Commentary

Zwart et al have made an important addition to the existing literature because only 3 studies have been previously done in children.¹ The conclusion in the Cochrane review by Del Mar et al¹ was that children do not differ from adults and that the benefit of PCV is modest. The prevention of complications was also limited. The study by Zwart et al differs in that it did not find any difference between the PCV and placebo groups with respect to DOS. However, a moderate difference in the rates of complications was observed.

The study raises some important questions.² Firstly, the use of ⩾2 Centor criteria: the authors hold that these criteria have not been validated in a population of children. In another study of adult patients, the authors used 3 or 4 criteria for patient inclusion and thus had a population with a greater degree of disease.³ Secondly, the use of throat swabs for detecting GAS may be of limited value especially in children where the carrier rate is even greater than that in adults. Thus, subgroups of children who have immunologically manifest disease may derive greater benefit from PCV than those studied by Zwart et al. To single out these patients, it is necessary to evaluate the Centor criteria and other clinical features in patients with immunologically confirmed disease.

The authors also found that the DOS was greater in the PCV3 group than in the placebo group, an odd finding that was also observed in a previous study of adult patients.³ The authors’ explanation was that a short course of PCV only reduces the natural immune response without eradicating the GAS.

This study will reinforce the reluctance of clinicians to give PCV to children with sore throat even if a GAS infection is confirmed. In clinical work, shared decision making with the parents or delayed prescription is a good strategy in children who are not so ill. As stated by the authors, the few patients who have complications can be treated when these occur.