Simplifying Sore Throats – A Pediatrician’s Perspective

Sore throats are puzzling for parents. Small children with sore throats cannot explain what is wrong; and older children– who can identify and locate their pain- still leave parents in a quandary. What is causing the problem, and when should they worry?

Q: What is a Sore Throat?

A: Pharyngitis (an inflamed or sore throat) is an infection that has a fairly typical set of symptoms associated with it although it can be caused by many different organisms. Children with sore throats almost always have: painful swallowing; neck soreness in the glands right under the jaw; decreased eating, especially of salty or “sharp” food; and decreased drinking, especially of acidic drinks like juice. A small child with a sore throat will push her bottle away, often crying as she refuses to drink. A sore throat can also be part of an illness that includes: fever, rash, and even cold or cough symptoms.

Sore throats can be caused either by viruses or– importantly– by a bacterium called Streptococcus pyogenes (“strep” for short.) A very significant point differentiates them from one another: a viral sore throat will go away by itself, but a strep throat must be treated with an antibiotic to avoid life-long complications. Said differently, antibiotics should be used for strep throats– and for strep throats only.

Q: What is a Strep Throat?

A: Caused by the bacterium Streptococcus pyogenes (or group A strep), strep throat is an infection seen in children aged 5-15 that has several distinctive features:

o It can come on quickly and usually includes fever in the 102°F (39°C) range, tender glands under the jaw, and white pus on the tonsils.

o It may also include a headache and stomach ache (mostly in older children), a “sandpapery” rash on the trunk, and/or nausea and vomiting. If the sandpapery rash appears, then this infection is called “scarlet fever.”

o It requires: a visit to the doctor, a throat swab for accurate diagnosis and-as noted above– antibiotic treatment to avoid serious complications.

Q: How Do I Know if My Child Has a Sore Throat?

A : The answer to this depends on whether or not your child can talk! A child who can talk will tell you, among other things, that: it hurts to swallow; he’s not hungry; his mouth, throat and/or neck “hurt”; he feels cold or achy (if he has a fever, too.) All of this is fairly straightforward.

A child who can’t talk is harder to read. He will refuse juice; be crankier than usual, especially when eating, and even push his food away; may drool his saliva and/or drinks; may put his fingers in his mouth; may be listless and sleepy if he has a fever.

Q: How Can I Keep My Child Comfortable?

A: There are several excellent tricks for keeping your child comfortable. You can help your child feel better by giving him ice chips, popsicles or ice cream. Cool, bland foods like yogurt or frozen fruit are great, too. Avoid salty, spicy foods like chips and pizza because they sting. Drinks like smoothies or milk– complete with a fancy straw-are easy to slip past a sore throat.

Feel free to give your child pain medicine like ibuprofen (Advil, Motrin) or

acetaminophen (Tylenol.), but take your child’s temperature before giving it to

him. The presence of a fever is one of the factors that your doctor will take into account when diagnosing your child. Avoid throat sprays and lozenges for your child: throat sprays can interfere with the gag reflex (!) and lozenges are a choking hazard in young children.

Q: When Should I Call the Doctor?

A: You should call the doctor urgently if your child:

o Is drooling and appears sick, with his mouth hanging open. If he is making noise when he breathes or looks afraid, please comfort him and call for help. Do not take his temperature as this may upset him further.

o Refuses to drink even small amounts of liquid especially if he is getting dehydrated (producing few tears and/or little urine);

o Has a worrisome fever for his age: over 100.4ºF (38ºC) for a baby less than 3 months; over 102ºF (39ºC) for a child less than 2 years; over 104ºF (40ºC) for a child over 2 years;

o Just “worries” you-especially if he is younger than 2.

Q: Will the Doctor Prescribe Medicine?

A: The doctor will ask lots of questions, as usual, and examine your child, especially his neck, throat and skin. If she is worried about strep throat, the doctor will touch your child’s throat with a long cotton swab (like a Q-tip) to use for a “rapid” strep test and/or a throat culture to establish the diagnosis. If the rapid strep test is positive, she will prescribe antibiotics; if it is negative, she will probably send the swab for culture. Cultures actually grow the bacteria swabbed from your child’s throat, and it takes a day or two for the results to come back. Finally, the doctor will ask you to call for throat culture results or with an update about your child in the next couple of days. Feel free to call back earlier if you remain concerned about your child.

Q: What are the Complications of a Sore Throat?

A: The complications of any sore throat-regardless of its cause- can include dehydration and airway occlusion. Dehydration occurs because it is so hard for a child to drink. You can watch for this by noting whether he is finishing his drinks, has tears when he cries, or is urinating as much as usual. Airway occlusion occurs if your child’s tonsils swell so much that air has difficulty getting through. This is fortunately very rare but can be life-threatening. Pay attention if your child is breathing noisily as noted above!

Complications of a strep throat not appropriately treated with antibiotics may include: ear infections, sinusitis, and infections near or behind the tonsils.

Much more rarely, blood infections, rheumatic heart disease and glomerulonephritis (a disease of the kidneys) will follow untreated strep. Given this list of complications, it certainly makes sense that your child should finish his antibiotics as prescribed! Because children with strep feel so much better after the first day or two of treatment, it is tempting to stop the antibiotics prematurely. But please hang in there so that your child can avoid any of these serious complications.

Q: When May My Child Return to Daycare or School?

A: There are three components to the answer of this question. Your child may return to school when he has had no fever for 24 hours (without taking fever medicine); when he is eating and drinking normally; and, assuming he has strep, after he has been on antibiotics for a day.

Q: How Can I Protect My Family from Sore Throats?

A: You can help protect your family from sore throats by avoiding contact with the mouth and nose secretions of your sick child. Of course this is easier said than done (!), but some golden rules apply. Try to avoid kissing him on the lips while your child is sick; do not share drinks or bathroom towels; wash hands (his and yours) often, especially before eating. The hardest is to teach children not to put their fingers in their mouths and noses (good luck!). Finally, limit contact with other sick children by avoiding sick play dates.

Sore throats are extremely common in pediatrics. Differentiating the good from the bad– and knowing how to help your child through either– will help you all feel better!

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The purpose of this article is to educate. While every effort has been made to ensure its accuracy, its content should not be construed as definitive medical advice and is not a substitute for the professional judgment of your child’s health care provider in diagnosing and treating illness. Because each child’s health care needs are unique and because medical knowledge is always evolving, please consult a qualified health care professional to obtain the most current recommendations appropriate to your child’s medical care. Neither the author nor the publisher shall be liable for any outcome or damages resulting from reliance upon the content of this publication.

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