Preventing and treating Lyme disease: What clinicians need to know

When spring arrives, Midwesterners know mosquito and tick season is also on its way. And, while the majority of insect bites leave behind only an itchy bump for a few days, some tick bites can cause bigger problems. Most people are used to hearing about deer ticks and Lyme disease in Minnesota, but health experts warn clinicians not to let their guard down on this potentially serious disease.

In the Talking Pediatrics episode, “Putting it all on the Lyme: What Clinicians Need to Know About Preventing and Treating Lyme Disease,” host Dr. Angela Kade Goepferd talks about current clinical guidelines for tick bites and Lyme disease in kids with Ashley Gyera, DNP, APRN, CPNP-PC, infectious disease nurse practitioner at Children’s Minnesota. Gyera is also the clinical advisor to the National Association of Pediatric Nurse Practitioners (NAPNAP) and Centers for Disease Control and Prevention (CDC) education initiative for Lyme disease.

Refresher: Lyme disease

Lyme disease is the most common vector-borne disease in the United States. It’s caused by a bacterium that is spread through the bite of infected deer tick, or blacklegged tick. When Lyme disease is discovered and treated early, most children and adults make a full recovery. But left untreated, it can attack several systems of the body, including the skin, heart, nerves and joints.

Many types of ticks bite, but blacklegged ticks are the only ones that carry the Lyme-causing bacteria, and not all blacklegged ticks are carriers. The most common time of year for active ticks and Lyme spread is April to October, but ticks can be active all year round. Lyme cases are seen mostly in the upper Midwest, Northeast and Mid-Atlantic states, but cases have been reported in every state in the U.S.

The CDC estimates approximately 476,000 people may get Lyme disease each year in the United States. However, because diagnosing Lyme can be difficult, many people who have Lyme may be misdiagnosed with other conditions. Many infectious disease experts believe the true number of cases is much higher. Anyone can contract Lyme disease more than once, even if it has been treated before.

Symptoms of Lyme disease

Early Lyme disease symptoms typically start 3 to 30 days after the tick bite (average is seven days). Symptoms include fever, chills, muscle and body aches, headache, fatigue, and swollen lymph nodes. Another prominent symptom for Lyme is the rash of erythema migrans, a flat, red, target shaped rash located at the site of the tick bite.

Symptoms for early Lyme can look like a lot of other things in kids, but the combination of the symptoms along with the distinctive rash makes a strong case for a clinical diagnosis of Lyme.

A tick bite is considered a high-risk for spreading Lyme if:

The tick has been identified as a blacklegged or deer tick.
The tick bite occurred in a state where Lyme is common.
The tick was attached for more than 36 hours and/or is engorged with blood.
There is an erythema migrans rash at the site of the bite.

Diagnosing and treating Lyme disease

If the tick bite cannot be classified as high risk, a “watch and wait” approach is recommended. Also, if it’s been more than 72 hours since the tick bite and the child isn’t presenting other symptoms, caregivers can continue to monitor the child at home.

For high-risk tick bites, the CDC recommends a two-step serum antibody (serology) testing protocol. Testing at the 3- or 4-day mark might miss a seroconversion, so if there is a very high suspicion for Lyme disease and the initial tests were negative, repeat testing in 2 to 3 weeks.

Treatment for Lyme disease in kids varies depending on their presentation, for example:

If the child is presenting with an erythema migrans rash and they’re in the early disease process, antibiotic therapy with doxycycline (preferred), amoxicillin or cefuroxime is recommended.
If the child is in the early disseminated or late stages of Lyme disease, then the dosing and duration of antibiotics changes based on their presentation. Most of the time this can be done outpatient.
If initial serology tests were negative, or it’s within 72 hours of a high-risk tick bite, a single dose of doxycycline (4.4 mg/kg; max dose 200 mg) can lower a patient’s chance of Lyme disease.

Some kids will be sick with symptoms of Lyme disease and then get better, which can be an indication they are progressing into the early disseminated and late stages of Lyme disease. Syndromes including carditis or CNS symptoms such as meningitis, radiculopathy and cranial nerve palsies might appear. “As pediatric providers we want to make sure we provide the best care possible without missing a diagnosis, so if we’re concerned for carditis or meningitis, we’ll send them to the ER,” said Gyura.

Protection and prevention

Ticks are typically found in wooded areas, tall grass, weeds, and bushes everywhere from outlying rural areas to urban backyards. Compared to wood ticks or dog ticks, deer ticks are extremely tiny, especially the nymph ticks seen more towards the spring and early summer; they can be tinier than a freckle. Adult deer ticks are about the size of a sesame seed.

Since there isn’t a way to get rid of all ticks, health care providers should advise families how to prevent tick bites, including:

Do skin checks. It’s important to check skin after every time spent outdoors. Ticks can hide under the armpits, behind the knees, in the hair and the groin. A bath or shower within two hours of being outside can reduce the risk of a tick bite.
Use insect repellent. Products with 10-30% DEET are recommended to use on kids, according to the American Association of Pediatrics (AAP), CDC and NAPNAP. This level of protection applied to exposed skin in a light layer protects kids for about 5 to 6 hours. Other effective repellents use the ingredient Picaridin, which has been found to offer about 4 to 5 hours of protection.

Wear long sleeves, socks and pants when in wooded areas and long grasses. This can be a tough order for anyone when it’s 90+ degrees outside but covering up with clothing can help prevent tick bites.
Avoid sunscreen-insect repellent combination products. Research has found sunscreen reduces the effectiveness of the repellent in these products. Also, sunscreen needs to be reapplied more often than repellent. It’s better to use separate products and apply sunscreen first, followed by repellent. Then reapply sunscreen as needed.
If you find a tick, remove it as soon as possible. In most cases, blacklegged ticks need to attach to hosts for at least 24 hours before transmitting the bacteria that causes Lyme disease. Resources are available online to help identify the type of tick.