Scott Webb (Host): Strep throat is very common. And for all of us parents in the audience, we want to know what it is, how it's treated, and most importantly, if we can prevent it. Joining me today is Dr. Katya Gerwein. She's a pediatrician with Stanford Medicine Children's Health. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Dr. Gerwein, thanks for joining me. How are you doing?

Dr. Katya Gerwein: It's my pleasure. I'm doing well. Thank you.

Host: Yeah. Well, it's a pleasure to have you here, and we're going to talk about something that's sort of near and dear to my heart and maybe the hearts of many parents. I was mentioning before we got rolling that I have kids and they've had strep, and then many times they didn't have strep, and it's all very confusing. So, it's great to have your expertise. Let's just have a baseline start here today. What is strep?

Dr. Katya Gerwein: So, strep is a bacteria, so that's why we treat it with antibiotics. Whereas a lot of sore throats are caused by viruses that you can't treat with antibiotics because they're not bacteria. And strep is an interesting bacteria. There are lots of different kinds of strep. What we're talking about is group A strep, so lots of different groups of strep that causes sore throats in general, but can cause a few other things as well. And most of the time, if kids get symptoms from it, it will be a sore throat and it may or may not have a fever, it may or may not have vomiting or a rash or belly pain.

And the interesting thing about strep is that it never comes with lots of sneezing or nasal congestion or tons of coughing. Like you could have a little clearing your throat type of cough, but you wouldn't have a lot. And in the olden days, before we had antibiotics, sometimes strep could also cause rheumatic fever, which is why people worry about it, you know, in the old books, Little Women or The Velveteen Rabbit. Scarlet fever was really scary, because it could lead to rheumatic fever as well. And so, that's why antibiotics became so important to treat strep.

Now, strep can also just be carried by kids in their throat and not cause any illnesses and not be contagious. And that's what's a little confusing. Depending on the study that you look at, between 5 to 20% of school-aged children carry strep around in their throat and it's not making them sick and it's not contagious. So, that's why it becomes important to figure out who you're going to actually test for strep if you really think they have it, because if you tested everyone, you might think more people had strep throat than actually do.

Host: Yeah. That makes sense. Maybe this is ironic, but it seems to me that with my kids, the more they felt like they had strep, they didn't. And when the symptoms were very minor, or relatively minor, they often ended up having strep, and let's just talk a little bit more about the symptoms so that parents and kids can kind of sort through this.

Dr. Katya Gerwein: So, sore throat is usually part of it. Almost always kids have a sore throat. And it could be fairly mild or most of the time it's pretty severe. And sometimes there's pus in the back of the throat or on the tonsils, often there's not. There's sometimes sort of bright red dots at the top of the palate, or the very back of the throat, that almost look like little dots of blood and we call them petechiae. But you could also get those with viruses and you can actually get pus on your tonsils from viruses as well. And kids' throats can look totally normal with strep as well. So if we could tell by looking, we would not have to test.

Host: Yeah, that's been my experience, that simply just looking at a child's throat is not scientific in any way. It sounds like it's very common. Do I have that right?

Dr. Katya Gerwein: It's pretty common. I would say it's one of the most common reasons that we prescribe antibiotics. But that said, most kids don't get strep, whereas almost all kids will get a cold. And that's a little bit of a mystery. Why do some people get strep? And some people just kind of carry it around in their throat, never makes them sick, never makes anybody else around them sick. And we don't understand that. We know that it's true, but we don't understand it, like many things in medicine that we wish we understood that we don't.

Host: Right. There's things that we know are empirically true, we just don't know why.

Dr. Katya Gerwein: Exactly. And that leads me to one other mystery of strep, which is that kids under the age of three really almost never get strep. There are a few exceptions. If everybody in the family has strep it's been known to happen. But under the age of 3, it is super rare for a kid to get strep. They get all sorts of other sicknesses. Like clearly, they're not, you know, immune to everything, but strep is something they don't tend to get. And we don't really understand why. Again, we just know that it is true. So, a lot of times I'll have somebody come in with her 18-month-old and say, "Oh, we're worried. Maybe she has strep." And I say, you know, usually the kid also has a cold and a runny nose and coughing, so I can pretty much eliminate strep anyway. But also, it just would be very, very rare for a kid under the age of three, unless the whole family had strep, to have strep.

