August 10th, 2010 – Researchers from the University of Louisville School of Medicine in Kentucky set out to determine whether children who received vaccines on a delayed schedule demonstrated different neurodevelopmental outcomes than children who were immunized on time. Children in the study were born between 1993 to 1997. They then underwent 42 neuropsychological tests when they were 7 to 10 years of age. Of 1,047 children, 491 were vaccinated on time; 235 were vaccinated with all vaccines but not on time, and 311 did not receive all recommended vaccines.

Results indicated that timely vaccination was associated with better performance on 12 of 42 outcomes. They also demonstrated better verbal skills and had higher IQs. Children who were not immunized on time did not perform better on any outcomes. The researchers wrote “This study provides the strongest clinical outcomes evidence to date that on-time receipt of vaccines during infancy has no adverse effect on neuro-developmental outcomes 7-10 years later. These results offer reassuring information that physicians may use to communicate with parents who are concerned that children receive too many vaccines too soon.

Dr. Miller Comment: There has been a steady significant increase in the number of parents who are delaying and or not vaccinating their children. This movement has continued to pick up steam, without any evidence of benefit and has only been promoted on a theory that there are too many shots given to our children. There are many thoughtful, caring parents who want to do the best for their children, but are paralyzed from making a decision to protect their children earlier. We are seeing rising epidemics of vaccine preventable diseases (Measles, Mumps, Pertussis).   An epidemic of Pertussis (Whooping Cough) is currently being monitored in California and South Carolina. The number of cases in California in the past 6 months is higher than that seen in 50 years and has resulted in the death of 6 infants.   This illustrates one example that these diseases are still out there just waiting for the right opportunity to make a comeback.

Each vaccine given, is timed to give the most protection at a critical age to prevent the most devastating infections. Getting more than one shot at a time isn’t a huge physical stress. Their immune systems handle far greater challenges from everyday exposure to germs on shared toys, doorknobs, and the playroom floor. As Dr. Paul Offit explains it: “Think about the bugs that caused your child’s last ear infection. Each single bacterium has 2,000 to 3,000 components that stimulate an immune response from the body. As those bacteria multiply, the challenge to the immune system increases exponentially. Your baby feels awful and likely has a high fever and lots of pain. The body pulls out the stops to fight it off. NOW COMPARE THAT TO THIS: The entire fourteen-shot course of childhood vaccinations contains only about 150 immunological components altogether,” says Dr. Offit. This is about a tenth of the challenge posed by exposure to just one microscopic germ.

What’s more, the bacteria and viruses used in vaccines are either killed or altered, says Martin Myers, M.D., author of “Do Vaccines Cause That?!” There are just enough to induce immunity, but not enough to make someone sick — and certainly not enough to overload the immune system of a healthy child. .

Lastly we want you to consider that coming in to the doctors office to “spread them out” increases your child’s exposure to illness.  Children with mild illnesses ride it out at home. The sicker children are brought to our office to be seen. While this risk is small, why expose your child to more illness or to the illness you may be trying to prevent, by spreading out the shots?  Finally, there is not one controlled study that shows spreading out the shots prevents autism or any other developmental or neurologic problems.  I make an appeal to parents to give each immunization on time.  I firmly believe that this approach is the safest and best protection to provide to your child. (Dr. Miller)

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Hand, foot, and mouth disease (Coxsackie Virus) is caused by one of several types of viruses.  Coxsackie viruses are a part of a family of viruses known as enterovirus. This family includes polioviruses. In fact, Coxsackie virus was discovered by a scientist named Gilbert Dalldorf in the late 1940s who was searching for a cure for polio. This virus he discovered was named after Coxsackie, New York, where the scientist had obtained some specimens in his research.

Hand, foot, and mouth disease is usually characterized by tiny blisters on the inside of the mouth and the palms of the hands, fingers, and soles of the feet. It is commonly caused by coxsackievirus A16 (an enterovirus), and less often by other types of viruses.

