Your youngster rousts you out of bed in the middle of the night wanting a drink of water. Her throat is scratchy and burning, she says, and she doesn’t feel well.
There are many reasons for a child–or an adult–to have a sore throat, and most are no cause for alarm. But the first thing that pops into a concerned parent’s mind is strep throat.
Strep throat, which can occur at any age but is particularly prevalent among children ages 5 to 15, is an infection from group A streptococcus bacteria. It’s one of the few sore throats which can and should be treated with antibiotics, and failure to do so can increase the risk of a much more serious illness, notably rheumatic fever or an inflammation of the kidneys known as nephritis.
Strep is not necessarily more severe than any other sore throat, and even a doctor cannot tell for sure if it’s a strep infection without taking a throat culture. In addition to the achy, swollen throat–which appears red with some white pus spots–there’s usually a fever and swelling of the lymph nodes under the jaw. Some patients also have a red rash, stomach pain and a headache.
A runny nose, cough, itchy eyes and congested nasal passages, on the other hand, are more likely to signal a cold rather than strep throat.
If it’s a cold, of course, there’s nothing you can do except be patient; antibiotics will neither lessen the severity of symptoms nor make them go away any sooner. Have your child gargle with warm, salty water and give her plenty of hot and cold fluids. Throat lozenges and acetaminophen or ibuprofen may also make the throat feel better. (Children under 18 should not be given aspirin because of the risk of Reyes Syndrome.)
Don’t Take Antibiotics Lightly
Prescribing an antibiotic on the mere chance that the problem may be strep throat is ill advised because misuse and overuse of antibiotics has created a major public health problem of antibiotic resistance–the development of strains of organisms able to survive an antibiotic assault and threatening the effectiveness of present medications.
If your child has been to the doctor before with suspected strep throat, she knows what’s coming: a cotton swab poked down her throat and moved around to get a culture. It’s not pleasant, and it usually takes 24 to 48 hours to get results. But a throat culture is nearly always accurate–as long as the swab really reaches the tonsils and the back of the throat and not just the back of the tongue. It’s the gold standard way to confirm strep and the need for antibiotic therapy.
A rapid antigen test, which also requires a swabbing of the throat, can provide on-the-spot results. If it’s positive, most doctors will begin antibiotic therapy. But false negatives are common with the rapid test so a throat culture is usually required as well.
There’s good reason to make sure the sore throat is or isn’t strep because the consequences of not treating an infection can be severe. On the other hand, there’s no harm in waiting for the results of a culture since antibiotic therapy is effective as long as it starts within seven to nine days of the onset of symptoms. In fact, one study found that a 48-hour wait for treatment resulted in increased immunity from future strep attacks.
The incidence of rheumatic fever, declining for many years in the United States, rose dramatically during the mid-1980s in certain parts of the country, prompting greater concern about diagnosing and treating strep infections.
Typically appearing a few weeks after the symptoms of strep throat have gone away, rheumatic fever is characterized by a red rash and warm, swollen joints–usually the ankles, knees, elbows and wrists. A child may also suffer fever, loss of appetite and a general feeling of sickness. The inflammation of the joints is usually short-term, but if the heart tissue becomes inflamed, permanent damage can occur to the heart valves. This can result in heart failure and a buildup of fluids in the body.
In some cases, the joints are not affected and, as a result, symptoms may be more difficult to spot but usually include fatigue, breathlessness, paleness and a puffy buildup of fluids under the skin of the legs and back. A red rash may appear on the elbows, knees, knuckles or the back of the head.
Rheumatic fever can be successfully treated, usually without hospitalization, but patients are susceptible again and must take special care the rest of their lives to avoid repeat strep infections. This may mean taking penicillin or other antibiotics indefinitely.
Another possible complication, kidney inflammation (nephritis), also develops about two or three weeks after the sore throat eases. Symptoms may include swelling in the hands and feet, headache, fever and sometimes blood in the urine.
In both cases, complications are believed to develop when antibodies produced to fight the strep infection turn their attack on the body. While such complications occur in fewer than three percent of persons with strep throat, they can be severe and need not occur if strep is properly treated.
Treatment of strep is ordinarily with penicillin–given either orally or with a shot. When given orally, some doctors recommend two (as opposed to three) doses a day to avoid having to see that the child is given medication at school or day care.
Even though sore throat symptoms are likely to clear up a day or two after the start of medication, it’s crucial that the full course be finished. Otherwise, not all organisms will be killed and the risk of rheumatic fever or nephritis will remain.
Some individuals are chronic carriers of streptococcus and will test positive even though they don’t have symptoms and don’t require treatment. On the other hand, a child who develops another sore throat shortly after treatment is more than likely suffering from a viral infection that is not going to respond to antibiotics. It’s normal for children to have 6 to 10 such respiratory infections over the winter, each caused by a different organism.
As most parents of small children eventually realize, sore throats are a fact of life. Because of the possible consequences of strep throat, parents must be constantly alert for the signs while at the same time trusting their doctor when she calls for a throat culture or says no medication is needed.
Tana N Kaefer, PharmD
