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Official reprint from UpToDate®

www.uptodate.com © 2022 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Acute pharyngitis in children and adolescents:

Symptomatic treatment
Author: Jan E Drutz, MD
Section Editor: Teresa K Duryea, MD
Deputy Editor: Mary M Torchia, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: May 2022. | This topic last updated: Sep 10, 2021.

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

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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 and diagnosis 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.

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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')

• 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

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infections')

• Neisseria gonorrhoeae (see "Treatment of uncomplicated Neisseria gonorrhoeae

infections", 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 "Treatment and prevention of Yersinia

enterocolitica and Yersinia pseudotuberculosis infection", section on 'Treatment')

• 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

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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

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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

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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.)
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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 side 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 [43,44], 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) [45-49]; this is particularly problematic if the child is taking these
nonprescription preparations in addition to prescribed medications.
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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 5th to 6th 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 10th to 12th 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

● 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 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

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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)

● 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)

● 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".)

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● 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.)

Use of UpToDate is subject to the Terms of Use.

REFERENCES

1. Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract
infections in children: systematic review. BMJ 2013; 347:f7027.
2. Bisno AL. Acute pharyngitis: etiology and diagnosis. Pediatrics 1996; 97:949.

3. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev
2013; :CD000023.
4. Thomas M, Del Mar C, Glasziou P. How effective are treatments other than antibiotics for
acute sore throat? Br J Gen Pract 2000; 50:817.
5. Bradley CP. Taking another look at the acute sore throat. Br J Gen Pract 2000; 50:780.

6. Middleton DB, D'Amico F, Merenstein JH. Standardized symptomatic treatment versus

penicillin as initial therapy for streptococcal pharyngitis. J Pediatr 1988; 113:1089.
7. Bisno AL. Acute pharyngitis. N Engl J Med 2001; 344:205.
8. Schmitt BD. Sore throat (pharyngitis). In: Instructions for Pediatric Patients, WB Saunders, P
hiladelphia 1999. p.91.

9. Snellman L, Adams W, Anderson G, et al. Institute for Clinical Systems Improvement. Diagn
osis and treatment of respiratory illness in children an adults. Updated January 2013. http
s://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalo
g_respiratory_guidelines/respiratory_illness/ (Accessed on August 25, 2016).

https://www.uptodate.com/contents/2875/print 11/21
6/19/22, 2:39 PM 2875

10. Weglowski J. An evidence-based approach to the evaluation and treatment of pharyngitis in

children. Pediatr Emerg Med Pract 2011; 8:1.

11. Flurbiprofen: new indication. Lozenges: NSAIDs are not to be taken like sweets! Prescrire
Int 2007; 16:13.

12. Ambroxol lozenges: new drug. Sore throat: better to just suck on hard candy. Prescrire Int
2009; 18:52.
13. Chenot JF, Weber P, Friede T. Efficacy of Ambroxol lozenges for pharyngitis: a meta-analysis.
BMC Fam Pract 2014; 15:45.
14. Little P, Stuart B, Wingrove Z, et al. Probiotic capsules and xylitol chewing gum to manage
symptoms of pharyngitis: a randomized controlled factorial trial. CMAJ 2017; 189:E1543.
15. Pierce CA, Voss B. Efficacy and safety of ibuprofen and acetaminophen in children and
adults: a meta-analysis and qualitative review. Ann Pharmacother 2010; 44:489.
16. Gehanno P, Dreiser RL, Ionescu E, et al. Lowest effective single dose of diclofenac for
antipyretic and analgesic effects in acute febrile sore throat. Clin Drug Investig 2003;
23:263.
17. Schachtel BP, Thoden WR. A placebo-controlled model for assaying systemic analgesics in
children. Clin Pharmacol Ther 1993; 53:593.
18. Bertin L, Pons G, d'Athis P, et al. Randomized, double-blind, multicenter, controlled trial of
ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of symptoms of
tonsillitis and pharyngitis in children. J Pediatr 1991; 119:811.

