diet (may be more palatable for those with difficulty swallowing due to pain or enlarged tonsils)

SYMPTOMATIC TREATMENT

Our approach

Soothing measures — We offer one or more of the following topical soothing measures to patients with throat pain due to acute pharyngitis. The interventions may be tried in any sequence or combination at patient/caregiver discretion. Although most of the interventions have not been studied in clinical trials, they may provide short term-relief and are unlikely to be harmful [7,9]. Adjunctive systemic therapy also may be warranted. (See 'Systemic analgesia' below.)

Suggested topical soothing measures include:

●Sipping cold or warm beverages (eg, tea with honey or lemon) – Honey should be avoided in children <12 months because of the possible contamination of honey with Clostridium botulinum spores, potentially leading to infantile botulism. (See "Botulism", section on 'Infant botulism'.)

●Eating cold or frozen desserts (eg, ice cream, popsicles).

●Sucking on ice.

●Sucking on hard candy – For children ≥5 years and adolescents, we suggest sucking on hard candy rather than medicated throat lozenges (eg, cough drops, troches, or pastilles) or medicated sprays. Hard candy and lozenges should not be used in children ≤4 years of age because they are a choking hazard.

Hard candy is probably as effective as medicated lozenges, less expensive, and less likely to have adverse effects [8,11-13]. (See 'Medicated topical therapies' below.)

●Gargling with warm salt water – For children ≥6 years of age and adolescents, we suggest gargling with warm salt water rather than other medicated oral rinses. Most recipes call for ¼ to ½ teaspoon of salt per 8 ounces (approximately 240 mL) of warm water. Children <6 years generally cannot gargle properly.

We do not suggest chewing gum for symptomatic relief of acute pharyngitis. In a randomized trial, neither sorbitol nor xylitol chewing gum decreased the severity of pharyngitis [14].

Systemic analgesia — For most children and adolescents with acute pharyngitis that limits oral intake, we suggest systemic analgesia rather than medicated topical therapies (eg, lozenges, sprays, oral rinses). We generally suggest acetaminophen or ibuprofen rather than other systemic analgesic agents. We use the following doses:

●Acetaminophen – 10 to 15 mg/kg orally every four to six hours as needed (maximum single dose: 1 g; maximum daily dose: 75 mg/kg per day up to 4 g/day; maximum of 5 doses per day)

●Ibuprofen – 10 mg/kg orally every six hours as needed (maximum single dose 600 mg; maximum daily dose 40 mg/kg per day up to 2.4 g/day)

Although some studies suggest that ibuprofen is more effective than acetaminophen in reducing throat pain, the additional benefit is small [15], and patients/caregivers may prefer one or the other agent for a variety of reasons. Aspirin should be avoided in children because of the risk of Reye syndrome, as well as its antiplatelet effect.

Systemic acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen have been shown to alleviate sore throat pain in randomized controlled trials and systematic reviews [4,15-20]. In addition, they may alleviate fever and inflammation. In a systematic review of studies evaluating control of pain of various causes (eg, sore throat, musculoskeletal trauma, vaccination, etc), both ibuprofen and acetaminophen were more effective than placebo [15]. In pooled analysis of six randomized trials in children, ibuprofen was superior to acetaminophen in reducing pain, but the effect was small (standardized mean difference 0.28, 95% CI 0.10-0.46). The reported rates of adverse events with ibuprofen and acetaminophen were similar. However, some experts suggest avoidance of ibuprofen in children with dehydration or who are at risk of dehydration given the potential increased risk of renal toxicity [21,22].

Our suggestion for acetaminophen or ibuprofen for relief of acute pharyngitis is consistent with guidance from the National Institute for Health and Care Excellence [23].

Worsening or persistent pain — Children and adolescents with acute pharyngitis and throat pain that worsens or persists for >3 days without improvement should be instructed to return for reevaluation [9]. Worsening throat pain or throat pain that persists for >3 days without improvement may indicate the development of a complication (eg, tonsillopharyngeal cellulitis or abscess, jugular vein septic thrombophlebitis) or the need to consider a different diagnosis [10]. (See "Peritonsillar cellulitis and abscess" and "Retropharyngeal infections in children" and "Evaluation of sore throat in children" and "Lemierre syndrome: Septic thrombophlebitis of the internal jugular vein".)

