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!