Strep throat or tonsillitis

How is this illness referred to? Throat infection? Tonsillitis? Pharyngitis?

These two different terms are quite similar.
Throat infection or pharyngitis – redness and pain in the back of the throat.
Tonsillitis – redness, pain and sometimes white exudates on the tonsils.
The tonsils are a lymphatic tissue found in the back of our throats.
There is, however, a slight clinical difference between these two terms. What I mean is that there is a difference between seeing a throat that is slightly red and seeing tonsils full of white pus. Even though, practically speaking, and for the purpose of this chapter, I will be using the term throat infection to describe all these different infections.

What causes throat infection in children (and adults)?

Throat infection is caused mostly by viruses, many different respiratory viruses but also viruses such as Epstein-Barr Virus and Cytomegalovirus that cause an infection called “kissing disease” or infectious mononucleosis. Learn more about infectious mononucleosis in the link here.
A small percentage of throat infections are caused by bacteria, mainly Group A Streptococcus.

What are the clinical manifestations of throat infections in general, and in those caused by Streptococcus in particular?

Strep throat tends to develop quickly (acutely) and includes symptoms such as fever, headache, pain on swallowing and abdominal pain. The child may have a characteristic voice referred to as “hot potato voice”.
A characteristic rash can develop indicating the onset of scarlet fever, see more about this below or in the link here.
When examining the throat, you can usually see redness behind the palate, swelling and redness of the tonsils as well as the presence of white exudates covering the tonsils. It is also common to find swollen and tender lymph nodes in the neck region.
Absence of fever and presence of symptoms such as cough, runny nose, eye infection or hoarseness indicate a viral infection, rather than a bacterial infection.

What age group does strep throat typically affect?

Strep throat is common in children 5 through 15 years old, but it can of course also affect people who are older or younger. Many times, parents catch strep from their kids and here and there I’ve seen grandmas catch it from their grandchildren…
The infection is not common in children under the age of 3 years. Even if you tell me that your 1-year-old tested positive for strep I can assure you that he/she are simply carriers and not actually ill. Keep reading to find out more.
There could be real cases of strep throat in children aged 2 years. These are, however, rare and will usually occur in children who have older siblings or who attend daycares with older children (over the age of 3). But this is still much less common.
So, if your physician tested your child, who is under 2 years, for strep throat (or worse, if they actually prescribed an antibiotic without testing first), try to ask them why they did so, because this will usually be a mistake. Even if the test comes back positive, as you will see below.

Can the physician (or mother) diagnose the cause of the throat infection just by looking at the throat?

Absolutely not! That type of attempt is just bound to fail. An experienced mother or physician will look into a child’s mouth and think to themselves (or out loud), “oh this looks like strep”, but even the best of doctors and best of mothers will not be able to identify the causing pathogen just by looking at the throat.
For example, throat infection due to infectious mononucleosis (find out more about it here) can look exactly like strep throat, at least in terms of the appearance of the throat.
There have been attempts in the past to try and create a scoring system that will help predict the likelihood of strep throat in children complaining of sore throat. Nonetheless, the ability of these scores to make an accurate prediction are low.
And therefore, because of this, every time there is a concern for strep throat you must make a proper microbiological diagnosis, which usually means taking a swab to test for strep.

What are the different types of throat swabs out there?

Rapid strep test – the main advantage to this test is that you get your result on the spot. A positive result confirms the presence of Group A Strep in a child’s throat. This swab is about 70-90% accurate, so if you get a negative result you have to obtain a regular throat culture. How to (successfully) take a throat culture from a child or an adult? Read here.
By the way, this is the only section in this post where management in adults will be different than in children. According to the official guidelines for adults, there is no need to obtain a regular throat culture if the rapid test is negative.
Throat culture – this is considered the most accurate test for strep throat. The only issue is that it takes time for the results to come out (approximately 2 days).

Is the swab always positive at the beginning of the illness?

This is a question I get asked almost every day. A classic scenario is a child that comes into a doctor’s office with a concern for strep throat. The doctor swabs the child and the mother questions whether a throat swab taken so early in the disease is reliable.
The answer is yes. If the child has strep throat, a test taken in the first few hours after the onset of symptoms will indicate strep throat (and I’ll tell you a secret, a test taken before those few hours will be positive, as well!). And if the result is negative and the swabbing technique was adequate, then the bacteria will not just pop up tomorrow.

How is a throat swab taken?

To reduce the probability of getting a false negative result, it is best to have a skilled professional perform the test.
I know that many parents do the throat swab either at home or at the pharmacy. When the swab is positive, streptococcus has been isolated in the throat. When the swab is negative and there is a reasonable concern for strep, see a professional and repeat the test.
My tips for taking a proper swab are to make sure the swab touches both tonsils and the back of the pharynx.
Often, a tongue depressor is required to push the child’s tongue down while swabbing. And why is that? This is because it is difficult to reach the back of the pharynx without depressing the tongue. Contact with the tongue is often the reason for false negative results.
You can read more about proper swabbing techniques in the link here.
And another word for parents who swab their kids at home, read the next paragraph before proceeding to do this. The fact that your child has streptococcus in their throat does not necessarily mean he/she has the infection.
Please avoid the unnecessary usage of antibiotics.

If the swab confirmed the presence of streptococcus bacteria, does this mean my child certainly has strep throat infection?

The answer to this is complex.
There is a large percentage of carriers in the general population (about 10-15%). There could be a scenario where a child comes to the office with a runny nose and a red throat – signs of a viral infection. If the physician decides to test him/her for streptococcus, the chance of isolating streptococcus is the same as the carrier rate in that same population. And then, getting a positive result will lead to unnecessary antibiotic treatment.
So, how can we distinguish between carrier state to the presence of bacteria because of a real infection? A throat swab should be taken only in children presenting with an acute illness that is likely due to streptococcus. In other words – a child in the common age group presenting with the characteristic clinical signs and symptoms of strep throat.
When a physician takes a throat swab, they are committing to the possibility of a real streptococcal infection that requires antibiotic treatment if positive.
Throat swabs should not be taken just for fun, in children who are not showing real signs of strep throat. They should never be taken just because the parents requested it.
I’ve been hearing about many children who get tested at the pharmacy lately. I think these tests should only be done after thorough history taking and clinical assessment.
Have a skilled healthcare professional take a look at your throat and determine whether there is a need for a throat swab. Don’t just go and get tested by someone that does the test without a full assessment.

So, are rapid strep tests useful?

When taken by skilled hands, rapid strep tests are a true asset when it comes to diagnosis and shortening of disease in children.
If your family physician does not have these tests in their office, I suggest you buy one and go to your family physicians with it.
If your physician suspects strep throat, you can ask them to perform the test using the rapid test that you purchased and by doing so to fasten the process and confirm the need for treatment.
Again, I encourage you not to make decisions on your own. See your family physician and allow them to make an educated decision based on their physical examination.