19. Benarrosh C. [Multicenter double blind study of tiaprofenic acid versus placebo in tonsillitis
and pharyngitis in children]. Arch Fr Pediatr 1989; 46:541.
20. Eccles R, Loose I, Jawad M, Nyman L. Effects of acetylsalicylic acid on sore throat pain and
other pain symptoms associated with acute upper respiratory tract infection. Pain Med
2003; 4:118.
21. Scottish Intercollegiate Guidelines Network. Management of sore throat and indications fo
r tonsillectomy. Guideline No. 117. April 2010. http://www.sign.ac.uk/guidelines/fulltext/11
7/ (Accessed on August 30, 2016).
22. Moghal NE, Hegde S, Eastham KM. Ibuprofen and acute renal failure in a toddler. Arch Dis
Child 2004; 89:276.
23. National Institute for Health and Care Excellence. Sore throat (acute): antimicrobial prescrib
ing. January 2018. Available at: https://www.nice.org.uk/guidance/ng84 (Accessed on Janua
ry 29, 2018).
24. Feder HM. Acute pharyngitis: fitting the drug to the bug. Contemp Pediatr 2001; 18:41.
https://www.uptodate.com/contents/2875/print 12/21
6/19/22, 2:39 PM 2875

25. Watson N, Nimmo WS, Christian J, et al. Relief of sore throat with the anti-inflammatory
throat lozenge flurbiprofen 8.75 mg: a randomised, double-blind, placebo-controlled study
of efficacy and safety. Int J Clin Pract 2000; 54:490.

26. Cingi C, Songu M, Ural A, et al. Effect of chlorhexidine gluconate and benzydamine
hydrochloride mouth spray on clinical signs and quality of life of patients with
streptococcal tonsillopharyngitis: multicentre, prospective, randomised, double-blinded,
placebo-controlled study. J Laryngol Otol 2011; 125:620.

27. Cingi C, Songu M, Ural A, et al. Effects of chlorhexidine/benzydamine mouth spray on pain
and quality of life in acute viral pharyngitis: a prospective, randomized, double-blind,
placebo-controlled, multicenter study. Ear Nose Throat J 2010; 89:546.
28. Questions & Answers: Reports of a rare, but serious and potentially fatal adverse effect wit
h the use of over-the-counter (OTC) benzocaine gels and liquids applied to the gums or mo
uth www.fda.gov/Drugs/DrugSafety/ucm250029.htm (Accessed on August 03, 2012).
29. US Food and Drug Administration. Risk of serious and potentially fatal blood disorder prom
pts FDA action on oral over-the-counter benzocaine products used for teething and mouth
pain and prescription local anesthetics. Available at: https://www.fda.gov/Drugs/DrugSafet
y/ucm608265.htm (Accessed on May 23, 2018).
30. Hopper SM, McCarthy M, Tancharoen C, et al. Topical lidocaine to improve oral intake in
children with painful infectious mouth ulcers: a blinded, randomized, placebo-controlled
trial. Ann Emerg Med 2014; 63:292.

31. Hess GP, Walson PD. Seizures secondary to oral viscous lidocaine. Ann Emerg Med 1988;
17:725.
32. Aertgeerts B, Agoritsas T, Siemieniuk RAC, et al. Corticosteroids for sore throat: a clinical
practice guideline. BMJ 2017; 358:j4090.
33. Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, et al. Corticosteroids for treatment
of sore throat: systematic review and meta-analysis of randomised trials. BMJ 2017;
358:j3887.
34. de Cassan S, Thompson MJ, Perera R, et al. Corticosteroids as standalone or add-on
treatment for sore throat. Cochrane Database Syst Rev 2020; 5:CD008268.
35. Chessman AW. Guideline: Experts recommend a single dose of oral steroids for pain relief
in acute sore throat. Ann Intern Med 2018; 168:JC2.
36. Fernandes RM, Oleszczuk M, Woods CR, et al. The Cochrane Library and safety of systemic
corticosteroids for acute respiratory conditions in children: an overview of reviews. Evid
Based Child Health 2014; 9:733.

https://www.uptodate.com/contents/2875/print 13/21
6/19/22, 2:39 PM 2875

37. Bereznoy VV, Riley DS, Wassmer G, Heger M. Efficacy of extract of Pelargonium sidoides in
children with acute non-group A beta-hemolytic streptococcus tonsillopharyngitis: a
randomized, double-blind, placebo-controlled trial. Altern Ther Health Med 2003; 9:68.
38. Mazzone A, Catalani M, Costanzo M, et al. Evaluation of Serratia peptidase in acute or
chronic inflammation of otorhinolaryngology pathology: a multicentre, double-blind,
randomized trial versus placebo. J Int Med Res 1990; 18:379.
39. Thamlikitkul V, Dechatiwongse T, Theerapong S, et al. Efficacy of Andrographis paniculata,
Nees for pharyngotonsillitis in adults. J Med Assoc Thai 1991; 74:437.

