All I want for Christmas is amoxicillin

Sore throat

It is important to accurately diagnose and treat group A streptococcal pharyngitis to prevent both suppurative and nonsuppurative complications. However, a recent systematic review reminds us that symptoms and signs cannot be used to definitively diagnose or rule out strep throat in children aged 3 to 18 years.² The same review looked at 15 studies assessing the accuracy of 5 prediction rules in children; none of the rules had a likelihood ratio that indicated it could be used to diagnose streptococcal pharyngitis (probability of group A streptococci > 85%).

Strep throat is rare in children younger than 3 years of age.³ Most children with upper respiratory tract infections (URTIs) do not have sore throat, and their probability of having strep throat is only 4% (CI 3.37% to 4.78%).⁴ The American Academy of Pediatrics, American Heart Association, and Infectious Diseases Society of America all recommend testing (rapid test or throat culture) in suspected cases and avoidance of testing in children with symptoms clearly consistent with viral URTI (ie, cough, rhinorrhea, congestion). It is safe to await results before treatment, given that treatment is aimed at prevention of complications.

Sore ears

In 2009, the Canadian Paediatric Society published comprehensive guidelines on the management of acute otitis media (AOM).⁵ Viruses have an important role to play in the pathogenesis of AOM and are the likely cause of AOM when it spontaneously resolves. Although AOM is still a primarily bacterial infection, the treatment effect of antimicrobials is small. Approximately 15 children need to be treated to have 1 child experience resolution of symptoms at 48 hours.⁶ Eighty percent of children with AOM will likely be better within 3 days without antibiotic treatment.

Most young, healthy patients older than 6 months of age can be treated with a “watchful waiting” approach, which comprises symptom management (analgesia) and the use of antibiotics only if symptoms persist beyond 48 to 72 hours (deferred prescription). This approach decreases the incidence of complications associated with antibiotic therapy without leading to an important increase in complications of AOM. Most parents are satisfied with this approach and will follow physician instructions.

Cough and cold

There is no role for antibiotics in the treatment of pediatric URTI. Lower airway inflammation is usually related to an underlying viral infection, bronchiolitis, or asthma—none of which requires antibiotic therapy.

In 2011, the Canadian Paediatric Society published a practice point on pneumonia.⁷ In young children, bacterial pneumonia is relatively rare. The most common causes of pneumonia in infants and preschool children are winter viruses like respiratory syncytial virus, influenza, parainfluenza, and human metapneumovirus.

Pneumonia should be suspected in children with fever (particularly with fever for more than 5 days or with a temperature persistently higher than 40°C), tachypnea, dyspnea, decreased oxygen saturation, persistent cough for more than 10 days, decreased air entry, or increased bronchial breath sounds. If pneumonia is suspected, diagnosis should be made using a chest x-ray scan, as pneumonia is overdiagnosed in the absence of radiologic confirmation. The presence of wheezing points to a diagnosis of bronchiolitis or asthma; abnormalities on chest x-ray scans might reflect the atelectasis or mucus plugging associated with these conditions. The routine use of chest x-ray scan for bronchiolitis in infants leads to inappropriate antibiotic use for this viral infection and is not recommended.⁸

Fever phobia

Fever is a common reason that parents seek medical care for their children; this is often owing to a belief that fever is dangerous and indicates a serious infection that needs antibiotic therapy. Impart the following key messages to parents of febrile children.

• Most fevers in healthy, well appearing, immunized children are caused by viruses.¹

• History and physical examination are used to identify the source of the fever and to determine whether any further testing or treatment is required.

• Fever is a normal immune response (and thus not dangerous).⁹

• Only 2% to 5% of infants and young children will have benign febrile seizures and this does not increase the rate of epilepsy or neurologic issues later in life.¹⁰

• Most children look unwell when the temperature is elevated; it is reassuring if they are interacting normally once their fever is treated and the temperature has decreased.¹

We have the opportunity to empower parents and caregivers to care for febrile children at home, avoiding unnecessary overtreatment and further use of health care resources. Of course, parents must be counseled carefully regarding the reasons their child should be assessed by a physician (eg, any fever for infants younger than 3 months of age; persistent fever for more than 5 days; persistent fever with a temperature higher than 40°C; lethargy despite adequate fever control; and dehydration or respiratory distress).

Gift of consistency

Health care providers who treat children in their offices, walk-in clinics, EDs, or elsewhere should be well versed in the treatment of pediatric febrile viral illness. Diagnostic tests like throat swabs and chest x-ray scans should be used appropriately to confirm diagnoses and initiate appropriate antibiotic therapy when required. Health care providers must be confident when counseling parents on supportive care that febrile children require. Parents need to hear a consistent message about fever and viral illness; let’s provide one that is evidence-based, sensible, and good for kids.