Sore throat in older children and adolescents
A viral infection, most commonly a cold, is also the most likely cause of sore throat in these age groups. Many parents or caregivers may be concerned about strep throat, although this typically accounts for less than a third of cases of acute sore throat.1 The FeverPAIN criteria is a useful way to determine the likelihood of strep throat.1 The next section shows how these criteria may be used as part of the NHS Pharmacy First Service for those aged 5 years and over.
FeverPAIN and the Pharmacy First Service
Start your assessment by considering whether the child has any of the following:1
Score 1 point for each sign that is present and then interpret the child’s FeverPAIN score according to this table:1,9
| FeverPAIN score | Likelihood of strep throat | Management | When to reassess |
|---|---|---|---|
| 0-1 | 13-18% | Offer self-care advice and OTC treatment for symptom relief. Antibiotics are not needed | If there is no improvement after 1 week |
| 2-3 | 34-40% | Offer self-care advice and OTC treatment for symptom relief. Antibiotics will make little difference to how long symptoms will last | If there is no improvement within 3-5 days |
| 4-5 | 62-65% | MILD symptoms: Offer self-care advice and OTC treatment for symptom relief | If there is no improvement within 3-5 days |
| SEVERE symptoms: Consider antibiotics plus self-care advice and OTC treatment for symptom relief | If there is no improvement after completion of course of antibiotics |
Everyone over 5 years of age may access the Pharmacy First Service for sore throat if they meet the relevant criteria. See the clinical pathway for sore throat for further details.9
Self-care advice for older children6,8,10
Click on the images to discover advice you can share with customers.
Drink plenty of water
Hydration helps to keep the throat lubricated
Rest
It gives the immune system time to recharge and resting the voice can help reduce throat irritation
Eat cool or soft foods
These are easier to swallow, can have a numbing effect and may help reduce swelling
Use a humidifier
(if suitable)
Breathing moist air can help to soothe the throat
Avoid smoky environments
Irritants from smoke can dry out the throat and worsen soreness
In children who are older, it can be helpful to suck ice cubes, ice lollies or hard sweets
These can have a numbing effect or may increase saliva production to keep the throat lubricated
Gargle with warm, salty water (if they are able)
Salt pulls mucus out of swollen, inflamed tissue and helps relieve discomfort
Add honey to a drink
Honey can help soothe an irritated throat
Symptom relief with Difflam
In addition to self-care measures, an OTC product may be required to relieve sore throat symptoms. There are various formats in the Difflam range that can bring targeted relief for sore throats. These products may be used for viral sore throats or alongside antibiotics for bacterial throat infection.
The Difflam range
Difflam Throat Spray11,12
Suitable for all ages
Dosing instructions
Children under 6 years (if child weighs at least 4 kg) 1 puff to be administered per 4 kg body weight, up to a maximum of 4 puffs, 1½-3 hourly
Children aged 6-12 years
4 puffs, 1½-3 hourly
Those over 12 years
4-8 puffs, 1½-3 hourly
Other indications
Mouth ulcers
Teething
Sore tongue or gums
Discomfort associated with dentures or dental work.
Contains alcohol equivalent to less than
1ml of beer or 1ml of wine in each puff
Difflam Sore Throat Lozenges13,14
Suitable from 6 years
Dosing instructions
Lozenges should be dissolved slowly in the mouth and not chewed or swallowed. In children aged 6-11 years, lozenges must be used under adult supervision
Those over 6 years
1 lozenge, 3 times a day
(maximum 3 lozenges per day)
Treatment must not exceed 7 days.
Not suitable for those with rare hereditary problems of fructose intolerance.
The lemon flavour should be used with caution in those with phenylketonuria
Difflam Sore Throat Rinse (200ml) / Oral Rinse (300ml)14,15
Suitable from 12 years
Dosing instructions
Those over 12 years
Rinse or gargle with 15ml
(using measuring cup provided), 1½-3 hourly
Uninterrupted treatment should not exceed 7 days, unless under medical supervision
Rinse around the mouth or use as a gargle for 20-30 seconds and then spit out – solution should not be swallowed. Should generally be used undiluted, but if 'stinging' occurs the rinse may be diluted with water
CAUTIONS AND CONTRAINDICATIONS11-16
Difflam products:
Should not be used in those with a hypersensitivity to benzydamine hydrochloride or any of the excipients listed in the SmPC for the particular product
Are not advised in those with a hypersensitivity to acetylsalicylic acid or non-steroidal anti-inflammatory drugs (NSAIDs)
Should be used with caution in those suffering from or with a history of asthma
Should not be used in pregnancy or during breastfeeding, unless considered essential by a doctor
The most common side effects with Difflam products are numbness and a stinging feeling in the mouth; these may occur with the spray, the sore throat rinse and the oral rinse.11,15,16
MEDICAL ATTENTION REQUIRED IF:8
Difficulty breathing or inability to swallow
Stridor (high pitched sound) when breathing
Weakened immune system (e.g. diabetes or having chemotherapy)
