by Julia Gaines MD, FAAP

Now that school is back in full swing, we’re seeing our usual increase in kids with sore throats. Parents are often confused about when they should seek care for a sore throat, what needs antibiotics, and how their kid got it in the first place. So here’s the scoop on sore throats in children!

First off, it’s important to know that sore throats in kids are usually the result of viral infection, are only minor infections, and will resolve without treatment. Typically viral pharyngitis (the fancy medical word for sore throat) will be accompanied by runny nose, cough, and, occasionally, pink eye. Generally, the kids have no fever or just a low grade one (there are a few noticeable exceptions to this) and feel pretty good or are just kind of whiney. When we examine them, their tonsils are not usually very inflamed or swollen, although parents and school nurses often think they are.

On the other hand, Strep throat, which is defined as a pharyngitis caused by infection with the Group A Streptococci bacteria, generally causes fever (102-104 degree range), a significant sore throat, and tender glands. The children may also complain about headache, stomachache, nausea, and vomiting. On exam, the tonsils are often beefy red with white pus and the lymph nodes in the neck are often enlarged and tender. Strep may also be accompanied by a distinctive rash – in which case we call it scarlet fever.

So how do we make the diagnosis?

Why can’t you just take a picture of your child’s throat, send it to us, and let us make the diagnosis over the phone? Unfortunately, it’s not that simple. Despite what many urgent care centers and insurance companies seem to think, you cannot diagnose Strep just by looking at it and you definitely cannot diagnose it over the phone. Studies have shown that clinicians are only about 50/50 in diagnosing Strep correctly by exam alone. Yes, some cases are very obvious but often times its not.

In order to diagnose Strep throat, your child must have a Rapid Strep Test.

I know they hate it. I know it means a trip to the office. I know it costs money. They still need it. If the test is positive, then we know exactly what is wrong with them, so if they don’t get better on the antibiotic, we know what to do and what complications to worry about. If it’s negative, we know they don’t need antibiotics and that we may need to look for other reasons for their symptoms.

Unfortunately, one complicating factor is that the test is not perfect. Commercially available Rapid Strep tests have a false negative rate around 5%. This means that the test will say the child does not have Strep when they really do. This problem is inherent to the test itself and has nothing to do with the strain of bacteria or the patient themselves. If one of your children has a false negative test and then gets his brother sick, brother is not at any increased risk of having a false negative test as well. Each test is a new roll of the dice. In addition, even a single dose of an antibiotic can invalidate a Rapid Strep test, so PLEASE do not give your child an antibiotic before you see a provider. It’s a bad idea for a number of reasons, but it makes it impossible for us to diagnose your child properly. In order to overcome the false-negative problem, all negative Rapid tests should be backed up by a throat culture where we try to grow the bacteria.

But really, what’s the big deal? Why can’t we just throw some antibiotics at the kid in case he has Strep? The answer, as always, is that it’s not the best thing for your child. I’ll give you two (out of a million) very real world examples.

Example 1:

The first is an example of a child who really had Strep but shows the problems that can come with treatment. Susie (not her real name, of course) was a six year old who caught Strep at school. She came to the office, had a positive Strep test, and I put her on amoxicillin, which is the usual treatment for uncomplicated Strep. A week later she was in the hospital with severe abdominal pain and diarrhea caused by a bacterium called Clostridium difficile. This is usually blocked from causing infection by the normal bacteria that live in your gut. My amoxicillin bomb knocked out all those good bacteria and allowed the ‘C. diff’ to gain access and it took 3 days in the hospital for her to recover. While the treatment in this case was completely appropriate, imagine if she was on the antibiotic for a condition she didn’t even have!

Example 2:

The second example is actually quite common. Janie, a fifteen year old girl, comes in with a severe sore throat for the previous 4 days. When she first started complaining, mom took her to the Super Doctors Express Mart Urgent Care down the street where a doctor looked in her throat (and then, apparently, in his crystal ball) diagnosed her with Strep, and sent her home with a prescription of something expensive. No Strep test, no other lab work, no further examination.

Mom dutifully started the medicine and, when she didn’t improve, brought her to see me. On exam, Janie had hugely enlarged red tonsils covered in pus, enlarged lymph nodes, and an enlarged spleen and had all the classic signs of Mononucleosis (what your mom used to call the “kissing disease”). Mono is a viral infection that can look very much like Strep in teenagers but does NOT respond to antibiotics and has potential complications. A negative Strep test should have prompted a further evaluation for mono, but, in this case, no Strep test was done and the patient was subjected to 4 days worth of antibiotics she didn’t need (see example above). Plus, it turns out the antibiotic she was on reacted with the mono virus and caused her to break out in an itchy uncomfortable rash that lasted a week and a half. She also didn’t know that her enlarged spleen necessitated that she stay out of lacrosse for several weeks to prevent a potentially fatal splenic rupture. Over all, not an impressive show by the urgent care.

I know this is probably making you think antibiotics are evil but there really are reasons why Strep needs to be treated although it may not be the reason you think. A simple case of Strep pharyngitis will actually resolve on its own without treatment although it will take a few more days and the child will be contagious longer. Obviously there’s an advantage to getting the kid back in school and curtailing the spread of the bug, but we worry much more about potential complications. Untreated Strep infections can lead to abscesses in the throat or lymph nodes, severe skin infections, kidney disease, and, most concerning, a heart infection called Acute Rheumatic Fever. Since the introduction of antibiotics, these complications are rare but can be deadly and are always in the back of our mind.

I could go on and on about different viral causes of sore throats, mono complications, different strains of Strep, etc. but I think this will do for today.

The take-home points are:

  • Most sore throats are caused by viruses and will not respond to antibiotics
  • Strep throat MUST be diagnosed by a Rapid Strep test or culture
  • Antibiotics have risks and should only be taken when appropriate and the diagnosis is known
  • Strep infections should be treated to prevent complications
  • Children should be discouraged from sharing personal items like cups and water bottles to help prevent spreading germs.
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