Doctors around the United States are seeing an explosion of strep throat cases among children, some of whom are presenting with few or atypical symptoms. Against a backdrop of other respiratory viruses and seasonal allergies, these strep infections may be trickier for parents to notice or providers to diagnose, experts warn.
And this year's unusual and severe strep season coincides with a nationwide shortage of the liquid version of the antibiotic used to treat strep, amoxicillin, NBC News previously reported. Officials first warned about supply issues with the common antibiotic due to increased demand back in October.
Strep throat is a highly contagious bacterial infection of the throat and tonsils caused by Group A streptococcus bacteria, and it's most common among children and teens.
The infection typically causes a sore or scratchy throat, fever, pain when swallowing, red or swollen tonsils, headaches and body aches, and it is spread between people through respiratory droplets produced by coughing or talking, for example, per the Mayo Clinic.
Strep throat can occur at any time of year, but peak season usually starts in December and goes through April, Dr. Victoria Regan, a pediatric specialist at Memorial Hermann in Houston, tells TODAY.com.
While it is normal to see strep throat surge in late winter and early spring, this is the worst it has been in a long time, experts warn. "Doctors are anecdotally reporting seeing many more cases than they've ever seen in the past," Dr. John Torres, NBC senior medical correspondent told TODAY in a segment aired April 12.
“I’ve been in infectious diseases and pediatrics for 30 years, and I’ve never seen it this bad,” Dr. Greg DeMuri, pediatric infectious disease physician with UW Health Kids in Madison, Wisconsin, tells TODAY.com. “We are at a level twice that of our worst year, looking back over the past 10, 20 years or so."
Strep tends to affect kids that are school-aged, says Regan, and 5 to 15 is the most common age group. But right now, doctors are seeing strep throat infections among a wider range of ages.
DeMuri says that this season he's seen strep surge among toddlers and infants, which is unusual. “Primary care clinics are just experiencing this explosion of strep throat in children and even some adults,” he adds.
The U.S. Centers for Disease Control and Prevention has also been tracking a more severe and rare form of strep called invasive group A strep, which has increased among adults and children and caused numerous pediatric deaths since the fall of 2022.
A possible rise in unusual strep symptoms
Additionally, some providers are warning that they are seeing an increasing number of children who test positive for strep throat but present with milder or atypical symptoms, making it more difficult to diagnose and treat the infection before it can spread to others or cause severe complications.
In a TikTok that's garnered over 460,000 views and 22,000 likes, Wisconsin-based pediatric nurse practitioner Dakota Felckowski explained the concerning strep throat trends she has noticed among her young patients.
“Over the last couple of weeks, I’ve been seeing a lot of patients who aren’t showing the typical (strep) symptoms that I would be looking for,” Felckowski tells TODAY.com.
Felckowski says she’s encountered “a lot of kids” who were exposed to strep at school or day care and test positive, despite having only one strep symptom or symptoms that weren’t “that classic fever or sore throat.” She adds that stomach ache and vomiting are also typical strep symptoms in kids.
While she has seen children still presenting with these hallmark symptoms, Felckowski says she is also seeing many children with congestion, a runny nose and cough. “These are not typical, which makes it really tricky to diagnose and treat, and strep infections need to be treated with antibiotics,” Felckowski stresses.
The purpose of her TikTok, Felckowski says, is to spread awareness about the range of strep symptoms among parents and encourage more testing.
“I think there’s a lot of people out there being exposed (or parents who have a child that’s been exposed) and not necessarily looking for these symptoms,” says Felckowski. She adds that she has seen kids with atypical or mild symptoms go untreated and end up spreading strep to the rest of their family.
It’s also possible to test positive for strep and have no symptoms at all — these people are called carriers, says Regan, and they can also shed the bacteria that causes strep and potentially infect others.
Strep throat and invasive strep on the rise
Group A streptococcus bacteria usually cause mild illness, from strep throat to a skin infection called impetigo to scarlet fever. But sometimes, the bacteria can invade other parts of the body it doesn't normally affect, like the bloodstream. This is called invasive Group A strep (iGAS), a rare condition which can cause severe or life-threatening illnesses, such as lower airway infections, flesh-eating disease or streptococcal toxic shock syndrome.
DeMuri calls the number of invasive infections he’s seen this season “disturbing. ... Normally we’d see a couple cases of invasive strep a year, and now it’s at least one to two a week.”
In March, the CDC issued a warning about the recent increase in invasive strep infections after two children died last fall, TODAY.com previously reported.
Illinois has seen five pediatric deaths so far this year due to invasive strep, NBC Chicago reported, and state public health officials have warned that strep A outbreaks are rampant in schools right now.
Why are strep infections surging right now?
