Understanding Strep and Why Your Kids Keep Getting Strep Throat

Tonsillitis caused by group A streptococcus bacteria.
Tonsillitis caused by group A streptococcus bacteria. Photo courtesy of the CDC.

Does your child get strep throat so often that you are thinking about getting his tonsils out?

While it is not uncommon for kids to get strep throat a few times a year once they are in school, it is even more common to get viral sore throats.

Strep throat, which can be treated with antibiotics, is caused by the group A Streptococcus (GAS) bacteria. And while a fast or rapid test can help determine if your child has strep throat or a virus, false positive (the test is positive, but the strep bacteria isn’t really making your child sick) results can sometimes confuse the picture.

Understanding Strep Throat

Before you can begin to understand why your child might be getting strep throat over and over again, you first have to understand strep throat and the current guidelines for diagnosing and treating strep.

“Diagnostic studies for GAS pharyngitis are not indicated for children less than 3 years old because acute rheumatic fever is rare in children less than 3 years old and the incidence of streptococcal pharyngitis and the classic presentation of streptococcal pharyngitis are uncommon in this age group.”

Infectious Diseases Society of America Guidelines

Strep throat is most common in children and teens between the ages of 5 and 15 years. While it might be possible for younger and older folks to get strep, especially if someone else in the house is sick with strep throat, since they aren’t considered to be at risk for acute rheumatic fever, it isn’t typically necessary to diagnose or treat them. It may surprise you, but strep throat does go away on its own – the main reason it is treated is so you don’t later develop rheumatic fever.

“Testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiological features that strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness, and oral ulcers).”

Infectious Diseases Society of America Guidelines

The classic symptoms of strep throat can include the sudden onset of a sore throat, fever, red and swollen tonsils (tonsillitis), possibly with white patches (exudate) and small, red spots (petechiae) on the roof of the child’s mouth, and tender, swollen lymph glands in their neck.

Kids with strep throat might also have nausea, vomiting, stomach pain, a headache, and a rash (scarlet fever).

Kids with strep throat will not usually have a cough, runny nose, hoarse voice, mouth ulcers, or pink eye with their sore throat. Those are symptoms that suggest a virus is causing the sore throat and they should not usually be tested for strep. This helps to avoid an unnecessary antibiotic prescription if your child tests positive, but really has a virus.

So basically, try to avoid over-testing for strep. But if your child does have strep throat symptoms and has a positive test, get an antibiotic that will clear the strep bacteria and finish all of your child’s prescription.

Avoiding Strep and Other Infections

Can you avoid getting strep?

As with other infections, the best way to avoid strep throat is to teach your kids to:

  • wash their hands properly
  • avoid close contact with people that are sick (for strep, that means until they have been on their antibiotic for at least 24 hours)
  • avoid drinking out of other people’s cups or glasses
  • consider taking a water bottle to school instead of drinking out of the water fountains
  • not touch their eyes or put objects (fingers, pencils, clothing, etc.) in their mouth, as that helps germs get in their body
  • cover their coughs and sneezes to avoid getting others sick

Most importantly, don’t wait until someone is sick in your home or lots of kids are getting sick at school to encourage your kids to avoid getting sick. By then, it will likely be too late.

Is Your Child a Strep Carrier?

If your child continues to get strep, especially if their strep test is always positive, it is likely time to consider that they may be a strep carrier.

“We recommend that clinicians caring for patients with recurrent episodes of pharyngitis associated with laboratory evidence of GAS pharyngitis consider that they may be experiencing >1 episode of bona fide streptococcal pharyngitis at close intervals, but they should also be alert to the possibility that the patient may actually be a chronic pharyngeal GAS carrier who is experiencing repeated viral infections.”

Infectious Diseases Society of America Guidelines

What does it mean to be a strep carrier?

It simply means that the strep bacteria are living or ‘hanging out’ in the back of your child’s throat. While that sounds bad, these strep bacteria aren’t causing any problems. They aren’t making your child sick, causing any symptoms, and don’t even make your child contagious.

