sore throat

According to JAMA, doctors are writing 6 times as many antibiotic prescriptions for adult’s sore throats as they should! And a whopping 70% of children with sore throats who are seen by a physician are treated with antibiotics, though at most 30% have strep (Group A Streptococcus, of GAS) infections, and half of those who have positive cultures are just strep carriers who have a cold or another common viral infection!

According to the Centers for Disease Control and Prevention (CDC) MOST SORE THROATS GET BETTER ON THEIR OWN, and with or without treatment most are better in 3-4 days.

So why are so many antibiotic prescriptions written? Well, it seems that most doctors, in spite of efforts from the CDC and other national health organizations to get docs to prescribe them less, are not getting the message and think they are needed to prevent the big scary concern — acute rheumatic fever, a potential consequence of strep. Yet this complication is exceedingly rare in the US. In fact, viruses, like the ones that cause a cold or the flu, cause most sore throats.

Antibiotic prescribing to patients who are unlikely to benefit is serious business – that is, BIG PHARMA business. All antibiotic use increases the prevalence of antibiotic-resistant bacteria –a global health crisis now sometimes leading to fatal, untreatable infections. Less dramatically, but still serious, antibiotic use leads to diarrhea in 5% to 25% of people treated with them and at least 1 in 1000 patients’ visits an ED for a serious adverse drug event! In children antibiotic use has been associated with asthma, eczema, and even ulcerative colitis! The good — and bad –news is that strep infections are still sensitive to penicillin so are still readily treated – but at least effectively.

How Do You Know When You Need an Antibiotic?

According to the CDC, here’s the differentiation between viral or allergy-driven sore throats (the kind that don’t require antibiotic treatment) and strep infection:

The following symptoms are often associated with sore throats caused by a viral infection or due to allergies:

  • Sneezing
  • Coughing
  • Watery eyes
  • Mild headache or body aches
  • Runny nose
  • Low fever (less than 101 °F)

Symptoms more commonly associated with strep throat include:

  • Red and swollen tonsils, sometimes with white patches or streaks of pus
  • Tiny red spots (petechiae) on the soft or hard palate (the roof of the mouth)
  • High fever (101 °F or above)
  • Nausea
  • Vomiting
  • Swollen lymph nodes in the neck
  • Severe headache or body aches
  • Rash

How do you know if you should have a strep test or antibiotics?


In adults, only 5-10% of all sore throats are due to group A Strep (GAS), and only GAS sore throats are an indication for antibiotic treatment. Since symptoms and a medical exam alone do not distinguish between strep and a viral sore throat. a rapid antigen detection test (RADT) is necessary to establish a strep diagnosis.

If you meet two or more of what are called the Centor criteria (fever, tonsillar exudates, tender swollen lymph nodes in your neck, no cough) you should receive a rapid antigen strep test (RADT). Throat cultures are not otherwise routinely recommended for adults. A positive strep test justifies antibiotic use.

If the throat culture is positive, giving antibiotics is not technically a medical necessity, though I do recommend it, as do most medical doctors. Antibiotic treatment does reduce the albeit small, but real risk of rheumatic heart disease, and reduces the transmission of strep to others in the family, so if you have a young baby or someone with immune problems in the household, it is prudent to consider using an antibiotic. Also, if your child does have strep, s/he cannot return to school until she’s been on antibiotics for 24 hours or until the illness is completely cleared up.


Streptococcal pharyngitis is primarily a disease of children 5-15 years old and is rare in children under 3 years old.In kids, during the winter and spring, up to 20% of asymptomatic children can be colonized with group A strep, leading to more false positives from RADT-testing and increases in unnecessary antibiotic exposure. Further, as with adults, symptoms and physical exam findings alone do not distinguish between GAS and viral sore throat.

