Acute Pharyngitis in Children — Symptoms and Treatment

What is acute pharyngitis?

Acute pharyngitis is inflammation of the pharyngeal (throat) mucosa, one of the most common reasons for medical consultation in pediatrics. It presents with sore throat, difficulty swallowing, and sometimes fever.

Differentiating between viral and bacterial (streptococcal) pharyngitis is essential, as only the bacterial form requires antibiotic treatment. Unnecessary antibiotic prescriptions for viral pharyngitis contribute to bacterial resistance.

Symptoms

Viral pharyngitis

• Gradual onset of sore throat
• Moderate fever (below 38.5°C)
• Associated rhinorrhea, cough, conjunctivitis
• Red pharynx without purulent deposits
• Relatively good general condition

Streptococcal pharyngitis

• Sudden onset of sore throat — intense, with marked odynophagia
• High fever — 39-40°C
• Intensely red pharynx — with palatal petechiae and yellowish-white deposits on the tonsils
• Anterior cervical lymphadenopathy — enlarged and tender submandibular lymph nodes
• Absence of cough and rhinorrhea — an important differentiating criterion
• Headache, abdominal pain, vomiting — especially in young children
• Scarlatiniform skin rash — in the case of scarlet fever (streptococcal pharyngitis with exanthem)

Causes

Viral causes (60-80% of pharyngitis cases)

• Adenoviruses — pharyngitis with conjunctivitis (pharyngoconjunctival fever)
• Epstein-Barr virus — infectious mononucleosis (very large tonsils, generalized lymphadenopathy)
• Enteroviruses — herpangina (vesicles on the palate and pillars)
• Influenza and parainfluenza viruses
• Rhinoviruses

Bacterial causes

• Group A beta-hemolytic streptococcus (GABHS) — the most important, responsible for 20-30% of pharyngitis cases in children
• Mycoplasma pneumoniae — in adolescents

Diagnosis

• ENT clinical examination — appearance of the pharynx, tonsils, mucosa, cervical lymph nodes
• Modified Centor score (McIsaac) — clinical scoring system for assessing the probability of streptococcal infection
• Rapid streptococcal test (RADT) — essential for confirmation; results available in minutes
• Throat culture — confirms the diagnosis if RADT is negative and clinical suspicion remains high
• Monospot / EBV antibodies — when mononucleosis is suspected

A rapid streptococcal test should be performed in any child over 3 years of age with acute pharyngitis and clinical suspicion of bacterial infection. Under 3 years, streptococcal infection is rare.

Treatment

Viral pharyngitis

• Symptomatic treatment — analgesics (paracetamol, ibuprofen)
• Adequate hydration with cool liquids
• Saltwater gargles — in cooperative children
• Throat sprays or lozenges with local analgesic effect
• Antibiotics are NOT indicated

Streptococcal pharyngitis

• Penicillin V or amoxicillin — 10 days, first-line treatment
• Macrolides — azithromycin (5 days) or clarithromycin, for patients allergic to penicillin
• Analgesics-antipyretics
• Rest for 24-48 hours after starting antibiotics (the child becomes non-contagious)

Full completion of the antibiotic course (10 days) is essential for preventing rheumatic complications, even if symptoms improve quickly.

When to see a doctor

• The sore throat is severe and the child cannot swallow liquids
• Fever exceeds 39°C or persists for more than 3 days
• Breathing difficulties or voice changes appear
• Trismus (inability to open the mouth) — a sign of abscess
• Associated skin rash (possible scarlet fever)
• Repeated episodes of pharyngitis — evaluation for chronic tonsillitis

Complications

Suppurative complications (local)

• Peritonsillar abscess — requires surgical drainage
• Retropharyngeal abscess — more common in children under 5 years
• Suppurative cervical adenitis
• Acute otitis media — associated middle ear infection

Non-suppurative complications (post-streptococcal)

• Acute rheumatic fever — cardiac (valvular disease), articular, and neurological involvement
• Post-streptococcal glomerulonephritis — renal involvement
• PANDAS syndrome — autoimmune neuropsychiatric disorders associated with streptococcal infection