Therapies of uncertain benefit

Medicated topical therapies

●Medicated lozenges and throat sprays – We generally avoid medicated lozenges or throat sprays for relief of throat pain in children and adolescents. Although there is some evidence from randomized trials that medicated lozenges and sprays provide symptomatic relief [7,24-27], it is not clear that they work any better than hard candy and have greater potential for adverse effects [8,11-13]. A 2010 systematic review found no good quality evidence on the effectiveness of nonprescription lozenges or throat sprays [21].

Medicated lozenges usually are designed to relieve dryness or pain. They commonly contain menthol (a cooling agent), antiseptics (hexylresorcinol, chlorhexidine), topical anesthetics (eg, phenol, benzocaine, hexylresorcinol, benzydamine), and/or anti-inflammatory agents (flurbiprofen). Medicated throat sprays usually contain topical anesthetics (eg, benzocaine, phenol, benzydamine).

Medicated throat lozenges and sprays have the potential to cause allergic reactions, and those that contain benzocaine may cause methemoglobinemia. Lozenges should not be used in children younger than four years (they are a choking hazard); sprays that contain benzocaine are contraindicated in children younger than two years [28,29]. (See "Methemoglobinemia", section on 'Acquired methemoglobinemia'.)

●Medicated oral rinses – We avoid medicated oral rinses because they have not been proven to be superior to placebo and have potential adverse effects (eg, toxicity from systemic absorption, allergic reaction) [21,28,30,31].

●Medicated agents to coat oral lesions – The use of topical therapies to coat oral lesions and/or soothe pain in children with throat pain due to oral ulcers (eg, herpetic gingivostomatitis; hand, foot, and mouth disease) is discussed separately. (See "Herpetic gingivostomatitis in young children", section on '"Magic mouthwash" and other topical therapies' and "Hand, foot, and mouth disease and herpangina", section on 'Supportive care'.)

Glucocorticoids — We suggest not using glucocorticoids for the symptomatic relief of acute sore throat in children and adolescents, regardless of etiology. In the context of shared decision-making, other experts suggest that a single low-dose of oral glucocorticoids may be warranted for immune-competent patients ≥5 years with sore throat that is not caused by infectious mononucleosis or related to recent surgery or intubation [32]. The balance of risks and harms for the individual patient is determined by the severity of pain and preference for rapid relief.

Although there is evidence that low-dose glucocorticoids can modestly reduce the duration of pain compared with placebo [33,34], safe and effective alternatives (eg, acetaminophen, ibuprofen) are available without prescription or office visit [15]. Studies directly comparing analgesic agents and glucocorticoids for the relief of throat pain are lacking [35]. (See 'Systemic analgesia' above.)

A meta-analysis included 10 randomized trials comparing low-dose glucocorticoids (usually dexamethasone) with placebo in addition to usual care in 1426 patients ≥5 years of age who were treated for sore throat in an emergency department or primary care office [33]. Glucocorticoids decreased the time to complete pain relief by 11 hours (33 versus 44 hours), decreased the time to onset of pain relief by approximately five hours (7 versus 12 hours), and increased the proportion of patients with complete pain relief at 24 hours (22 versus 10 percent) and 48 hours (61 versus 43 percent). However, concurrent administration of antibiotics and analgesics as a component of usual care in most of the included studies makes it difficult to isolate the pain-relieving effect of any single intervention. Whether glucocorticoids reduce the risk of bad/intolerable symptoms, recurrence, relapse, number of school/work days missed, or antibiotic prescriptions remains uncertain.

The rates of adverse events were similar between glucocorticoid and placebo recipients, but few adverse events were reported [33]. In a systematic review of short-term glucocorticoids for respiratory conditions in children (eg, croup, bronchiolitis, asthma), glucocorticoids were not associated with increased risk of adverse events (eg, gastrointestinal bleeding, hypertension, behavioral effects) [36]. Adverse effects of long-term glucocorticoid use are discussed separately. (See "Major adverse effects of systemic glucocorticoids".)

Studies of patients with infectious mononucleosis were excluded from the meta-analysis described above. The use of glucocorticoids for symptomatic relief in infectious mononucleosis, including relief of upper-airway obstruction, is discussed separately. (See "Infectious mononucleosis", section on 'Symptomatic treatment' and "Infectious mononucleosis", section on 'Complications including airway obstruction'.)