The COVID-19 pandemic likely played a role, the experts note. “Part of it is during the pandemic, everybody was masking, (distancing) and following (hand) hygiene, so we had the lowest levels of strep we’ve seen in many years,” says Regan.
Now that children are being exposed to these viruses and bacteria again, says Regan, infections are rebounding to prepandemic levels — or worse.
There was also a lull in respiratory syncytial virus (RSV) and influenza cases during the pandemic, which may have contributed to the surge this past fall.
The 2022-23 flu and RSV seasons hit earlier and lasted longer than usual, and "it's the same thing with strep throat," says Torres.
In the recent CDC warning about invasive strep infections, officials noted that children's reduced exposure to Group A strep bacteria during the pandemic “might have predisposed children to (invasive strep A) infection when pandemic restrictions were lifted," TODAY.com previously reported.
The agency also warned that the recent surge in respiratory viruses may play a role. "When you have any virus that weakens the immune system, it makes you more susceptible to other infections, (such as strep)," Regan notes.
Why may strep throat look different this year?
It's still too early to tell for sure, the experts note, but there are several possible explanations.
One is the sheer increase in cases. “When you have lots of numbers of something, the rare presentations also increase — a rising tide floats all boats,” says DeMuri, adding that there isn’t data yet on the percentage of cases with these atypical symptoms, but it is clear that pediatricians are seeing more of them.
Another possible explanation is that atypical symptoms of strep are much more common among younger children and infants, the experts note, and cases have been surging among this group.
“I’ve had lots of young kids who don’t have a very significant sore throat history, or when you’re looking physical exam, we don’t see all the redness or the swelling of the tonsils,” Dr. Shannon Godsil, pediatrician at Omaha Children’s Hospital & Medical Center, tells TODAY.com.
In children under 3, a strep A infection rarely manifests as an acute sore throat, per the CDC — it usually causes a low-grade fever, congestion and a runny nose. "Little kids are not necessarily able to vocalize symptoms (or a sore throat) well either, so they may just be more irritable or not feeding as well," says Felckowski.
The experts also point to the backdrop of cold-like viral illnesses circulating among children right now and allergy season, which are causing a myriad of overlapping symptoms.
“We think one of the reasons could be that it’s not necessarily the strep causing the nasal congestion, runny nose and cough, but it’s all of these other viruses,” says Godsil.
“A lot of the times with the younger children, you’ll see that they have a virus on top of strep, and sometimes strep will be missed because we’re not necessarily looking for it when you hear about the these cold-like symptoms,” Godsil adds.
The rise in invasive strep may also be involved in providers seeing more unusual strep symptoms. "All the really bad manifestations of strep are really popping out,” DeMuri says.
Testing and early treatment are key
"It is important to recognize strep because if we treat it, then you can prevent complications," Dr. Alin Abraham, a pediatrician at Northwestern Medicine Central DuPage Hospital, tells TODAY.com.
The sore throat and other symptoms of strep throat usually go away on their own within five to seven days, says Abraham. But it’s still necessary to seek treatment from a health care provider in order to treat the bacterial infection itself. If left untreated, it can lead to complications like abscesses, ear or sinus infections, rheumatic fever and kidney problems, the experts note.
Strep is treated with antibiotics such as penicillin or amoxicillin, says Godsil, or an appropriate second-line drug. The American Academy of Pediatrics has published recommendations for alternative therapies amid the shortage of liquid amoxicillin — including amoxicillin tablets or capsules, which are not impacted by the shortage and can be crushed or added to foods for children who have trouble swallowing pills.
Testing for strep is relatively fast and easy, but it requires a health care provider to administer. You can get a rapid strep test at your doctor's office, says Abraham. "If this is negative, then we can send out a strep culture, which takes about two days to come back," she adds. Another type of test is called the group A strep PCR swab, says Godsil, which is more sensitive and specific (and has a faster turnaround time than a culture), but not all offices provide them.
Who should consider getting tested for strep or consult their doctor about whether a test is appropriate? Anyone who has:
- Classic symptoms of strep, especially a fever, for 24 hours
- Cold-like symptoms that are not improving or getting worse
- Been exposed to strep by family members, friends or classmates
"The point is, if someone has a runny nose or a cough, that doesn't mean it's not strep. ... It is still something to look into and maybe do a test to see if it is strep throat or not," says Abraham.
The experts encourage parents to talk to their child's health care provider if they have any concerns. "It may warrant at least a doctor to evaluate them and then decide if a strep test is necessary," says Felckowski.
If a child does test positive for strep, they can go back to school and resume activities 24 hours after they start antibiotics (if they are fever-free), says Abraham. Without antibiotics, a person can remain contagious for up to two weeks, she adds.