Anyone can get hand, foot, and mouth disease.  Virtually every child has coxsackie virus at some point.

Young children are primarily affected, but it may be seen in adults. Most cases occur in the summer and early fall. Outbreaks may occur among groups of children especially in child care centers or nursery schools. Symptoms usually appear 3 to 5 days after exposure.

Hand, foot, and mouth disease is usually spread through person-to-person contact.   People can spread the disease when they are shedding the virus in their feces. It is also spread by the respiratory tract from mouth or respiratory secretions (such as from saliva on hands or toys). The virus has also been found in the fluid from the skin blisters. The infection is spread most easily during the acute phase/stage of illness when people are feeling ill and have a fever, but the virus can be spread for several weeks after the onset of infection.

The symptoms are much like a common cold with a rash.  The rash appears as blisters or ulcers in the mouth, on the inner cheeks, gums, sides of the tongue, and as bumps or blisters on the hands, feet, and sometimes other parts of the skin such as the buttocks. The skin rash may last for 7 to 10 days.

There is no specific treatmentfor the virus that causes hand, foot, and mouth disease.  Cold drinks and or freeze pops help sooth the area.  Another option is to make a mixture of 1 part antacid (like mylanta) with 1 part benadryl liquid (generic is diphenhydramine).  Mix these into a paper cup.  Then swab the inside of the mouth and tongue with the mixture.  Older children may swish the mixture in the mouth and then spit out.  It is ok if some is swallowed.

Help prevent and control the spread of hand, foot, and mouth disease by:

>Washing hands well, especially after going to the bathroom, changing diapers and/or handling diapers or other stool-soiled material.

>Covering the mouth and nose when coughing or sneezing.

>Washing toys and other surfaces that have saliva on them.

>Excluding children from child care or school settings if there is a fever, or ulcers in the mouth and the child is drooling.

Call us if your child shows signs of dehydration (e.g. not urinating 3 times in 24 hours), or the mouth and tongue are dry with very little drinking.  You should also call if the initial fever goes away and returns (after 48 hours).

Dr. Miller Comment:  Coxsackie virus (named for Coxsackie, NY) is a right of passage in childhood.    Almost all children have it at least once or more.  There are many different strains and infection only produces antibodies for the strain that your child is exposed to.    Coxsackie virus can show itself in many forms.   Hand, Foot and Mouth is one common form.  In older children and adolescents the infection can result in irritation along the breast bone (where the ribs connect).  This is known is costochondritis.  It can be very painful, but usually responds to heat and ibuprofen. 

Coxsackie virus is treated symptomatically, and while it can make parents worry (due to the occasional high fever), and can lead to dehydration due to throat pain, it almost always resolves on its own without serious concerns.

Dr. Miller & Dr Elmer Comment:  It is hard to draw a firm conclusion from this one study.   On one hand, we can begin to think that higher exposure to pesticides leads to behaviors that look like ADHD.   In particular, organophosphate pesticides disrupt the activity of acetylcholine, a neurotransmitter (a brain chemical) also implicated in ADHD.  If this is true, it is similar to what can happen with lead exposure.  On the other hand, it is possible that children with ADHD may engage in more behaviors that cause higher ingestion of pesticides (e.g. they may not wash their fruit off before eating it, or may walk through properties with signs stating that a recent application of a pesticide was applied).  

While we need more information to add to this study (done on 1 spot urine in the children studied), we can all agree that less pesticide exposure is preferable.  Like many things, an approach to pesticides and organic foods require a balance.    For example, according to a 2008 US report, detectable concentrations of the organophosphate malathion were found in 28% of frozen blueberry samples, 25% of strawberry samples, and 19% of celery samples.  We do need to remember that most testing of fruits and vegetables is done WITHOUT washing.

