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Strep Alert

I have no formal medical training, but as the mother of three kids who've never met a microbe they didn't invite home, I'm on a first-name basis with lots of germs. So I'm pretty good at recognizing typical childhood afflictions like the flu or an ear infection.

But what sometimes eludes me: group A streptococcal infection, aka strep throat. It seems to be different each time -- or, at least, in each child. Sam, 8, my oldest, gets strep four or five times a year. The first thing he does is complain of a headache. Then he throws up. It's only when I ask him point-blank if his throat hurts that Sam mentions that, yes, it's pretty sore.

Henry, 4, will complain bitterly of both a headache and a sore throat. When I take him in for a throat culture, he almost always has strep, as well as an ear infection. Or two ear infections.

At 2, Joe, the baby of the family, has never had strep throat, but last winter he had a weird, blisterlike diaper rash. Our pediatrician told me it was impetigo, an infection caused by the same bacteria that cause strep throat.

It doesn't help that strep is a bacterial infection that kids can catch repeatedly, often with slightly different symptoms each time. Unlike a virus, which triggers an immune response that helps prevent reinfection, a child can be ill with strep, start to feel better, then catch it all over again from the very family members to whom he passed on the illness in the first place. Last winter my kids and I shared a strep bug, in a variety of forms, for five weeks before we finally got everyone well.

I emerged exhausted but determined to find out more about the illness so I can do a better job of keeping my family healthy.

Hello, Group A

Strep bacteria most often cause strep throat, impetigo, and scarlet fever (a throat inflammation and body rash); less often, the bacteria are the cause of ear infections and sinusitis. They produce more than 10 million cases a year, mostly in kids ages 3 to 10, according to the Centers for Disease Control and Prevention. The infection is usually mild, and it responds readily to inexpensive antibiotics. Even untreated, most cases get better in about three days.

So why treat it? "We don't treat strep to decrease the duration of symptoms -- antibiotics will shorten them only by a day or so," says Terence Dermody, M.D., professor of pediatrics, microbiology, and immunology at Vanderbilt University School of Medicine, in Nashville, Tennessee. "We treat it because we're concerned about the very real possibility of post-strep complications."

The litany of these possible complications is frightening. Fortunately, they are exceedingly rare. But they're worth noting because they're serious, sometimes fatal, yet are almost always preventable.

One class of complication is "invasive strep." The body is pretty good at keeping strep bacteria confined, but sometimes -- especially in children with other illnesses, either acute or chronic -- they can break through. In the lungs, strep A can cause pneumonia; in the blood, toxic shock; in the muscles, a rare form of the bacteria can lead to necrotizing fasciitis, better known as "flesh-eating disease."

The second class is autoimmune disease. Typically, strep throat goes away by itself, but new symptoms, such as painful, swollen joints, appear one to five weeks later. These are symptoms of rheumatic fever, in which the body attacks itself; it can damage connective tissue (collagen), impair the heart, and cause arthritis. How this occurs is becoming clearer: Last year scientists sequenced the strep A bacterium's genome -- a breakthrough that may one day lead to a vaccine -- and discovered that strep produces a protein almost identical to collagen. So when the immune system attacks strep, collagen may be an unwitting target. (A different autoimmune response may lead to a kind of kidney disease called glomerulonephritis.)

There's no need to be alarmed, just alert. "Group A strep deserves a healthy respect," says Dr. Dermody. "We want parents to be aware of the importance of testing for and treating strep." That vigilance has paid off: Since pediatricians began testing and treating, these illnesses have declined dramatically. Only about 1 person in 1 million contracts rheumatic fever each year, and in a typical year, there are fewer than 10,000 cases of invasive strep.

Such progress should continue -- if parents and pediatricians remain alert. But don't assume that you'll recognize what's strep and what's not -- even doctors can't be sure without a lab test. Still, some signs are clear enough for you to know it's time for a doctor visit.

Classic strep throat

It starts most often with a very sore throat that comes on suddenly in kids ages 3 to 12, usually about two to five days after a child is first exposed. He may feel like his throat is on fire. Other common symptoms include a sudden headache, swollen lymph nodes in the neck and below the jaw, and a fever above 101°F. Sometimes there's nausea, vomiting, or abdominal pain -- but in other cases, a child's symptoms are quite mild. The back of the child's throat may appear bright red and swollen, and on the tonsils there may be whitish or yellow-colored pus.

A sore throat from a virus, by contrast, tends to come on slowly, with only a low-grade fever. Usually, there are other upper-respiratory symptoms, such as watery eyes, a runny nose, and hoarseness. Strep typically doesn't cause laryngitis.

