Pediatric Pharyngotonsillitis Sore Throat

RN First Call Certified Practice Adult Decision Support Tool: EAR, NOSE AND THROAT – PHARYNGOTONSILLITIS

THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC 1

© CRNBC July 09/Pub. 712

This decision support tool is based on best practice as of February 2009. For more information or to provide feedback on this or any other decision support tools, e-mail [email protected]

PEDIATRIC PHARYNGOTONSILLITIS (SORE THROAT)

DEFINITION

This is a painful condition of the oropharynx associated with infection of the mucus membranes of the pharynx and

the palatine tonsils. The peak prevalence is found in children less than 5 years.

POTENTIAL CAUSES

Infectious

Viruses

adenovirus

enterovirus (more common in children less than 3 years of age)

coxsackievirus

Epstein – Barr (mononucleosis)

herpes simple

influenza virus

parainfluenza virus

Bacterial

group A beta-haemolytic strep (GAS)

mycoplasma pneumoniae (10% of adolescents)

pneumococci

staphylococcus aureus

H. Influenzae.

PREDISPOSING RISK FACTORS Exposure to cigarette smoke

Previous episodes of pharyngitis or tonsillitis

Overcrowding,

Poor nutrition

TYPICAL FINDINGS OF SORE THROAT (PHARYNGOTONSILLITIS) See Appendix 1 for pathogens and clinical appearance of tonsils

See Appendix 2 to aid decision making for Group A Streptococcus

Bacterial

History

Acute onset

Very sore throat

Fever

Headache

Abdominal pain and vomiting

General malaise

mailto:[email protected]




Physical Assessment

Significant fever

Tachycardia

Weigh until 12 years of age for medication calculations

Pharyngeal and tonsillar erythema

Petechiae of soft palate

Tonsillar exudate (particularly with streptococcal infection, diphtheria or mononucleosis)

Anterior cervical lymphadenopathy

Erythematous “sandpaper” rash of scarlet fever (may be present with streptococcal infection)

Erythematous rash (particularly if child is receiving amoxicillin)

lymphadenopathy with splenic enlargement in children with mononucleosis

Koplik spots

Usually not associated with coryza

Cough minimal or absent (this is a helpful diagnosis for sexually transmitted infections clue)

Viral

History

Acute sore throat combined with symptoms consistent with a viral URTI (rhinorrhea, cough and often

hoarseness)

Physical Assessment

Fever (low-grade to significant)

Tachycardia

Weigh until 12 years of age for medication calculations

Pharyngeal and tonsillar erythema and swelling

Petechiae of soft palate

Tonsillar exudate similar to that occurring with bacterial infection may be present, particularly in adenovirus

pharyngotonsillitis

Anterior cervical lymphadenopathy

Vesicles and ulcers may be present with coxsackievirus infection

Hepato- and splenomegaly

Diagnostic tests

Throat swab for culture and sensitivity

Monospot if suspect viral

Do not swab a child you suspect has epiglottitis and is drooling and sitting in the tripod position




MANAGEMENT AND INTERVENTIONS

If the child is greater than 2 years old, culture the throat before treatment or do rapid Strep antigen test; if negative,

do throat culture.

Bacterial

Goals of Treatment

Control pain and fever

Prevent complications

Rapid reduction in infectivity

Prevent spread of Group A Streptococcus

Decrease antibiotic resistance

Non-pharmacological Interventions

Rest and increase fluid intake

Avoidance of irritants (smoke)

Saline gargles (1tsp of salt in 2 cups of warm water )

Increase room humidity

Pharmacologic Interventions

All drugs must be calculated by weight until age 12

Pen V 40mg/kg/day PO divided bid for 10 days

Penicillin Allergy:

Erythromycin 40mg/kg/day PO divided tid for 7-10 days

Viral

Goals of treatment

Relieve symptoms

Supportive care

Non-pharmacological Interventions

Rest

Increase oral fluids

Avoid irritants

Warm saline gargles qid, (1 tsp of salt in 2 cups of warm water)

Pharmacological Interventions

All drugs must be calculated by weight until the age of 12

Acetaminophen (Tylenol) 10-15mg/kg PO q4-6h prn (not to exceed 75mg/kg per 24 hours)




POTENTIAL COMPLICATIONS

Bacterial

Retropharyngeal abscess

Acute glomerulonephritis

Invasive GAS disease

Otitis media

Sinusitis

Acute rheumatic fever

Viral

Epstein Barr Virus (splenomegaly)

CLIENT/CAREGIVER EDUCATION AND DISCHARGE INFORMATION Advise on condition, timeline of treatment and expected course of disease process

Saline gargles as described above

Counsel parents/caregiver about appropriate use of medication (dosage, compliance, follow-up)

If patient has any difficulty swallowing, seek help immediately

MONITORING AND FOLLOW UP Return to clinic in 48 hours if awaiting culture results

Return for care if no improvement in 48 hours

CONSULTATION AND/OR REFERRAL Consult a physician or Nurse practitioner if child has recurrent bouts of GAS pharyngotonsillitis: greater

than 5 episodes in one year.

DOCUMENTATION As per agency requirements

REFERENCES B.C. Health Services (2003). Diagnosis and management of sore throat. Author.

Campisi, P., Tewfik, T. (2003). Tonsillitis and its complications. Canadian Journal of Diagnosis. pp. 99-105

First Nations and Inuit Health Branch (2006) Pediatric clinical practice guidelines for primary care nurses. Health

Canada

Public Health Agency of Canada. CCDR 2006; 32S2:1-26.Guidelines for the Prevention and Control of Invasive

Group A Streptococcal Disease

Shaiu, C., Toren, A. (eds) (2006). Toronto Notes: Comprehensive Medical Reference and Review. University of

Toronto.




APPENDIX 1

Source: Campisi and Tewfik. (2003). Tonsillitis and Its Complications.

APPENDIX 2

Source: BC Health Services Diagnosis and Management of Sore Throat. (2003).

Documents

Pediatric Pharyngotonsillitis Sore Throat