Four Seasons Pediatrics

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Insect Repellant Updates

TICKS: April through August are the most common months that Lyme Disease is reported in New York State. We continue to have a high number of phone calls about ticks and anticipate an increase through the fall. In addition, we are getting calls about mosquito bite reactions.  Deer ticks can transmit Lyme Disease. The most important preventive measures are to use an insect repellent and checking the skin and removing ticks daily.   We recommend that you consider using an insect repellent.  Most products will protect your child from Ticks for up to 6-8 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 in areas with brush. An infected deer tick requires an attachment and blood meal for at least 36-48 hours to transmit Lyme Disease. This means that you can prevent transmission by removing the ticks daily when going outside. Most ticks will be found at the edge of properties in wooded areas. The overall risk of Lyme Disease from a TICK is less than 1-3%. Our area is considered a moderate risk area for ticks.  For more information about Lyme Disease,  go to the Search section of our website and enter Lyme Disease.

Prevention – Insect Repellants – DEET is an effective tick and mosquito repellent. New Recommendations as of 2023:

US Age Limit: If under 2 months old, avoid all DEET products. (AAP)
US: For children 2 months to 2 years old, use 10% DEET.
After 2 years old, can use 30% DEET.Protection: 10% DEET protects for 2 hours. 30% DEET protects for 6 hours.

With the above in mind here is what we recommend:
2 months – 6 months – Cutter All Family Mosquito Wipes (7.15% DEET).
6 months – 2 Years: 1) Sawyer Picaridin Insect Repellant 20%. 2) Nutrapel Picaridin Spray 20%.
OVER 2 Years: 1) Ultrathon 8 hour (25% DEET). 2) Repel Insect Repellent Scented Family (15% DEET).
OVER 3 Years: 1) Repel Lemon Eucalyptus Insect Repellent.

We recommend one application rather than multiple applications. Our other recommended products over age 2 have been shown to protect for 6-8 hours. We recommend one application per day ONLY and showering at the end of the day. Showering has been shown to remove ticks that have not attached and you are most likely to see ticks that have attached.

Tick Repellent for Clothing – Permethrin: Permethrin-containing products (e.g., Duranon or Permanone Tick Spray) are highly effective tick repellents.

An advantage over using DEET is that they are applied to and left on clothing instead of skin. Apply it to clothes, especially pants cuffs, socks and shoes. You can also put it on other outdoor items (mosquito screen, sleeping bags).

If you use Permethrin, do not apply to skin (Reason: it’s rapidly degraded on contact with skin)
 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. Four Seasons Pediatrics follows recommendations from the American Academy of Pediatrics.   For children with a Tick Bite, 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), and again the test is not very accurate.  It is prone to false negatives and false positives.   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.

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 (see pictures below). 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.  After this amount of time, the tick will be engorged (full of blood). An engorged tick has a globular shape and is larger than a flat 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 American Academy of Pediatrics Infectious Diseases Red Book Committee (reviews studies on treatment of infections in children) 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 great than or equal to 36 hours (based upon the tick being engorged and not flat 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).

If the person meets ALL of the above criteria, we recommend that you call BEFORE the 72 hour period after tick removal.  We will review the risk benefit of treatment at an appointment for children under 8 years old.  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. 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 un-treatable 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.

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:

National Center for Infectious Diseases:

American Lyme Disease Foundation, Inc:

Pictures of Deer Ticks showing approximate size compared to a dime:

Pictures of Dog Ticks:

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