Strep throat is a common childhood illness – if you’re reading this, chances are you’ve had strep throat at least once in your life. Not all sore throats mean a strep throat diagnosis, so let’s unpack the basics of what parents need to know about strep, including the different types of strep bacteria, symptoms, contagiousness, treatment, affiliated illnesses, and even some controversy.
Streptococcus – The Bacteria Behind Strep Throat
Strep throat is a bacterial infection of the throat and the tonsils. “Strep” is short for streptococcus, which, to children, may sound like the name of a dinosaur, but is actually the name of the round bacteria that infects the throat. Directly translating to “twisted chain of berries”, streptococcus bacteria is identifiable under a microscope by its round, chain-like structure. There are many types of streptococcus, some harmless and others serious. Strep throat is most commonly caused by Group A Streptococcus which will be the focus of the information in this blog.
Not all sore throats are bacterial infections, like strep throat. In fact, viruses are the common culprit for most sore throats, with only about 30% of sore throats in children being diagnosed as strep and even less in adults (about 10%). Strep throat is most commonly found in children between the ages of 5 and 15 years and is extremely rare in babies under 2-3 years old (more on this later in the blog).
Some children with strep throat will develop a reaction called Scarlet Fever. In Scarlet Fever, children will have the typical strep throat symptoms of fever and sore throat, but they also develop a bumpy red tongue (called “strawberry tongue”) and bright red rash that covers much of the body. Scarlet Fever may sound alarming to some people, as it was once considered a dangerous childhood disease. Parents may remember it as the cause of severe illness in older popular media and literature like Little Women, The Velveteen Rabbit, Frankenstein, and Little House on the Prairie. However, a diagnosis of Scarlet Fever is no longer nearly as worrisome due to the development of effective antibiotics as treatment.
How Do I Know if My Child Has Strep Throat?
Common symptoms of strep throat include:
- The telltale red and swollen tonsils
- Discomfort and some difficulty when swallowing
- Fever
- Swollen lymph nodes in the throat
- White patches in the mouth and on the tonsils
- Abdominal pain
- Unexplained bad breath (halitosis)
- Lack of cold symptoms or coughing
Strep throat is a bacterial infection and as discussed, most sore throats are caused by viruses (which are not treated with antibiotics). Strep throat is definitively diagnosed by a throat culture, which is conducted by taking a long cotton swab and gently swiping the back of the throat by the tonsils. Afterwards, the swab is then placed in a culture container which allows the bacteria to grow if it is present. Clinicians will commonly also perform a quick-test called a “rapid antigen test” at the same time as they would perform a culture. These tests are very sensitive and if positive, the child will be treated with antibiotics and no further testing is needed. If it is negative, there is still a small chance that there might be strep throat so the culture is sent to a laboratory to see if the bacteria grows in a petri dish. Most clinicians will not treat with antibiotics, though, unless the culture comes back positive (usually within a day). At Concierge Pediatrics, all strep tests are done at our in-house laboratory, where we have a throat culture incubator.
In addition, most clinicians will not test children less than 2-3 years old. This is because strep throat is extremely rare in this age group. In the rare case that it is strep, the risk of complications is extremely low. There are occasions where a child this age may be tested, including:
- If the child has had close contact with someone who tested positive for strep
- If the child has unusual or worsening symptoms, like a rash, high fever, or significant difficulty swallowing
- If the pediatrician has other clinical concerns based on their exam
Strep is contagious and spreads through respiratory droplets, so it is best to teach children practice good hygiene including good hand washing practices, covering their mouth with their elbow when coughing or sneezing, and avoiding the sharing of straws, utensils, cups, etc. Once exposed to strep, it can take 2-5 days before symptoms appear.
The Importance of Antibiotics for Strep Throat
If your child is over age 2 (sometimes age 3 in other practices) and tests positive for strep, they will be prescribed an antibiotic. It is important to take antibiotics to treat strep throat. When left untreated for long periods of time, strep throat can cause complications like kidney issues or rheumatic fever, an inflammatory disease that can affect a child’s joints and heart. These complications are rare in developed countries like the United States, but highlight the importance of treatment.
