Sore Throat

There are many reasons your child may have a sore throat and most of them have nothing to do with strep throat. By far the most common reason for a sore throat is a viral infection. There are two different general types of viral infection that may cause a sore throat. The most common of these is a cold. When you get a cold you generally have nasal congestion. This congestion often runs down the back of your throat and it causes irritation. If you have runny nose, congestion, sneezing, or cough associated with a sore throat then you DO NOT have strep throat.

There are also some viruses that can cause an isolated sore throat. Some on the main culprits are things like infectious mononucleosis (Mono) and Coxackie (Hand-foot-and-mouth disease). These viral infections are self-limited and generally cause sore throat, malaise, and fever.

On occasion your child's sore throat may be caused by the bacteria Streptococcus pyogenes or Group A Strep. This is the causative agent of the "strep throat." It is generally associated with severe sore throat, abrupt onset, high fever, pus on the tonsils, and tender glands in the neck.

As with most childhood illness, strep throat is generally not dangerous. Most cases will resolve on their own if you just let the body do its job. However, in rare cases some children have a complication associated with Strep throat, and there are two that we care about from a medical perspective: Acute Rheumatic Fever & Peritonsillar abscess.

This falls into the catergory of autoimmune disorders. Simply stated, when the body mounts a response against the strep infection, that response cross-reacts with the body. It can lead to damage in various organs. The are many different signs and symptoms of ARF, but the most important is heart involvement, which occurs in about 10% of cases of ARF.

But just how common is a AFR? In the Western world, it is very uncommon. It is estimated to occur about 1:30,000 untreated cases. However, remember that complications only occur in 10% of cases, thus likelihood of a complication of ARF in untreated patients is 1:300,000. This means that you would need to treat 300,000 kids to prevent one case of complicated ARF.

Is it prevented by taking antibiotics? Antibiotics decrease the likelihood of ARF by about 2/3, but do not prevent it completely.

Is it dangerous? Rarely, only about 1% of all cases are serious and potentially fatal. Thus, about 1:3,000,000 chance of having a fatal complication of ARF. Or stated another way, you would need to treat around 3,000,000 kids with antibiotics to prevent one fatal complication of ARF.

What is the require treatment? Penicillin is the treatment for ARF. Thereafter, a pencillin injection is generally given every month through childhood to prevent recurrence.

Click here to read more about ARF.

The short answer is no. Penicillin is a medication and all medications have side-effects. The side effects are not common but then neither is the side-effect of strep throat - acute rheumatic fever.

Pencillin reaction can be broken down into three groups - mild, severe, and death.

Mild reactions include mild symptoms like diarrhea and rash. They are common and probably occur as often as 1:25 patients.

Severe reactions include things like severe skin reactions, severe swelling in the mouth and throat, and severe asthma-like symptoms. These reactions occur about 1:200 to one in 1:400. Remember now these are serious reactions, not a reactions where you can just take a little benadryl and call your doctor in the morning. These are serious reactions that land you in the hospital or ER.

Some of these severe reactions result in death. These serious reactions that result in death are not common but they are estimated to occur in approximatley 1:70,000 to 1:200,000 patients treated with penicillin.

Take two hypothetical practices of say 3,000,000 children each. Now let's imagine that they all come down with strep throat at the same time. In practice A, everyone gets penicillin. In practice B, no one gets penicillin.

Let's look at practice A first. At the beginning of the week 3,000,000 kids have strep throat. After treating all 3,000,000 kids for strep throat virtually all the children will be cured from their strep throat. However(and I will assume the lowest published risk), 15 of those 3 million kids will now be dead from a severe reaction to penicillin.

Now let's look at practice B. At the beginning of the week 3,000,000 kids have strep throat. After letting strep throat run its course and resolve on its own, which it generally does, NO children will have died from a severe reaction to penicillin. However, roughly 100 children will have contracted Acute Rheumatic fever. 10 of those children will have complications from acute rheumatic fever (but the will live) and one child will have died from those complications.

Thus, if death is the most important outcome then...

Penicillin 15, No treatment 1

Perhaps, but if your doctor is trying to prevent Acute Rheumatic Fever by treating your child with penicillin, I do not feel like the benefits of trying to prevent ARF outweigh the risks of penicillin.

So what about the Peri-tonsillar abscess?

