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PubMed This is a summary of 16 peer-reviewed journal articles Updated
Pediatrics · Acute Rheumatic Fever

The Three Pillars of Treatment and Protection

At a Glance

Acute Rheumatic Fever treatment requires three steps: a 10-day antibiotic course to clear the strep bacteria, anti-inflammatory medications like supervised aspirin for joint pain, and long-term penicillin injections (secondary prophylaxis) to protect the heart valves from permanent damage.

The medical management of Acute Rheumatic Fever (ARF) is a long-term commitment that focuses on stopping the current attack and preventing future ones [1]. Doctors divide this care into three essential parts, often called the “three pillars” of treatment [2].

Pillar 1: Eradicating the Bacteria

The first step is to ensure that every last trace of Group A Streptococcus (GAS) is gone from your child’s body [2]. Even if your child no longer has a sore throat or their throat swab comes back negative, they will still receive a full 10-day course of antibiotics (usually penicillin) [2][3]. This is done to stop any remaining bacteria from continuing to trigger the immune system’s overreaction [2].

(Note: If your child is allergic to penicillin, do not worry—there are safe and effective alternative antibiotics available [2].)

Pillar 2: Managing Inflammation

To help your child feel better and reduce the swelling in their body, doctors use anti-inflammatory medications [4].

  • For Joints: High-dose aspirin or other NSAIDs (like naproxen) are very effective at calming joint pain and fever [4][5].
    • A Critical Warning for Parents: You have likely been told never to give your child aspirin due to the risk of Reye’s syndrome—a rare but life-threatening condition. Never give your child aspirin without a direct prescription and strict supervision from a doctor. However, in the case of ARF, when managed carefully by a medical team, the benefits of using high-dose aspirin to quickly control extreme inflammation outweigh the risks. To keep your child safe, the doctor will closely and regularly monitor their liver function with blood tests [4][5].
  • For the Heart: If your child has severe heart inflammation (carditis), doctors may sometimes use corticosteroids (steroids) to help reduce the immune response, though their ability to prevent long-term valve damage is still a subject of medical research [5][6].

Pillar 3: Secondary Prophylaxis (The “Shield”)

This is the most critical part of your child’s care. Once a child has had ARF, their immune system is “primed” to react again if they ever catch strep throat in the future [7]. Every new strep infection carries a high risk of causing more permanent damage to the heart valves [8].

To prevent this, children receive Secondary Prophylaxis—regular doses of antibiotics to act as an invisible shield against new infections [9]. The gold standard is an injection of Benzathine Penicillin G (BPG) given every 3 to 4 weeks [10][11]. If your child is allergic to penicillin, alternative long-acting antibiotics will be used [9].

Managing Injection Pain: While these injections are life-saving, they are deep muscle injections and can be quite painful for a child [11]. You can advocate for your child by asking the clinic about pain management strategies, such as using numbing creams (like lidocaine), cold packs, vibration devices, distraction techniques, or working with a child life specialist [10].

How Long Will Treatment Last?

The duration of these protective injections depends on how much the heart was affected during the initial illness [12].

Heart Status at Diagnosis Typical Duration of Protection
No Carditis (No heart involvement at all) At least 5 years, or until age 21 (whichever is longer) [13][12]
Carditis (Heart was inflamed, but no permanent damage/RHD) 10 years, or until age 21 (sometimes up to age 25 or 30) [13][12]
Persistent RHD (Permanent heart valve damage is present) 10 years after the last attack, or until age 40 (sometimes lifelong) [14][15]

Note: These durations may be extended if your family lives in an area where strep infections are very common [12].

Adhering strictly to this injection schedule—without ever missing a dose—is the single best way to ensure that a childhood illness does not become a lifelong heart condition [9][16].

Common questions in this guide

Why does my child need antibiotics if their throat swab is negative?
A full 10-day course of antibiotics is required to ensure every trace of Group A Streptococcus is eradicated. Even if your child's symptoms are gone, any remaining bacteria can continue to trigger the immune system's harmful overreaction.
Is it safe to give my child aspirin for rheumatic fever?
While parents are usually told to avoid giving children aspirin due to the risk of Reye's syndrome, high-dose aspirin is used in rheumatic fever to quickly control extreme joint inflammation. This must only be done under strict medical supervision with regular blood tests to monitor liver function.
How long will my child need penicillin injections for rheumatic fever?
The length of time depends on whether the heart was affected during the initial illness. Children with no heart involvement usually need injections for at least 5 years or until age 21. Those with permanent heart valve damage may need them for 10 years or even lifelong.
How can I make the penicillin injections less painful for my child?
Benzathine Penicillin G injections are deep muscle shots and can be painful. You can ask your clinic about using numbing creams, cold packs, vibration devices, or distraction techniques to help manage your child's pain during the procedure.
What happens if we miss a penicillin injection appointment?
Missing an injection leaves a gap in your child's invisible shield against new infections. Every new strep infection carries a high risk of causing more permanent damage to the heart valves, making it crucial to strictly stick to the 3- to 4-week schedule.

Questions for Your Doctor

5 questions

  • •What dose of aspirin or NSAID is my child taking, and exactly how often will you check their liver function while they are on it?
  • •If my child's echocardiogram shows heart inflammation, does that change the length of time they will need penicillin injections?
  • •What is the exact date my child needs their next penicillin injection to ensure there is no 'gap' in their protection?
  • •Can we use a numbing cream, a cold pack, or a child life specialist to make the injections less painful for my child?
  • •How will we know when it is finally safe to stop secondary prophylaxis?

