Strep Throat

What is it?

Strep throat is so common that it is almost a ritual of childhood. Today we can think of strep throat as a fairly minor illness because of antibiotics. Before the antibiotic era, however, strep throat caused thousands of cases of serious illness every year. The bacterium that causes strep throat is the "Streptococcus." A typical strep throat illness begins with symptoms of a cold or upper respiratory infection, like runny nose, cough, and a little fever. By the third day of symptoms children develop a sore throat, often with painful swallowing. They usually have foul-smelling breath. Most children with strep throat have grayish-white or yellow patches on their tonsils. Many children get swelling of the lymph nodes (blood filters) in the neck. These "swollen glands" can be quite tender. Children with strep throat also often have headache and stomach aches. They feel miserable and usually haven’t got much energy or appetite.

Untreated strep infections can lead to disastrous consequences. Although it is nearly unheard of in the United States today, acute rheumatic fever (ARF) affected thousands of children every year until the antibiotic era. In ARF, the body’s immune system attacks normal body tissue, mistaking it for strep germs. ARF can cause heart disease, brain injury, and arthritis. Another dangerous consequence of strep infection can be kidney disease. This is more common with strep infections of the skin, such as impetigo.

The biggest immediate concern in children with strep throat is usually the pain and fever. It’s also important to try to limit the spread of the infection between children. The longer term concern is to prevent serious consequences like ARF.

The most important treatment for strep throat is antibiotics. Many doctors will send a throat culture or do a "rapid test" for strep to be sure that’s what is causing the sore throat. In some cases the doctor may feel that the diagnosis is so obvious that s/he will skip the test. Once your doctor is sure your child has strep, s/he will prescribe an antibiotic to treat the infection. Please remember that the goal in treating strep throat with antibiotics is mainly to prevent the serious consequences. This makes it even more important than ever that parents give every dose of the medicine. Strep throat tends to go away on its own whether or not the child takes antibiotics. This can lead parents to stop the medicine too soon, and puts the child at risk for ARF and other problems.

Penicillin is still the first drug doctors turn to for treating strep throat. Liquid penicillin tastes awful. If your child is too young to swallow pills, your doctor may prescribe amoxicillin (many brand names), because its liquid and chewable forms taste much better. If your child is allergic to penicillin, your doctor will prescribe a different drug. Please be sure to give every dose until the medicine is gone. If you are using a liquid medicine, please be sure to shake it up immediately before each dose. This way your child will get the same amount of medicine with each dose. You may want to read our Aftercare Instructions on Administering Oral Medications.

You can use acetaminophen (Tylenol®) or ibuprofen (Advil® or Motrin®) to control fever and pain. Fever is not dangerous, but it can make the child uncomfortable. If your child seems comfortable there is no reason to give any medication just for fever. Please read our Aftercare Instructions about Fever. For the throat pain, you may want to try a topical spray such as Chloraseptic® if your child will tolerate it. This can relieve some of the irritation and is safe to use as often as every 2 hours. Chloraseptic®, Cepacol®, or other "medicated" throat lozenges may help too. Please do not use any lozenges in children under the age of ten years to avoid choking. Even in older children, please make sure your child has finished the lozenge before putting him or her to bed. A humidifier in your child’s room can also help soothe the throat. Please remember to change the water every day, and please don’t put any medication in the water.

Please check with your doctor before you use any of the many different cough and cold medicines available. Most doctors feel that cold medications and decongestants do not help younger children with congestion. These medicines always increase heart rate and can make younger children fussy. If you do decide to try one of the cough or cold medicines, whether over-the-counter or by prescription, please read the label carefully. Many of these medicines (such as Nyquil® or Theraflu®) contain multiple ingredients, and often contain acetaminophen (the active ingredient in Tylenol®, Feveral®, and other fever and pain medicines. If you give your child one or more of these medicines in combination with Tylenol® or other fever medicine, you can accidentally overdose your child on the Tylenol® type medicine. To make matters worse, Tylenol® and other fever medications also come in combination with cough or cold medicines (these include Tylenol Cold® and TylenolPM®). This means it is also possible to accidentally overdose a child on a decongestant or on one of the other ingredients. If you have any doubt about which medicines you can give in combination, please ask your doctor or pharmacist.

