Melanie Cole, MS (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And here to highlight strep throat for us today is Dr. Brittany Sakhno. She's an Assistant Attending Pediatrician at New York Presbyterian Hospital, Weill Cornell Medical Center, and she's an instructor in Pediatrics at Weill Cornell Medical College - Cornell University.

Dr. Sakhno, I'm so glad to have you with us. As a parent of two older children now, I know how many times they got strep and my daughter still got tonsil issues at 22. So, this is a thing every parent at some point is going to deal with. So, I would like you to tell everyone, what is strep throat? And are there different types?

Dr. Brittany Sakhno: Absolutely. Thank you so much for having me. I'm so excited to be here and to share some important and hopefully useful information on this important topic. So, just to start, strep throat is also known as strep pharyngitis, and it's the most common cause of a bacterial sore throat, and it's caused by the bacteria Streptococcus pyogenes. This bacteria, it can cause a variety of different infections in people from the respiratory tract, including strep throat, to skin and soft tissue infections like impetigo, to life-threatening systemic infections like toxic shock syndrome.

So, there's different types of Streptococcus bacteria, but only group A strep can cause strep throat, which usually will occur in older children, usually three years and older. And it'll typically present with, of course, a sore throat, but it'll often also have associated symptoms like fever, headache, abdominal pain, and tender swollen lymph nodes in your neck.

Melanie Cole, MS: Wow, thank you so much for that. Now, there are different types of strep. Like, I got a strep B shot before I delivered. So, that's a different whole thing altogether, yeah?

Dr. Brittany Sakhno: Absolutely. So, something that a lot of listeners will have heard of is something called group B strep, which is a different type of streptococcus bacteria that pregnant individuals are often swabbed for because infection with group B strep can cause severe infection in a neonate. So, being positive for something like group B strep is a different infection and treated differently in pregnant individuals and neonates.

Melanie Cole, MS: Thank you for clearing that up. Well, you know, we hear the word strep, so we're like, "Okay, strep this and that." And so, we're not sure, but strep throat, if a child has a sore throat as a parent, the first thing we always do is look in the back of their throat, you know, look for the white dots and look for the swollen tonsils. But there are other things that go along with strep throat. It's not just a sore throat. So, tell us a little bit about how concerned we should be and what are we looking for when we look in there before we call you?

Dr. Brittany Sakhno: So, in strep throat infections, usually those symptoms like cough and congestion and runny nose are actually not present. So, if your child has a sore throat along with those symptoms, that would be more typical of a viral infection like the common cold or other viruses. If your child has a sore throat with fever and headache, but without those cough congestion symptoms, that would be much more concerning for strep throat and we would advise you coming into the clinic for testing.

Sometimes strep throat infection in young children less than three, it's much more rare, but it can actually present a little bit differently than your classic strep throat in older children with lower grade fevers, some fussiness, decreased appetite, and some nasal discharge. And often they've had a sick contact like in an older sibling or at daycare with strep throat.

Melanie Cole, MS: What about a sore belly? A tummy ache, is that one of the things that goes along with strep?

Dr. Brittany Sakhno: So, things like fever, headache, abdominal pain, and those tender swollen lymph nodes in your neck are those classic kind of strep signs.

Melanie Cole, MS: Yeah, that's what I remember when my kids would say, "Oh, and my stomach hurts," I'd be like, "Okay." And now, sometimes as a parent, we would be glad it was strep over a virus because we knew that when you gave us treatment and an antibiotic, it would be fantastic and they'd feel better in 24 hours. So, how do you diagnose that that's what it is?

Dr. Brittany Sakhno: Like you mentioned, on exam when I'm looking at a child who may have strep throat, I'll often see pretty significant redness on the back of the throat. Those white spots that you mentioned are called exudates. It's kind of like a little bit of pus that's formed from the strep bacteria. And sometimes you'll often see little pinpoint red dots on the palate of the mouth called petechiae. Sometimes, in children, you'll see that the sore throat is accompanied by a rough rash on their skin that feels really rough, almost like sandpaper, along with a bumpy tongue that resembles the skin of a strawberry, and we'll call this scarlet fever. So, these additional like tongue and skin findings are actually a reaction to an exotoxin produced by the strep bacteria.

And as far as kind of just officially diagnosing strep throat, there's different diagnostic tests used by clinics. So, one common strep testing tool is the rapid antigen test, which gives us results in just a few minutes, which is great. But one drawback is that this test, the rapid antigen test, can miss up to 30% of cases of strep throat. So, if the rapid antigen test is negative, it is recommended to send a confirmatory throat culture, which can take a few days to come back. So, because of this, many clinics, including Cornell, has transitioned to rapid strep PCR assays, which gives results in about 20 minutes and actually have a really high sensitivity and specificity of 95% or greater. So, that confirmatory test actually isn't needed, which is great.

Melanie Cole, MS: Yeah, that's awesome. So, we get to find out if we just sit in the office for a few minutes or we leave and then you call us pretty quickly.

Dr. Brittany Sakhno: Exactly.

