Why Does My Kid Keep Getting Strep Throat?

Thoughts on Infections, Carriers, and Tonsillectomies

If it feels like every family you know has been battling strep throat this year, you could be right. 

We’ve seen a record number of kids coming to our office for strep throat – often more than once. Adding to the chaos, kids have been experiencing uncommon symptoms of this bacterial infection, and it has been difficult to treat. These unique differences have led to delayed diagnoses, recurring infections, and toooooo many missed school days. 

No one knows why strep throat has been so bad this year, and a retrospective analysis to give us these answers will be months away. Meanwhile, as a Doc working today, I think about my community’s experience in real-time. Taking a moment to blend scientific knowledge with current observations helps me understand where we are now, and how we can keep our kids healthier tomorrow. To me, that’s time well spent. 

Here are a few reasons why I think your kid keeps getting strep throat. 

Theory #1: Strep does not play well with others. 

There is evidence that viral infections, specifically influenza and chicken pox, change the ability of the immune system to fight against the strep bacteria, leaving us more susceptible to severe infection. The mechanism for this increased vulnerability is exceptionally complex and remains an active area of research.

The viral-bacterial relationship becomes relevant when we look back to the fall of 2022. Remember all the RSV, flu, and COVID we saw this year? Everyone was coughing, everyone was sick. If it’s possible that other viral infections also increase strep susceptibility, it might explain one way the rise of strep was so steep and severe. And as viral infections and strep continue to spread this spring, this combo may be a set-up for repeated infections. 

While we are learning more, it’s clear that vaccination is protective against bacterial superinfections. Yet another reason to stay up-to-date with your shots. 

Theory #2: A germ with many costumes. 

Strep is an exceptionally common bacteria, most famously causing throat pain, fever, headache, and nausea. This year, however, we’ve seen strep infections presenting with uncommon symptoms, like headache and fever, or nausea and rash. Some kids are presenting with only a red, bumpy tongue. When common infections present in uncommon ways, they get missed.

In addition, we’ve seen strep infections presenting with common, but exceptionally mild symptoms. In these cases, it’s not surprising that parents assume the mild sore throat or brief headache was caused by seasonal allergies or a respiratory virus. Meanwhile, these infected kids are still going to school, volleyball games, and sleepovers – until they get worse. 

While we continue to see community spread, be aware of the more uncommon presentations of strep infections, like: 

I know it’s not always easy to know when your child needs to be seen by the doc, and you don’t want to bring them to the office for every little thing. But with all the strep going around, it might be best to check in with your doc if your child is feeling unwell for more than a few days. 

Theory #3: We ran out of amoxicillin and things got weird. 

When it comes to choosing the correct antibiotic therapy for childhood illnesses, we lean heavily into the expertise of our infectious disease leaders and the clinical guidelines they create. Except for kids with drug allergies, amoxicillin is the first-line choice for strep throat. Until we couldn’t get it. 

For many weeks during this illness season, it was hard to find “the pink stuff" and our community was forced to use alternatives. During this time, my unscientific, biased observation was an increase in recurring strep infections in kids prescribed certain alternates. The good scientist in me can offer a variety of plausible explanations for this observation. However, the persistence of antibiotic tolerance patterns was hard not to notice. 

If it’s true that certain drug choices were less effective on the infection, we could assume the kids on amox-alt drugs were heading back to school and unknowingly spreading the bacteria to others. This may have added a few weeks onto an already grueling illness season and falsely elevated the true recurrence rates. 

Thankfully, amoxicillin has returned to our local shelves. And outside of kids with severe penicillin allergy, this first-line agent and other friendly beta-lactams are getting the job done. 

Theory #4: The Littles are caught in a rising tide. 

With the dramatic increase in school-aged kids getting infected, younger siblings are also getting infected. This upswing is evident in this data from Epic.

If you look closely at the graph, every age group has seen a rise — even the Littles. 

As a medical community, we have been well taught that we don’t test or treat kids under the age of three years. Strep in that age group is a self-limited illness and doesn’t result in the complications we worry about in older kids. However, during these odd days, it’s possible that untreated Littles are the cause of continuing spread and repeat infections in household members. Think: sloppy kisses and shared drinking cups. 

Testing and treating more Littles may decrease re-infection rates within homes and decrease the spread of infection through childcare centers. In my office, we are continuing to be conservative in this effort. We balance the risks of antibiotic exposure with the benefit of treating symptomatic strep-positive Littles. If you are seeing repeat cases in your home, talk with your doctor about their expert opinion for your family. 