Pediatricians are clear on one point: When in doubt, always take your child to the doctor for a strep test. "There can be a large overlap of symptoms," says Dr. Dermody. "Doctors have often predicted strep after looking at a patient's throat only to find none -- or expected a virus, only to find strep."


This skin infection can be caused by staph bacteria, or staph plus strep A. Staph-only impetigo is characterized by tiny blisters that may burst, revealing red skin. When strep A is involved, there's a characteristic honey-colored crust too. The incubation period is seven to ten days; the treatment for either kind is antibiotics, oral or topical.

Impetigo that involves strep often attacks the tender skin around the nose and mouth, but it seems to prefer the site of a previous skin injury. So skin that's inflamed by an allergic reaction to soap, or by poison ivy or eczema, is vulnerable. The bacteria can hitchhike on your hands when you scratch, so the infection can migrate to other areas of the body.

Scarlet fever

At first, it looks like a bad sunburn (harder to see on kids with darker skin), but on closer inspection it's made up of zillions of tiny red dots -- and feels like sandpaper. The rash, which may itch, typically appears first on the face and neck, then spreads (frequently within hours) to the chest and back, and then to the rest of the body. (It skips the elbows, nose, and mouth.) The rash will disappear when you press it with your finger.

In many cases, the child's tonsils will have the same whitish or yellow coating characteristic of strep throat and the tongue may have a similar coating, called "strawberry tongue." Later in the infection, the skin on the hands and feet will begin to peel. As with strep throat, antibiotics are an effective treatment.

What the Doctor Does

If your child shows any of these symptoms, see the pediatrician right away for an accurate diagnosis. Doctors confirm a suspected case of strep throat by swabbing the throat and running a rapid-screen test, which offers results in less than ten minutes. A positive result is considered accurate.

However, a negative result -- that is, no evidence of strep -- from the rapid-screen test isn't 100 percent reliable. So if it's negative but your child has the classic symptoms of the disease, your doctor should order a backup culture, which takes up to three days. Fortunately, this one is close to 100 percent reliable in diagnosing strep infections.

A word about babies: The classic sore throat usually won't appear. Instead, they may have a runny nose and sores around the nostrils and may run a low-grade fever. Or they may just be cranky. If there's been an outbreak of strep at your baby's daycare center, or if you have an older child with a recently confirmed case of strep and your younger one shows these symptoms, ask your pediatrician to culture her for strep.

Once you've got an accurate diagnosis from the pediatrician, the drug of choice for treatment is penicillin or one of its cousins (or, in the case of penicillin-sensitive children, erythromycin), given for ten days. If that's not feasible, a doctor can also administer a single intramuscular injection -- a big fat shot, time-delayed to release the drug over a ten-day period.

There's no advantage, clinically, to one form of treatment over the other. Though the injection is obviously more painful than a spoonful of syrup -- and even more painful than ordinary vaccine injections (it's a real doozy, according to my son Sam, who had to have one when he was diagnosed one Sunday night after our pharmacy had already closed) -- it does offer a one-time-and-you're-done advantage to parents whose child makes a gigantic fuss over taking medicine. It's also worth considering if you're so busy that you don't trust yourself to correctly dose your child each day.

Before prescribing antibiotics, a pediatrician will usually get the results of either the rapid-screen test or a backup culture. If your child has a viral infection rather than strep, for example, antibiotics will do no good, and by causing side effects and possibly breeding resistance, they may do harm. Once your child starts taking antibiotics, the sore throat and other symptoms should begin to improve within 24 hours. In the meantime, you can ease the sore throat by having her gargle with salt water every few hours if she's old enough to do so and offering ice water (or chipped ice), plenty of fluids, and candy to suck on (if she's 4 or older); give her acetaminophen or ibuprofen for pain and fever relief. If she's not feeling better after two or three days, has a rash that looks like it's getting worse, or has a fever that's not going down, call the doctor.

Back to School or Daycare

Strep isn't contagious after 24 hours on antibiotics, so if your child's symptoms have eased off and he's fever-free, he can return to civilization. But it's vital that all medication be taken on schedule and finished completely, even if symptoms appear to subside immediately.

"Group A strep bacteria are sensitive to penicillin, but they won't roll over and die in one day," says Dr. Dermody. "To avoid complications, you want the penicillin on board for the full ten-day period."

With 10 million-plus strep infections occurring a year, it's comforting to know that this is one potentially risky disease you can actually do something about. You just have to know what to look for.

Margaret Renkl, a contributing editor to PARENTING, wrote about birth order in the June/July issue.