Children with strep throat may not want to swallow. This can lead to dehydration, especially while your child has a fever. Please be sure to encourage lots of cool, soothing liquids and soft foods. Some children may prefer warm broth or hot chocolate. In general, the best fluids to give a child with a sore throat are the fluids s/he wants and will drink. Please avoid sharp, tangy, or acid foods or drinks that might sting. A decreased appetite is normal for a few days. If your child doesn’t want solids, both you and your child will do better to focus mainly on liquids.

Strep throat usually clears up within 5 – 7 days of the first symptoms. Children may be miserable for much of that time, but there’s usually no real danger. Because strep throat can have complications, and because some other conditions can start off looking like strep throat, here is a list of things to watch for:

• Fever that lasts more than 72 hours after starting antibiotics
• A persistent sore throat that hasn’t improved in 5 – 7 days
• Severe abdominal pain with vomiting – most children with strep throat get mild tummy-aches, but the pain is not usually severe
• Signs of dehydration:
• Sunken appearance of the eyes
• Dry tongue and mouth (dry lips are common and are not a sign of dehydration)
• A sunken fontanel (soft spot) in an infant
• Less than normal urination, or dark or strong-smelling urine
• Being too sleepy (lethargic) or being very irritable or fussy
• Cold, pale hands and feet even if the room is warm
• Holding the head tilted to one side (wry neck, or "torticollis")
• Redness over swollen lymph glands
• Dark brown or red urine
• Severe pain with swallowing, or drooling because of inability to swallow saliva
• Stiff neck
• Difficult or noisy breathing
• Lethargy (too sleepy)

Some children get repeated episodes of strep throat. Some experts recommend having the tonsils out in children who get five or more proven strep throat infections in one 12 month period. Your doctor may refer you to an ear-nose-and-throat specialist if this is the case.

Strep infections of the throat can lead to more serious complications. An abscess of the area next to the tonsils can cause difficulty swallowing, and can spread into nearby tissue. A surgeon needs to drain this so-called "peri-tonsillar abscess." People with these abscesses usually have flushed skin, glazed eyes, and have pain on opening their mouths. They usually can’t swallow their saliva, and feel that they have to spit it out. These abscesses are more common in older children and teens. Younger children can get a different kind of abscess in the space behind the throat. These so-called "retro-pharyngeal abscesses" can be even more dangerous, because they can rapidly spread up into the neck or down into the chest. Children with these abscesses also look quite ill, with persistent high fevers. They often hold their necks stiff, or at an unusual angle.

Children under the age of 2 years old don’t get strep throat nearly as often as older children. When they do, they aren’t at such a big risk for the long-term complications like ARF. Many doctors don’t make the diagnosis of strep throat, or treat sore throats with antibiotics, in children under 2 years old.

Many other things can cause sore throats. Children at any age commonly get viral infections that cause very intense throat pain. These usually come on quite suddenly and without many other symptoms. Especially in summer time, toddlers and younger children can get hand, foot, and mouth disease and other viruses that cause tiny sores in the throat. You can read our Aftercare Instructions on Viral Sore Throats and Hand, Foot, and Mouth Disease.

Older children and teens often get a virus that causes mononucleosis, or mono. Mono tends to produce a sore throat that lasts for 2 – 3 weeks. People with mono are often very tired and sleep a lot. They may have pain in the upper abdomen, on the left if they have swelling of the spleen, and on the right if their liver gets inflamed. They may produce dark red or brown urine. Mono is not usually serious, but people who have it should avoid vigorous activity and contact sports. Please remember that even if a strep test comes back positive, this does not rule out the possibility of mono. If your child has a sore throat that lasts longer than 5 -7 days, please be sure to check back with your doctor.

A sore throat that lasts for more than a week can sometimes be a sign of a serious disease like leukemia, or blood cancer. Children with leukemia look fairly sick. They may be pale, bruise easily, or have unusual rashes. If your child’s sore throat lasts a week or more, and she looks ill to you, please let your doctor know at once.

Having a sick child at home can be tiring and frustrating. As badly as you feel for your child, you yourself may feel out of control, inadequate, or even angry – these are normal feelings. Babies and children who are sick are often fussy and irritable, and parents often feel stressed to the breaking point, especially when there are other children or adults to take care of. One of the best things you can do for your child is to be sure you take care of yourself. If possible, try to have other adults take care of your child for an hour or two each day so you can get some rest or just some quiet time. If you get so stressed that you are worried about your child’s safety, call your local Parents’ Anonymous Hotline or visit the Parents Anonymous website to find a group near you.