An Evidence-Based Approach to the Evaluation and Treatment Of
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June 2007 An Evidence-Based Approach To Volume 4, Number 6 The Evaluation And Treatment Of Author Brent R. King, MD, FAAP, FACEP, FAAEM Pharyngitis In Children Professor of Emergency Medicine and Pediatrics; Chairman, Department of Emergency Medicine, The University of Texas Medical School at Houston, TX You are somewhat puzzled as you enter the examination room. The chart in your hand has a chief complaint of “strep throat, not getting better,” which is, Peer Reviewers in your experience, unusual. Joseph Toscano, MD In the room, you find a mother and her adolescent daughter. The girl looks Emergency Physician, San Ramon, CA tired and pale, but not seriously ill. Her mother looks at you and, with near-des- peration in her voice, says, “I hope you can help us, Doctor. My daughter has Paula J. Whiteman, MD, FACEP been to our regular doctor twice and to another emergency room. She is on her Medical Director, Pediatric Emergency Medicine, Encino-Tarzana Regional Medical Center; Attending third different antibiotic but her throat is still sore and she sometimes has trou- Physician, Cedars-Sinai Medical Center, Los Ange- ble swallowing. This afternoon she really scared me because she said she was les, CA having trouble breathing!” When you examine the girl’s throat, you see very swollen tonsils coated with CME Objectives exudates. You are momentarily confused but then remember something from After reading this article, you should be able to: way back in residency. You look at the mother and say, “Ma’am, I think I know what’s wrong but I need to do a blood test to be sure.” 1. Identify life-threatening causes of pharyngitis in children. or most experienced clinicians, sore throat is a “run of the 2. Describe the differences between the recom- mended diagnostic evaluation of older adoles- Fmill” complaint and hardly a reason for serious concern. cents and younger children. However, sore throats can herald life-threatening illnesses. Addi- 3. Discuss the role of the clinical examination in tionally, the management of this “simple” condition is the subject the management of the child or adolescent with of considerable controversy. Most physicians understand that pharyngitis. pain relief and hydration are important considerations in all 4. Describe the role of various testing strategies in patients, but there is considerable disagreement regarding the cri- the evaluation of the child or adolescent with teria by which patients with group A beta hemolytic streptococcal pharyngitis. pharyngitis are identified, and there is some disagreement 5. Discuss the treatment of pharyngitis, including regarding the appropriate choice of antibiotic therapy for the use of analgesics. confirmed cases. In this issue of Pediatric Emergency Medicine Practice, an evidence-based approach to the management of Date of original release: June 1, 2007. Date of most recent review: April 5, 2007. pharyngitis in children is presented. After reading this article, See “Physician CME Information” on back page. you should be able to accurately identify most life-threatening causes of pharyngitis and discuss the various acceptable Editorial Board Emergency Medicine, Chicago, Pritzker School of Assistant Professor of Gary R. Strange, MD, MA, Morristown Memorial Hospital. Medicine, Chicago, IL. Emergency Medicine and FACEP, Professor and Head, Jeffrey R. Avner, MD, FAAP, Pediatrics, Loma Linda Department of Emergency Professor of Clinical Ran D. Goldman, MD, Alson S. Inaba, MD, FAAP, Associate Professor, PALS-NF, Pediatric Medical Center and Children’s Medicine, University of Illinois, Pediatrics, Albert Einstein Hospital, Loma Linda, CA. Chicago, IL. College of Medicine; Director, Department of Pediatrics, Emergency Medicine Pediatric Emergency Service, University of Toronto; Division Attending Physician, Kapiolani Brent R. King, MD, FACEP, Adam Vella, MD, Assistant Children’s Hospital at of Pediatric Emergency Medical Center for Women & FAAP, FAAEM, Professor of Professor of Emergency Montefiore, Bronx, NY. Medicine and Clinical Children; Associate Professor Emergency Medicine and Medicine, Pediatric EM Pharmacology and of Pediatrics, University of Pediatrics; Chairman, Fellowship Director, Mount T. Kent Denmark, MD, FAAP, Toxicology, The Hospital for Hawaii John A. Burns School Department of Emergency Sinai School of Medicine, FACEP, Residency Director, Sick Children, Toronto. of Medicine, Honolulu, HI; Medicine, The University of New York Pediatric Emergency Pediatric Advanced Life Texas Houston Medical Medicine; Assistant Professor Martin I. Herman, MD, FAAP, Mike Witt, MD, MPH, Attending FACEP, Professor of Support National Faculty