Strep test horrors

The Pediatric Insider

© 2009 Roy Benaroch, MD

Sandy said, “Do you have a suggestion on how to handle a child who is hysterical at the thought of a strep test? Not just ‘I don’t want to’ but screaming and crying hysterically, running around the exam room to avoid the nurses.”

I’ve seen kids like this—scared out of their wits. I know a strep test isn’t the most pleasant thing in the world, but some children think they’re the most painful, horrible thing possible. Fighting and holding them down won’t help dispel their fears!

First, I hope that your pediatrician only wants to do a strep test if it’s really necessary. Most sore throats, even in the winter during strep season, are not caused by strep bacteria. Strep throat typically looks like this:

  • Sudden onset
  • Severe sore throat, with red and swollen tonsils
  • Swollen, tender lymph nodes in the neck
  • Usually fever
  • Sometimes abdominal pain, nausea, or vomiting
  • Sometimes headache
  • Seldom cough or runny nose

Most viral sore throats are more like this:

  • More gradual onset
  • Milder sore throat, without swollen nodes, or with small non-tender nodes
  • Often runny nose and cough
  • Fever, if present, will only be there for the first day or so

Based on the symptoms and physical exam, you and your doc can make a pretty good guess whether it’s likely to be strep. If it seems far more likely to be viral, it’s unnecessary to do the test. In fact, it’s more than unnecessary—it’s a very bad idea. A strep test isn’t perfect; if the “pre-test probability” of strep is very low, even a positive test will probably be incorrect.

What if based on the symptoms and physical exam the possibility of strep is very high? In that case, it may also be a good idea to skip the test—your doctor is probably going to prescribe antibiotics anyway, so why do the test? Strep tests are most important in that grey zone, when it’s kind of hard to know for sure whether an infection is likely to really be strep.

Taking it a step further, what would happen if you and the doctor decided to just skip the test, and make a guess? One of these four scenarios would occur:

  1. The child really has strep, and you’ve decided to give antibiotics. Well, that’s just peachy.
  2. The child really has strep, but you’ve decided against giving antibiotics. In this case, Junior will most likely get better anyway—but it will take a few extra days, and in the meantime he might be infecting other people. There’s also a small, but real chance that the infection can spread into an abscess, and a very small risk that untreated strep could result in heart damage from rheumatic fever (this is often given as the main reason to do the strep test, to avoid untreated strep. But in fact rheumatic fever for reasons unknown has become very rare in the developed world, even without antibiotics being used.)
  3. The child doesn’t have strep, but you put him on antibiotics anyway. We’d like to avoid doing this—unnecessary antibiotics contribute to bacterial resistance, and put your child at risk for allergies. Still, a single course of antibiotics is unlikely to make a huge difference in any significant way.
  4. The child doesn’t have strep, and you’ve decided to withhold antibiotics. Perfect.

Though it sounds like sacrilege to say it, this Pediatric Insider thinks: none of these four scenarios is likely to end in disaster.

So think carefully, and ask for your pediatrician’s input: for a child truly terrified of a strep test, is it really necessary to do it? Under ordinary circumstances, I think a strep test should always be done prior to antibiotics—there are risks of antibiotic overuse that are a real problem—but in an individual case where a child is going to be traumatized, there really is wiggle room for compassion and judgment.

OK, you’ve decided: you need to do the test. There are ways to (hopefully) minimize the discomfort and anxiety of the child. Some of these tricks I’ve tried:

  • Let the doctor do it instead of the nurse. I think some patients think I’m more gentle. I don’t know if that’s correct, but if makes Junior feel better, I’m game to try.
  • Let the child do it himself. Really. Tell Junior to hold the stick, and stick it down there, and swoosh it around. I’ll look with a flashlight to make sure you did it right, and I’ll keep my hands behind my back—promise. This really has worked for me, more than once.
  • If the child’s willing to work slowly with me, I’ll take the swab and just rest it on his tongue awhile. Let him get used to it. Keep talking, distracting, and inching it back. It sometimes might take a few false starts, but this can work.
  • Spray benzocaine solution back there to numb things up, wait 10 minutes, then do the test. Honestly, I’m not sure if maybe the benzocaine spray might interfere with the test—but at least the child feels he’s overcome some fear, and you can build from this positive experience in the future.

One thing I would not recommend is brute force. It might work—once—but it reinforces the worst lessons and scariest feelings, leaving the child vulnerable and completely out of control. It also makes future interactions a nightmare. Whether a strep test is done is never a critical issue. This isn’t someone who might be having a heart attack, or who needs an essential test to see if he has cancer. Keep things in perspective, and have some compassion. He probably feels pretty bad already, and doesn’t need some big galoot holding him down!

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6 Comments on “Strep test horrors”

  1. Beth Says:

    This is why our kids love you so much. Heck, this is why their dad and I do too!


  2. Nichole Says:

    That’s the best answer you could hope for from any doctor. My daughter is medicated for severe anxiety and this is one of them. I hate it when she sick we end up leaving crying and screaming and nothing done except me apologizing for her fears. We have had one pediatrician who would look and see the obvious and treat her while everyone else needed to charge a test. So if all doctors could See your point of view life for people like my daughter and myself would be so much easier.


  3. Marley Says:

    I really appreciate this post! My child has had a very sore, strep-y looking throat for a week and just could not complete the strep test at the doctor’s office after 2 valiant efforts. After reading your post, it does seem like this is more than a viral illness and I feel a lot better about going ahead with the antibiotics, even though we aren’t completely sure what we’re dealing with. Thank you.


  4. Kay Says:

    I am a teen, but I am still extremely mental about strep tests. I hate them Hecate then HATE THEM! My gag reflex is insanely strong, which makes it all worse! Believe me: I would, no, I WANT to go sit down and get it over with, but I’ve had some very traumatic experiences, including the last. I fought off the nurse and the doctor. In all, they had three nurses AND a doctor in the room, and still didn’t end up doing it. I JUST CANT!! It frustrates me sooo much and I’m so mad at myself! My parents hate taking me to the doctor because of this. Well, I have to go to the doc tomorrow because my mom has strep and I think I do too. Any quick solutions, new technology, or SOMETHING THAT WILL HELP?!?!?


  5. Ace Says:

    I am 10.. And mate, I am extremely hysteric about strep tests. I hate them! Anytime I go to the doctor need to be held down against my will, while my mom forces my hands together so I cant instinctively fight them off. I was also diagnosed with S.A.D and regular A.D. And trust me it doesn’t help at all. And I WANT to go sit down and get it over with, but I just can’t! My mom hates needing to take me to the doctor because of me leaving screaming, while sometimes throwing up with fear, anxiety, and the fact that I had a giant pussy stick going directly into my throat. Even worse, I have to go to a new doctor within minutes because my mom just came back and she has an upper respitary infection, and I am also sick with similar symptoms so her doctor wants me to get checked. gOD pLEase, Is there any way to get tested for strep, resp, ect without using a culture?


  6. Tanya Lofton Says:

    Thank you for this post. My son who is 12 now is petrified of this test. A dr. many years ago threw my son up against the wall and took me by surprise. He made it like he was going to play a game and had him put his hands in his pants and bamn! It was said and done. Before this my son never had fear or severe anxiety. Now It is traumatizing. I don’t want to keep forcing him. He gets humiliated and he is scared to death. For myself I can’t do this anymore and every freaking time the test is normal.


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