“…the recovery of GAS does not establish causality. The tests do not distinguish carriage of GAS in a child with pharyngitis attributable to another cause from an acute infection caused by GAS.”

“Group A Streptococci Among School-Aged Children: Clinical Characteristics and the Carrier State” Pediatrics. 2004 Nov;114(5):1212-9.

The big problem with being a strep carrier is that whenever you have a strep test, these strep carrier bacteria will make the test positive, even if they aren’t what is causing your child’s symptoms.

This is often why people get diagnosed with strep and flu or strep and mono at the same time.

If you still don’t understand strep carriers, consider that if you go to almost any school and test every child, up to 20 to 25% of the kids will test positive for strep, even though they aren’t sick and have no symptoms. They are likely just strep carriers.

“We recommend that GAS carriers do not ordinarily justify efforts to identify them nor do they generally require antimicrobial therapy because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or nonsuppurative complications (eg, acute rheumatic fever).”

Infectious Diseases Society of America Guidelines

What kind of efforts are they talking about? We sometimes hear about doctors ordering antibody tests, doing rapid strep tests and cultures on kids after they finish their antibiotics, testing everyone who lives in the house, or even testing the family dog.

None of this is usually necessary.

One thing that can be helpful is that if your pediatrician thinks that your child is a strep carrier, then instead of the more typical penicillin or amoxil antibiotics, they might treat your child with a stronger antibiotic, like clindamycin. This can help ‘knock out’ the carrier bacteria.

And then learn to be much more selective about getting strep tests, avoiding them if your child has more classic viral symptoms, like a cough and runny nose.

In addition to the idea of being a chronic carrier, there are other theories about why kids get recurrent strep throat infections, including:

  • antibiotic resistance – although this is thought to be rare or non-existent when it comes to the GAS bacteria and penicillin, amoxicillin, and cephalosporins. There is some resistance between azithromycin and strep, which is why it should only be prescribed if your child is allergic to the other antibiotics that are used to treat strep throat.
  • noncompliance – not finishing your antibiotic or not taking it as prescribed
  • influence of other bacteria – there are theories that other bacteria may be inactivating penicillin or amoxicillin (so you need a stronger antibiotic) or even that other beneficial bacteria help to kill the GAS bacteria, but may be gone if your child is frequently on antibiotics
  • you are starting antibiotics too quickly – some people think that if you don’t wait a few days and let the body start to fight the strep infection on its own, then it is more likely to come back

Or if your child had true strep throat symptoms, got well quickly after being on an antibiotic, but then got strep (with classic strep symptoms) again quickly, it is possible that it is just a new infection.

“We do not recommend tonsillectomy solely to reduce the frequency of GAS pharyngitis.”

Infectious Diseases Society of America Guidelines

If it is happening over and over again, consider the possibility that your child is a strep carrier and teach him or her how to avoid getting sick as much as possible.

Why not just get your child’s tonsils out? The problem is that many studies have shown that while this might help for a year or so, after that, these kids start getting strep just as much as they did before. So unless your child also has sleep apnea or has had complications of strep infections, like a peritonsillar abscess, you probably shouldn’t rush into a tonsillectomy.

What To Know About Recurrent Strep Throat Infections

Some other fast facts to know include that:

  • having tonsillitis does not automatically mean that your child has strep. Remember that viruses are an even more common cause of sore throats.
  • you can’t tell if someone has strep just by looking at their tonsils. Even having pus (white stuff) on their tonsils doesn’t automatically mean strep. Viruses can do that too. That’s why a rapid strep test, with a backup culture for negative tests, is important to make the diagnosis.
  • throwing out your child’s tooth brush every time they have strep isn’t necessary, after all, you don’t do that after they have other infections, do you? Instead, encourage your kids to routinely rinse their toothbrush after each use and replace it every 3 to 4 months.

Hopefully you have a better understanding of strep throat now.

Sore throat infections, including strep throat, are common, but remember to look for other answers besides just getting your child’s tonsils out if they get strep over and over.

More Information About Strep Throat

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