40. Spasov AA, Ostrovskij OV, Chernikov MV, Wikman G. Comparative controlled study of
Andrographis paniculata fixed combination, Kan Jang and an Echinacea preparation as
adjuvant, in the treatment of uncomplicated respiratory disease in children. Phytother Res
2004; 18:47.
41. Cáceres DD, Hancke JL, Burgos RA, et al. Use of visual analogue scale measurements (VAS)
to asses the effectiveness of standardized Andrographis paniculata extract SHA-10 in
reducing the symptoms of common cold. A randomized double blind-placebo study.
Phytomedicine 1999; 6:217.
42. Brinckmann J, Sigwart H, van Houten Taylor L. Safety and efficacy of a traditional herbal
medicine (Throat Coat) in symptomatic temporary relief of pain in patients with acute
pharyngitis: a multicenter, prospective, randomized, double-blinded, placebo-controlled
study. J Altern Complement Med 2003; 9:285.

43. Huang Y, Wu T, Zeng L, Li S. Chinese medicinal herbs for sore throat. Cochrane Database
Syst Rev 2012; :CD004877.
44. Frye R, Bailey J, Blevins AE. Clinical inquiries. Which treatments provide the most relief for
pharyngitis pain? J Fam Pract 2011; 60:293.
45. Sas D, Enrione MA, Schwartz RH. Pseudomonas aeruginosa septic shock secondary to
"gripe water" ingestion. Pediatr Infect Dis J 2004; 23:176.

46. Newmaster SG, Grguric M, Shanmughanandhan D, et al. DNA barcoding detects

contamination and substitution in North American herbal products. BMC Med 2013;
11:222.

47. Rodríguez-González M, Benavente Fernández I, Zafra Rodríguez P, et al. Toxicity of

remedies for infantile colic. Arch Dis Child 2014; 99:1147.
48. Wille D, Hauri-Hohl M, Vonbach P, et al. Too much of too little: xylitol, an unusual trigger of
a chronic metabolic hyperchloremic acidosis. Eur J Pediatr 2010; 169:1549.

https://www.uptodate.com/contents/2875/print 14/21
6/19/22, 2:39 PM 2875

49. Aviner S, Berkovitch M, Dalkian H, et al. Use of a homeopathic preparation for "infantile
colic" and an apparent life-threatening event. Pediatrics 2010; 125:e318.
Topic 2875 Version 33.0

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GRAPHICS

Infectious causes of acute pharyngitis in children and adolescents

Clinical syndrome Clinical clues

Bacteria (requires antimicrobial therapy)

Streptococcus, Tonsillopharyngitis and scarlet fever Acute onset, fever, headache,

group A abdominal pain, tonsillopharyngeal
erythema and exudate, tender
(most common
anterior cervical lymph nodes
cause requiring
antimicrobial
therapy)

Streptococcus, Tonsillopharyngitis and

groups C and G scarlatiniform rash

Neisseria Pharyngitis Oral-genital contact in sexually active

gonorrhoeae adolescents

Fusobacterium Jugular vein suppurative Primarily affects adolescents and

necrophorum thrombophlebitis (Lemierre young adults, high fever (>39°C
syndrome) [102.2°F]), rigors respiratory
symptoms, unilateral neck swelling
or pain

Arcanobacterium Pharyngitis and scarlatiniform rash More common in adolescents, rash

haemolyticum occurs in approximately one-half

Corynebacterium Diphtheria Tightly adherent membrane in nose

diphtheriae and throat, history of travel
(particularly to former Soviet Union,
Africa, or Asia), lack of immunizations

Tularemia Ulcerative-exudative pharyngitis Ingestion of poorly cooked wild

animal meat or contaminated water

Atypical bacteria (may require specific therapy or infection control measures)

Mycoplasma Pneumonia, bronchitis, and Adolescents and adults

pneumoniae pharyngitis

Viruses that infect the pharynx directly

Epstein-Barr virus Infectious mononucleosis Fever, severe pharyngitis, frequent

(EBV) exudates, anterior and posterior
cervical lymphadenopathy,
prominent constitutional symptoms

