Four Seasons Pediatrics

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Large Numbers of Ticks This Spring

April 4, 2016 – we have received a few phone calls about Tick Bites.  We expect high Tick counts this year.  Please do tick checks when your child has been outside, especially in wooded areas.  Please note that an infected Tick requires prolonged attachment (48 hours or more) to transmit Lyme Disease.

TICKS: May through August are the most common months that Lyme Disease is reported in New York State. Deer ticks are active in April through July. It is these ticks that transmit Lyme Disease. We recommend that you consider using an insect repellent such as Off Family Family Care Smooth and Dry. This will protect your child from Ticks for up to 8 hours. Tick’s do not jump on the body, they require direct contact with leaves or brush at a level of up to 18 inches. We recommend that you check your child daily if they are outside. An infected deer tick requires an attachment and blood meal for at least 48 hours to transmit Lyme Disease. This means that you can prevent transmission by removing the ticks daily when going 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 more information about Lyme Disease,  go to the Search section of our website and enter Lyme Disease.

Prevention is the best approach for Ticks (use a repellant like Off Family Care Smooth and Dry or Natrapel 8 hour with picaridin; both provide protection for more than 8 hours according to Consumer Reports). We recommend one application rather than multiple applications. As noted, in addition, check you child daily for TICKS and remove them carefully. We recommend using a TICK remover 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 and does not increase the risk for lyme disease. 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. See below for more information about ticks and lyme disease.

Patient information: What to do after a tick bite Authors: Anna R Thorner, MD – Deputy Editor — Infectious Diseases – Instructor in Medicine, Harvard Medical School. Allen C Steere, MD – Editor — Lyme Disease – Professor of Medicine, Harvard Medical School. Leah K Moynihan, RNC, MSN – Associate Editor — Patient Information. © UpToDate, Inc.

TICK BITE OVERVIEW: There are many different types of ticks in the United States, some of which are capable of transmitting infections. The risk of developing these infections depends upon the geographic location, season of the year, type of tick, and for Lyme disease only, how long the tick was attached to the skin. 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), Four Seasons Pediatrics follows recommendations from the CDC and the American Academy of Pediatrics. Treatment is not recommended for children under 8 years of age, as preventive antibiotics have not been shown to be effective in preventing Lyme. For children over this age, we advise one of two approaches: Observe and treat if signs or symptoms of infection develop OR 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. The current test available is not reliable for diagnosis.  A false positive test can occur just from bacteria found in the mouth.  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, we recommend that you carefully remove the tick and make note of its appearance. Only the Ixodes species of deer tick causes Lyme disease.

HOW TO REMOVE A TICK:  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.

AFTER THE TICK IS REMOVED: 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 (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 — we 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).

Antibiotic treatment can begin within 72 hours of tick removal.

The person can take doxycycline (eg, the person is not pregnant or breastfeeding or a child <8 years of age).

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, we follow recommendations from the IDSA, the CDC and the AAP and do 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.

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.

Web Sites that are reputable:

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

National Institute of Allergy and Infectious Diseases: http://www.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

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