This week the world will celebrate Bubble Wrap Appreciation Day, Chocolate Cake Day, Blueberry Pancake Day, Cornchip Day, and International Fun at Work Day. However, celebrating anything is hard when you have a sore throat!
Sore throats can really slow kids down, prompting parents to visit the pediatrician or family doctor. For most kids, sore throats are caused by a virus, and will resolve themselves within a week without any intervention (Foisy, Martin, Domino, & Becker, 2011). However, some sore throats are caused by bacteria, like group A beta-hemolytic streptococcus (GABHS) or fusobacterium necrophorum, and need intervention to prevent future health complications like glomerulonephritis or rheumatic fever.
Distinguishing sore throat of viral versus bacterial origin is tough – signs and symptoms are not enough to classify which kids need intervention or not, and throat culture or rapid antigen testing can be unreliable (Ebell, Smith, Barry, Ives, & Carey, 2000). Because of this, antibiotics are commonly prescribed. This can be problematic because antibiotics may cause adverse events, and also lead to bacterial resistance in the community. This increases the importance of knowing which antibiotics work, how safe they are, and if there are other effective interventions.
A Cochrane overview that included 43 trials and 18,393 participants considered all of those factors to determine the optimal approach to sore throat treatment. While the overview considered the use of corticosteroids and Chinese herbal medicine, evidence did not support the general use of these interventions for treating sore throat, so we focus on the evidence for antibiotics.
How effective are antibiotics for children with sore throat?
- Compared to placebo, antibiotics did not reduce fever or throat pain at three and seven days.
- When comparing immediate and delayed prescribing, children who were immediately given antibiotics were less likely to have throat pain and fever at three days. Children whose physician delayed prescribing antibiotics were more likely to have vomiting at three days; however, this was most likely due to their illness rather than an adverse event.
- Overall, antibiotics did not significantly reduce sequelae (glomerulonephritis, acute rheumatic fever, and suppurative complications such as acute otitis media, sinusitis, peritonsillar abscess) in placebo-controlled and delayed prescribing trials.
Choice of antibiotics:
- The standard treatment, ten days of oral penicillin, was the most effective treatment for sore throat.
- While no other treatments were more effective than penicillin, macrolides were the least optimal choice. Children taking macrolides experienced more side effects and were more likely to have recurring illness.
- Because adolescents are more likely to have a sore throat associated with the necrophorum bacteria, macrolides are particularly ineffective for teens because they are ineffective at treating F. necrophorum bacteria.
What is the evidence-based approach to treating sore throat?
Viral: Parents should reassure their children, provide pain relief, and understand the natural progression of the illness (Scottish Intercollegiate Guidelines Network, 2010).
Bacterial: The standard ten-day course of oral penicillin is the optimal treatment for children and teens with bacterial sore throat. Macrolides are not recommended because they may lead to poorer outcomes. Current evidence does not support the general use of corticosteroids and Chinese herbal medicine.
In light of this evidence, the authors of the overview highlight a key point for physicians prescribing antibiotics: “Any potential benefit of antibiotic treatment must be weighed against the cost of treatment and the possibility of adverse effects. Children with a past history of rheumatic fever or those living in a region with a high prevalence of this condition are more likely to benefit from antibiotics than those without these risk factors.”
- Linder JA, Bates DW, Lee GM, Finkelstein JA. Antibiotic treatment of children with sore throat. JAMA 2005; 294(18):2315–2322.
- Ebell MH, Smith MA, Barry HC, Ives K, Carey M. The rational clinical examination. Does this patient have strep throat? JAMA 2000; 284(22): 2912–2918.
- Scottish Intercollegiate Guidelines Network. Management of sore throat and indications of tonsillectomy: A national clinical guideline; 2010.
- Foisy, M., Martin, B., Domino, F., & Becker, L. A. (2011). The Cochrane Library and the treatment of sore throat in children and adolescents: An overview of reviews. Evidence‐Based Child Health: A Cochrane Review Journal, 6(3), 810-823.