Host: Yeah, I see what you mean. I've often wondered, how is strep transmitted? Like, how do kids get strep throat? Is it just from talking and being kids? Is it from sharing water bottles? How does it happen?

Dr. Katya Gerwein: Yeah, all of those things. So, it's transmitted by respiratory droplets and saliva, so you could get it from sharing a toothbrush or water or glass. But most of the time, it's transmitted the same way a cold is transmitted, that when we're talking or coughing or anything like that, we're transmitting respiratory droplets into the air and then other people breathe those in. And it can make you sick if they had strep.

Host: And you mentioned antibiotics, and this is anecdotal at best, doctor, but it seemed to me when my kids were younger, antibiotics from pediatricians and from the doctor's office flowed a little bit easier. They were given out a little bit easier. I don't mean to suggest they were given out willy nilly like candy, but it seemed it was a little easier to get antibiotics for sick kids. Today, not so much. So, let's talk about the treatment and maybe also, if you could explain why maybe there's been a sort of a rethinking when it comes to antibiotics and just sort of handing them out to everybody.

Dr. Katya Gerwein: Sure. So, the reason that we give antibiotics is for two reasons for strep. One is to prevent scarlet fever, rheumatic fever, some of the complications that you can get from strep. And those are really rare, and they've gotten more rare over time. And again, we don't understand why, but the strain of strep that causes rheumatic fever has become more rare. And we know that lots of people have sore throat and fever and don't go to their doctor to be tested, so we know that there are a lot of times that people have strep and it's not treated, and very few children get rheumatic fever. But because rheumatic fever can cause irreversible heart disease, I've never wanted to take that chance of not treating strep for that reason, but there's definitely debate in the adult literature, because adults are even less at risk for rheumatic fever from strep of whether or not you should even treat strep with antibiotics because, you know, strep untreated, most people will get better within five to six days without treatment.

And with treatment, you get better usually in 24-48 hours, but if you wait until day four to get your treatment, it's not necessarily going to save any time on the length of your illness. That said, it will prevent rheumatic fever if you treat within 10 days of the symptoms starting, even if your symptoms are better. And so, it's not so much a debate in the pediatric literature, because nobody wants to take that chance, even though it's very rare. So, the debate is more who do you test because you don't want to get a false positive. You don't want to test that kid who has a runny nose and a cough and a sore throat and you get a positive strep culture, but they're actually just a carrier and that's not what's causing their symptoms, because strep doesn't cause runny nose, cough, et cetera. And so, that's where it's become more of a push for pediatricians, not test because then you might want to treat.

And the reason that we're not handing out antibiotics as easily as before is for several reasons. One is antibiotic resistance, okay? So, the more people or animals that take antibiotics, the higher the rates of resistance, both in the person who's taking it and in the world at large. And this is a huge issue in terms of animals that we eat, that we give antibiotics just like water, literally, like a lot of them are just drinking it in their water. And it's causing a huge amount of antibiotic resistance in humans. And so, that's an enormous issue. And then, there are a lot of antibiotic stewardship committees in hospitals to make sure that humans are also not over prescribed antibiotics or not prescribed the wrong ones so that we don't also contribute both within an individual person's body to resistance, or to larger community.

But the other reason is that every time you take antibiotics, it kills off your good bacteria as well as your bad bacteria. And so affecting your microbiome, this sort of invisible, well not really invisible, but microscopic community of good bacteria and good viruses and good little other creatures too small to see, it turns out that it can lead to more long-term issues with autoimmune diseases, asthma. Many things have been tied to repeating courses of antibiotics. And so, that's the other reason that we're trying not to prescribe antibiotics if you don't need them. If you need them, they can save your life. They can prevent complications. But if you don't need them, they can cause other problems. So, we try not to give them unless you need them.

