Should we treat strep in kids younger than age 3?

It is widely accepted in the medical community that the presentation of pharyngitis caused by Streptococcus pyogenes in children aged younger than 3 years is rare and does not require treatment because there is no risk of rheumatic heart disease. However, in my practice, strep pharyngitis in this age group is not so rare, and I have observed many cases of untreated strep develop into otitis media, perforations of the tympanic membrane, mastoiditis, wheezing, pneumonia, or even personality changes.

Therefore, I treat children under age 3 who have a positive strep culture with antibiotics. A large percentage of children where I work tend to live in close proximity. It is therefore reasonable to believe that when older siblings and neighbors have strep, their younger siblings and neighbors, even if they are babies, can contract strep as well.

Few, if any, studies have followed untreated strep in children under 3 years because many in the medical community believe that strep infection does not exist or is harmful in this age group. I know it does occur, probably more frequently than current statistics state, but many patients are treated unknowingly because they develop simultaneous ear infections or other negative sequelae.

With the upsurge in antibiotic resistance, healthcare providers, including myself, have been trying to limit antibiotic use. However, I do not know whether it is appropriate to withhold antibiotics when treating strep in children under 3. Is it safe and ethical not to treat until negative sequelae appear? What happens to mild cases if they are not treated? Are the patients who are not treated earlier in the course of their illness at greater risk of having developmental delays or other more serious consequences?

Conversely, is it wrong to treat? Would strep in this age group get better on its own with no sequelae even after it progresses only slightly? If detected early, is watchful waiting appropriate and is the antibiotic use more harmful than helpful?

For now, until there are more concrete answers, I am inclined to treat strep at any age. My hope is that more physicians will recognize that strep does affect this age group, but my ultimate goal is to encourage those interested and capable of clinical research to conduct a study following these children with strep and provide guidance on management.

RACHEL SISSER, MD

Brooklyn, New York

I encourage feedback regarding this issue. Send queries or comments to rsisser@yahoo.com

Dr Sisser is a pediatrician at ODA Primary Healthcare Network, Brooklyn, New York.