Here are some guidelines from the Centers for Disease Control for helping you choose next steps in testing and treatment:
Children with sore throat plus 2 or more of the following symptoms should have a RADT test:

  • Any child with a sore throat and no cough
  • Presence of tonsillar exudates or swelling
  • Fever (or recent fever since other symptoms started)
  • Age < 15 years

Children under 3 generally do not need a strep test;  GAS rarely causes sore throat at that age, and rheumatic fever is uncommon.
According to the Infectious Diseases Society of America and the CDC, If the RADT comes back negative, a culture should be done before starting antibiotics; if the RADT comes back positive, antibiotics are appropriate. The throat culture is different from the rapid strep test done in the office – it is actually a culture the doctor sends out to a lab and usually takes about a day or two to get results back. They recommend that the physician write a prescription for antibiotics but suggest that it not be filled unless the throat culture comes back positive.

Treating strep with an antibiotic may also prevent a consequence of untreated or inadequately treated strep infection –  a condition called Pediatric autoimmune neuropsychiatric disorder — or PANDAS. PANDAS is a pediatric condition with symptoms of obsessive compulsive disorder (OCD) or tic disorders and are exacerbated by group A streptococcal (GAS) infection. One theory suggests that strep infection in a susceptible child, causes an abnormal immune response with resultant central nervous system disorders.

If you do choose to use an antibiotic for what seems like a true strep infection — a totally appropriate decision– make sure to also use a probiotic while on the antibiotic and for a few weeks after. Even little children can safely take a probiotic. This can help to prevent some of the health consequences to the gut flora associated with antibiotic use. It is most common between the ages of 5 and 12 years old, and the association with strep may just be one of numerous causative or contributing factors. Nonetheless, this is one reason that it may be prudent to treat culture diagnosed or high Centor scoring presumed strep infections with an antibiotic course. Any child presenting with PANDAS symptoms in conjunction with strep throat should absolutely be treated with an appropriate course of antibiotics.

Red Flags: When to See a Doctor

Medical attention is absolutely needed if you see any of the following red flags: sore throats lasting more than a week, a child looking very sick, shaking chills, high fever (greater than 102°F [39°C]) with any of these other symptoms, night sweats, and neck swelling or pain only on one side, talking funny, or drooling. These red flags might indicate a more serious illness. Also, if a sore throat in a teenager goes away and comes back with a vengeance or just won’t clear up, this can also be a sign of sever infection called Lemierre’s disease or a peritonsillar abscess, and requires immediate medical attention.

Natural Sore Throat Treatments

Home remedies can be used to reduce discomfort from a sore throat:

Here’s what I do in my practice – and in my family for garden-variety sore throats. Treating strep without antibiotics is a little more involved. The comfort measures below can still be used, but some more advanced herbal therapies are also often needed. Garlic and goldenseal figure big in that picture but I don’t address that here.

Common Home Remedies

  • Simplify the diet and remove all dairy and sugar, including fruit juices
  • Gargle with warm salt water once every hour – or more often–to help reduce swelling and relieve discomfort. To prepare mix ½ teaspoon of sea salt into 1 cup of warm water. Even little kids can learn to gargle and it’s ok if they swallow some of the mixture.
  • Stay hydrated — Warm beverages, such as tea or broth can help decrease throat irritation. If kids (or grown ups) are having trouble drinking because of pain, using a drinking straw can really help. Lemon water can also be soothing.
  • Use a vaporizer or humidifier. Warm or cool mist can soothe inflamed air passages.
  • Get plenty of rest rather than rushing back to work or school.

Herbal Remedies and Supplements

  • Garlic Lemonade: One of my classic and reliable remedies — palatable to most and appropriate for all ages and even during pregnancy and breastfeeding. To prepare: Finely mince 2 cloves of fresh garlic (do not put them in a press)and place them in a 1-quart mason jar. Fill the jar with boiling water and cover for 30 minutes. Strain out the garlic, and to the liquid add the juice of 1 whole lemon. Sweeten to taste with honey. Give warm, can be taken freely.
  • Herbal sprays and remedies containing Osha, echinacea, and propolis are particularly great for sore throats, viral infections, and sometimes even strep. Goldenseal is another reliable antimicrobial and anti-inflammatory but tastes awful so use in tincture and for the strong of taste. Licorice is classic in tea and tincture, as well as lozenges. None of these are appropriate in pregnancy, except licorice for no more than a few days at a time, and not if you have high blood pressure.
  • Herb Pharm Soothing Throat Spray: Ingredients: Echinacea root, 
Propolis, Hyssop leaf & flower, Sage leaf, St. John’s Wort flowering tops.  (Not for use in pregnancy; ok for use for a few days while breastfeeding)
  • Gaia Herbs Throat Shield Lozenges (not for pregnant women or little kids because of choking risk)
  • Ricola Throat Lozenges (Lemon and Echinacea varieties are safe for short term use during pregnancy)
  • Zinc lozenges (not for children under 5; children 5-10 years old: 5-10mg/day, over 10 years old 15-20 mg once or twice daily)