Meanwhile the growth of organic foods encourages us to jump on this bandwagon.  But organic is a relative term.  Even the USDA has determined that the organic movement represents a spectrum of practices, attitudes, and philosophies. On the one hand are those organic practitioners who would not use chemical fertilizers or pesticides under any circumstances. These producers hold rigidly to their purist philosophy.  At the other end of the spectrum, organic farmers espouse a more flexible approach. While striving to avoid the use of chemical fertilizers and pesticides, these practitioners do not rule them out entirely.  Instead, when absolutely necessary, some fertilizers and also herbicides are very selectively and sparingly used as a second line of defense. Nevertheless, these farmers, too, consider themselves to be organic farmers.

For many shoppers, the decision often comes down to money.  You may pay up to 100% more for organic for some foods.   Organics are one of the fastest-growing categories in the food business and are becoming big business.    But not all organic-labeled products offer added health value.   A recent Consumer Reports Health article recommended that it’s worth paying more for organic for the following:

• apples
• peaches
• spinach
• milk
• beef

This is to avoid chemicals found in the conventionally produced versions of those items.

Some foods that have undetectable levels of pesticides are:

• asparagus
• broccoli
• seafood which has labels that are often misleading.

See the following for excerpts of the report of which foods to consider buying organic:

BUY THESE FOODS AS OFTEN AS YOU CAN:

The group has also released a list of “Clean 15″ foods that had the least chemical residue. Most of them have skin that are taken off before consumption. They include: onions, avocados, sweet corn, pineapples, mango, sweet peas, asparagus, kiwi, cabbage, eggplant, cantaloupe, watermelon, grapefruit, sweet potatoes and sweet onions.

Four Seasons Pediatrics suspended the use of the Rotateq until we were able to see and review the FDA opinion. We also sought to review the basis for the opinion and any further scientific information that was used in the FDA opinion. Our independent review of the available information concurs that use should be continued. Over 100 million doses have been distributed worldwide. The benefit of saved lives exceeds the risk of DNA fragments found that have not been shown to cause any disease in humans. If you missed this vaccine last week, when we suspended the use, please call us to schedule a nurse visit to get the vaccine. Thank you for your understanding – Dr. Miller and Dr. Elmer on behalf of Four Seasons Pediatrics.

For more information, please see this link:

FDA Link for information

It has been determined that the Merck vaccine contains two strains of a porcine (pig) virus DNA.  Neither of these strains causes disease in humans and one of the strains is found in meat that is consumed by humans and felt to be safe.   The product used by Four Seasons Pediatrics (Rotateq) was one of the most extensively tested vaccines before it came to the market.  Four Seasons Pediatrics waited one year after FDA approval before we used this vaccine.    Approximately 6 million doses of Rotateq have been distributed in the United States and have dramatically reduced this diarrheal illness in the United States.

A rotavirus vaccine protects children from rotaviruses, which are the leading cause of severe diarrhea among infants and young children.   Each year more than 500,000 children die from diarrheal disease caused by rotavirus, and another two million are hospitalized.  Nearly every child in the world will suffer an episode of diarrhea caused by rotavirus before age five.  Although the severity of rotavirus infections differs between children living in developed and developing countries, the rates of infection is similar in both settings.   Clean water supplies and good hygiene have little effect on the transmisssion of infection, and further improvements are unlikely to prevent disease.

Based upon the effectiveness of the vaccine, a 2009 review estimated that vaccination against rotavirus would prevent about 45% of deaths due to rotavirus gastroenteritis, or about 228,000 deaths annually worldwide.  Since there are about 20-60 deaths in the United States from rotavirus infection, this translates to saving about 9 to 27 deaths per year in the United States.

Practice Comment From Dr. Miller and Dr. Elmer:

 A scientific review at this time shows that the risk of the virus itself (a known risk), exceeds the risks of the DNA of the porcine virus in the vaccine (no evidence of any disease in humans).  More than 6 million doses of vaccine have been distributed in the United States, and 106 million doses have been distributed worldwide. This gives us great comfort, as we have not seen any significant problems with the vaccine and the vaccine is highly effective.