Melanie Cole, MS: That's better. So if it's not strep, what other diagnoses are you concerned about? What could be causing that sore throat?

Dr. Brittany Sakhno: When I'm seeing a patient in the clinic and they're coming in with a sore throat, one of the first things I look for in their chart to make sure I'm right off the bat is, are they up-to-date on their vaccines? So, one vaccine that I'm looking for in particular is the Haemophilus influenzae type B vaccine. Because infection with this bacteria, it can cause a life-threatening throat infection called epiglottitis, which can actually close off the airway.

So, the other vaccine that's really important that I check for is the DTaP vaccine because the D in DTaP stands for diphtheria, and that's another life-threatening disease that can present with sore throat. Obviously, thankfully, both epiglottitis and diphtheria are incredibly rare since the introduction of these vaccines, which is one of the many, many reasons that vaccines are so important.

Once confirming the child is up-to-date on their vaccines, I chat with the patient and the caregiver on whether anyone in their home or their close circle is ill. And like we talked about earlier, the most common cause of a sore throat in children and adults is actually not strep throat. It's rather a viral infection like coronavirus or the seasonal flu or Epstein-Barr virus, which can cause mono and just many other viruses. So, in general, if there's multiple associated viral symptoms like the runny nose and congestion and cough or eye redness or diarrhea, this would make my suspicion for strep throat relatively low.

Melanie Cole, MS: Let's talk about transmission for a second. Remember with COVID, we heard about asymptomatic carriers. But with strep, does that happen too? I mean, every kid I've ever known, when it was me, and I had my tonsils and adenoids out, because the kids of my family would get strep all at the same time, and that was back in the day when the doctor would come to your house and just give us all an antibiotic because he knew we were all gonna get it. But is there an asymptomatic, like you could have strep and not have a sore throat?

Dr. Brittany Sakhno: That's actually a really great question. And this totally does happen with strep. So, there's actually an interesting study that was done just to look at this particular question. And basically, this was where healthy children with no signs of infection or sore throat had strep testing done. And they found that 12% of children were found to be strep positive or carriers of the group A strep bacteria. And this carrier state they found in these children could persist for many months or even years when they're not having any symptoms at all.

So, treatment with antibiotics in this carrier state is really not necessary, because chronic carriers of strep are very unlikely to develop strep complications such as acute rheumatic fever. And they're also very unlikely to transmit the bacteria to others when they're in that chronic carrier state. It's actually like far less than 1% risk of transmission. and that's thought to be just because of the lower density of bacteria in the throat. The tools, unfortunately, that we have to test for strep cannot really differentiate between a strep carrier and those who may be having a sore throat due to some other viral cause, and a true strep pharyngitis. So, there is a little bit of nuance in determining that.

So because of this, if a child has multiple episodes of strep throat, it can be really difficult to determine is this strep bacteria truly the cause of the sore throat or instead is it just because the child's a carrier? So, in that situation, what I'll do is I'll have the child tested for group A strep when they're completely healthy without symptoms, and that can kind of clarify if they're a carrier.

Melanie Cole, MS: Wow, that's so interesting. I never knew that. And now, let's talk about treatment, Dr. Sakhno, because I mentioned antibiotics before. Why is it important to treat strep with antibiotics? Do we always do that? Because we hear a lot about antibiotic stewardship, but in the case of strep, this is something that generally is a reason that a pediatrician is going to give our child an antibiotic.

Dr. Brittany Sakhno: Fortunately, we have extremely effective antibiotics against group A strep. Generally, it'll be penicillin or amoxicillin for 10 days as the preferred first line treatment for strep throat. Often in children, interestingly, we'll choose amoxicillin just because this tastes much better than penicillin. Of course, if your child is allergic to one of these medicines, your pediatrician will select an alternative one that's appropriate. And as far as antibiotic stewardship and making sure that we are treating appropriately, this is so important, for a number of reasons. Number one, to prevent complications of strep throat and, number two, to prevent transmission to others.

So, I'll just go over a couple of kind of like the worrisome complications of strep throat. Just to start, one of the more worrisome complications after a strep throat infection is something called acute rheumatic fever, which can progress to rheumatic heart disease over time, which really is a major public health issue, especially in resource-limited countries where access to antibiotics is more limited. This acute rheumatic fever disease will occur in about 1% of untreated strep infections, and it'll generally present within about two to three weeks of a prior strep throat infection. Some symptoms that you would see in acute rheumatic fever would be joint pain, chest discomfort, or shortness of breath from something called carditis or inflammation of the heart. Sometimes abnormal movements known as chorea, as well as some characteristic rash and skin findings. And interestingly, the reason that so many areas of the body can be affected in acute rheumatic fever is that the person's own immune system in targeting the strep bacteria actually creates antibodies that will unintentionally also attack all of these other systems like the joints, the heart, etc.