Want to learn a whole lot more about natural remedies for kids that you can learn to use at home? Study with me in my latest course, Healthy All Year and boost your child’s immunity and learn to reduce unnecessary antibiotics at the same time! Click here to learn more or sign up now. 

P.S. I’ve got a gift for you!!! Get my FREE Ebook, Herbal Medicines for Kids. To receive your copy, click here. In one easy step it will be delivered to your inbox.



Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Ann Intern Med. 2001;134(6):509-17.

Hersh AL, Jackson MA, Hicks LA, et al. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics. 2013;132(6):1146-54.

Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86–102.



  1. I was taught (at ACTCM – MS in ChineseMedicine) that Golden Seal is very cold & not to use it over 10 days ever because it like some commonly used Chinese Herbal Medicines – Yin Qiao San can damage white blood cells with overuse.

    An older book still of great value: Dr.Robert Mendelsohn’s How To Raise a Healthy Child In Spite of Your Doctor.

    • Hi Amy, Goldenseal is indeed a vary cold herb — that is part of what makes it such an effective antibiotic and anti-inflammatory. Coptis is another like this. I would usually only recommend its use for the duration of an illness – not for a prolonged period of time. A couple of weeks is absolutely reasonable though I am less inclined to use it if there are liver problems or in young children. It is also contraindicated in pregnancy.

      Mendelsohn’s book remains a gem! He was one of my early inspirations!

  2. Thanks for the great info on strep diagnosis. For the past 3 or 4 years my husband and I have used echinacea tincture at the first hint of a sore throat and are very happy with the results. We tilt our head back, squirt a dropperful on the back of the throat and let it stay there for about six seconds before swallowing (could spit it out if alcohol is problematic). The sore throat disappears like magic and the nasty colds which usually follow rarely develop.

  3. Hi timely post for us. I am going to take my 5 yo to dr today she has been coughing now for about 3 weeks. Pertussis seems to be rampant where we are now. I tried to let he go but 3 week is just to long for me to feel comfotable. She can not sleep due to constant choughing. I have been propping her up. The only thing that has helped is ricola drops. Last night they didn’t work. So I have cold meds. So off we go as soon as I can get her in :(. I just can’t let it go a longer and feel good about it.

    • hmmm… the link working? thanks for letting me know. will have my office partner (that’s my husband 🙂 get right onto it).

  4. Hi Aviva,

    great video! thanks for sharing the ideas for herbs and supplements too… I was wondering what you think of essential oils? I use them topically on the lymph nodes, and gargle or use a throat spray made of certified pure therapeutic grade oils. I also use a diffuser to humidify and get the oils into the air – a blend of peppermint, melaleuca, wintergreen, and lemon.

    if you recommend them, what are your favorites?

    • i think your uses are splendid! i limit my use of EOs to topical (including vaginal) and occasionally internally for fungal infections (i.e. oregano). i also limit use just because it takes a LOT of herb to make a little EO. but they can be valuable medicines. warmly, aviva

  5. Thank you, as always, for your wisdom. I appreciate the knowledge and the support to make choices about antibiotics. I have felt pressured more than once that my children or my husband needed to take them when my gut told me otherwise. Having a bench mark to make those choices when it comes to a sore throat is another nice tool to add to my mama tool box. 🙂

  6. Aviva,
    Thanks for sharing this valuable information. I will add it to my cold and flu notes. My youngest son is applying to medical schools and hoping to be accepted for fall. I love sharing alternative remedies with him. He isn’t completely on board with herbal medicine as of now, but I hope that the seeds I have planted in him will eventually show up in his medical practice. (Actually, he did use the brain tonic tincture I gave him before his recent MCAT test. (He bumped up his score from a 27 to a 30 ~ exactly what he hoped for) ! Maybe he is on his way to becoming a believer ! Be Well ~

    • Love it! Congrats, too. Make sure to tell him about the University of Arizona Integrative Residency program and also the Institute of Functional Medicine — he might be interested! And we need all of the consciensious docs we can get!

