Is it strep? What parents need to know about sore throats in children

At this time of year, it seems like everyone is sick. Most children will pick up up to 10 viral illness a year! Sore throats are most often caused by viruses, and will get better on their own, but some are caused by bacteria, such as strep, which can cause complications if untreated. Read on to learn who needs to be tested for strep, how to tell the difference between strep and viruses, and when to see a doctor.

Do babies get strep throat?
It is extremely rare for babies or toddlers to get strep throat. Most babies still have immunity from their mothers that protects them from a strep throat infection and they have undeveloped tonsils that are not likely to get infected. Strep bacteria can cause some other illnesses for babies and toddlers such skin infections and scarlet fever, but strep throat is so rare under age 3 that the American Academy of Pediatrics and the CDC recommend that children under 3 not be tested for strep throat. Most throat infections in babies and toddlers are caused by viruses.

At what age does strep become more common in kids?
Strep is most common between ages 5 and 15. Younger and older children who are in contact with children in that age range may have a higher risk of strep and other common illness if they are exposed by a sibling. Strep throat almost never affects infants or toddlers under 3 years old.

What causes strep throat in kids?
Strep throat is a bacterial throat infection caused by a bacteria called Group A streptococcus. In some children, this bacteria does not cause any symptoms. But in some, it can multiply in the tonsils and cause the classic symptoms of strep throat. Children can pass it to one another by direct contact or by respiratory droplets that are spread by coughing or sneezing.

What are the symptoms of strep in kids? Do these vary based on age?
Group A strep can cause several different types of infection. Children ages 5 and older get classic strep throat- whose symptoms include: fever > 100.4, swollen, painful lymph nodes in the neck, and a sore throat with enlarged, red tonsils and pus on the tonsils. If a child has a cough, congestion, hoarseness, or sores on their tonsils, these are typically caused by a virus, and are signs that the infection is not strep throat.

In toddlers, group A strep usually causes different infections, but not strep throat. These include skin infections such as cellulitis or impetigo, with symptoms of fever, warm, red, painful areas of skin, or sometimes red sores with a honey-colored crust. Scarlet fever is a common infection in toddlers caused by group A strep bacteria – the symptoms include a rough, sandpapery, skin-colored or pink rash to the torso and sometimes face, a high fever, and a red appearing tongue. It can cause a sore throat, congestion, and cough as well.

In babies, strep throat does not occur, but Group A strep can cause skin infections such as cellulitis or impetigo, or sepsis- a bacterial infection in the blood. Any infant under 3 months old with a fever should be seen by a doctor, who will test their blood for bacteria. Skin infections caused by strep can cause red, warm, swollen, painful areas of skin, or a red sore-like rash with a honey-colored crust and sometimes a fever.

When should parents see a doctor for Strep?
While strep throat gets better on its own in most cases, treating it with antibiotics can help it to get better a few days faster and prevents a serious complication called rheumatic fever, which can lead to lifelong heart problems. If your child is over 3 years old and has a sore throat along with fever, pus on the tonsils, or swollen lymph nodes, they should see a doctor and be tested for strep. Children under three with a fever that lasts longer than 3-4 days, or symptoms of scarlet fever such as high fever with a sandpapery rash to their torso, reddened, bumpy tongue, and sore throat, should see their doctor. While strep throat usually goes away on its own, and antibiotics are used to prevent complications, scarlet fever needs to be treated with an antibiotic. Infants under 3 months old with any fever over 100.4 need to be seen by a doctor right away.

Do doctors give strep tests to babies and toddlers? Why or why not?
A well-trained doctor with proper pediatric education should not be performing strep tests on any children under age 3, except in very rare cases. Some providers without pediatric training will give strep tests to all babies with a fever, but this is not a good idea. Strep bacteria do not usually cause strep throat in children under age 3. They cause different types of infections that a doctor can recognize by the symptoms. Most throat infections in babies and toddlers are caused by viruses, not strep bacteria, and testing these babies and toddlers is uncomfortable, and can lead to false positive tests and unneeded antibiotics, which can cause serious side effects.