Vitamin D and Calcium are important for bone growth and to prevent Rickets.   New recommendations for Vitamin D are based on new clinical trials and support a role in preventing Diabetes and Cancer.  Of the two of these calcium is found in abundant sources.  (See below for examples).  Vitamin D is more difficult to find on a consistent basis.  For a list of foods with vitamin d, click here.  If you cannot eat these foods, we do recommend that children TAKE a supplement.  See the products below – along with the links posted.

What are the current recommendations for Vitamin D?

1. Breastfed infants and partially breastfed infants should be supplemented with 400 IU/day of Vitamin D until your infant is weaned to at least 18-20 ounces of vitamin fortified formula.  Supplement  with 400 IU when switching to milk at 12 months of age.  Whole milk should be used until age 2 unless overweight is a concern or in those with a family history of obesity, high cholesterol or early heart disease before the age of 55.

2. Older children (older than 12 months of age should receive 400 IU per day of vitamin D. 

3. Adolescents who do not obtain 400 IU of vitamin D per day through vitamin D milk (100 IU per 8 ounces) and vitamin D fortified foods (such as cereal and eggs) should receive a vitamin D supplement of 400 IU per day.

Here are some of the choices to supplement Vitamin D:

• Enfamil D Vi Sol - vitamins – contains vitamin D.  Contains 50 doses.  1 ml contains 400 IU of vitamin D
• Bio-D Mulsion – 1 drop contains 400 IU of vitamin D.  Contains 750 doses.  Just be careful using, there is a risk of incorrect dosing since this is very concentrated.  It is also inexpensive
• Just D – Sunlight Vitamins Inc.  Contains 50 doses.  Contains only vitamin D with no additives.  www.sunlightvitamins.com
• Enfamil Tri Vi Sol vitamins – contains vitamins A, D, and C.  Contains 50 doses.  1 ml contains 400 IU of vitamin D
• Vitamin D tablets – 1 tab contains 400 IU

 

What are the current recommendations for calcium?

How much calcium your body needs varies according to age. You need the most calcium between 9 and 18 years of age.

The American Academy of Pediatrics recommends the following daily intake of calcium:

How to get calcium

The best way to get the calcium that you need is by eating and drinking foods that naturally contain calcium. Many foods contain some calcium, but the best sources include the following:

• Low-fat milk, yogurt, and other milk products are generally super sources of calcium.
• Flavored milks, such as chocolate or strawberry, have as much calcium as plain milk but may have more calories.
• Dark green, leafy vegetables such as kale and turnip greens are low in calories and high in calcium. However, spinach is not a good source of calcium.
• Broccoli, tofu, chickpeas, lentils, split peas, and canned salmon and sardines (and other fish with bones) also are good sources of calcium.
• Calcium-fortified juices and cereals can help boost the calcium in your diet, but limit yourself to 8 to 12 ounces (1½ cups) of juice a day.

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Ticks are widespread at this time. Deer ticks are active in May through July. It is these ticks that transmit Lyme Disease. We recommend that you check your child daily if they are outside. Most ticks can be found at the edge of properties in wooded areas. The overall risk of Lyme Disease from a TICK is less than 1-2%. For this reason, the best approach is prevention (use a repellant like Bug Out if outside for less than 4 hours and 3M Ultrathon if outside for more than 4 hours). We recommend one application rather than multiple applications.  In addition, check you child daily for TICKS and remove them carefully. We recommend using a TICK remover (we sell them) or tweezers. Gently pull up enough to tent the skin and wait for the TICK to detach. (Please have a seat and be patient, the Tick will usually release on its own in 1-4 minutes – do not attempt to pry the Tick off as it will likely break).  If you break the Tick, the embedded piece does not need to be removed, it will come out on its own.  Other preventive measures include: 1) wear light colored clothing and tuck pants into socks and shirts into pants 2) after removing a tick, disinfect the bite with soap, rubbing alcohol or hydrogen peroxide.</p>