School, Houston, TX. Physician, Division of of Emergency Medicine and Representative, American Pediatrics, Loma Linda Pediatrics, Division Critical Robert Luten, MD, Professor, Emergency Medicine, Care and Emergency Heart Association, Hawaii & Pediatrics and Emergency Children’s Hospital Boston; University Medical Center and Pacific Island Region. Children’s Hospital, Loma Services, UT Health Sciences, Medicine, University of Instructor of Pediatrics, Linda, CA. School of Medicine; Assistant Andy Jagoda, MD, FACEP, Florida, Jacksonville, Harvard Medical School Director Emergency Services, Vice-Chair of Academic Jacksonville, FL. Michael J. Gerardi, MD, FAAP, Research Editor Lebonheur Children’s Medical Affairs, Department of Ghazala Q. Sharieff, MD, FAAP, FACEP, Clinical Assistant Center, Memphis TN. Emergency Medicine; Christopher Strother, MD, Professor, Medicine, FACEP, FAAEM, Associate Mark A. Hostetler, MD, MPH, Residency Program Director; Clinical Professor, Children’s Fellow, Pediatric Emergency University of Medicine and Director, International Studies Medicine, Mt. Sinai School of Dentistry of New Jersey; Assistant Professor, Hospital and Health Center/ Department of Pediatrics; Program, Mount Sinai School University of California, San Medicine, Chair, AAP Section Director, Pediatric Emergency of Medicine, New York, NY. on Residents Medicine, Children’s Medical Chief, Section of Emergency Diego; Director of Pediatric Center, Atlantic Health Medicine; Medical Director, Tommy Y. Kim, MD, FAAP, Emergency Medicine, System; Department of Pediatric Emergency Attending Physician, Pediatric California Emergency Department, The University of Emergency Department; Physicians. Commercial Support: Pediatric Emergency Medicine Practice does not accept any commercial support. All faculty participating in this activity report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. management options. As with all forms of treat- self-limited. The test of treatment effectiveness is ment, the goals to be achieved include: identifica- the prevention of rheumatic fever and its attendant tion of serious illness, relief of symptoms, assurance complications. Of course, rheumatic fever is incred- of adequate hydration, and, when appropriate, ibly rare in the developed world. It would be administration of effective antibiotics. Attention to nearly impossible to conduct a study to demonstrate these issues will ensure that patients receive safe, that one treatment strategy was more effective than appropriate, and cost-effective care while serious another in the prevention of rheumatic fever. There- complications are prevented and inappropriate fore, even when using well-conducted studies, the antibiotic use is limited. emergency physician may find limited guidance. Critical Appraisal Of The Literature Guidelines The clinician seeking guidance on the management Despite these limitations, many organizations have of pharyngitis will find ample information in the published proposed guidelines for the management medical literature. However, all of this information of patients with pharyngitis. Some of these are should be viewed with a somewhat jaundiced eye. intended to apply to adults and are less relevant to First, it must be recognized that the vast majority of the management of pediatric patients, but because children with pharyngitis require only management they do include older adolescents, they are pre- of their symptoms. In fact, of all of the potential sented here. Given the flaws in the available litera- causes of pharyngitis in children, the emergency ture, it is not surprising that the guidelines disagree physician is primarily concerned with the diagnosis on some issues. In fact, the limitations in the med- and treatment of infections caused by group A beta ical literature require that some of the guideline rec- hemolytic streptococci (GABHS). Even if one nar- ommendations be based upon the opinions of rows his/her search to focus on GABHS, there are experts rather than randomized controlled trials. In severe limitations to the available literature. For many cases, the practitioner is presented with a example, the most frequently employed criterion range of acceptable options, offering yet more evi- standard for the diagnosis of GABHS is a throat cul- dence of the previously described difficulties with ture on sheep’s blood agar. However, a streptococ- the medical literature. Table 1 summarizes the most cal carrier with viral pharyngitis may still have a important practice guidelines. positive throat culture and the patient with a true While it is true that the practice guidelines dis- GABHS infection may have a negative throat cul- agree in some areas, they agree about many impor- ture if the culture was collected or incubated tant issues. First,