Strawberry Tongue in Children: Causes and Concerns

Tongue issues?

Starting from April 5th, three children began to develop fevers one after another.
The youngest child had a fever on April 5th but it resolved quickly.
The second child had a fever that ended on April 6th without any prolonged high fever.
However, the eldest child started experiencing fever accompanied by vomiting from April 7th to April 9th.
Due to vomiting for two consecutive days and being unable to eat, we took them to the emergency department at Taoyuan General Hospital, where they were diagnosed with enterovirus (a throat culture was taken, but the emergency physician did not schedule a follow-up appointment, so we did not see the culture report).
The high fever and vomiting symptoms have improved (antiemetic medication was administered).
On April 10th, we noticed that all three children had red spots on their tongues, making their tongues appear bright red and covered with small dots, resembling strawberries.
We would like to understand what this condition might be and if there is anything we should pay special attention to.
(Currently, their fevers have resolved, and the eldest child is able to eat normally again.)

San Baotai de Mama, 20~29 year old female. Ask Date: 2019/04/11

Dr. Pei Rensheng reply Pediatrics

Hello, unless the temperature exceeds 42 degrees Celsius, it is unlikely to cause brain damage.
Normal body temperature fluctuates throughout the day and can be influenced by age, activity level, and other factors, so measurements may vary each time.
The average normal core body temperature is 37 degrees Celsius, typically ranging from 36.4 degrees Celsius to 37.5 degrees Celsius.
A core temperature exceeding 38 degrees Celsius indicates a fever.
The following values can be used as reference for defining a fever: (1) rectal temperature over 38 degrees Celsius, (2) oral temperature over 37.5 degrees Celsius, (3) axillary temperature over 37.2 degrees Celsius, (4) ear temperature over 38 degrees Celsius.
However, factors such as age and ambient temperature should also be considered.
Regarding how to measure body temperature: Accurate temperature measurement is crucial for determining fever.
Relying solely on touching the face or forehead is insufficient; a specialized thermometer must be used to accurately measure core body temperature.
The most commonly used thermometers today are infrared thermometers and electronic thermometers.
Glass mercury thermometers have been completely discontinued in Taiwan due to concerns about mercury poisoning if broken.
Let’s briefly discuss the characteristics of infrared thermometers and electronic thermometers: (1) Electronic thermometers: These utilize the relationship between resistance, voltage, and current with environmental temperature to display body temperature in digital form.
They typically have one measurement type that can be used for rectal, axillary, and sublingual measurements.
Since they need to be placed in the rectum, armpit, or mouth for a period to obtain accurate readings, they may be inconvenient and uncomfortable, especially for young infants.
However, they are generally more economical than infrared thermometers.
(2) Infrared thermometers: These thermometers measure the thermal radiation emitted by objects and can be divided into ear thermometers and forehead thermometers.
A.
Infrared ear thermometers: There is a high correlation between ear temperature and rectal temperature.
The Taiwan Pediatric Association recommends that ear temperature can replace rectal temperature when necessary, but it is important to ensure the ear canal is clear, as earwax can affect accuracy.
If using an ear thermometer with a cover, ensure it is properly fitted and replace it if damaged to avoid measurement errors.
Most ear thermometers measure temperature in 1 to 3 seconds, significantly faster than electronic thermometers, making them a popular choice.
B.
Infrared forehead thermometers: These detect skin temperature from the forehead's outer side and are more convenient to use compared to electronic thermometers and infrared ear thermometers.
They are commonly used in public settings; however, this measurement method can be influenced by various factors, including environment, sweat, and hair.
It is recommended to remain in a stable environment for 30 minutes before using a forehead thermometer.
There are both contact and non-contact forehead thermometers, so it is important to read the instructions carefully to avoid measurement errors.
There are numerous brands on the market, with imported brands being among the top two, while most others are local Taiwanese brands, each with unique designs.
Regardless of the type of thermometer used, it is essential to read the product manual before use and calibration may be necessary to ensure accurate temperature readings.
Wishing you safety and health.
Sincerely, Dr.
Pei Ren-Sheng, Attending Physician, Pediatrics, Taoyuan Hospital, Ministry of Health and Welfare.

Reply Date: 2019/04/11

More Info

Strawberry tongue is a clinical sign characterized by a bright red, swollen tongue with a bumpy or "strawberry-like" appearance. This condition can be associated with several underlying causes, particularly in children. Given your description of your children experiencing fever and vomiting, followed by the appearance of strawberry tongue, it is essential to consider the potential causes and implications.

One of the most common associations with strawberry tongue is scarlet fever, which is caused by group A Streptococcus bacteria. Scarlet fever typically presents with a sore throat, fever, and a characteristic rash, along with the strawberry tongue. The tongue may initially appear white due to a coating, which then peels off, revealing the red, bumpy surface underneath. Other infections, such as Kawasaki disease, can also present with strawberry tongue, alongside other symptoms like fever, rash, and conjunctivitis.

In your case, since the children had fevers and were diagnosed with enterovirus, it's important to note that enteroviral infections can also lead to various oral manifestations, including changes in tongue appearance. While strawberry tongue is not a classic symptom of enterovirus, the viral infection could potentially lead to inflammation in the oral cavity, resulting in a similar appearance.

Here are some key points to consider regarding strawberry tongue and its potential causes:
1. Infectious Causes: As mentioned, scarlet fever is a primary consideration. If your children exhibit other symptoms such as a sore throat, rash, or swollen lymph nodes, it would be prudent to consult a healthcare provider for a throat culture or rapid strep test.

2. Kawasaki Disease: This is a serious condition that primarily affects children and can lead to heart complications. It is characterized by prolonged fever, rash, conjunctivitis, and strawberry tongue. If your children develop persistent fever, rash, or other concerning symptoms, seek medical attention promptly.

3. Other Viral Infections: Various viral infections can cause changes in the oral cavity. While enterovirus typically presents with gastrointestinal symptoms, it can also lead to herpangina or hand-foot-and-mouth disease, which may cause lesions in the mouth.

4. Hydration and Nutrition: Given that your oldest child experienced vomiting and difficulty eating, it's crucial to ensure they stay hydrated. Offer clear fluids and bland foods as tolerated. If they continue to have difficulty eating or drinking, or if they show signs of dehydration, seek medical advice.

5. Monitoring Symptoms: Keep an eye on any additional symptoms that may develop, such as persistent fever, difficulty swallowing, or signs of dehydration. If the strawberry tongue persists or worsens, or if you notice any concerning changes, consult your pediatrician.

In summary, strawberry tongue can be indicative of several underlying conditions, particularly infectious ones. Given your children's recent illnesses, it is essential to monitor their symptoms closely and consult a healthcare provider if you have any concerns. Early intervention can help manage any potential complications and ensure your children recover fully.

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