Sore Throats

Strep Throat

Strep throat occurs at all times of the year and is one of the most common reasons kids go to the doctor. Strep throat is caused by Group A streptococcus, and accounts for 15% of all sore throats. That means that 85% of all sore throats are caused by something else.

It's passed by contact with respiratory secretions of infected people, usually among family members or in schools. Kids under 2 usually don't get strep.


The symptoms of strep are sore throat, difficulty swallowing and fever. Kids can also get fatigue, headache and belly pain. If your child has a runny nose, a cough or is hoarse, or has evidence of an eye infection at the same time, the cause of the disease is unlikely to be strep. It would fall into the category of something else.

Most people think of strep as causing "white spots" in the back of the throat. It definately does, but all white spots are not strep. And lack of white spots doesn't exclude strep.

Scarlet fever

I know that "scarlet fever" always sounds really scary, but it's just strep throat with a rash. I think that before strep was found to be the cause of scarlet fever, the diseases (scarlet fever and strep throat) were considered separate. They aren't. Just some kids are lucky enough to get the whole package ( that was sarcasm). And just as you can get strep throat more than once, you can get scarlet fever more than once.


Even the best doctors in the world can only predict strep based on physical exam alone about half the time ( we can all guess right half the time!). We only prove the presence of strep in the throat by testing for it. We do a "rapid strep" when you come to the office to test for the Group A strep antigen. It's right about 90% if done well. And a positive test is very helpful. A negative one isn't. That's why we run a back up culture on all rapid strep tests that are negative. We are testing, with that backup culture, not only for the presence of Group A strep, but for other members of the strep family and for other sore-throat-causing bacteria. Neither the rapid strep nor the culture will detect viral infections.


We only need to treat certain bacteria. Group A strep is a problem because it makes us feel awful, but moreso because it causes harmful consequences if it isn't treated appropriately.

If you've ever read "Little Women" (or at least rented the movie-- remember I was an English major!) Beth dies not from her scarlet fever, but from rheumatic fever. That was way before the days of antibiotics, and some people did get better without any medicine for strep. But they were at risk for rheumatic fever and this kidney condition where you urinate blood. Both are a bummer, and are the reason we tell you to take all your medicine. You or your child should be treated within 9 days in order to prevent the consequences of the disease.

Penicillin is the drug of choice for documented strep infections. We usually use Amoxicillin (the pink stuff) because liquid penicillin is awful tasting and amoxicillin is bubble gum flavored and therefore, kids take it better. My treatment for choice for most other causes of sore throat is popsicles. Not antibiotics.

Going Back to School

Your child needs to be on antibiotics 24 hours prior to returning to school or work or whatever. If the strep test is negative, returning to activities when your child feels better, even the next day, is fine.

The Pink Stuff Didn't Work!

I hear this all the time: "amoxicillin isn't strong enough." Now's the time for a crash course in microbiology. Each antibiotic has a certain range of bacteria that it takes care of. When we treat ear infections, pneumonia, sinusitis or other bacterial infections, we are basing the treatment on which bacteria, if any, we think are most likely to be causing the disease, and then tailoring the treatment based on what we know about antibiotic resistance patterns of those particular bacteria.

When we do a rapid strep, and it's positive, there is no guessing. The disease is caused by Group A strep. Period. And there isn't a Group A strep bug out there that is resistant to penicillin/amoxicillin.

Many kids get the infection, get treated right away and then, as soon as they get off medication, get it again.  This usually happens during the school year when strep is all over.  Since strep is really sensitive to penicillin, if we treat it early enough (within a day or two of symptoms, then the immune system may not have even known it was there. So, when you are around people with strep again, you get it again, since your body never made antibodies against your last infection.  Some researchers suggest waiting for symptoms to progress for 2 days prior to  treatment.  I haven't done that, but the risk we run is that you get re-infected as soon as you're off medication.

If the medicine didn't work then, what's going on? First, you could be allergic to penicillin  and we used some other medication.  Other medications, especially Zithromax, have resistance to group A strep and frequently don't work.  If I use Zithromax , I use it high doses, trying to battle some of that resistance.  Second,  it turns out that about 10% of kids in school are carriers of Group A strep. That means that they can come in with a sore throat from a virus and still test positive for strep. In fact, you could come in with a broken leg and no throat complaints whatsoever, and we could find strep in the back of your throat if you were a carrier. Often, I like to culture kids with a history of many strep infections when they have no complaints to evaluate the possibility of a carrier state.  Carriers of strep very rarely ever pass the strep to anybody else.

There are a few different options for kids with a strep carrier state, all of which we need to discuss face to face.

Hand- Foot and Mouth Disease

I'm going to talk about a few of the other sore throat things that aren't bacterial. It's the season for hand-foot and mouth disease, a summer viral infection. As you can guess, it involves the hands (including the palms), the feet (including the soles) and the mouth.

The mouth involvement is in the form of painful sores, called ulcers. These ulcers can be found on the inside of the cheek and tongue. And the sores can appear on different parts of the body besides the hands and feet-- I think the title just gets too long if we include all affected body parts!)

This virus, cocksackie virus, can cause a fever to 102 for one or two days. The disease itself lasts about a week.

Watch for the signs of dehydration.


This is a disease caused by another summer virus (enterovirus) and again causes mouth ulcers, especially on the tonsils. This one can also cause fever, as high as 105 can be expected. Kids may have vomiting, headache, and gum swelling. In fact, the gums will often bleed. This disease is common in kids ages 3-10 and lasts about a week.

The biggest problem is dehydration, as the mouth sores may cause the kids to refuse liquids.


This one's caused by a member of the herpes virus family (not the herpes virus, but another family member). It's usually seen in kids 6 months to 3 years of age.

Kids with this virus start out irritable and with a fever and then progress to having vesicles on their lips, gums and tongue, and sometimes the roof of their mouth. The gums can swell and even bleed. The vesicles eventually break leaving a gray ulcer. The whole process gets worse over 4 or 5 days and then takes another week to get fully better.

The biggest complication, aside from pain, is dehydration, because it's not uncommon for kids with the virus to refuse liquids.

Signs of Dehydration

call us if your child

  • Hasn't wet their diaper in more than 6 hours (mind you, diapers can suck up a lot of liquid without it being too obvious. Put a cotton ball or a piece of tissue paper in the front of the diaper, and if that gets wet, then you know when your child has urinated).
  • If potty trained, hasn't urinated in 8- 12 hours
  • Doesn't cry tears when crying
  • Has a dry, sticky mouth ( kids will often have dry lips and a coating on their tongue when they are sick. Those things don't help us as much in determining who is dehydrated).