Strep throat
Strep infections can be serious, but often they are not. In most cases, they are easily treated once the diagnosis is made.
What is Group A strep?
Some of you wrote to me and mentioned seeing headlines reporting higher rates of invasive Group A strep infections than in years past. And this is why this topic is important: it is true that we are seeing many of these (still quite rare) situations, and we do not really know why.
Group A strep (or Strep pyogenes) is a bacteria that can cause many different types of infection. The common ones are familiar to most parents, such as strep throat or impetigo. But it can cause an array of other illnesses, ranging from mild to severe.
Historically, invasive or severe Group A strep infections are more likely if a person is also co-infected (or infected concurrently) with a viral condition — especially Influenza. So it may be that the impact of the current viral infections is creating this secondary effect, but it may also be true that this is somehow an as-yet-not-understood impact of C-19. Time will tell.
What you didn’t know about strep
Most adults have been infected with Group A strep - often more than once. It is ubiquitous and very contagious. The good news is that in most cases, it remains susceptible to many of the routine antibiotics we have available.
What most people don’t understand about strep infections is that a healthy immune system is able to clear it without any antibiotic treatment.
But especially in anyone over the age of 3y, it is still an infection that always needs antibiotic treatment. Although one benefit of treating Strep is that we feel better and can go back to our normal lives, the more important benefit that many parents are unaware of is that untreated (or incompletely treated) strep infections can lead to long-term very serious complications.
The Pediatrician Mom Note: For this reason, especially for strep, it is critically important to complete the entire prescribed antibiotic course — you should never stop the medication just because your child is “feeling better”. If your child is having trouble tolerating the medication, talk to your pediatrician about an alternative.
Types of Strep infection
GAS most commonly causes infection of the throat (“strep throat” or “strep pharyngitis”) or of the skin (“impetigo”). I will go through some of the common presentations below.
Strep throat
Strep throat is typically seen in children over 3 years old.
Symptoms
Fever
Abrupt onset of a sore throat
Red, swollen tonsils (sometimes with white patches)
Red spots, or petechiae, on the roof of the mouth (see here for a picture)
Swollen anterior cervical lymph nodes (the nodes in the front of the neck, under the angle of the jaw)
Headache
Fatigue/malaise
Abdominal pain, vomiting or nausea (often a missed presentation)
Here are more pictures.
Impetigo
Impetigo is more common in children aged 2-5y, especially when they have colds or drool a lot. Its hallmark is a honey-colored crust rash. You can learn more here.
Scarlet Fever
This is most common in children aged 5-15y. 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.
Symptoms
Rash that begins as small red blotches on neck, under arms or over groin area
Usually begins 1-2 days after start of illness (but can be up to 7 days later)
Spreads rapidly and has a characteristic “sandpapery” feel
Strawberry tongue
Fades within about a week but can have skin peeling afterwards for several weeks, especially around groin or fingers/toes.
Peri-anal strep
This manifestation of strep is often mis-diagnosed as an irritant or fungal diaper rash. It has a classic appearance.
Symptoms
Well-demarcated circle around the anus
Can be tender or itchy
Sometimes associated with blood in stool or pain/discomfort with defecation
May also see swollen nodes
Usually no other systemic symptoms
If you really want to see pictures of the rash, click here and here.
Infection in kids under 3y: a specific separate case
You may have heard that kids under 3yo “don’t get strep” — and this is mostly true. The data shows that strep infection is very rare for infants and young toddlers (PMID: 10532665; 8045744; 22965026).
However, rare is not impossible, and if these children have a direct contact with strep infection (which is more likely right now) they may still catch it. Without a known contact, we often do not test children in this age group — remember, the reason we treat strep is to prevent the complications of untreated strep infections down the line. These complications are almost unheard of in children under the age of 3y.
Testing for strep in this age group is only recommended when they have a) symptoms consistent with strep and b) a known contact with strep.
Symptoms in this age group can look different from children over age 3y though.
Symptoms
Prolonged nasal congestion or cough
Low-grade (or no) temps
Fussiness
Poor feeding
Swollen lymph nodes
“Invasive” GAS
Invasive GAS infections are often seen when a child is co-infected with a virus alongside GAS. Influenza and Varicella (chickenpox) are known to be culprits, but any virus could do it. One way to help protect your child is by being ensuring they are up to date on shots.
In most cases, these patients will be admitted to the hospital and require support in the form on intravenous fluids, antibiotics, and even respiratory or life support. The prognosis can vary but it is important to know these are extremely serious illnesses.
The likelihood of these increases with immune-compromise, or with concurrent infection with other viral conditions, such as C-19, Varicella (chicken pox) or influenza. The best way to decrease the risk of a routine strep infection progressing to invasive, life-threatening disease is to ensure your child is up to date on their immunizations.
