Pediatrician’s Journal—

Sore Throats In Children

By Jeff Cersonsky, MD

My son had a sore throat and I took him to his pediatrician, but the doctor didn’t even do a throat culture. How can I be sure it’s not strep?

Sore throat has many causes. Our job as physicians is to determine the correct cause (strep throat, post nasal drip, viral illness, allergies, etc) and to treat that cause appropriately. Most sore throats are not due to a strep infection and should not be treated with antibiotics. How can we tell the difference between all the causes? Read on!

Streptococcal pharyngitis (also known as “strep”) is caused by a bacteria called Group A Streptococcus pyogenes, a bacteria with a long history of causing human ailments. This bacterium is particularly worrisome because of its rare ability to cause rheumatic fever (which can severely affect the heart) and glomerulonephritis (which can cause kidney failure). The particular variety of strep that infects the throat is also the one that can cause rheumatic fever. Treating strep throat is very effective in preventing rheumatic fever and other complications of strep, but is only slightly effective in shortening the course of the illness and making a child feel better. Most children who have strep throat would recover without antibiotics but we would not want to take the chance of untreated strep causing these uncommon but severe complications.

When strep infects the throat, it causes redness and sometimes exudate (white patches) on the back of the palate, the tonsils, the back wall of the throat, or the uvula. If there is no redness visible in these areas, there is no inflammation and, therefore, no strep throat. A pediatrician who sees no redness has ruled out strep throat without need for a culture or quick strep test. If the doctor were to do one of these tests and pick up the strep bacteria, the conclusion would be that that child carries strep in their throat but is not infected. Carrying a bacteria means that the bacteria is an innocent bystander, in this case in the throat, not causing infection. Many people (up to ten percent of the population) carry strep in their throats and do not need antibiotics. In fact, prescribing antibiotics for a carrier of strep might not eliminate the carrier state, and would not benefit the child.

An upper respiratory infection (or cold) can cause a postnasal drip that makes the throat feel really sore. There usually is no redness seen in the throat. The symptoms tend to be worse when lying down or upon awakening. Tylenol and throat lozenges may help, but antibiotics are not necessary. Similarly, a sinus infection can cause a postnasal drip and throat soreness, but not truly a throat infection. The sinus infection is treated with antibiotics and the sore throat is treated with acetaminophen (Tylenol).

Many viruses can cause throat infections with symptoms (including a red throat) identical to strep. Here, the tests for strep (culture and quick strep) are useful. If they are negative, the child needs no antibiotics. One of the worst viral throat infections is caused by a virus called EBV. The resultant illness is infectious mononucleosis, or mono. This infection can wax and wane for months with the only treatment being rest, acetaminophen, and good nutrition.

Laryngitis and croup can give the child the feeling of soreness in the throat. The soreness is farther down than we can normally see by looking in the mouth, so no redness is apparent and no strep test is necessary. Hoarseness is frequently a sign because there is inflammation around the larynx or voice box. Treatment consists of humidification and rest. These illnesses are caused by viruses so no antibiotic is necessary.

Epiglottitis is a very serious bacterial infection that is thankfully very rare nowadays due to immunization against Hemophilus influenza b (HIB). This infection causes constriction of the throat, drooling, and high fever. Treatment is a combination of intubation (to bypass the obstruction) and antibiotics.

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VIRAL THROAT INFECTION--NO ANTIBIOTICS

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MOST LIKELY STREP--ANTIBIOTICS NECESSARY

 

TEST FOR STREP

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NOT STREP (Could be cold, laryngitis, sinusitis)

 

REDNESS?

  There are less common causes of sore throat, such as aspirated toys and coins, but for the child with a sore throat, the above causes comprise the vast majority of cases.

SORE THROAT