SUNBURN PREVENTION

SUNSCREEN DO’S AND DONT’S:

DO SLATHER ON ENOUGH. People typically use about 25 to 75 percent less sunscreen than they should, according to studies. Be sure to apply 2 to 3 tablespoons of sunscreen for maximum full-body protection of an adult. 
DON’T USE EXPIRED SUNSCREEN. Sunscreens aren’t required to post expiration dates as long as manufacturers can prove that they’ll last for at least three years. So if your sunscreen doesn’t have an expiration date, be sure to write the date on it in permanent marker when you buy it. And remember to discard it after three years.
DON”T MISS THESE SPOTS. Lips, ears, feet, hands, bald spots, and the back of your neck are all areas that are easy to forget.
DO REAPPLY REGULARLY. The maximum protection time of a sunscreen is based on the number of minutes it takes for you to burn multipled by the SPF number. So say you have fair skin and burn within 20 minutes and you’re using enough of an SPF 15 sunscreen. That will give you about five hours of protection. Nevertheless, reapply sunscreen every two hours just to be on the safe side. If you’re swimming or doing lots of sweating on the beach or the tennis court, you may want to reapply it more often than that. Also, keep in mind that reapplying sunscreen after you’ve exceeded your maximum protection time doesn’t mean that you can safely stay in the sun longer. Instead, be sure to cover up or get out of the sun!</p>

Products to consider:

We tend to get more calls this time of year for rashes after being in the sun with sunscreen.  As many products have increased their SPF, they have added more chemicals to create the higher SPF.  This has meant more rashes for children.   Neutrogena has excellent UVA/UVB coverage at SPF’s of 15 to 30 or higher.  Higher is not better since some products (like Neutrogena) get 100% protection (if you reapply) and you only may increase the chance of a rash with a higher SPF.   There are also more options for SPF clothing than ever before.  Coverage with this clothing will give protection to areas that will not need to be re-coated with sunscreen.  Just google “SPF clothing for children” or “babies” to see options.  SPF clothing for a baby is ideal.  For babies under 6 months the only sunscreen made for this age is Blue Lizard.  We recommend SPF clothing as described above, a brim hat and avoidance during the peak high UV rays (10 am to 3 pm).  If you must use a sunscreen, for this age, limit to the areas you cannot cover.

We want the greatest health and safety for the children we care for in our practice

1. In the past year, there has been a steady increase in the number of parents choosing to not vaccinate, to follow their own schedule and or delay vaccination
2. There have been pockets of increased vaccine preventable diseases in the United States.  Many of these pockets have involved un-vaccinated children as a strong component of these surges in disease.
3. Well funded, well polished Anti-Vaccine Groups have continued to re-cycle non evidence based hype regarding vaccines lending confusion to this issue.  This emotional appeal to parents leads to confusion and is a disservice to well intentioned parents who want to do what is best for their children.  It needs a strong un-equivocal statement from doctors to show confidence in vaccination.
4. School policy has traditionally been consistent with the principle that the needs of the many outweigh the needs of the few.   Therefore schools have required children to be vaccinated to attend with few exceptions.   We believe this approach to be appropriate.  We believe it is also medically appropriate to exclude un-vaccinated children from a pediatric practice to protect the vaccinated children from communicable infectious diseases.