  7. My pediatrician told me when my daughter was 6 months that it was impossible that she had strep, because kids her age don’t get it. She was so sick and a week later I was diagnosed with it. Is that true?

  8. Thank you so much for your always informative blogs!! I love all the detail you provide which really gives us, as parents, the tools to understand and make informed decision!!
    Thank You!!
    🙂 🙂

  9. Thank you Aviva for such a thoughtful and well written article. Our family absolutely avoids going to the Dr office unless its urgent or a medical condition that is simply persistent. My husband, myself and my oldest daughter had both recently healed from nasty sore throats using methods posted above. Unfortunately, my husbands youngest child (nearly 18) heavily influenced by the biological mother (who doesn’t seem concerned about overuse of antibiotics) didn’t believe us when we told her that her sore throat should be tried to healed at home. She was insistent that since her boyfriend was being treated with antibiotics for strep that she needed antibiotics as well. However, in my heart of hearts, experience and this article I am confident we were right and we will continue to pursue natural healing as much as possible. Thanks again!

  10. Hi
    Thanks. Very interesting and helpful read as usual. And coming at a time when a young boy (8 years old) in a nearby community recently passed away from a sudden illness – his autopsy revealed Strep A septicaemia!
    Not sure of his whole build-up though.
    I find your article very practical clear and helpful! Thanks

    • Yes, that is a complication that can happen from strep anywhere on the body and is very serious — and thankfully, rare! But it is important to be practical and get medical help when it is needed!!!

  11. I tried to download your blog on earaches and sore throats to send to my daughter, but I keep getting the “did not convert message”. I will try something else. She could use this information when my grandchildren get sick. Thank for all you do and great information to help us find alternative ways to stay healthly.

    • hi kathy,
      absolutely! and there is the Ebook through my website and also my book, Naturally Healthy Babies and Children which is a treasure trove of recipes I used with my own kids and in my practice. if downloading the blog doesn’t work you can cut and paste the link into an email. thank you for your note! aviva

  12. How would one make the Herb Pharm Soothing Throat spray? Dried herbs? In a tincture of…? Thanks for this article, it’s great timing and so helpful!

    • Super easy — combine similar alcohol extracts and some water in a spray bottle — you could use equal parts or sub in or out some of the herbs. and voila! Done. 🙂

  13. awesome! thank you & I shared via FB. I make echinacea tincture so combining with water in a spray bottle – could that be used on my 2 year old grand-daughter if needed? Thank you again!!

  14. Is there any research that the herbal remedies you’ve suggested work and how they work? Also what are the side effects? Ive seen studies that Echinacea does not work.

    • TONS!
      see natural standards database, american botanical council, and american herbal pharmacopoeia websites for research resources.
      best, aviva

  15. HI Aviva, Thank you so much for such an informative view on strep throat. I just have one question about antibiotics. Our nephew had strep (well supposedly!) and then it spread to the rest of our family. Right now I have tender lymph nodes, sore throat and no cough, but besides that feel quite good. If I am healthy can I simply take herbal remedies and eat and drink appropriately, and wait to see if this passes through? Or if I am tested positivity for strep, do you just recommend going on antibiotics?

    • Going the natural route is absolutely a possibility. I’ve worked with many folks who opted not to take the antibiotics for strep. of course, it’s a legit reason to take one if you feel quite ill and need it. Be well! aviva

    • Yes, this is a small risk — so it should be treated appropriately! The problem is over treatment, not so much appropriate treatment. Great question!

