Lyme Disease

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Sneaking away for the weekend is a much needed escape for us Brooklynites!  Seeing our little ones roll in the open field, or hike through the mountains is precious!  But open fields and mountains can mean deer, and anywhere there are deer, we have to worry about Lyme disease.

Lyme disease is one of those conditions that many people have heard of, but I think it’s worth it to review all the nuances of a very preventable and justifiably frightening disease.  

How do we catch Lyme disease?

In almost all cases, the disease comes from a deer tick that is infected with the Lyme bacteria.  This means that dog ticks should not have the bacteria that carry Lyme disease, although it does get tricky if your dog just went hiking with you to Bear Mountain!

A larger deer tick can be pretty easy to identify, but the tiny ones (nymphs) can be very hard to even spot (as small as a poppy seed), and can indeed be carriers of Lyme.   Not all deer ticks have themselves been infected with the bacteria, called Borrelia Burgdorferi, that cause Lyme disease.  The percentages vary according to the area with certain areas being endemic, or very high rates.  

But the most important concept in Lyme prevention comes not in the preparation before you go outside.  Yes – you should put on bug spray, and even Deet containing products (less than 30%) in the older ones.  And yes – you should wear long pants, tucked in socks on hikes and light colored clothing, which makes spotting the ticks easier.  By far, the most important concept is a rigorous full body tick check every 24 hours.  These ticks can hide, and I have seen them hiding beneath thick hair, under a testicle, and even attached to the inner ear canal!   Doing a full tick check takes time and patience on both of your part as well as your squirmy energetic child, but please do as complete a check as possible.  

Do a very thorough tick check every 24 hours.

As long as you FIND a NEW TICK that has NOT BEEN THERE yesterday, you CAN’T CATCH LYME!   

Even if the tick does have the dreaded bacteria in its body, and did bite your child, as long as you remove it within 24 hours, there just isn’t the chance that the Lyme has spread.  Ticks usually need 36-48 hours or longer to get engorged, and transfer the bacteria.  So if you do see that new tick, just remove it completely, and you should be fine.  

There are different approaches to taking out a tick, involving Vaseline, or oils, and some even suggest heat or other ways to disrupt the tick.  But the bottom line is use a tweezer and remove the entire tick, especially the head and body, but even the legs, and wash the area thoroughly after.

If for any reason you just forgot, or aren’t sure, and the tick is engorged, you still should remove the tick, but now we have to do a careful watch and wait method. 

You can indeed save the tick, and your pediatrician can look at it and help identify it as a deer versus dog tick.  Many ask for us to send it off to a laboratory for analysis.  If we could get an accurate results in a day, that certainly seems worth it.  We asked Dr. Michael Tosi, an experienced Pediatric Infectious Disease specialist from Mount Sinai Hospital what he thinks, and he shared his wisdom with us for this article.  He said the lab testing of a tick is not routinely recommended because the testing itself isn’t accurate enough and takes weeks to get back a result.   Further, Dr. Tosi notes that even if tick had the Lyme bacteria, it doesn’t mean it spread it to the child.  Even if we knew the tick had the Lyme bacteria, it’s never been proven to be effective to treat each child without any symptoms, as the child may never get Lyme.

What signs should we look for after a tick bite?

A very specific type of rash, called Erythema Migrans often comes, and usually within a 2-3 weeks.  It is true - it doesn’t always come – but in most cases it does.   It can be quite characteristic – starting as a reddish papule at the site of the bite, and expanding to almost a bulls-eye larger circle with some central clearing.  Other symptoms may include fever, malaise, headache, neck stiffness, muscle or joint pains.  Note a cold or cough isn’t one of the symptoms, so don’t worry if they catch a cold as you wait – that isn’t Lyme.

There are times where you missed the tick, and it falls off, and no rash comes, but other symptoms appear, including limping, facial nerve palsy, weakness or unexplained fevers, and later stages of Lyme can get more serious, including arthritis, usually of the knees, neurological symptoms, and even heart disease.  

There are so many horror stories on the internet, but the majority of Lyme disease is indeed caught early and treated fully.  Not every child who feels tired for a few days needs a Lyme test, but you never want to “miss it” either, as it will progress.   Nothing is better than a full history and physical exam when it comes to the trickier or more subtle presentations of Lyme, and an experienced pediatrician should always have Lyme on the radar.  

When should we treat?

The anxiety of knowing your child had a real tick bite – even if it wasn’t engorged or in for days – but certainly if it was engorged and for days, can be overwhelming.   Explaining to a parent that we should not (statistically or scientifically) start antibiotics can be a very difficult thing.

The decision to treat preventatively or prophylactically is based on many factors.  The incidence, or how common the infection is – as the more likely Lyme is in a given area, the more beneficial the treatment might be.  But other questions are important to consider.  Are there any side effects of antibiotics? Absolutely there could be – and the most studied and perhaps “best” antibiotic for Lyme – called doxycycline is not normally given for very young kids.  Can you partially treat the infection with a small one time dose – or is it best to treat for the “full course” if there truly is infection?  No scientific study shows this, but it is a concern – whether one dose given early will truly “ward off” infection effectively.  

The scientific answer based on well done studies is that adults have been shown to benefit from a preventative dose of antibiotics when an engorged tick is found for more than 2 days in an endemic area, but that in kids, it just isn’t recommended to give antibiotics for each tick bite without any symptoms.  

Since the rash usually comes with true Lyme disease – perhaps up to 75% - it is thought of as best to wait for the rash, or any symptoms, and then treat fully, rather than give one dose of an antibiotic and hope the Lyme doesn’t come or is fully cured.  With that said, there are always exceptions, and your doctor will discuss the pros and cons with you based upon each individual case.  

Dr. Tosi agrees, and explains that the evidence doesn’t support enough benefit for a one time preventative dose in all cases, but he would even feel comfortable using the doxycycline as a one-time preventative dose for young kids, if the tick was in for many days, fully engorged, in a very endemic area.  

Testing for Lyme

The test for Lyme is looking for the antibodies we form against the bacteria and that takes time to develop.  It can usually take 2-3 weeks after the bite, so there really is no reason to draw labs right after the tick bite, but we certainly will do testing if symptoms arise.  The testing is really very accurate in terms of percentages of false negatives.  There is a two-step process to confirm Lyme and a negative can be trusted to be a negative.  There are some false positives, which mean if you check 100 healthy adults with no symptoms and no tick bites at all, you will see some false positives.  That is why we don’t like to check a child who is just a bit weak, or once had a little knee pain.  We don’t want false positives and then need weeks of antibiotics for no good reason.  But of course we don’t want to miss Lyme either.  

Treatment for Lyme

Dr. Tosi wanted to reassure us that when Lyme is caught early, the treatment allows for a full cure.  There are reports of Lyme leading to chronic symptoms, but this is extremely rare.  The antibiotic we use – doxycycline in older children and adults, and amoxicillin in younger kids – will eliminate the Lyme bacteria in just about all cases.  But it is true, that Lyme can be missed, and then it can progress or spread, and there are cases where a later, more systemic case of Lyme may need up to 4 weeks of intravenous antibiotics, but luckily these cases are not common.  

So let’s all continue to hike and enjoy the great outdoors!  It’s good for our city kids!   But let’s really do a full thorough tick check every 24 hours, and when needed, be on the look-out for any symptoms of Lyme.  

Dr. Michael Tosi as a seasonedexpert in Pediatric Infectious Diseases, and is available for consults (212.241.6930) at the Mount Sinai Medical Center.

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