Host: Yeah, that makes sense. As you say, like, short term they may do some good, but long term some harm. And, yeah, I'm glad to have you clarify, because in my mind I was like, it seems like we could get them easier before, and not so much anymore. But as you say, you only want to give them to people who are sick, and we only want to test people who we think really have strep. So, again, great to have your expertise and sort through some of this stuff today. And if we think about what we can do to minimize risk in our kids, do we just tell them stop being kids, stop talking, stop yelling, stop sharing things? Is there anything else we can do?

Dr. Katya Gerwein: Yeah, you definitely don't want to do that. You want them to be kids, and run around and you know, whisper secrets into each other's ears and stuff like that. I'm just going to make one more plug for a healthy microbiome for two things, okay? So if you do need antibiotics, as your microbiome regrows, there are things you can do to make it healthier. And in general, there are things you can do to have a healthier microbiome, and that seems to create better immune system. And so, you might be less likely to get strep in the first place.

So, the things you can do to create a healthier microbiome are things that your doctors are probably telling you to do all the time anyway, like eat lots of fruits and vegetables and unprocessed foods, whole grains like brown rice, millet, , whole oats, things like that, fish, tofu, and try to stay away from processed foods like cereal and bars and cookies and chips, that are all more damaging to the microbiome. Drink water, don't drink soda, things like that, can help your microbiome.

Other things that help your immune system are getting more sleep. So, kids who get more sleep are less likely to get sick. Kids who get lots of exercise every day are less likely to get sick. And then, creating a healthy pattern of communication in the household also prevents illness. So, they did a study of families where one person was yelling a lot at other people and, in those families, people were more likely to get sick. It actually impairs your immune system to have people yelling at you. And there are ways to communicate with healthier yelling too. It's not that you can't ever raise your voice, but the patterns of communication so that you're being very direct and you're not being passive-aggressive and you're not being sarcastic or demeaning are disrespectful. So, it's not really the raised voice per se, it's a method of communication. And I'll give a shout out to John Gottman of the Gottman Institute. No relationship, but he has some nice descriptions about healthy patterns of communication, especially within a marriage, or not so healthy, but it really applies to all relationships. It doesn't need to be a marriage.

Host: That's so interesting. I'm just processing that. And again, so glad to have you here today. What can we do as we wrap up here, doctor? What can we do to make our kiddos feel better when they have strep? Whether they got antibiotics or not, what else can we do?

Dr. Katya Gerwein: So, I just want to also say, once you start antibiotics, you're not contagious by the next morning. So, they're hugely effective, but you do have to take them the full 10 days in order to prevent rheumatic fever, which is really what they're for. So even when your kid starts to feel better, you should finish the course. Not true for all antibiotics, but definitely true for the ones prescribed.

And in terms of feeling better, I think saltwater gargles if your kid is old enough to do that can help with healing. Also, just warm liquids in general. So, chicken soup always gets a shout out, right? But it can also be vegetable soup, warm tea, chamomile tea, honey, apple cider vinegar and honey can be good, lemon and honey. But even just straight up honey, especially if it's raw honey, not under the age of one, but those kids are not getting strep anyway, can help in activating your immune system to help healing as well as symptomatically making you feel better. If your kid is old enough to have a throat numbing, throat drop, that's fine to do, but you have to be worried about choking hazards for younger kids.

And of course, ibuprofen, so Motrin or Tylenol, can help with pain as well. And just always remember you never have to bring down a fever. Fevers never do harm, they're there to help your body, they're there to burn up the bacteria or viruses, and they help you feel better faster. But if you are miserable, you can take acetaminophen, or ibuprofen, and that will make you feel better. It may make your recovery a few hours longer, but that's okay. If you're miserable, it's okay to take them anyway.

Host: Sure. Well, I really appreciate your expertise today. I just love pediatricians. I've said this before on the podcast. I just wish I could still see a pediatrician. You're just so nice and thoughtful and knowledgeable for families and kids. I appreciate your time. Thanks so much and you stay well.

Dr. Katya Gerwein: Thank you. You too.

Host: And for more information, go to stanfordchildrens.org. And we hope you found this podcast to be helpful and informative. If you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.