2What this session includes Diagnosing and managing sore throatsThe use of throat swabsUpdate on antibiotics for Strep AWhat to do with recurrencesTips on taking on taking antibioticsStorage of antibiotics
3Diagnosing and managing Strep A sore throats Difficult to always differentiate clinically between strep A and viral sore throatsA throat swab is the gold standard for identifying the presence of strep A in the throathowever cannot differentiate whether there is infection or carriage
4When do you take a throat swab All symptomatic children in school sore throat management clinics should have a throat swab taken and results received before commencement of antibioticsIn rapid response clinics – may consider giving antibiotics to high risk individuals without a throat swabIf throat swab taken, good practice to let client know results of swab; consider discontinuing antibiotics if throat swab GAS negativeThe Heart Foundation does not routinely recommend re-swabbing patients after an antibiotic course is completed
5Treating Group A streptococcal sore throats (based on 2014 Heart Foundation guidelines) First line treatmentAmoxicillin orally for 10 days< 30 kg: 750 mg daily≥ 30 kg: 1000 mgBenzathine penicillin G, intramuscular injection, single dose< 30 kg: 450 mg (600,000 Units≥ 30 kg: 900 mg (1,200,000 Units)Definite or possible anaphylaxis to penicillin or amoxicillinErythromycin ethyl succinate orally for 10 days40 mg/kg/day in 2 – 3 dosesNote:Decrease in maximum dose of amoxicillin from 1500mg to 1000mgMaximum dose for erythromycin ethyl succinate – 3200 mg (Medsafe datasheet) to 4000 mg (New Zealand Paediatric Formulary)Penicillin V not included as a first line treatment due to issues with adherence – has to be taken on an empty stomach, does not taste good. In order to improve antibiotic adherence we recommend once daily amoxicillin or im penicillin. Oral penicillin can be considered if you suspect glandular fever as amoxicillin can cause a rash in these people. Symptoms of glandular fever include: fever, sore throat, swollen glands, headache. More common in older adolescents and young adults.
6Managing children who keep presenting with a GAS positive sore throat - a challenge for all Concern expressed repeatedly at meetings, DHB visits, question timesTypically child or young person who presents with recurrent sore throats and throat swab is positive each timeSometimes post treatment swab is positiveCausing concerns to parentsUndermining the relationship between the professional and the parent/patient
7Confirming a Strep A carrier Suspect if closely spaced symptomatic recurrences of pharyngitis with a positive throat swab i.e. child with repeated sore throats who always has a positive swabConfirm by testing to check after an effective course of antibiotic has been deliveredVerbal assurance of adherence?Directly Observed Therapy?IM injection?If positive swab after a known effective course of antibiotics – they are a Strep carrier
8What does being a Strep carrier mean? Not alone. Around 1 in 8 school age children in NZ are strep A carriersVery little or no risk for Rheumatic FeverCan transmit the strep A to others who may become infected and therefore at risk of RFEspecially if also have a coughBut much less likely to that those have an actually infectionDon’t swab asymptomatic children (GAS positives most likely carriage)
9What do you do when you find a Strep carrier Explain to the child and/or caregiver what being a carrier meansTo help them avoid passing the bug onto household contactsEmphasise the importance of sneeze and cough etiquetteHighlight the importance of not crowding children- especially when they sleepRefer to your GP or nurse practitioner to decide whether and how to treat
10Deciding whether to treat a carrier Unwise to treat a known carrier if obvious viral symptoms - cough and runny noseDon’t keep giving courses of oral amoxicillin to people who are GAS carriers - it won’t make any difference to the child and may contribute to antibiotic resistanceRefer to your lead GP or nurse practitionerMinistry and NHF are producing a fact sheet and guidance to assist GPs and nurse practitioners80% sore throats are viral.
11Should carriage be treated? Possible to “clear” the strep A carriageWhich reduces the confusionBut takes powerful antibioticsTheoretically carriage may protect against infection with strep AClear once.Key question is whether to do it again and what to do if notFact sheet will pick up these issues
12For more informationGregory P deMuri and Ellen R Wald. The Group A Streptococcal Carrier State Reviewed: Still an Enigma. Journal of Paediatric Infectious Diseases Society April 2014
13Most school-aged children are able to learn to swallow tablets and capsules Children are able to learn to swallow tablets or capsules from around six yearsMost master the technique on their own by age ten yearsSome children, particularly those with chronic conditions requiring daily medicines, can be taught to swallow pills at a younger age
14Possible Barriers Anxiety Strong gag reflex Texture, size and shape Children who fear swallowing pills are likely to be tense when attempting to do so which can make the process more difficult.This tension, especially the throat, neck and chest can make the child feel like they are having trouble breathing make them feel anxious.Learning strategies to swallow tablets and capsules effectively can help reduce the child’s anxietyOften the parents who are also reluctant or unable to swallow medicines themselves. So it is important parents lead by example and demonstrate that swallowing pills or capsules is easy.Fussy eaters or those who gag frequently on food and drink can often struggle with swallowing medicines.Getting the child to take a deep breath before inserting a tablet or capsule in their mouth can help them to suppress their gag reflex.The size and shape of the tablet or capsule, and the nature of the coating can affect the ease of swallowing.
15Techniques for swallowing tablets and capsules Ask the child to have a drink of water or their favourite drink to moisten their mouthPlace the tablet or capsule into the centre of the child’s mouthAsk the child to take a big sip of their drink, and then swallowThere are many techniques for swallowing tablets and capsules, and it is appropriate for children to find the one that works for them.In general, it is best not to throw a tablet or capsule towards the back of the mouth. This is because it can actually make swallowing more difficult.A recommended technique for swallowing a pill or capsule is to:Ask the child to have a drink of water or their favourite drink to moisten their mouthPlace the tablet or capsule into the centre of the child’s mouthAsk the child to take a big sip of their drink, and then swallow
16Top tips Yoghurts and thick drinks A straw A small spoonful of apple sauce or ice creamYoghurts and thick drinks, such as milkshakes, can help ease tablets or capsules down. They may help to reduce a child’s awareness of a tablet or capsule being swallowed.Using a straw to drink, with a tablet or capsule already in the mouth, may also help by getting the child to concentrate on the suction of the straw rather than thinking about the tablet or capsule going down.Another technique is to put the tablet or capsule into a small spoonful of apple sauce or ice cream. This can help them slip down the throat more easily
17Capsules Leaning forward when swallowing can help the capsule go down Ask the child look down at the floor instead of up at the ceilingSlip the capsule into the centre of the child’s mouth.Ask the child to take a big sip of their favourite drink or water while still looking at the floor.The capsule should float to the back of the child’s mouth and roll down their throat with the drinkLeaning forward when swallowing can help the capsule go down.This technique may not be comfortable for everyone but some children may wish to try this.- Ask the child look down at the floor instead of up at the ceiling- Slip the capsule into the centre of the child’s mouth.- Ask the child to take a big sip of their drink while still looking at the floor.The capsule should float to the back of the child’s mouth and roll down their throat with the drink
18Practice Makes Perfect Encouraging children to swallow tablets and capsules:Giving medicines to children:Teaching children to swallow medicines is all about practice.Using lollies that are easy to swallow can be an effective way of practising taking tablets or capsules.Children begin practising with small lollies and progressively increase to larger sized lollies, which are comparable in size to tablets or capsules.