From the Guidelines
Throat culture for Group A beta-hemolytic Streptococcus (GABHS) is not routinely indicated in young children under 3 years old due to the low risk of acute rheumatic fever and the uncommon incidence of streptococcal pharyngitis in this age group. This recommendation is based on the guidelines from the Infectious Diseases Society of America, as stated in the 2012 update 1. The guidelines suggest that diagnostic studies for GAS pharyngitis are not indicated for children under 3 years old, unless they have other risk factors, such as an older sibling with GAS infection.
The symptoms of strep throat in young children are often non-specific and can be similar to those caused by viral infections, making clinical diagnosis less reliable. Young children typically don't complain of sore throat and may instead have symptoms like fever, irritability, and decreased appetite. Testing all young children with these non-specific symptoms could lead to overdiagnosis and unnecessary antibiotic use, which can contribute to antibiotic resistance and disrupt the child's normal gut flora.
As stated in the guidelines, testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiological features that strongly suggest a viral etiology 1. Additionally, the guidelines from the American Family Physician also support this recommendation, stating that testing is generally not recommended in children younger than three years unless the child has risk factors, such as an older sibling with the illness 1.
In most cases, supportive care and monitoring for worsening symptoms is the recommended approach for managing sore throats in young children. However, if a child under 3 has been exposed to a family member with confirmed strep throat or if they have persistent symptoms, testing may be considered on a case-by-case basis. The guideline for the management of acute sore throat also supports this approach, stating that throat culture is not necessary for routine diagnosis of acute sore throat to detect group A streptococci 1.
Some key points to consider when managing sore throats in young children include:
- The low risk of acute rheumatic fever in children under 3 years old
- The uncommon incidence of streptococcal pharyngitis in this age group
- The non-specific symptoms of strep throat in young children
- The potential for overdiagnosis and unnecessary antibiotic use
- The importance of supportive care and monitoring for worsening symptoms.
Overall, the current evidence supports a conservative approach to managing sore throats in young children, with a focus on supportive care and monitoring for worsening symptoms, rather than routine testing for GABHS.
From the Research
Reasons for Not Routinely Indicating Throat Culture in Young Children
- Group A Streptococcus is an uncommon etiology of pharyngitis in patients under 3 years old, and sequelae are rare in this age group 2
- Inappropriate testing leads to increased healthcare costs and unnecessary exposure to antibiotics 2, 3
- Rapid streptococcal tests (RSTs) for group A Streptococcus pharyngitis are not routinely indicated in children under 3 years old 2, 3
- The Infectious Diseases Society of America (IDSA) guidelines advise against routine testing for patients younger than 3 years, patients without pharyngitis, and patients with symptoms suggesting a viral infection 3
Consequences of Inappropriate Testing
- Misdiagnosis and inappropriate use of antibiotics 3
- Allergic reactions and loss of school days 3
- Increased risk of antibiotic-resistant bacterial strains 4
Alternative Approaches
- Use of rapid diagnostic tests (RDTs) to detect group A streptococcal pharyngitis in combination with clinical scoring systems, such as the McIsaac score, to reduce antibiotic prescribing rates 5
- Implementation of point-of-care molecular testing to improve turnaround times and enhance antimicrobial stewardship 6