Toxic Shock Syndrome
Can start from any source (eg a wound, sore throat)
Fever, chills, vomiting —> which then rapidly progresses to shock and organ failure
Necrotizing Fasciitis
“Flesh-eating disease”
Painful, red swollen areas of skin - progresses rapidly and eventually these areas develop ulcers, black spots as the skin dies
Very serious
Complications of Strep
Some of the complications we see from strep infections occur as a result of the bacterial infection itself - others are a result of the body’s immune response to the bacteria.
Abscesses, Cellulitis, invasive disease
If an infection is inadequately treated, it can become a deeper infection. It can penetrate deeper muscle tissue or bone or even go to the blood (causing sepsis) or the brain. This is why seeking treatment - and getting seen if a child is worsening despite treatment - is so important.
Autoimmune complications
Thankfully, these are rare. We don’t yet know which children are most likely to have these complications - but we do know that treating strep infections adequately, with a full course of antibiotics, can decrease some but not all of these complications.
Acute Rheumatic Fever
This is a complication that is not often seen in communities with access to healthcare and antibiotics. It is more common in the developing world. I have seen it once in my entire career.
Autoimmune condition where the body attacks the heart, brain and joints
Usually occurs 1-5 weeks after acute infection but can be later
Symptoms can include: fever, painful/swollen joints, chest pain, shortness of breath, rapid heart rate, abnormal or unusual body movements, congestive heart failure.
Here is more information on this condition.
Post-Streptococcal Glomerulonephritis (PSGN)
This is a form of kidney disease that can occur after any type of strep infection. The good news is that most people recover fully. However, it is possible to have long-term kidney damage so many of these patients are followed by a kidney specialist.
Usually 1-3 weeks after a GAS infection
Symptoms can include: brown/reddish urine, swelling of the hands, feet, face (especially around the eyes), decreased urination, protein in the urine, headaches and extreme fatigue, high blood pressure.
Treatment usually focuses on supportive care, including managing the swelling and blood pressure.
More information can be found here.
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep)
This neurologic condition is related to PANS (which is similar but not associated with strep specifically)
Very poorly understood but thought to be related to strep antibodies mistakenly attacking the brain or nerve tissue
Sudden onset neurologic or psychiatric changes that occur shortly after a strep infection
Symptoms can include: severe anxiety, tic disorders, abnormal movements, obsessions and compulsions, mood disorder
Most pediatricians (including myself) are not well-versed in this condition and we do not yet have good treatment protocols. But there are many unethical folks out there that promote evidence based “cures” — this is a condition where anxious parents who are hoping to help their children feel better are often taken advantage of. I usually refer to experienced infectious disease specialists and neurologists. The NIMH has some resources and occasional trials, and another good resource is the PANDAS Physicians network.
Strep pharyngitis
In children, the most common presentations of strep infection are strep pharyngitis (or strep throat) and impetigo. For more on impetigo, click here.
Symptoms and testing
Strep throat is typically seen in children over 3 years old. Testing should not be done on every child with a sore throat - remember, the most common cause of a sore throat in a child is still viral (not strep). Making sure we are looking at the criteria to determine when to test avoids unnecessary antibiotic treatment.
Symptoms can include:
Fever
Abrupt onset of a sore throat
Red, swollen tonsils (sometimes with white patches)
Red spots, or petechiae, on the roof of the mouth (see here for a picture)
Swollen anterior cervical lymph nodes (the nodes in the front of the neck, under the angle of the jaw)
Headache
Fatigue/malaise
Abdominal pain, vomiting or nausea (often a missed presentation)
Here are more pictures.
Scarlet fever (sometimes called a scarletiniform rash, or scarlatina) is another possible presentation of strep throat.
The Pediatrician Mom Tip: The presence of congestion, cough, runny nose, “sores” in the throat, are more suggestive of a viral cause. The absence of these symptoms in a child over 3y are a helpful “positive” when it comes to determining whether to test.
Children under 3y
Strep infection is rare in infants and young children. A few studies have looked at the likelihood of a +strep culture in children under the age of 2-3y, even in children who present with a sore throat, and the incidence is low. (PMID: 10532665; 8045744; 22965026; CDC)
However, this year in particular, we have seen more infections in infants than in years past. We do not know why. Perhaps it is simply a result of more widespread infection in our communities (and thus, more exposure for those infants).
Testing for this age group is recommended only if a child has a direct contact and clinical features consistent with strep. The reason for this is because the potential serious consequences of untreated strep infections, such as Acute Rheumatic Fever, are almost unheard of in children under 3y.