Fortunately, something important to note is that treatment of strep throat with antibiotics can significantly reduce the risk of acute rheumatic fever by up to like 70-80%, which is wonderful. One other complication of strep that I'd like to mention is damage to the kidneys after a strep infection, which is a phenomenon that we call post-strep glomerulonephritis, which can present with swelling in the arms and legs, blood in the urine, sometimes looking like Coca-Cola colored urine, and high blood pressure, about again two to three weeks after a strep infection. And although the prognosis of this kidney involvement is generally very good, it's thought that early treatment of strep infections with antibiotics can prevent or greatly reduce the severity of this kidney involvement.

And then, one last thing that I'll say about why treating strep infections is so important is because the strep bacteria itself can actually spread from the initial throat infection to other areas of the body causing abscesses in the tonsils, behind the throat, ear infections, sinus infections and very rarely can spread to the bloodstream and cause sepsis or spread to the nervous system and cause meningitis or brain abscesses.

Melanie Cole, MS: Wow. So, it really can cause these serious complications. And we don't think about that because, you know, you just think strep is strep, but it really can be something that needs to be treated. Now, the sore throat, the antibiotics are great, and they work pretty quickly. Usually, a child feels better within 24 hours. But what can we do at home? If they're on antibiotics, can we give them Motrin or Tylenol for that sore throat? And what about their stomach? Tell us a little bit about some symptom relief things we can do at home.

Dr. Brittany Sakhno: So, at home, supportive measures are great, and would include things like warm liquids, lozenges, Tylenol and Motrin for pain and fever reducing, and although those are great, they should never be viewed as alternative treatments, but rather supplementary to those antibiotics, just for those reasons we discussed previously.

Melanie Cole, MS: And what about school? When can we send them back to school since this is relatively contagious? How long do they have to have been on the antibiotics before they can go?

Dr. Brittany Sakhno: Actually, there's a really great study looking at this very topic of strep and when can my kid return to school. It was published in the Journal of Pediatric Infectious Disease, and it looked at children with confirmed strep throat who were treated with their first dose of antibiotics by 5:00 p.m. on a particular day, and the study found that 91% of these children were found to test negative for group A strep the following morning, which is kind of where your pediatrician will get the recommendation from for it's okay to return to school after 12 hours at least on antibiotics.

Melanie Cole, MS: That is wild. I would have thought 24 to 48 hours, but that's incredible. I know it does work so fast. I mean, kids literally wake up and feel better. Now, some kids, like my daughter, got it regularly, and she did not get her tonsils out because that wasn't so common back then when she was 9, 10, 11 years old. Now, she's 22, and nobody wants to do it because it's harder when they're older. So, what do parents do whose children seem to get that strep repeatedly? What time, when should they consider more advanced interventions?

Dr. Brittany Sakhno: So if someone is having persistent or recurrent symptoms with strep, we think about a few different things. The first thing we want to make sure of is did the patient fully complete their entire 10-day course of antibiotics. Next, we would want to make sure that the patient's symptoms are truly consistent with an active strep throat infection. Because with recurrent strep throat infections, we'll always ask ourselves, kind of like we talked earlier, is this truly a repeated strep throat infection, or is this simply a patient who is a chronic strep carrier that actually has sometimes recurrent viral infections and they're just swabbing positive because they are a carrier. Again, this is when testing a patient when they're healthy, maybe at a well visit between episodes can be helpful in distinguishing the two. But if we feel that a patient truly has distinct recurrent episodes of strep throat, generally we would repeat a 10-day course of antibiotics. And for patients with many, many recurrences, there is real evidence from large studies that switching to a different antibiotic class can reduce the risk of relapse. So, trying an antibiotic like Augmentin or Cefalexin or clindamycin, your pediatrician may recommend one of those.

And to answer your question, procedures like tonsillectomy or removal of the tonsils, they're usually not indicated for recurrent strep infections. And the reason for this is because there really is a natural decline in tonsil-related problems as a child gets older. So, watchful waiting and appropriate antimicrobial use is often successful. But of course, in children with severe and recurrent episodes, I will sometimes advise that they have an ENT consultation just to see if they would be a candidate for a tonsillectomy.

Melanie Cole, MS: Wow, you've given us so much great information. Dr. Sakhno, wrap it up. What's your best advice about strep throat for parents listening?

Dr. Brittany Sakhno: One important take home point from this talk would be if your child has a sore throat with fever and maybe headache or abdominal pain and no significant cough and congestion symptoms, that would be a great time to have them come on into the clinic for strep testing just because it is so important to treat strep throat with antibiotics for the reasons we discussed.

Melanie Cole, MS: Thank you so much, Dr. Sakhno, for joining us today. I imagine you are just such a great pediatrician, because I can just hear how well you'll educate parents so that they really understand what's going on. Thank you again.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Kids Health Cast. We'd like to invite our audience to to download, subscribe, rate, and review Kids Health Cast on Apple Podcasts, Spotify, iHeart, and Pandora. And for more health tips, go to weillcornell.org and search podcasts. And don't forget to check out Back to Health. We have so many great podcasts there as well. I'm Melanie Cole. Thanks so much for joining us today.

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