Severe symptoms worsening quickly
Sore throat that does not improve after a week
Sore throat with very high temperature or feeling hot and shivery
Recurring sore throats
1. NICE CKS. Sore throat – acute. 2023. Available at: https://cks.nice.org.uk/topics/sore-throat-acute/
2. NHS. Colds, coughs and ear infections in children. 2021.
Available at: https://www.nhs.uk/conditions/baby/health/colds-coughs-and-ear-infections-in-children/
3. NHS Healthier Together. Tonsillitis or sore throat.
Available at: https://www.swlondon-healthiertogether.nhs.uk/professionals/gp-primary-care-staff/safety-netting-documents-parents/sore-throat-advice-sheet
4. NHS. Tonsillitis. 2024.
Available at: https://www.nhs.uk/conditions/tonsillitis/
5. Chertoff J. Healthline: What to do when your baby has a sore throat. 2019.
Available at: https://www.healthline.com/health/baby/baby-sore-throat
6. Duggal N. Healthline: What’s the Difference Between Tonsillitis and Strep Throat? 2023.
Available at: https://www.healthline.com/health/tonsillitis-vs-strep-throat
7. NHS. Hand, foot and mouth disease. 2021. Available at: https://www.nhs.uk/conditions/hand-foot-mouth-disease/
8. NHS. Sore throat. 2021.
Available at: https://www.nhs.uk/conditions/sore-throat/
9. NHS England. Clinical pathways. 2024.
Available at: https://www.england.nhs.uk/wp-content/uploads/2023/11/PRN00936_ii_Pharmacy-First-Clinical-Pathways-v.1.6.pdf
10. Holland K. Help for sore throats. 2023.
Available at: https://www.healthline.com/health/cold-flu/help-sore-throats#_noHeaderPrefixedContent
11. Difflam 0.15% w/v Spray. SmPC. 2021. Available at: https://www.medicines.org.uk/emc/product/827/smpc/print
12. Difflam 0.15% w/v Spray. PIL. 2021. Available at: https://www.medicines.org.uk/emc/files/pil.827.pdf
13. Difflam 3mg lozenges – orange-honey flavour. SmPC. 2023. Available at: https://www.medicines.org.uk/emc/product/9690/smpc/print
14. Difflam 3mg lozenges – lemon flavour. SmPC. 2023. Available at: https://www.medicines.org.uk/emc/product/9882/smpc/print
15. Difflam 0.15% w/v sore throat rinse. SmPC. 2021. [Online.] Available at: https://www.medicines.org.uk/emc/product/9258/smpc/print
16. Difflam 0.15% w/v oral rinse. SmPC. 2021. Available at: https://www.medicines.org.uk/emc/product/9257/smpc/print
Online references last accessed April 2024
Difflam 3 mg Lozenges (benzydamine hydrochloride) Lemon and Orange-Honey flavour Essential Information
Presentation: Difflam 3 mg Lozenges, contains 3mg of benzydamine hydrochloride equivalent to 2.68 mg of benzydamine. Indications: Difflam is indicated in adults and children over 6 years of age for symptomatic local treatment for the relief of pain and irritation of mouth and throat. Dosage and Administration: : For oropharyngeal use. Adults and children over 6 years of age: one lozenge 3 times a day. Lozenge should be dissolved slowly in the mouth. Do not swallow. Do not chew. The treatment must not exceed 7 days. Contraindication: Hypersensitivity to the active substance or to any of the excipients. Warnings and Precautions: Benzydamine use is not advisable in patients with hypersensitivity to salicylic acid or other NSAIDs. Bronchospasm may be precipitated in patients suffering from or with a previous history of bronchial asthma. Caution should be exercised in these patients. In a minority of patients, buccal/pharyngeal ulceration may be caused by serious disease processes. Patients whose symptoms worsen or do not improve within 3 days, or who appear feverish or have other symptoms, must therefore seek the advice of their doctor or dentist as appropriate. Difflam lozenges contain: Aspartame and Isomalt; aspartame is hydrolysed to phenylalanine which may be harmful for people with phenylketonuria. Isomalt is unsuitable for patients with rare hereditary problems of fructose intolerance and so should not take this medicine. Interactions: Not Known Pregnancy and lactation: Difflam Lozenges should not be used in pregnancy or lactation. Undesirable effects: Serious (frequency not known): Anaphylactic reaction which can be potentially life-threatening, Hypersensitivity reactions, Hypoaesthesia oral. (Uncommon): Photosensitivity, (Rare): Burning mouth, Dry mouth, (Very rare): Laryngospasm, Angioedema. Basic price (UK): RRP 20 lozenges £7.59 Product licence number: Lemon flavour PL 46302/0096, Orange-Honey flavour PL 46302/0097. Legal Category: P.