Programming note: I first saw this Epic data in 33Charts, an excellent Substack written by Dr. Bryan Vartabedian. If you are interested in health data, leadership, and amusing anecdote - you should check him out.

Theory #5: Swabs suck. 

Strep throat is diagnosed by testing a sample of saliva taken from the back of the throat. These throat swabs are necessary and quick, but notorious for causing kids to gag. And some kids hate throat swabs so much, they will lie about any throat symptoms to avoid getting the test. And that was 2019. 

Now, try approaching that same wary child with a Q-tip-thing after they have had three years of repeated nasal swabs for flu and COVID testing. Now it’s really not easy.

I know many kids who will keep going to school and activities for DAYS before they finally tell their parents they are not feeling well, just to avoid getting swabbed. Meanwhile, they are sharing germs with friends and classmates along the way. 

Theory #6: Tripping before the finish line. 

When a child is diagnosed with strep, you have to finish all the medicine prescribed and up-level the oral hygiene. 

When you don’t finish antibiotics as prescribed, infections come back. We treat strep throat to prevent the serious complications the bacteria can cause. Feeling better quickly after starting antibiotics is merely a pleasant consequence. Antibiotic therapy needs time to penetrate infected tissues and eradicate harmful bacteria. If you stop the antibiotics before they can do this job, the infection will harbor, fester or return. 

Finally, don’t forget dental hygiene. A few days after starting your antibiotics, grab a new toothbrush. I know this recommendation has been challenged. But with all the recurring infections going around, it’s not a bad idea. It was probably time to get a new one, anyway. 

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Now, some bonus content! Here are the top three questions about strep throat that I’m hearing in my office. 

What if I think I missed my kid’s strep infection? Should I get them tested now?

For children who don’t have any illness symptoms, the benefit of randomly testing for past strep infection is hard to do and rarely helpful. 

Strep throat can go away on its own with symptoms resolving in three to five days. Kids may have a few mild strep infections that self-resolve from time to time. Our immune system can use various techniques to trap and kill the bacteria so it doesn’t cause us further harm, and there’s evidence that we develop antibodies against strep bacteria as we age. 

Even with a super-star immune system, making the choice to avoid testing or treating strep is a bad idea. Not every infection will create protective antibodies, and the strep bacteria does seem to have the ability to work around our immune system to cause disease. (This is a bit of why the hunt for a strep vaccine is still in pursuit.) Plus, untreated strep infections put people at risk of complications. 

In the future, the best practice is to test when suspicious symptoms are present, especially after a known exposure to someone with a recent infection. 

What about strep carriers? Should my whole family be tested?

Strep carriers are individuals who harbor strep bacteria in their throats while being completely asymptomatic. Kids being strep carriers is not uncommon, with rates as high as 20% reported in some studies. 

As serious as symptomatic strep infections are, we don’t worry too much about carrier status. Strep bacteria are not harmful to the carriers themselves. The germ just hangs out, not causing symptoms or any nasty complications. And since the chill bacteria is not causing trouble in the carrier, the carrier is not very contagious to others. In turn, a carrier’s role in perpetuating household infections is debated. 

When strep outbreaks are occurring or repeat infections are in the home, finding and treating asymptomatic carriers is a consideration. To do this, most docs grab a throat culture on a child who has recently completed antibiotics and doesn’t have any symptoms. If the culture is positive, the child is thought to be a carrier and treatment could be an option. 

This season, I have rarely tested for carrier status simply because there is so much symptomatic disease. And with a little digging, I’ve found most kids with repeated infections have simply been repeatedly exposed. However, if you feel that someone in your home may be carrying strep and infecting others in the household, talk with your doc about the next steps. 

Is it time to get their tonsils out? 

Historically, a few strep infections in a year meant tonsils got yanked. Although I certainly have kids who get their tonsils removed every year, most of those kids have additional reasons for their removal besides a few strep infections. 

Since this strep season has been particularly weird, I have not been referring many kids for elective tonsillectomy. This is not a typical landscape to measure the number of infections required to determine if elective surgery will have any benefit. Keep in mind, even when tonsils are out, kids can still get infected. And, some argue that getting tonsils removed in childhood doesn’t make a huge difference in the long run. 

As always, talk to your child’s doc about what they recommend for your family. 

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Pediatricians everywhere are just as eager to have this season of illness behind us. We appreciate your continued patience as we do our best to care for all of our kids this spring — and we look forward to seeing you for well visits this summer. (Read: Make your appointments now!)

Stay well and be safe,