With these issues in mind, the following reflects our vaccine policy

Four Seasons Pediatrics Vaccine Policy Statement

• We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.
• We firmly believe that parents want their children safely protected from infectious diseases.
• We firmly believe in the safety of our vaccines, though we understand that they are a drug.
• We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics.
• We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities. We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities, although none of the vaccines we use contain thimerosal.
• We firmly believe that vaccinating children and young adults may be the single most important health-promoting intervention we perform as health care providers, and that you can perform as parents/caregivers. The recommended vaccines and their schedule given are the results of years and years of scientific study and data gathering on millions of children by thousands of our brightest scientists and physicians.
• We firmly believe that public health policy excluding un-vaccinated children from school is appropriate for a school setting, and is also appropriate at this time in our office setting.   The sickest children are seen in a doctors office and can be a source of spread of infectious disease to patients.
• We firmly believe that much of the protection of vaccines comes from herd immunity.  Most vaccines produce immunity in 90-95% of children.  The remaining 5-10% who do not produce immunity are protected from herd immunity, meaning that a highly vaccinated population limits the spread of most infections.  As more people choose not to vaccinate, herd immunity is eroded.  Now more than ever, it is important to protect parents who choose to vaccinate their children from those who do not vaccinate.
• We firmly believe that we have spent hundreds of hours educating parents individually, in the community and through a series of articles on our website.  Our education has been solidly founded on evidence.

These things being said, we recognize that there has always been and will likely always be controversy surrounding vaccination.  Indeed, Benjamin Franklin, persuaded by his brother, was opposed to smallpox vaccine until scientific data convinced him otherwise. Tragically, he had delayed inoculating his favorite son Franky, who contracted smallpox and died at the age of 4, leaving Ben with a lifetime of guilt and remorse. Quoting Mr. Franklin’s autobiography:

“In 1736, I lost one of my sons, a fine boy of four years old, by the smallpox…I long regretted bitterly, and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”

The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether or not they should be given. Because of vaccines, many have never seen a child with Hemophilus influenza, tetanus, whooping cough, bacterial meningitis, or even chickenpox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent or even lazy about vaccinating. But such an attitude, if it becomes widespread, can only lead to tragic results.

Over the past several years, many people in Europe have chosen not to vaccinate their children with the MMR vaccine after publication of an unfounded suspicion (later retracted) that the vaccine caused autism. As a result of under-immunization, there have been outbreaks of measles and several deaths from complications of measles in Europe over the past several years.  These outbreaks are now becoming more common here in the United States with more frequency and involving more diseases.  In a study based on nationwide surveillance data from 1985 through 1992, children with non religious exemptions were 35 times as likely to contract measles as nonexempt children.¹ In another study in Colorado based on data for the years 1987 through 1998, children with exemptions, as compared with unvaccinated children, were 22 times as likely to have had measles  and almost six times as likely to have had pertussis.²

Our policy is written to emphasize the importance of vaccinating children. We recognize that the choice may be a very emotional one for some parents. We will do everything we can to convince you that vaccinating according to the schedule is the right thing to do. Please be advised, however, that delaying or “breaking up the vaccines” to give one or two at a time over two or more visits goes against expert recommendations, and can put your child at risk for serious illness (or even death) and goes against our medical advice as providers at Four Seasons Pediatrics. We follow the recommendations of the American Academy of Pediatrics and its schedule, and as such do not recommend that parents pick their own schedule or follow schedules like the “Dr. Bob” schedule. 

Four Seasons Pediatrics follows the recommended schedule of the American Academy of Pediatrics.  Click here to view this schedule. 

If despite our recommendations, you feel you cannot follow the CDC and AAP recommendations for these vaccines, we will ask you to find another health care provider who shares your views.   We do not keep a list of such providers, nor would we recommend any such physician, any more that we would recommend a doctor who prescribes antibiotics by request. This approach does not include parents who choose to not vaccinate for certain vaccines based on firmly held religious beliefs.

As medical professionals, we feel very strongly that vaccinating children on schedule with currently available vaccines is absolutely the right thing to do for all children and young adults.   We want your trust and will work to earn it.  Thank you for your time in reading this policy, and please feel free to discuss any questions or concerns you may have about vaccines with any one of us.

1. Salmon DA, Haber M, Gangarosa EJ, Phillips L, Smith NJ, Chen RT. Health consequences of religious and philosophical exemptions from immunization laws: individual and societal risk of measles. JAMA 1999;282:47-53. [Erratum, JAMA 2000;283:2241.]

2. Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE. Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA 2000;284:3145-3150.

