Introduction to Pharyngitis in Pediatric Age

Pharyngitis, commonly known as sore throat, is inflammation of the pharynx, the area in the back of the throat. It is one of the most frequent reasons for pediatric healthcare visits, especially during the winter and early spring months. Pharyngitis can affect children of all ages, from infants to adolescents, and its impact on the child's quality of life and potential complications make it a significant concern for pediatricians and family practitioners.

While most cases of pharyngitis in children are self-limiting viral infections, bacterial causes, particularly group A beta-hemolytic streptococcus (GABHS), require specific management to prevent complications. Understanding the nuances of pharyngitis in the pediatric population is crucial for accurate diagnosis and appropriate treatment.

Etiology of Pediatric Pharyngitis

The causes of pharyngitis in children can be broadly categorized into infectious and non-infectious etiologies:

Infectious Causes:

• Viral (70-80% of cases):
  • Rhinovirus
  • Adenovirus
  • Coronavirus
  • Epstein-Barr virus (EBV)
  • Influenza virus
  • Parainfluenza virus
  • Respiratory syncytial virus (RSV)
  • Coxsackievirus
• Bacterial:
  • Group A beta-hemolytic streptococcus (GABHS) - most common bacterial cause
  • Group C and G streptococci
  • Mycoplasma pneumoniae
  • Chlamydophila pneumoniae
  • Neisseria gonorrhoeae (in sexually active adolescents)
  • Corynebacterium diphtheriae (rare in vaccinated populations)

Non-Infectious Causes:

• Allergic rhinitis
• Gastroesophageal reflux disease (GERD)
• Environmental irritants (e.g., smoke, air pollution)
• Trauma (e.g., from foreign body ingestion)

The prevalence of different etiologies varies with age, season, and geographic location. GABHS pharyngitis is most common in children aged 5-15 years, while viral causes predominate in younger children.

Clinical Presentation of Pharyngitis in Children

The clinical presentation of pharyngitis can vary depending on the etiology and the child's age. Common symptoms include:

• Sore throat (may be difficult for younger children to articulate)
• Fever
• Difficulty swallowing (odynophagia)
• Enlarged, tender cervical lymph nodes
• Headache
• Abdominal pain (particularly in streptococcal pharyngitis)
• Nausea and vomiting
• Fatigue

Specific Presentations:

• Viral Pharyngitis:
  • Often associated with cough, rhinorrhea, and conjunctivitis
  • May present with oral ulcers (e.g., herpangina in coxsackievirus infection)
• Streptococcal Pharyngitis:
  • Sudden onset of severe sore throat
  • High fever (>38.5°C)
  • Tonsillar exudates
  • Petechiae on the soft palate
  • Scarlatiniform rash in scarlet fever
• Infectious Mononucleosis (EBV):
  • Prolonged sore throat
  • Significant fatigue
  • Generalized lymphadenopathy
  • Splenomegaly

It's important to note that clinical features alone are often insufficient to differentiate between viral and bacterial etiologies, particularly in children.

Diagnosis of Pediatric Pharyngitis

Accurate diagnosis of pharyngitis in children involves a combination of clinical assessment and laboratory testing:

Clinical Evaluation:

• Detailed history of symptoms and exposures
• Physical examination, including:
  • Inspection of the oropharynx
  • Palpation of cervical lymph nodes
  • Assessment for rash or other systemic signs

Scoring Systems:

Modified Centor (McIsaac) score can be used to estimate the likelihood of streptococcal pharyngitis:

• Temperature > 38°C (1 point)
• Absence of cough (1 point)
• Swollen, tender anterior cervical nodes (1 point)
• Tonsillar swelling or exudate (1 point)
• Age 3-14 years (1 point), 15-44 years (0 points), ≥45 years (-1 point)

Laboratory Tests:

• Rapid Antigen Detection Test (RADT): For group A streptococcus
• Throat Culture: Gold standard for diagnosing GABHS
• Complete Blood Count (CBC): May show lymphocytosis in viral infections
• Monospot Test: For suspected infectious mononucleosis (EBV)
• Polymerase Chain Reaction (PCR): For specific viral pathogens

Imaging:

Usually not required, but may be considered in cases of suspected peritonsillar abscess or other complications:

• Lateral neck X-ray
• CT scan or ultrasound for suspected deep space infections

The American Academy of Pediatrics recommends testing for group A streptococcus in children with pharyngitis only when appropriate clinical features are present, to avoid unnecessary antibiotic use.

Treatment of Pharyngitis in Children

The treatment approach for pediatric pharyngitis depends on the etiology and severity of symptoms:

Supportive Care (for all types of pharyngitis):

• Adequate hydration
• Rest
• Analgesics/antipyretics (acetaminophen or ibuprofen)
• Saltwater gargles (for older children)
• Throat lozenges (for children old enough to safely use them)

Viral Pharyngitis:

• Primarily supportive care
• Antiviral medications are not routinely recommended

Bacterial Pharyngitis:

Group A Streptococcal Pharyngitis:

• First-line treatment: Penicillin V or Amoxicillin for 10 days
• For penicillin-allergic patients:
  • Cephalexin (if non-anaphylactic allergy)
  • Clindamycin
  • Macrolides (e.g., azithromycin, clarithromycin)

Other Bacterial Causes:

• Treatment based on specific pathogen and antibiotic susceptibility

Special Considerations:

• Infectious Mononucleosis: Supportive care; avoid amoxicillin due to risk of rash
• Peritonsillar Abscess: May require drainage and parenteral antibiotics

It's crucial to educate parents about the appropriate use of antibiotics and the importance of completing the full course when prescribed.

Complications of Pediatric Pharyngitis

While most cases of pharyngitis in children resolve without sequelae, complications can occur, particularly with untreated or inadequately treated streptococcal infections:

Suppurative Complications:

• Peritonsillar abscess (quinsy)
• Retropharyngeal abscess
• Cervical lymphadenitis
• Otitis media
• Sinusitis

Non-suppurative Complications (associated with GABHS):

• Acute rheumatic fever
• Post-streptococcal glomerulonephritis
• Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)

Other Potential Complications:

• Dehydration (due to reduced oral intake)
• Airway obstruction (rare, in severe cases)
• Chronic pharyngitis
• Reactive arthritis (particularly with certain viral infections)

Early recognition and appropriate management of pharyngitis, especially streptococcal infections, is crucial in preventing these complications.

Prevention of Pharyngitis in Children

While it's not always possible to prevent pharyngitis, several measures can reduce the risk and spread of infection:

General Preventive Measures:

• Proper hand hygiene
  • Regular handwashing with soap and water
  • Use of alcohol-based hand sanitizers when soap and water are unavailable
• Avoiding close contact with infected individuals
• Covering mouth and nose when coughing or sneezing
• Not sharing personal items (e.g., utensils, towels)
• Maintaining good overall health through proper nutrition and adequate sleep

Specific Preventive Strategies:

• Vaccination:
  • Annual influenza vaccine
  • Routine childhood vaccinations (e.g., diphtheria)
• Environmental Measures:
  • Reducing exposure to environmental irritants (e.g., secondhand smoke)
  • Maintaining good indoor air quality
• Management of Underlying Conditions:
  • Proper control of allergies and GERD

Prevention of Recurrence and Spread:

• Completing the full course of antibiotics when prescribed
• Replacing toothbrushes after recovery from streptococcal pharyngitis
• Keeping children home from school or daycare until fever-free for 24 hours and on antibiotics for at least 24 hours (if prescribed)

Education of children, parents, and caregivers about these preventive measures is crucial in reducing the incidence and spread of pharyngitis in the pediatric population.