  16. I’m confused about the Centor Critieria. I thought I read that strep isn’t as common in young kids, but my 2 and 4 year old get an extra point? Both have a fever, but the 2 year old is coughing like crazy (and congested) and the 4 year old is not coughing. Neither have complained about a sore throat, but I read that small children often don’t complain of sore throat when it’s strep- they more commonly complain of a belly ache- which they both did. And the only reason I’m even worried about strep is that the 3 year old I watch twice a week got sick at the same time and his mom texted me this morning saying he tested positive for strep (rapid test). And then my 6 year old has been scratching her eczema so bad with this cold snap that there are infected spots and last year a family friend’s 8 year old died of a strep complication…

    I know you are busy, and I absolutely love your website and insight and perspective and I’ve been in love since I discovered you. You are a gem. And I’m feeling information overload from sources I don’t know if I can trust, and I trust you. So thank you for all your work and books and blog posts and everything!

    • Thank you Marcee. USUALLY cough = upper respiratory infection and NOT step. But if your kids have had a lot of exposure it’s certainly possible. A strep culture via a throat swab should resolve your question and point the way to the best treatment! Severe complications are very rare — but always better safe than sorry. As for the infected eczema — sounds like your 6 yo needs some good immune boosting and reduction in overall inflammation. Once you get past this current concern, working with an elimination diet (see my blog on that ) and doing some gut healing could be super beneficial. And of course, if you can get into a functional or integrative medicine doc skilled in pediatrics, even better! Sending those kids of yours wishes for a speedy recovery and you peace of mind! 🙂 Aviva

      • Dr Romm, what are the best resources for finding the best integrative or functional docs skilled in pediatrics in your area currently relocating to VT and wondering what you recommend? Thank you!

      • Also what do you recommend for immune boosting? And do you find that eczema is usually corelated to inflammation from diet or could something like teething cause a flare up?

        • Stay tuned for my newest course, coming 3/2015 — it will answer all of your questions! It’s all about immune boosting and includes info on diet, lifestyle, environmental exposures, natural therapies, and much more! 🙂

  17. Hello!
    My 8-year-old daughter has had a sore throat (it looks horrible!) for three weeks. A lab test shows she has Strep B. The doctor told me we didn’t have to do anything about it. I was relieved at first, because antibiotics are so destructive. But now I wonder when her pain and discomfort will fade and whether Strep B could cause other problems is left untreated. Do you have any advice on this?
    Thank you,
    Nicole HB

  18. Hi- I just took my 7 year old son to get a strep culture on Sunday. He started having mild symptoms Friday – belly ache, throat slightly hurt to swallow and a 1 day fever of 100. We treated him Fri/Sat with propolyis, collodial silver, apple cider vinegar and probiotics. We were hoping to avoid antibiotics. We did a rapid test at our local pharmacy Sun afternoon. The NP first said the test was negative but then said he thought he saw a faint line (which I could not see even though he tried to show me numerous times). He said because he had the symptoms and what appeared to be a faint line we should do antibiotics. We did start them – he has had 2 doses. I am just wondering if there is a danger if we do them for a couple days and then go back to our natural remedies? We have been working on repairing his gut since birth due to antibiotics given as a 1 day old so it pains me to give him a 10 day course of antibiotics.

    • Hmmm… this is a tough one. The thing with quitting antibiotics midstream is that it increases the risks of antibiotic resistance for everyone. So it might be best to finish this round, get back onto gut repair, and then reconsider in the future whether to do an antibiotic if a test is equivocal — a second opinion might be appropriate if your doc isn’t sure.

  19. Aviva-

    Thank you for the helpful information you’ve written here. I have a question and hope you can help me navigate my situation.

    My 9 yo son got strep last March(rapid strep culture) and his ND recommended we treat with antibiotics(his first western medication). Day 7 he broke out in hives(amoxicillin; I have a penicillin allergy). We stopped the antibiotics per the ND’s suggestion and worked to rebuild his gut.

    Fast forward to this March. My son got strep again(rapid strep culture), wanted to avoid antibiotics again so we went the herbal route(different ND treated because we could get into her more quickly) Took a good 10 days to get his symptoms under control. Tonsils were still very swollen and there were what we thought were cold sores around his lips. Continued with vitamins and more mild herbs. Now it’s been a month and I took him back to our normal ND to check the tonsils and sore. Rapid culture came back positive and sores are bacterial strep. Her recommendation is antibiotics(z-pack this time) with a topical prescription for the sores. I asked for an herbal option and she made up a tincture that would take about two weeks to rid the strep, although she really recommended the antibiotics.

