Symptoms of Strep in kids
Most parents are familiar with strep throat or impetigo.
But strep infections in kids can show up in many different ways, some of them pretty weird. And they can get missed or mis-diagnosed, which his dangerous because left untreated, strep can cause serious complications.
This post goes over some of the weird signs of strep infection pediatricians sometimes see.
What causes strep?
Strep infections are usually caused by a bacteria called Group A Streptococcus (GAS, also called Strep pyogenes). Note that this is different from the “Group B strep” that is part of routine prenatal testing.
What most parents don’t know about strep
Group A strep spreads easily. Thankfully, it is still very sensitive to common antibiotics.
But here’s what surprises many parents: a healthy immune system can sometimes clear strep on its own. Your child may start to feel better without antibiotics.
But that does not mean it is safe to skip treatment.
Without antibiotics (or if you don’t complete the full course of antibiotics), strep can trigger the body's immune system to attack itself. That is where we see long-term complications, such as heart inflammation. Although these complications are rare, they can be life-changing, which is why we take strep infections seriously.
The risk of these complications doesn’t seem to be present in kids under age 3 years. For kids age 3 and up, we always treat confirmed strep infections with a full course of antibiotics. For kids under 3 years, clinical judgment plays a role. I sometimes test / treat if there is a clinical reason to do so.
The Pediatrician Mom Tip: Even if your child is feeling better, never stop the antibiotic early. Incomplete strep treatment increases the risk of serious complications. If your child won’t take the medicine, ask your pediatrician about alternatives.
Common types of Strep infection
Strep throat
Typically seen in kids over age 3.
Symptoms
Fever
Sudden sore throat
Red, swollen tonsils (sometimes with white patches)
Red spots (petechiae) on the roof of the mouth
Swollen lymph nodes in the front of the neck, under the angle of the jaw
Headache
Fatigue and malaise
Abdominal pain, vomiting or nausea (often a missed presentation)
Here are some helpful pictures.
More information (including when we test and how we treat) can be found here.
Scarlet Fever
Yes, it’s caused by STREP! Scarlet fever is most commonly seen in elementary-school aged kids, and it has a characteristic rash. Before antibiotics, this infection could be fatal, and there are many depictions within historic literature of characters that died of this disease, including Beth, from Little Women.
Signs include:
Red rash with a sandpaper-like texture
Strawberry tongue
Begins on the neck, underarms, or groin and then spreads quickly.
The Pediatrician Mom Tip: Scarlet fever rash usually fades within a week, but the skin of the fingers, toes and groin can peel for several weeks after infection.
Peri-anal (“butt”) strep
I know, I know. You’re saying WTF. Although this is rash has a classic appearance, it is sometimes misdiagnosed as a fungal or irritant diaper rash.
What it looks like:
Bright red rash around the anus with clear borders
Tender or itchy
May have blood in the stool or discomfort with bowel movements
May also see swollen nodes
If you really want to see pictures of the rash, click here and here.
Impetigo
Seen commonly in kids aged 2 to 5 years, especially when the skin starts to get raw because of drool or a runny nose. But it is also common to have outbreaks in children who play contact sports, like wrestling.
Key sign: Honey-colored crusting near the nose or mouth.
Learn more here.
Strep in Children Under Age 3
You may have heard that toddlers “do not get strep.” It is mostly true. Research shows that true strep throat is rare in children under age 3 years (PMID: 10532665; 8045744; 22965026), possibly because of antibodies they received before birth from mom, and because they have smaller tonsils.
In this age group, we usually test only when there is both:
A known contact with confirmed strep infection and
Symptoms consistent with strep
Complications from untreated strep are extremely rare in children under age 3, which is why testing and treatment guidelines are different. But, as with anything, there is a clinical judgment piece too. And rare is not impossible.
When young kids have strep infections, the symptoms can look a little different:
Prolonged congestion or cough
Low-grade (or no) fever
Fussiness
Poor feeding
Swollen glands / lymph nodes
When does strep become dangerous in kids?
Invasive Group A Strep: The Serious Forms
These are the cases that make the news. They are extremely rare but very serious, and kids often need hospitalization, IV antibiotics, and sometimes even breathing support.
These rare complications are more likely in people with a weak immune system, or when a person has both strep and a viral infection at the same time. Certain viruses are notorious for increasing the risk of Strep-related complications: Influenza, Varicella (Chickenpox) and Covid-19.
The Pediatrician Mom Tip: You can reduce the risk of these complications by making sure your child stays up to date on their shots.
Toxic Shock Syndrome:
Can begin anywhere strep has entered the body
Fever, chills, vomiting
Then rapid progression to shock and organ failure
Necrotizing Fasciitis (Flesh-Eating Disease):
Rapidly worsening pain, swelling, and redness
Skin can become blistered or black as tissue dies
Requires immediate emergency care
Local or Deep Infection:
Abscesses
Cellulitis
Bloodstream infection (sepsis)
This is why treating strep completely and following up if symptoms worsen is so important.
Autoimmune Complications
Strep can also cause the body’s immune system to act up. These types of complications usually happen several weeks after the initial infection, and knowing the symptoms can help make sure your child gets help fast. Treating strep properly helps lower the risk of some, but not all, of these conditions.
Acute Rheumatic Fever (ARF)
More common in parts of the world with limited access to antibiotics. I have only seen it once in my career.
Immune system attacks the heart, joints, and brain
Symptoms may include fever, chest pain, shortness of breath, swollen joints, rapid heart rate, or unusual movements
Can appear as early as 1 to 5 weeks after strep, but may be longer.
Here is more information on this condition.
ARF can usually be prevented by adequate treatment of the infection with antibiotics.
Post-Streptococcal Glomerulonephritis (PSGN)
A kidney condition that can occur after any type of strep infection. Unfortunately, antibiotic treatment does not prevent this complication.
Dark, reddish-brown or “Coke-colored” urine
Swelling around the eyes, hands, feet, or face
High blood pressure
Fatigue
Decreased urine output
More information can be found here. Most kids recover fully, but some need long-term monitoring.
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep (PANDAS)
PANDAS is a very poorly understood condition. One theory is that it may be caused by antibodies mistakenly attacking parts of the brain after strep infection. There is a lot of misinformation out there, and I have seen many clinicians who take advantage of vulnerable parents by claiming they have “cures”. Believe me when I say, if we really had a definitive cure, a pharmaceutical company would have marketed it immediately.
Symptoms:
Sudden / abrupt onset of OCD and restricted eating patterns
Motor or vocal tics
Anxiety or mood changes
Frequent urination
Behavioral regression
Difficulty sleeping
Problems at school
We don’t have great diagnostics or treatment protocols yet, but the AAP recently published helpful info which can be found here.
Families should work with specialists in infectious diseases, psychiatry, psychology and neurology, along with their pediatrician.
NIMH and PANDAS Physicians network also provide helpful resources.
When to test a sore throat for strep? How to treat Strep in kids?
A full article on sore throats and when to test for strep here. And more information on strep throat (including treatment) specifically here.