Amoxicillin is the most common antibiotic used to treat Strep throat because it is most effective at fighting off the group A streptococcus bacteria and shortening the duration of symptoms. This antibiotic also has few and generally mild side effects and there has been no reported drug resistance. A doctor may sometimes choose a different antibiotic due to risk of allergic reactions or other specific situations related to the child. It is important to make sure your child finishes the complete course of antibiotics as directed by your prescriber, unless they tell you to stop. It can be tempting to discontinue antibiotics once your child is feeling better, but stopping too soon creates risk for antibiotic resistance in the future, meaning the bacteria could become stronger than the medicines we use to fight off the bacteria.
Sometimes, antibiotics can cause mild side effects such as upset stomach or a secondary yeast infection. Eating greek yogurt can help to reduce these side effects, as greek yogurt is full of probiotics. Probiotics will not interfere with your antibiotic treatment and will help to restore gut balance, easing stomach discomfort and reducing the possibility of yeast infection. If your child is experiencing any other mild side effects, do not stop the antibiotics, but be sure to give your pediatrician a call to talk through solutions. If your child is experiencing life-threatening anaphylactic reactions like difficulty breathing, hives, or facial swelling after taking antibiotics, seek medical care immediately.
Once your child receives a strep throat diagnosis, they should rest at home and begin their antibiotic treatment. After 24 hours on the antibiotics, if they are starting to feel better and have also been fever-free for at least 24 hours, they can return to school and most activities.
In addition to antibiotics, home remedies and comfort measures (also called supportive care) can be taken at home to help relieve symptoms of strep or any sore throat, including:
- Gargling with warm saltwater
- Acetaminophen (Tylenol etc.) and Ibuprofen (Motrin, Advil, etc.) for pain and fever management
- Drinking plenty of fluids, especially warm liquids like tea and soup
- Plenty of rest, which will allow your body to heal
- Eating soft, bland foods to avoid irritation
It is important to stress again that most sore throats are viruses and antibiotics will not treat a virus. Taking antibiotics unnecessarily is indeed problematic because, as discussed, they can cause side effects or other reactions as well as contribute to antibiotic resistance.
Strep Can Come Back
It is possible to get strep throat more than once a year. Sometimes kids will test positive for strep and be considered “strep carriers” meaning they aren’t showing symptoms of strep throat but pose a risk of infecting others because they are carrying the bacteria in their throat. If your child has 7+ strep throat diagnoses in one year or 5+ infections per year 2 years in a row, you may want to speak with your pediatrician or an ear, nose, throat (ENT) specialist about treating as a carrier or, if these are true repeated infections, the possibility of a tonsillectomy. A tonsillectomy is the removal of tonsils and while it is possible to get strep throat without tonsils, the likelihood is reduced. A tonsillectomy may also have other benefits like improved sleep and improved ease of swallowing.
PANDAS
Many parents have been discussing a syndrome called PANDAS so we will briefly discuss it here. Recurrent strep infections can sometimes be associated with a rare condition called PANDAS, which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. This is often a controversial diagnosis, with more research needed to fully understand the potential link with strep infection.
Most researchers believe that PANDAS is an autoimmune reaction (i.e., the child’s immune system overreacting to the strep infection) that can appear during childhood, usually between 3 years old and the age of puberty. Symptoms typically appear very suddenly following a strep infection, and can be significant. There is also thought that people with a family history of autoimmune diseases or rheumatic fever are at higher risk. Symptoms include obsessive-compulsive behavior or motor or vocal tics similar to someone with Tourette’s syndrome, sometimes paired with increased irritability or anxiety, difficulty sleeping, or bed wetting. There is no test to diagnose PANDAS – it is a diagnosis based on experience and the clinical examination of the healthcare provider. It can be treated with cognitive behavioral therapy and sometimes medication. Importantly, a full course of antibiotics must be taken to eliminate the streptococcus infection that may have been the cause.
While the idea of PANDAS can understandably cause concern, it is considered a very rare condition. There are many impassioned conversations among parents regarding PANDAS but it is important to speak directly with your pediatrician about any concerns you may have, to ensure you receive accurate and evidence-based information and an appropriate path forward for your child based on their personal history and circumstances.
It can be frustrating to navigate childhood illnesses, but with the right information, parents and caregivers can be empowered to take action towards the path to recovery. Remember, if you ever have questions about your child’s symptoms or care plan, don’t hesitate to reach out to your pediatrician — we’re here to guide you with expert, compassionate support every step of the way and help your child feel better, faster.