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Strep A: what does an unwell child look like?

Written by Caidr's team of doctors and pharmacists based in UK | Updated: 26.01.2023 | 5 min read
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Parents are understandably anxious about the rise in Group A strep cases currently. Streptococcus A is a very common bacterial infection affecting those from 4 to 14 years old, and it usually causes a mild sore throat and fever. Concerns have been raised in late 2022 that cases are higher than usual at this time of year, with reports of deaths causing parents and teachers alarm.

Although rare, some children contract an invasive form of Group A Streptococcus (iGAS), leading to severe illness requiring hospital treatment and possible threat to life.

Advice from the public health bodies has emphasised presenting your child when they appear very unwell, but what does this mean? Let’s talk you through how to recognise the signs, when to seek help and when to worry.

What does strep A throat look like?

If you look at the back of the throat, you should see a dark hole at the back of the tongue, a boxing bag hanging down the middle (the uvula), and the tonsils making up the walls on either side. In a healthy throat, this makes a symmetrical ‘M’ shape. If one or both sides of the tonsils are bulging, very red or with white spots (pus), this could be reason to suspect a strep throat.

While most sore throats are caused by viruses and get better without treatment, doctors sometimes use a scoring system, known as the FeverPAIN score for strep pharyngitis, to guide whether they will give antibiotics. It adds together findings from their examination along with symptoms that point more towards strep throat and away from viral infection. The score suggesting strep throat includes:

  • severely inflammed tonsils
  • pus on the tonsils
  • symptoms starting within 3 days
  • fever in the last 24 hours
  • no cough or other cold symptoms (a cough makes viral infection more likely)

Another scoring system, the Centor score for strep pharyngitis, adds in the presence of enlarged lymph glands in the neck and a suspected or confirmed COVID-19 infection.

Viral infections are much more likely to cause a sore throat and they do not respond to antibiotics, they usually just get better within 7 days.

What does scarlet fever look like?

Scarlet fever is caused by strep A, and describes a collection of symptoms that start with a flu-like illness – a high temperature, sore throat, swollen neck glands and possibly headache, nausea and vomiting, muscle or body aches. A distinctive rash develops 12 to 48 hours later, with tiny red raised bumps on the chest and stomach, which rapidly spread to other areas.

The key characteristic is that this feels rough to the touch, like sandpaper. In skin of colour, the red colour may be less easy to see, but it will have the characteristic rough feel.

Some children develop what is called a strawberry tongue, where the tongue is bright red with white dots like strawberry pips. Their cheeks do not have the distinctive rash but can look very red.

It’s important that children with scarlet fever are assessed urgently and given antibiotics, to prevent complications such as pneumonia and sepsis, and to prevent spread to others.

Treating a fever

Many parents know when their child has a fever – they look hot, sweaty and flushed, and they may feel cold, shivery or distressed. It’s best to have a digital thermometer to hand – a fever is a temperature over 38°C – so you can be accurate and also monitor how well it responds to any treatment.

You can give paracetamol or ibuprofen, but only give one at a time. They can both take up to 30 minutes to work if given as liquid or tablets (or 60 minutes as suppositories). Paracetamol is usually the safer to start with, followed by ibuprofen if it hasn't taken sufficient effect after 1 hour. Check the label to ensure you don’t exceed the recommended maximum dose within 24 hours.

When to worry about a fever?

A fever is one of the body's defence mechanisms in fighting an infection, but it can cause problems if prolonged, very high or your child is not adequately fighting off any virus or bacteria.

You should see a doctor if:

  • your baby is under 3 months and has a temperature of 38°C or higher
  • your baby is 3 to 6 months and has a temperature of 39°C or higher
  • your child seems well but has a fever for 5 days or more
  • your child seems unwell
  • it's not clear what is causing your child's fever
  • your child's fever does not improve with regular paracetamol and ibuprofen

Avoid tepid sponging, flannels or fans, and do not strip them of clothes, as this can make your child more unwell.

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What does a dehydrated child look like?

Let’s keep it simple – hydration is about fluids in and fluids out. During infection and fever, your child needs to drink more than usual. You need to keep offering them fluids little and often, and keep a record of what they’re drinking. Likewise, breast feeding or formulas may need to be shorter and more frequent, or you may need to top up with water if your baby is feeding less.

As doctors, we worry if they are drinking less than half in a 12 hour period, or passing urine much less in the same time. Children and especially babies become dehydrated more quickly than adults, as they have a much smaller surface area, putting them at greater risk of severe illness.

If urine looks dark and smells strong, and there’s a low volume or it’s infrequent, these are signs that your child may be becoming dehydrated. As doctors, we look for other signs, like dry lips and tongue, crying without tears, sunken eyes, or cool fingers and toes. Illness and dehydration can make babies and children drowsy or difficult to wake, and this is reason to seek help urgently.

When should I seek urgent help?

Great Ormond Street Hospital, the world-renowned children’s hospital, has outlined the following reasons in suspected strep throat or scarlet fever to call 999 or go to the Emergency Department:

  • your child is having difficulty breathing – you may notice grunting noises or their tummy sucking under their ribs or using their neck muscles to breathe
  • there are long pauses (more than 10 seconds) when your child breathes
  • your child’s skin, tongue or lips are blue
  • your child feels very cold or clammy to touch
  • your child is difficult to wake up or keep awake
  • your child has severe pains in their arms, legs neck or back
  • your child has a painful, red area of skin, especially if it is getting bigger quickly

As a parent, you should trust your instinct and seek urgent help if you feel that your child or baby is seriously unwell.

Related topics

Read more about Strep A related topics:

What is Strep A?

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