Cytomegalovirus Infectious mononucleosis Fever, mild or no pharyngitis,

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(CMV) anterior and posterior cervical

lymphadenopathy, prominent
constitutional symptoms

Human Primary HIV infection Mononucleosis-like syndrome with

immunodeficiency fever, weight loss, diffuse
virus (HIV) adenopathy, rash, splenomegaly,
lymphopenia

Herpes simplex Pharyngitis Exudative or nonexudative

virus types 1 and tonsillopharyngitis in sexually active
2 adolescents, ulcerative lip lesion in
10 to 40 percent of cases

Influenza A and B Influenza Fever, cough, pharyngitis, headache,

viruses myalgia, seasonal epidemics

Enteroviruses Herpangina and hand-foot-and- Vesicles in posterior pharynx may be

(Coxsackie A) mouth disease accompanied by lesions on hands
and feet

Adenovirus Pharyngoconjunctival fever and Conjunctivitis, tonsillopharyngeal

acute respiratory disease erythema and exudates

Severe acute Pharyngitis Clinical features are variable; may

respiratory include fever, persistent cough,
COVID-19
syndrome shortness of breath, gastrointestinal
coronavirus 2 MIS-C symptoms, cutaneous findings,
(SARS-CoV-2)* epidemiologic link to individuals with
SARS-CoV-2 infection

Viruses that cause nasopharyngitis (generally do not require specific therapy or infection
control measures)

Rhinovirus Common cold Nasal symptoms predominate

Coronaviruses, Common cold Nasal symptoms predominate

including SARS-
CoV-2*

Respiratory Bronchiolitis, common cold Nasal symptoms predominate,

syncytial virus seasonal epidemics

Parainfluenza Common cold, croup Stridor, hoarseness, prominent nasal

symptoms

This table is meant for use with UpToDate content on acute pharyngitis in children. Refer to
UpToDate content for additional information (eg, indications for testing, management).

COVID-19: coronavirus disease 2019; MIS-C: multisystem inflammatory syndrome in children.

* SARS-CoV-2 requires strict infection control measures in health care settings and the community.

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Graphic 63398 Version 10.0

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Etiology of sore throat by age

Cause Infants and young children Older children and adolescents

Viral pharyngitis* Respiratory viruses Epstein-Barr virus (infectious

mononucleosis)*
Herpangina (enterovirus)*
Respiratory viruses*
SARS-CoV-2
HIV

Herpangina (enterovirus)

HSV

SARS-CoV-2

Bacterial Group A Streptococcus Group A Streptococcus*

pharyngitis
Fusobacterium necrophorum and other Neisseria gonorrhoeae
anaerobic bacteria (±Lemierre's
Fusobacterium necrophorum and other
syndrome¶ )
anaerobic bacteria (±Lemierre's
Other bacteriaΔ syndrome¶ )

Other bacteriaΔ

Other infections Retropharyngeal abscess¶ Peritonsillar abscess¶

Lateral pharyngeal abscess¶ Retropharyngeal abscess¶

Epiglottitis¶ Lateral pharyngeal abscess¶

Epiglottitis¶

Miscellaneous Steven-Johnson syndrome Psychogenic pharyngitis

conditions
Kawasaki disease Referred pain

Behçet syndrome Steven-Johnson syndrome

PFAPA syndrome Kawasaki disease

Behçet syndrome

PFAPA syndrome

Traumatic injury Foreign body Irritation of the mucosa*

Chemical exposure

HIV: human immunodeficiency virus; HSV: herpes simplex virus; SARS-CoV-2: severe acute
respiratory coronavirus 2; PFAPA: periodic fever with aphthous stomatitis, pharyngitis, and adenitis.

* Common causes of sore throat in children.

¶ Life-threatening causes of sore throat in children.

Δ Other bacteria that can cause acute pharyngitis include group C and G Streptococcus,
Arcanobacterium hemolyticum, Mycoplasma pneumoniae, Chlamydia pneumoniae, Francisella tularensis,
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Corynebacterium diphtheriae, and Neisseria gonorrhoeae.

Graphic 60174 Version 18.0

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Contributor Disclosures
Jan E Drutz, MD No relevant financial relationship(s) with ineligible companies to disclose. Teresa K
Duryea, MD No relevant financial relationship(s) with ineligible companies to disclose. Mary M Torchia,
MD No relevant financial relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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