A peritonsilar abscess(PTA) is an infection inside the tonsil. If is generally associated with sore throat and fever. However, becasue of the location of the tonsil, you also get "trismus" when you have an abscess in your tonsil. Trismus is the fancy name for difficulty opening your mouth.

But just how common is a PTA? In patients untreated it occurs in somewhere between 1:30 to 1:200 patients.

Is it prevented by taking antibiotics? Antibiotics decrease the likelihood of a PTA, by about 6-fold, thus to somewhere around 1:180 to 1:1200.

Is it dangerous? Only if untreated.

What is the require treatment? Drainage, can be done in the ER or office, or if your child is very young, it can be done in the OR.

The simple answer is no. Kids with strep throat can be divided into kids with tonsillitis and kids with pharyngitis. Tonsillitis is when you have redness, swelling, and pus on the tonsils. Pharyngitis is when you have redness in the back of the throat, but NOT swelling and pus on the tonsils.

A great study looked at the effect of antibiotics for preventing the development of a PTA. If you had a diagnosis of tonsillitis then antibiotics seemed to be helpful, probably reduced the risk of PTA by about 40%. However, if you had just pharyngitis antibiotics made absolutely no difference, mainly because kids with just pharyngitis are unlikely to progress to PTA.

So, I think an obvious question for your doctor is..."Does my kid have tonsillitis or just plain old pharyngitis?"

If your kid has just plain old pharyngitis, then I am not sure the benefit of taking penicillin (no benefit) outweighs the risks ... but of course you must decide for yourself.

I have attached a link below to the article if you want to review for yourself. By the way quinsy is just a fancy name for PTA.

British Journal of General Practice: 2007

Yes, it is true. If you have strep throat and you take antibiotics it WILL help you get better faster. But just how fast is faster and is it worth the risk?

Most studies suggest that if you have strep throat and use penicillin for treatment you will get better, on average, 16 hours faster.

If you child has a sore throat, a positive rapid strep test, and your doctor offers you penicillin....

1. If you give it to prevent ARF, your child is more likely to die from a severe reaction to the pencillin than contract and die from ARF.

2. If you take it to prevent a PTA and your child only has pharyngitis, you will be expose them to all the risks of penicillin and they will receive no protection against a PTA.

3. If you give it to prevent a PTA and your child has tonsillitis, they will be about 40% less likely to get a PTA, but you risk the mild and severe side-effects of penicillin.

4. If you give it to get your child better faster, you can expect to have them back to school and be back to work about one day sooner, but again, that is if your child does not have one of the side-effects that keeps them home and you out of work.

Now, just to give you reassurance that I do not make this stuff up I have attached a link to an article from the American Association of Pediatrics journal Pediatrics. This article contains all the statistics that I have quoted and went on to perform a cost analysis of 6 different ways of dealing with sore throat. Their conclusions ... the cheapest and lowest morbidity (harm) approach - DO NOT test and DO NOT treat patients with uncomplicated sore throat.

Pediatrics: 2006

At Home

1. I strongly encourage simple home remedies before coming to the doctors office. Most cases of sore throat can be effectively managed at home. See section below.

2. If your child is complaning of pain and refusing to eat and drink you can try a dose of tylenol or motrin to ease the pain.

3. If nasal congestion is also present try treating the nasal congestion.

4. If despite the above measures your child is complaining of severe pain, inability to take any fluids, inability to open their mouth, stiff neck, or difficulty breathing, then a call or visit to your doctor is generally warranted.

In the ER

1. I do not test or treat who have sore throat plus runny nose, cough, and congestion.

2. I do not test or treat kids who complain of a sore throat unless they meet one of the following criteria:

a. High fever plus pus, swelling, and redness on the tonsils
b. Any evidence of ARF
c. Trismus
d. Complete inability to eat and drink

3. If the test is positive I then explain the risk and potential benefits of treatment. In many cases I will offer the parents close observation versus treatment with penicillin.

4. If the child is able to take oral medication there is no benefit of a shot over the oral medication.

More to come.

More to come.

It is important for everyone to understand that the purpose of this website is educational - to provide information. It is not a replacement for your doctor and I am not entering into a doctor-patient relationship with any of the readers of these pages or their children. It is my goal that by providing you with easy to understand information based on the latest research you will be empowered to work with your doctor to raise...healthy kids!