While many people are concerned after being bitten by a tick, the risk of acquiring a tick-borne infection is quite low, even if the tick has been attached, fed, and is actually carrying an infectious agent. Ticks transmit infection only after they have attached and then taken a blood meal from their new host []. A tick that has not attached (and therefore has not yet become engorged from its blood meal) has not passed any infection. The risk of acquiring Lyme disease from an observed tick bite, for example, is only 1.2 to 1.4 percent, even in an area where the disease is common.

If a person is bitten by a deer tick (the type of tick that carries Lyme disease), a healthcare provider will likely advise one of two approaches:

• Observe and treat if signs or symptoms of infection develop
• Treat with a preventive antibiotic immediately – only under certain circumstances

There is no benefit of blood testing for Lyme disease at the time of the tick bite; even people who become infected will not have a positive blood test until approximately two to six weeks after the infection develops (post-tick bite).

The history of the tick bite will largely determine which of these options is chosen. Before seeking medical attention, the affected person or household member should carefully remove the tick and make note of its appearance. Only the Ixodes species of deer tick causes Lyme disease.

The proper way to remove a tick is to use a set of fine tweezers and grip the tick as close to the skin as is possible. Do not use a smoldering match or cigarette, nail polish, petroleum jelly (eg, Vaseline), liquid soap, or kerosene because they may irritate the tick and cause it to behave like a syringe, injecting bodily fluids into the wound.

The proper technique for tick removal includes the following:

• Use fine tweezers to grasp the tick as close to the skin surface as possible.
• Pull backwards gently but firmly, using an even, steady pressure. Do not jerk or twist.
• Do not squeeze, crush, or puncture the body of the tick, since its bodily fluids may contain infection-causing organisms.
• After removing the tick, wash the skin and hands thoroughly with soap and water.
• If any mouth parts of the tick remain in the skin, these should be left alone; they will be expelled on their own. Attempts to remove these parts may result in significant skin trauma.

Tick characteristics — It is helpful if the person can provide information about the size of the tick, whether it was actually attached to the skin, if it was engorged (that is, full of blood), and how long it was attached.

The size and color of the tick help to determine what kind of tick it was;

•  Ticks that are brown and approximately the size of a poppy seed or pencil point are deer ticks. These can transmit Borrelia burgdorferi (the bacterium that causes Lyme disease) and a number of other tick-borne infections. Deer ticks live primarily in the northeast and mid-Atlantic region (Maine to Virginia) and in the midwest (Minnesota and Wisconsin) region of the United States, and less commonly in the western US (northern California).
• Ticks that are brown with a white collar and about the size of a pencil eraser are more likely to be dog ticks (Dermacentor species). These ticks do not carry Lyme disease, but can rarely carry another tick-borne infection that can be serious or even fatal (Rocky Mountain spotted fever).
• A brown to black tick with a white splotch on its back is likely an Amblyomma americanum (Lone Star tick; named after the white splotch). This species of tick has been reported to spread an illness called STARI (southern tick-associated rash illness). STARI causes a rash that is similar to the erythema migrans rash, but without the other features of Lyme disease. Although this rash is thought to be caused by an infection, a cause for the infection has not yet been identified. This type of tick can also carry and transmit another infection called human monocytic ehrlichiosis.
• A tick that was not attached, is still flat and tiny and is not full of blood, and was easy to remove or just walking on the skin, could not have transmitted Lyme disease or any other infection since it had not yet taken a blood meal.

Only ticks that are attached and have finished feeding or are near the end of their meal can transmit Lyme disease. After arriving on the skin, the tick that spreads Lyme disease usually takes 24 hours before feeding begins. Even if a tick is attached, it must have taken a blood meal to transmit Lyme disease. At least 36 to 48 hours of feeding is required for a tick to have fed and then transmit the bacterium that causes Lyme disease. After this amount of time, the tick will be engorged (full of blood). An engorged tick has a globular shape and is larger than an unengorged one.