Questions for You

4 questions

  • •Does your child have any known allergies to penicillin or other medications?
  • •Have you noticed any side effects from the anti-inflammatory medication, such as stomach pain, nausea, or unusual bruising?
  • •How are you keeping track of the strict 3- or 4-week injection schedule to ensure an appointment is never missed?
  • •What comfort items or distractions work best for your child during stressful medical procedures?

References

References (16)
  1. 1

    Concomitant rapidly progressive glomerulonephritis and acute rheumatic fever after streptococcus infection: a case report.

    Pornrattanarungsi S, Eursiriwan S, Amornchaicharoensuk Y, et al.

    Paediatrics and international child health 2022; (42(2)):100-104 doi:10.1080/20469047.2022.2046966.

    PMID: 35298890
  2. 2

    Carditis in Acute Rheumatic Fever in a High-Income and Moderate-Risk Country.

    Fabi M, Calicchia M, Miniaci A, et al.

    The Journal of pediatrics 2019; (215()):187-191 doi:10.1016/j.jpeds.2019.07.072.

    PMID: 31587860
  3. 3

    Structured review of primary interventions to reduce group A streptococcal infections, acute rheumatic fever and rheumatic heart disease.

    Bennett J, Rentta N, Leung W, et al.

    Journal of paediatrics and child health 2021; (57(6)):797-802 doi:10.1111/jpc.15514.

    PMID: 33876472
  4. 4

    Acute rheumatic fever: 10-year single-center experience: clinical and laboratory findings, with subclinical carditis and treatment complications.

    Bulbul L, Akyol MB, Civan HA, et al.

    Cardiology in the young 2021; (31(9)):1489-1494 doi:10.1017/S1047951121003528.

    PMID: 34462031
  5. 5

    The efficacy and safety of naproxen in acute rheumatic fever: The comparative results of 11-year experience with acetylsalicylic acid and naproxen.

    Çetin İİ, Ekici F, Kocabaş A, et al.

    The Turkish journal of pediatrics 2016; (58(5)):473-479.

    PMID: 28621087
  6. 6

    Anti-inflammatory treatment for carditis in acute rheumatic fever.

    Cilliers A, Adler AJ, Saloojee H

    The Cochrane database of systematic reviews 2015; CD003176 doi:10.1002/14651858.CD003176.pub3.

    PMID: 26017576
  7. 7

    How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018).

    Ghamrawy A, Ibrahim NN, Abd El-Wahab EW

    PLoS neglected tropical diseases 2020; (14(8)):e0008558 doi:10.1371/journal.pntd.0008558.

    PMID: 32804953
  8. 8

    The roles of immuno-modulator treatment and echocardiographic screening in rheumatic fever and rheumatic heart disease control: research from Aotearoa, New Zealand.

    Wilson N, Anderson A, Baker MG, et al.

    Journal of the Royal Society of New Zealand 2025; (55(2)):241-266 doi:10.1080/03036758.2024.2306981.

    PMID: 39677380
  9. 9

    Adherence to penicillin treatment is essential for effective secondary prevention of rheumatic heart disease: a systematic review and meta-analysis.

    Ambari AM, Radi B, Dwiputra B, et al.

    Annals of medicine and surgery (2012) 2024; (86(4)):2116-2123 doi:10.1097/MS9.0000000000001833.

    PMID: 38576943
  10. 10

    An outbreak of acute rheumatic fever in a remote Aboriginal community.

    Egoroff N, Bloomfield H, Gondarra W, et al.

    Australian and New Zealand journal of public health 2023; (47(5)):100077 doi:10.1016/j.anzjph.2023.100077.

    PMID: 37625204
  11. 11

    Population pharmacokinetic study of benzathine penicillin G administration in Indigenous children and young adults with rheumatic heart disease in the Northern Territory, Australia.

    Kado J, Salman S, Hand R, et al.

    The Journal of antimicrobial chemotherapy 2022; (77(10)):2679-2682 doi:10.1093/jac/dkac231.

    PMID: 35822635
  12. 12

    Acute Rheumatic Fever: A Review of Essential Cutaneous and Histological Findings.

    Heard MA, Green MC, Royer M

    Cureus 2021; (13(1)):e12577 doi:10.7759/cureus.12577.

    PMID: 33575142
  13. 13

    Preliminary consultation on preferred product characteristics of benzathine penicillin G for secondary prophylaxis of rheumatic fever.

    Wyber R, Boyd BJ, Colquhoun S, et al.

    Drug delivery and translational research 2016; (6(5)):572-8 doi:10.1007/s13346-016-0313-z.

    PMID: 27465618
  14. 14

    Rheumatic Heart Disease Prophylaxis in Older Patients: A Register-Based Audit of Adherence to Guidelines.

    Holland JV, Hardie K, de Dassel J, Ralph AP

    Open forum infectious diseases 2018; (5(6)):ofy125 doi:10.1093/ofid/ofy125.

    PMID: 29942824
  15. 15

    The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease.

    Ralph AP, Noonan S, Wade V, Currie BJ

    The Medical journal of Australia 2021; (214(5)):220-227 doi:10.5694/mja2.50851.

    PMID: 33190309
  16. 16

    The Effect of Secondary Prophylaxis Adherence on Rheumatic Heart Disease and Determinants of Poor Adherence in Children: A 10-Year Retrospective Cohort Study.

    Ulkersoy I, Karagozlu F, Coskun YI, et al.

    Pediatric cardiology 2025; doi:10.1007/s00246-025-04005-1.

    PMID: 40879674

This information explains the standard treatments for Acute Rheumatic Fever for educational purposes only. Always consult your child's pediatrician or pediatric cardiologist before starting or stopping any medications.

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