Difflam™ 0.15 % w/v Spray (benzydamine hydrochloride)
Presentation: Difflam™ Spray contains benzydamine hydrochloride 0.15% w/v. Each metered dose pump spray delivers approximately 175mcl per puff. Indications: Difflam™ Spray is a locally acting analgesic and anti-inflammatory treatment for the throat and mouth. It is especially useful for the relief of pain in traumatic conditions such as following surgical removal of tonsils or the use of a naso-gastric tube; dental surgery. Dosage and administration: Adults and elderly: 4 to 8 puffs, 1½ to 3 hourly. Children aged 6-12: 4 puffs, 1½ to 3 hourly. Children under 6: One puff per 4kg body weight, up to a maximum 4 puffs, 1½ to 3 hourly. Contra-indications: Patients with known hypersensitivity to ingredients. Warnings and Precautions: Not advisable in patients with hypersensitivity to acetylsalicylic acid or other NSAIDs. Bronchospasm may be precipitated in patients suffering from or with a previous history of bronchial asthma. Caution should be exercised in these patients. The small amount of alcohol in this medicine will not have any noticeable effects. Some inactive ingredients may cause allergic reactions. Avoid contact with the eyes. Interactions: None known. Pregnancy and lactation: Difflam™ Spray should not be used in pregnancy or lactation unless considered essential by the physician. There is no evidence of a teratogenic effect in animal studies. Undesirable effects: Serious (frequency not known): Anaphylactic reaction which can be potentially life-threatening. Hypersensitivity reactions. Angioedema (Uncommon): Oral tissue numbness or ‘stinging’ sensations in the mouth may occur which may disappear on continuing treatment. (Very rare): pruritus, rash, urticaria, photosensitivity reaction, laryngospasm / bronchospasm. Prescribers should consult the Summary of Product Characteristics in relation to side-effects. Special precautions for storage: Do not store above 30°C. Do not refrigerate or freeze. Keep out of reach of children. Basic price (UK): RRP 30ml spray £8.49. Marketing Authorization number: PL 46302/0160 Legal category: P.
Difflam™ Sore Throat Rinse & Difflam™ Oral Rinse (benzydamine hydrochloride)
Presentation: Difflam™ Sore Throat Rinse & Difflam™ Oral Rinse contain benzydamine hydrochloride 0.15% w/v. Presented as a gargle/oral rinse in a 200ml and 300ml glass bottle respectively. Indications: Locally acting analgesic and anti-inflammatory treatment for the relief of painful inflammatory conditions of the throat including pharyngitis. Dosage and administration: Rinse or gargle with 15ml (using measuring cup provided) every 1½-3 hours as required. Expel solution from the mouth after use. If stinging occurs the rinse may be diluted with water. Uninterrupted treatment should not exceed seven days, except under medical supervision. It is not suitable for children aged 12 years or under. Contra-indications: Patients with hypersensitivity to ingredients. Warnings and Precautions: Not advisable in patients with hypersensitivity to acetylsalicylic acid or other NSAIDs. Bronchospasm may be precipitated in patients suffering from or with a previous history of bronchial asthma. Caution should be exercised in these patients. The small amount of alcohol in this medicine will not have any noticeable effects. Some inactive ingredients may cause allergic reactions. Avoid contact with the eyes. Interactions: None known. Pregnancy and lactation: Difflam™ Sore Throat Rinse should not be used in pregnancy or lactation unless considered essential by the physician. There is no evidence of a teratogenic effect in animal studies. Undesirable effects: Serious (frequency not known): Anaphylactic reaction which can be potentially life-threatening. Hypersensitivity reactions. Angioedema (Uncommon): Oral tissue numbness or 'stinging' sensations in the mouth may occur. (Very rare): pruritus, rash, urticaria, photosensitivity reaction, laryngospasm/bronchospasm. Prescribers should consult the Summary of Product Characteristics in relation to side-effects. Basic price (UK): RRP Difflam™ Sore Throat Rinse 200ml bottle £8.99 Difflam™ Oral Rinse 300ml bottle £11.19 Product licence number: Difflam™ Sore Throat Rinse PL 46302/0161 & Difflam™ Oral Rinse PL 46302/0159 Legal category: P
Marketing Authorisation Holder: Mylan Products Ltd, Station Close, Potters Bar, Hertfordshire, EN6 1TL, United Kingdom. Date of preparation of Essential information: July 2024 Ref number: UK-DIFF-2024-00031
The SmPC for this product, including adverse reactions, precautions, contra-indications, and method of use can be found at: Find product information about medicines and from Mylan Medical Information, Building 4, Trident Place, Hatfield Business Park, Mosquito Way, Hatfield, Hertfordshire, AL10 9UL, phone no. 01707853000, Email: info.uk@viatris.com
Please continue to report suspected adverse drug reactions with any medicine or vaccine to the MHRA through the Yellow Card Scheme. It is easiest and quickest to report adverse drug reactions online via the Yellow Card Scheme website: Yellow Card | Making medicines and medical devices safer or search for MHRA Yellow Card in the Google Play or Apple App Store. Alternatively, you can report via some clinical IT systems (EMIS/SystemOne/Vision/MiDatabank) or by calling the Commission on Human Medicines (CHM) free phone line: 0800-731-6789. Adverse reactions/events should also be reported to MAH at e-mail address: pv.uk@viatris.com
If users experience any side effects, they should discontinue use and seek pr ofessional medical advice.
To report any potential side effects, contact us or use the MHRA’s Yellow Card Scheme available at https://yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store.