The organism that causes Lyme disease, B. burgdorferi, lies dormant in the inner aspect of the tick’s midgut. The organism becomes active only after exposure to the warm blood meal entering the tick’s gut. Once active, the organism enters the tick’s salivary glands. As the tick feeds, it must get rid of excess water through the salivary glands. Thus, the tick will literally salivate organisms into the wound, thereby passing the infection to the host.

Need for treatment — The clinician will review the description of the tick, along with any physical symptoms, to decide upon a course of action. The Infectious Diseases Society of America (IDSA) recommends preventive treatment with antibiotics only in people who meet ALL of the following criteria:

• Attached tick identified as an adult or nymphal I. scapularis (deer) tick
• Tick is estimated to have been attached for =36 hours (based upon how engorged the tick appears or the amount of time since outdoor exposure)If the person meets ALL of the above criteria, the recommended dose of doxycycline is a single dose of 200 mg for adults and 4 mg/kg, up to a maximum dose of 200 mg, in children = 8 years. If the person cannot take doxycycline, the IDSA does not recommend preventive treatment with an alternate antibiotic for several reasons: there are no data to support a short course of another antibiotic, a longer course of antibiotics may have side effects, antibiotic treatment is highly effective if Lyme disease were to develop, and the risk of developing a serious complication of Lyme disease after a recognized bite is extremely low.
• Antibiotic treatment can begin within 72 hours of tick removal
• The local rate of tick infection with B. burgdorferi is =20 percent (known to occur in parts of New England, parts of the mid-Atlantic states, and parts of Minnesota and Wisconsin)
• The person can take doxycycline (eg, the person is not pregnant or breastfeeding or a child <8 years of age)

MONITORING FOR LYME DISEASE

Many people have incorrect information about Lyme disease. For example, some people are concerned that Lyme disease is untreatable if antibiotics are not given early (this is untrue; even later features of Lyme disease can be effectively treated with appropriate antibiotics). Many local Lyme disease networks and national organizations disseminate unproven information and should not be the sole source of education about Lyme disease. Reputable sources are listed below see below.

Signs of Lyme disease — Whether or not a clinician is consulted after a tick bite, the person who was bitten (or the parents, if a child was bitten) should observe the area of the bite for expanding redness, which would suggest erythema migrans (EM), the characteristic rash of Lyme disease

The EM rash is usually a salmon color although, rarely, it can be an intense red, sometimes resembling a skin infection. The color may be almost uniform. The lesion typically expands over a few days or weeks and can reach over 20 cm (8 inches) in diameter. As the rash expands, it can become clear (skin-colored) in the center. The center of the rash can then appear a lighter color than its edges or the rash can develop into a series of concentric rings giving it a “bull’s eye” appearance. The rash usually causes no symptoms, although burning or itching has been reported.

In people with early localized Lyme disease, EM occurs within one month of the tick bite, typically within a week of the tick bite, although only one-third of people recall the tick bite that gave them Lyme disease. Components of tick saliva can cause a short-lived (24 to 48 hours) rash that should not be confused with EM. This reaction usually does not expand to a size larger than a dime.

Approximately 80 percent of people with Lyme disease will develop EM; 10 to 20 percent of people have multiple lesions. If EM or other signs or symptoms suggestive of Lyme disease develop, the person should see us for proper diagnosis and treatment.

National Library of Medicine: http://www.nlm.nih.gov/medlineplus/lymedisease.html

National Institute of Allergy and Infectious Diseases: http://www3.niaid.nih.gov/topics/lymeDisease

National Center for Infectious Diseases: http://www.cdc.gov/ncidod/dvbid/lyme/

American Lyme Disease Foundation, Inc:   http://www.aldf.com/faq.shtml

Pictures of Lyme Disease:

• Pictures of Ticks
• Bull’s Eye Rash - known as Erythema Chronicum Migrans
• Update of Lyme Disease Discussion - reviewed every 4 months