Is it Strep?

If you have a child over 2 you’ve probably asked this question at least once, and chances are you’ll ask it many more times in the years to come.

Your little guy is looking a bit punky.  He rejects his after-school snack and lies down on the sofa instead of running off to work on that insane Lego project he’s got going in the family room.  When you ask what’s wrong he points to his throat and says “My neck hurts, Mom”.

The worry monster in the back of your head wakes up, you grab the thermometer and a flashlight (oh god, does it work or are the batteries long dead?), and sneak a quick peek at the clock on the microwave … 3:46 … there’s still time to run screaming into the pediatrician’s office before they close.

Scenario 1:  Temp is 100.8 with the digital thermometer under the arm.  Throat’s red, but how red?  Hard to say.  Nose is runny, and you notice the beginnings of  a cough.  He protests but swallows the Tylenol with a bit of watered-down sports drink, plays his most recent addictive video game (just for a few minutes, while you make a game plan), and a while later he’s asleep.  After 27 minutes (yes, you timed it) of constant busy signal at the doctor’s office, you finally get through.  But do you really need to rush him in, or can you wait it out and see what the morning brings?

Scenario 2:  Temp is 102.2 with the digital under the tongue, but who knows if he really kept it under?  Throat is bright, cherry red with some gross gray/white stuff stuck to the … are those tonsils?  He struggles to swallow the liquid Tylenol, but before you even have a chance to grab the juice for him to wash it down, he barfs it up. Aaarrgg.  You decide to wait a few minutes to try again, while you hit redial to try and get through the busy signal at the doctor’s office.  Just as the nurse picks up and you breathe a sigh of relief, he sits up and vomits again.  Help!  Do you hang up and run to him, or tell her what’s going on while he’s covered with puke?

Strep throat is a common infection that anyone can get, but it’s most common in school-age kids and teens.  The bacteria that causes it (group A streptococcus) hangs out in the back of the nose and throat, and causes a seriously painful sore throat, fever  that’s typically on the high side, headache, nausea, and general feeling of SICK with a capitol ‘S’ (what doctors call malaise).  These suckers require antibiotics … more about that later.

But not all sore throats are strep throats.  In fact, way more than half of sore throats are caused by viruses, and will go away on their own without medication.  Antibiotics don’t touch them because they have no power against viruses, only bacteria.

So how can you tell?  The “gold standard” is a throat culture, but there are lots of clues that can help you figure it out and avoid a premature trip to the doctor’s office or letting strep go untreated.

In the scenarios above, it’s far less likely that kiddo #1 has strep.  His fever is low grade (100.8) and he’s not acting terribly sick.  His throat is red, but not WOW red, and he’s able to swallow a fever reducer, drink a little, and play video games.  He has a runny nose and a cough, typical viral symptoms that we don’t see as much with strep.  You’re OK watching this little guy, letting him rest, and re-evaluating tomorrow.  As long as things gradually get better with symptomatic treatment, you can skip the doctor.

Kiddo #2 needs to be seen.  He’s got a high temp, throat is bright red with white patches (technical term is exudate, and it’s typical of strep infection), he has trouble swallowing, and is vomiting.  He seems pretty sick. Tell the nurse you’re coming in.

When you get there, the doctor will likely do a rapid strep test (takes about 5 minutes) and a throat culture.  If the rapid test is positive he has strep, but if it’s negative he may still have strep (the rapid test is great, but it misses sometimes).  The throat culture will tell you for sure, but that can take up to 3 days and requires growing the bacteria in the lab.

In this case, the symptoms look so much like strep that your doctor will probably prescribe antibiotics, even if the rapid test is negative, at least until the culture results come back.  Which antibiotic depends on the doc’s experience with the bugs currently floating around your community, and what they’re sensitive to.

Why is it important to treat strep throat quickly?  Untreated strep, or incompletely treated strep (this is important, make sure you finish all the antibiotic) can result in complications.  Rheumatic fever, scarlet fever, wide-spread infection, and kidney disease can all be caused by group A strep run amok.

Within 24 hours of starting antibiotics, most kiddos begin to feel better and are no longer contagious. After 2 or 3 days most symptoms will resolve.  A child whose strep throat isn’t treated is most infectious when the symptoms are severe but can be contagious for up to 21 days.

Caring for your little one with strep while the antibiotics do their magic is much the same as with other childhood illnesses.  Plenty of fluids (warm liquids can be soothing), pain and fever reducers (acetaminophen or ibuprofen) as instructed, and plenty of Mama’s love.

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Rachel Zahn, MD is a pediatrician turned health writer who had three kids during medical school and pediatric training—crazy, huh?


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