    My question is, in this case, is antibiotics the best option for him, even tho his gut healthy will be destroyed again OR is it prudent to see this through with herbs like I had hoped? Do these strong herbs(antibiotic herbs) have the same affect on the gut as prescription antibiotics do? I am guessing the possibility of him getting strep often could happen and I need to have a plan of action that won’t destroy his gut each time. Obviously I don’t want him to have any long term damage from strep so it’s a hard decision to make for me. Any advice would be so helpful. Thank you!

  20. Thank you for your helpful advice. I have a similar situation as above^. We took our daughter to urgent care three days ago because we noticed she had very swollen tonsils. They did a rapid test and declared it strep without really looking at her or asking any questions. They prescribed an abx, we went ahead abd filled it as we had the same diagnosis about five weeks earlier, which that time we held off on the abx. Yesterday, we took her to her regular ped and he does not think she had strep. He suspects she is just a carrier as she has none of the other markets for strep. She has had three days of abx on a 10 day course. Her doctor was very wishy washy on whether we should see the course through or not. He gave us no definitive answer. I would really like to stop giving them to her if they’re not necessary. We obviously want our daughters best interests met, but don’t want to risk the greater community. Any thoughts on what we should do? Thank you.

  21. Hi Dr. Romm,
    I find your work so inspiring. Thank you for sharing your time and energy. I would like to know more about what pregnant women can do in the case of strep (along with care of midwive/ob). Thank you!

  22. In the above remedies, if you do not mention whether one is safe or unsafe during breastfeeding, can I assume it is safe? I’m currently breastfeeding my 8 month old and want to avoid antibiotics if possible.

  23. My 10 year old daughter is allergic to 2 families of antibiotics (sulfa and amoxicillin), so I tend to work vigilantly with herbs on infections. We are on day 2 of what I suspect is strep throat (mild fever, white coating tonsils and tiny red spots on soft palate, very swollen lymph, miserably painful swallowing). Worked with echinacea and osha added to elderberry syrup yesterday, made a throat spray with echinacea, andrographis, propolis tinctures and a bit of glycerine. Thyme and licorice root tea, water, bone broth and water kefir have been her drinks.
    I feel confident that she is a normally healthy and active kid, but I worry because she discovered her first molar was loose yesterday (new one coming in). Today that area is very painful and the lymph is more swollen in the jaw below that loose tooth. Other signs show that she is stabilizing and will probably feel a lot better tomorrow. My concern is that her loose tooth is now very very loose and I wonder if it could create an invitation for bone or blood infection. I am calling our advise nurse, but am curious if this is something to add to a “red flag” list.
    Thank you so much for your time and generosity in sharing information!

    • Sounds like a visit to the doc is definitely in order! There are antibiotic alternatives. Elder and echinacea aren’t likely enough to tackle strep…Concerned that you follow up with some good local medical advice!

  24. thank you for your work…our son had a positive strep test result and was prescribed a penicillin based antibiotic which we discontinued after he had an immediate adverse reaction…because his strep seemed to dissipate and while we were recovering from the penicillin reaction, we did not get a alternate antibiotic. now, two weeks later he has lingering cold-like symptoms (congestion, cough, some lethargy/moodiness) but, most worryingly, now has joint pain in his knees and ankles and, having read up on rheumatic fever, i am *freaked* out. we’re headed back to the doctor tomorrow for an alternate antibiotic but i’m really worried about this ‘very rare’ complication of rheumatic fever and the long term affects it may have on my otherwise incredibly healthy kid today and down the line.

  25. Hi, My 6 yr old daughter, almost 7 as this is her bday month, has white spots on tonsils, pain in throat. She has fever 100 to 101 for a day, and i have given her ibugesive plus and no fever for the past two days. But white spots are still there on tonsils and little throat pain , should I still show her to doctor?

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