Strep Throat in Children: Signs, Testing, and Treatment

How strep throat differs from a regular sore throat

Most sore throats in children are caused by viruses and clear up on their own. Strep throat is caused by a specific bacterium — group A Streptococcus — and tends to come on more suddenly. Providers look for a cluster of features that together raise suspicion 1Ref 1Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C (2012).Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.Diagnostic criteria, testing approach (rapid test + culture backup for children), first-line antibiotic treatment (penicillin/amoxicillin 10 days), and return-to-school guidance after 24 hours on antibiotics:

• Sore throat that comes on quickly
• Fever (often 101°F / 38.3°C or higher)
• Swollen, tender lymph nodes in the front of the neck
• Red, swollen tonsils — sometimes with white patches or streaks
• Headache or stomach pain
• Absence of a runny nose, cough, or hoarse voice (these are more common with viral infections)

Because the symptoms overlap with many other illnesses, a test is the only reliable way to confirm strep 1Ref 1Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C (2012).Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.Diagnostic criteria, testing approach (rapid test + culture backup for children), first-line antibiotic treatment (penicillin/amoxicillin 10 days), and return-to-school guidance after 24 hours on antibiotics2Ref 2Centers for Disease Control and Prevention (2025).Clinical Guidance for Group A Streptococcal Pharyngitis.Throat culture as gold-standard test; recommendation to back-up negative rapid tests with culture in children; first-line antibiotic regimens; return-to-school timing.

Testing for strep: rapid test and throat culture

A provider swabs the back of the throat (briefly uncomfortable but quick) and tests the sample. The rapid strep antigen test gives results in minutes and is the standard first step 2Ref 2Centers for Disease Control and Prevention (2025).Clinical Guidance for Group A Streptococcal Pharyngitis.Throat culture as gold-standard test; recommendation to back-up negative rapid tests with culture in children; first-line antibiotic regimens; return-to-school timing. If negative but symptoms are strongly suggestive — particularly in children — a throat culture should be sent to a lab for a more sensitive result; cultures are returned in 1–2 days and are considered the gold-standard diagnostic test 1Ref 1Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C (2012).Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.Diagnostic criteria, testing approach (rapid test + culture backup for children), first-line antibiotic treatment (penicillin/amoxicillin 10 days), and return-to-school guidance after 24 hours on antibiotics2Ref 2Centers for Disease Control and Prevention (2025).Clinical Guidance for Group A Streptococcal Pharyngitis.Throat culture as gold-standard test; recommendation to back-up negative rapid tests with culture in children; first-line antibiotic regimens; return-to-school timing.

Strep is uncommon in children under 3 years old; it becomes more prevalent starting around age 5 and peaks in the school-age years (5–15).

Treatment with antibiotics

When a test confirms strep, a provider will prescribe antibiotics — most commonly a 10-day course of penicillin or amoxicillin, which remain the first-line choices 1Ref 1Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C (2012).Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.Diagnostic criteria, testing approach (rapid test + culture backup for children), first-line antibiotic treatment (penicillin/amoxicillin 10 days), and return-to-school guidance after 24 hours on antibiotics2Ref 2Centers for Disease Control and Prevention (2025).Clinical Guidance for Group A Streptococcal Pharyngitis.Throat culture as gold-standard test; recommendation to back-up negative rapid tests with culture in children; first-line antibiotic regimens; return-to-school timing. Shorter courses of other antibiotics may be used for children with penicillin allergy. It is important to complete the full course even if the child feels better after a few days, to ensure the infection fully clears.

Children are generally no longer contagious after 24 hours on antibiotics and once they are fever-free — at that point they can typically return to school or childcare 1Ref 1Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C (2012).Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.Diagnostic criteria, testing approach (rapid test + culture backup for children), first-line antibiotic treatment (penicillin/amoxicillin 10 days), and return-to-school guidance after 24 hours on antibiotics. Without antibiotics, strep remains contagious for 2–3 weeks.

Why treating strep matters: preventing rheumatic fever

Most children with untreated strep will improve on their own — but treatment shortens illness, reduces contagiousness, and lowers the risk of complications. The main complication that treatment aims to prevent is acute rheumatic fever — a rare but serious inflammatory condition that can damage heart valves. Antibiotic treatment of strep pharyngitis is highly effective at preventing rheumatic fever when started within 9 days of symptom onset 3Ref 3Gerber MA, Baltimore RS, Eaton CB, et al. (2009).Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis.Antibiotic treatment of group A strep pharyngitis prevents acute rheumatic fever when started within 9 days of symptom onset.

Other uncommon complications include peritonsillar abscess (a collection of fluid near the tonsils) and post-streptococcal glomerulonephritis (kidney inflammation).

Comfort measures while recovering

While waiting for antibiotics to take effect (usually 1–2 days), several measures can help:

• Age-appropriate acetaminophen or ibuprofen for fever and throat pain (ibuprofen is not recommended under 6 months)
• Cold fluids, ice chips, or cold foods like frozen fruit — cold can soothe a sore throat
• Soft foods if swallowing is painful
• Rest

Warm saltwater gargles can help older children who are able to gargle.

Recurrent strep and tonsillectomy

Some children get strep throat repeatedly. Current ENT guidelines suggest watchful waiting when there have been fewer than 7 episodes in the past year, fewer than 5 per year in the past 2 years, or fewer than 3 per year in the past 3 years 4Ref 4Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, et al. (2019).Clinical Practice Guideline: Tonsillectomy in Children (Update).Watchful waiting thresholds for recurrent strep before tonsillectomy referral (7/1yr, 5/2yr, 3/3yr). When a child has frequent, confirmed, and severe cases beyond these thresholds, a provider may discuss a referral to an ENT specialist to consider whether tonsillectomy (removing the tonsils) might help. This is a decision made carefully with a specialist after a documented pattern of recurrence.