When a sore throat becomes more than just a little scratchy… ie. there is substantial pain… it is time to worry about a bacterial infection in the throat (“Strep throat”).

A couple of important points here:

  • Most(> 95%) very sore throats are viral, and antibiotics won’t help.
  • Strep throat is uncommon, even rare, in children under 2 years of age.
  • As many as one quarter of children who are placed on antibiotics will have some sort of side effect that makes them feel worse.
  • It is usually easy to tell if your child doesn’t have strep throat; many kids have pain without much redness, and the other signs of bacterial infection. But at least 50% of all children who have a markedly red throat, swollen lymph nodes and junk on the tonsils have a virus as a cause. No doctor can just look at your child and accurately diagnose strep throat; a throat swab needs to be done.

So there are a couple of rational approaches to the child with a fever and sore throat. The first is to do a throat swab, start the child on antibiotics, and then stop the antibiotics if the swab comes back negative. The second is to do the swab and wait for the rapid antigen test that can usually be obtained within hours. Obviously, a doctor in an office practice may have less access to this sort of test, and may rationally choose the first pathway over the second. I favor the second, because I practice in emergency, and because I don’t want to expose my kids to a risk of side effect unnecessarily.

The critical message, though, is that a throat swab is necessary. The rule should be: no throat swab, no antibiotics.

Dr. Brett Taylor is an emergency pediatrician, an associate professor of pediatrics and emergency medicine and a masters candidate in health informatics based in Halifax, Nova Scotia, Canada.

See also our article on the BC Nurseline.