Alternative therapies — We avoid probiotics or other complementary/alternative therapies (eg, herbal therapies, homeopathic therapies, dietary supplements) in the symptomatic treatment of acute pharyngitis in children and adolescents. They have not been proven to be effective and may be harmful.

In a factorial randomized trial, probiotics (24 x 10⁹ colony-forming units of lactobacilli and bifidobacteria) did not reduce severity of pharyngitis in patients ≥3 years of age [14]. Although other complementary/alternative therapies have been studied in randomized trials [37-42], high quality studies are lacking [43-45], and most have not been studied in children. In addition, the US Food and Drug Administration does not regulate the safety, purity, or potency of herbal products or dietary supplements (which may vary from lot to lot or capsule to capsule). These therapies may contain potentially harmful unlabeled ingredients (pesticides, herbicides, pharmaceuticals, allergens) [46-50]; this is particularly problematic if the child is taking these nonprescription preparations in addition to prescribed medications.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Streptococcal tonsillopharyngitis".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Basics topics (see "Patient education: Sore throat in children (The Basics)" and "Patient education: Strep throat in children (The Basics)" and "Patient education: What you should know about antibiotics (The Basics)")

●Beyond the Basics topics (see "Patient education: Sore throat in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Causes of acute pharyngitis – In children and adolescents, acute pharyngitis is usually caused by a viral infection or group A Streptococcus (table 1). (See 'Causes of acute pharyngitis' above.)

●General management – General management of acute pharyngitis includes:

•Provision of education about the expected course of illness, indications for reevaluation, indications for antibiotics and potential harms of inappropriate use of antibiotics, and strategies for pain management (see 'Patient or caregiver counseling' above)

•Treatment of the underlying cause as indicated (eg, antiviral therapy for influenza, herpes simplex virus, HIV; antibiotics for laboratory-documented bacterial pharyngitis/tonsillitis) (see 'Treat underlying cause as indicated' above)

•Supportive care (rest, adequate fluid intake, avoidance of respiratory irritants, soft diet) (see 'Supportive care' above)

●Treatment of throat pain

•We offer one or more of the following topical therapies to children and adolescents with throat pain due to acute pharyngitis (see 'Soothing measures' above):

-Sipping cold or warm beverages

-Eating cold or frozen desserts or sucking on ice

-Sucking on hard candy rather than medicated lozenges or throat sprays (for children ≥5 years of age)

-Gargling with warm salt water rather than medicated oral rinses (for children ≥6 years of age)

•For most children and adolescents with acute pharyngitis that limits oral intake, we suggest systemic analgesia rather than medicated topical therapies (eg, lozenges, sprays, oral rinses) (Grade 2C). We use acetaminophen or ibuprofen depending on patient preference. (See 'Systemic analgesia' above.)

We use the following doses:

-Acetaminophen – 10 to 15 mg/kg orally every four to six hours as needed (maximum single dose: 1 g; maximum daily dose: 75 mg/kg per day up to 4 g/day; maximum of 5 doses per day)

-Ibuprofen – 10 mg/kg orally every six hours as needed (maximum single dose 600 mg; maximum daily dose 40 mg/kg per day up to 2.4 g/day)

●Worsening or persistent pain – Children and adolescents with acute pharyngitis and throat pain that worsens or persists for >3 days without improvement should be instructed to return for reevaluation. Worsening or persistent pain may indicate the development of a complication or the need to consider a different diagnosis. (See 'Worsening or persistent pain' above and "Evaluation of sore throat in children".)

●Therapies of uncertain benefit

•We suggest not using systemic glucocorticoids for the symptomatic relief of throat pain in children and adolescents with acute pharyngitis (Grade 2C). Although low-dose glucocorticoids may modestly reduce the duration of pain compared with placebo, safe and effective alternatives (eg, acetaminophen, ibuprofen) are available without prescription or office visit. (See 'Glucocorticoids' above.)

The use of glucocorticoids for upper airway obstruction in infectious mononucleosis is discussed separately. (See "Clinical manifestations and treatment of Epstein-Barr virus infection", section on 'Treatment'.)

•We avoid probiotics, herbal therapies, homeopathic therapies, dietary supplements, or other complementary/alternative therapies in the treatment of sore throat in children and adolescents. They have not been proven to be effective and may be harmful. (See 'Alternative therapies' above.)