Symptoms in this age group are also not the same as what we see in older kids (they are easier to mistake for a virus):
Prolonged nasal congestion or cough
May or may not have fever - usually low-grade if it is there
Fussiness
Decreased appetite
Transmission & Incubation:
Group A strep is most commonly transmitted in crowded settings such as schools or college housing, or in intimate settings such as within a household. It is spread via:
Respiratory droplets
Contact with secretions (saliva, wounds such as impetigo, nasal secretions)
Although not common, it is also possible to spread via food or surfaces
The incubation period is 2-5 days.
Testing
Only about a third of cases of sore throat in children above 3y are caused by group A strep. Obviously if there is a known contact, the risk is higher.
Clinical judgment often plays a role in determining who needs a strep test.
A throat swab is the most common way to obtain a sample for a strep test - a rapid antigen test can often be run in a clinic, or sometimes samples are sent to a lab to grow a throat culture (this is the gold standard test).
If a rapid swab test is negative and there is high clinical suspicion, a clinician may consider treating with antibiotics while awaiting throat culture results, since those can take 48h.
Strep swabs can often be really stressful for parents and children.
The key is to remember to hold securely if a child is younger and seated on their parents lap. Most of the time, the parents hold them too gingerly, which prolongs the test or means that an inadequate sample is taken. A squirming child is also at more risk of injury from the throat swab.
A firm (but gentle) hold is helpful to make the entire process as quick and painless as possible.
The Pediatrician Mom Tip: For children, having them open their mouth and “pant like a puppy” or “roar like a dinosaur” during the swab can be really helpful. Those sounds elevate the palate and make the tonsils easier to visualize. It means your clinician is not swabbing blindly!
Treatment of strep throat in kids
Did you know that a healthy immune system can recover from strep within a few days even without antibiotics? But even if this is true, antibiotics are necessary to treat strep infections.
This is because the reason we treat strep infections is not just to help a child feel better, and to decrease how contagious they are, but because untreated strep infections are associated with serious complications, including Acute Rheumatic Fever, which is an inflammatory condition that can lead to heart failure.
Treatment is usually in the form of a 10 day course of antibiotics (often Amoxicillin). For patients who are allergic to Penicillins, there are other antibiotic options available.
What can I do for the symptoms of strep throat?
Symptomatic relief can take many forms. Here is a post that goes through evidence based ways to help alleviate sore throats.
Pain:
The pain from a sore throat from strep can be severe, and it can lead to dehydration because of an unwillingness to drink. Here is a post that goes through evidence-based ways to help with this pain.
Fever:
Remember, your focus here is comfort. Sometimes fever can make kids uncomfortable, less likely to drink, and breathe faster - so use fever-reducing medications as needed. If fever is continuing despite antibiotic treatment, it is imperative to reach out to your doctor.
Dosing for fever reducers is here.
Hydration:
Pedialyte, popsicles, smoothies, cold jello
Watch for signs of dehydration; see this post for more.
When to call the pediatrician
This is not a comprehensive list. In general, always err on the side of calling your pediatrician if you have any concerns about your child. There is a lot to be said for a parent’s gut instinct, and I promise: your pediatrician would rather you called!
If your child is not improving within 24h of starting antibiotics, or if they seem to be getting worse, call your pediatrician. Other concerning symptoms include:
Confusion
Dizziness
Ongoing fever
Worsening of throat pain
Lethargy or severe fatigue/difficulty arousing
A change in the sound of the voice
Inability to open mouth or discomfort with moving head/neck
Drooling or inability to swallow
Swelling of the hands/feet/face
Brown urine
Ulcers, painful or rapidly spreading rash
Dehydration — see my prior posts for signs to look for. I also have a new free cheat sheet under guides with step by step instructions on what to do.
Any signs of difficulty breathing (see here).
Any underlying medical conditions or risk factors
Anything else tickling your spidey sense!!
FAQs
When can my child go back to school?
They can return to school once they fever is gone and they have been on antibiotic treatment for 12 hours (PMID: 26295745)
What complications can be seen from GAS infections? How else can GAS present?
Sometimes GAS infections can become deeper, more severe infections (even when being treated). These can progress rapidly and become serious, even fatal, within hours. It is so important to trust your gut. If your child is acting different, or does not seem to be improving, get them evaluated.
Does my child need to replace their toothbrush?
This was common advice in the past. The data on it is actually mixed, and more recently, a small study that was presented at the Pediatric Academic Societies Meeting by a researcher from UTMB did not find that GAS lingered on toothbrushes.
What about strep carriers?
People who are GAS carriers will sometimes test positive even without clinical symptoms. They are much less likely to transmit the infection or to develop acute symptoms. Sometimes carriers are more likely to be given antibiotics inappropriately if they have a sore throat from another source.
The Infectious Disease Society of America and the CDC have helpful guidelines about how to manage carriers.
