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I am a general pediatrician with nearly 30 years of experience. Pardon me, but I bristle at some of the discussion relating to treating and testing for streptococcal infections in children. GAS pharyngitis is not necessarily the benign self-limited illness that some seem to feel it is. Go back and review pediatric texts from the 19th century and death rates of up to 30% were described in scarlet fever epidemics. Death could occur due to exsanguination as soft tissue infection of the anterior neck eroded into great vessels. My crystal ball has never worked well and I seem never to be able to predict who will get a peritonsillar abscess and who will not. 
Say what you may, antibiotics work for GAS. Children can be significantly ill for several days and are better in a day and normal in two days with a few doses of an inexpensive antibiotic. Perhaps we are not preventing many cases of rhemumatic heart disease, but our patients get better more quickly. They return to school more quickly and their parents get back to work. The societal savings are no doubt significant. 
Does symptomatic GAS pharyngitis occur in children less than age two? Without a doubt. I see it infrequently but blindly asserting that it doesn't because somebody said it doesn't will lead to errors, unavoidably. I have seen GAS in one year old's and even in an infant in the first two weeks of life who was significantly ill and whose mother had GAS pharyngitis. Choose your victims carefully for testing but if you never look, you will never know. I concede that blanket testing of febrile toddlers by midlevel providers will lead to overdiagnosis but that is an entirely separate issue. 
Too many times it seems that we are prejudiced against our smallest patients. Some are suggesting not treating children with GAS pharyngitis because of a lack of risk of rheumatic fever and its usual benign course. More suggest not treating ear infections in children.  What would you do if you were ill, took time off work, had a painful ear or GAS and your provider suggested observation with treatment in a few days if things didn't improve spontaneously? I am betting you would be looking for a new physician. Yet that is what the current trend seems to be. This is not an issue of overuse of antibiotics. If we could prevent the use of antibiotics for colds and "tonsilitis" and "bronchitis" and eliminate the inaccurate diagnosis of otitis in a febrile child with a "pink ear" the problem would be solved. How many subscribers of this list use pneumatic otoscopy routinely? The vast majority of the time when I evaluate children with "otitis" for their persistent high fevers, they have clean ears. Those children seen in emergency rooms previously were not appropriately examined and many times have huge amounts of cerumen that someone has miraculously looked right through.
Part of what I pledged to do as a physician was try to help people. Over the years I have learned that s__t does happen. Withholding treatment for GAS is an invitation to get your shoes dirty and is a disservice to your patients.
Scott Nau, MD
Cedar Rapids, IA

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