How is strep treated in children?
Some minor strep skin infections respond very well to a prescription antibiotic ointment, while other strep infections, such as cellulitis or scarlet fever, will need an oral antibiotic. In rare cases, more severe strep infections will need an IV antibiotic. In children over age three with a positive strep test and symptoms of strep throat, there are several effective antibiotics including penicillin, amoxicillin, and cephalosporin antibiotics like cephalexin (Keflex). In most cases, your child will need 10 days of antibiotics to prevent complications, though their symptoms will usually get better faster than that. If your child is allergic to first-line antibiotics, your doctor may prescribe a different family of antibiotics, like azithromycin or clindamycin. Strep throat infections will usually get better on their own without treatment, but an antibiotic can help symptoms to go away a day or two faster and prevent serious complications. Your doctor should never prescribe an antibiotic for strep throat without doing a strep test first and getting a positive result. Over 60-75% of sore throats in children are caused by viruses and do not need an antibiotic.

How can parents prevent strep and keep their little ones healthy?
Strep is passed from child to child by respiratory droplets. Teaching your children not to share food and drinks, to avoid touching their face or putting objects in their mouth, and to wash or sanitize their hands regularly can help them to avoid being exposed to these infectious droplets. You can help your child prevent spreading strep throat by teaching them to cover their coughs and sneezes and wash or sanitize their hands regularly. Any child with a fever or symptoms concerning for strep throat should stay out of school until their fever has resolved and if they are strep positive, until they have been on antibiotics for 24 hours.

What else should I know about strep?
5-15% of children carry strep bacteria in their throats. This means that they test positive for strep but are not infected. Therefore, it is very important that they only get a strep test when they have classic symptoms of strep throat and are in the correct age range for strep throat (> age 3). If they have a lot of cough, hoarseness, or sores on their throat, or are under age 3, their sore throat is far more likely to be a viral illness, and they should not be tested for strep in that case. That could lead to a false-positive diagnosis and unneeded antibiotics.

Another thing to know is that the rapid strep test only catches about 3 out of four cases of strep throat. Your doctor should always send a throat culture if the rapid strep test is negative to see if any strep bacteria grow in the lab. Your child should never receive antibiotic treatment for strep throat unless they have a positive rapid test or throat culture. There is no harm to waiting a few days for the throat culture result before starting treatment. Treating sore throats with antibiotics when they are not caused by strep will not help your child feel better any faster and can cause antibiotic resistance and other complications.

How can I make a sore throat feel better?
Most sore throats are caused by viruses; there is no medicine that makes them go away faster. And, even on proper antibiotics, strep can cause 5-7 days of sore throat. A sore throat can be miserable- here are some simple over-the-counter treatments that can help:

  1. Use over-the-counter pain medication such as ibuprofen (for children > 6 months old) or acetaminophen (Tylenol). Ibuprofen also has some anti-inflammation effect that can help with swollen tonsils.
  2. Salt water gargles: mix 1 tsp salt in 1 cup of warm water and have your child gargle or rinse their throat as needed.
  3. "Magic mouthwash:" You can make a soothing mixture of Maalox or Mylanta liquid mixed with diphenhydramine (Benadryl) liquid. Mix 2.5 mL (1/2 teaspoon) of each liquid and have your child gargle and swallow every 6 hours as needed.
  4. Warm fluids: warm tea or warm water with honey can help keep the throat moistened and be soothing.
  5. Allergy medicines: If the sore throat is caused by seasonal allergies, a cold, or postnasal drip (mucous dripping down the throat), using fluticasone (Flonase) nasal spray and a daily allergy medicine like cetirizine or loratidine may help.
  6. Throat sprays and lozenges: these contain a numbing medicine that can help ease sore throats in older children (check the package for age limits).
  7. Run a humidifier: most sore throat will feel better when the throat is moist. Running a humidifier while sleeping, sipping plenty of fluids, and spending time in a steamy bathroom can all help keep the throat lubricated.