Ticks and Lyme Disease: a Pediatrician’s Perspective

Lyme disease has gotten a bad name. Originally described in Connecticut and New York, on the coast, near the town of Old Lyme, it was found to be carried by the deer tick (the vector), a far less common tick than the tree or dog tick. It now has also been found in most parts of the country and cannot be transmitted from person to person. The deer tick is very small, about the size of the head of a pin, and as opposed to a wood (dog) tick will not engorge with the blood of other mammals, so it is often times very difficult to see when scanning the skin. This tick must remain attached and feeding for 24 to 48 hours before it is capable of transmitting disease. Only about 5% of tick bites with the deer tick in an endemic area will result in Lyme disease in the human. Ticks and tick bites are far more common during the summer months so that is when your powers of observation need to be finely tuned. You should carefully examine your children at least twice a day for the presence of any tick attached to your child’s skin. Be sure to look in those places not easy to observe such as the scalp, between the fingers and toes, and in the pubic and the perineal areas (between the genital area and the anus).

When found, these ticks should be removed from the skin by applying a tweezer to the mouth parts firmly very close to the skin, and with firm steady traction (not sudden and jerky) pull the tick from the skin. You may leave some dark mouth parts in skin; don’t try to remove them but cleanse the area well with soap and water and treat as you would for any abrasion or cut. Those mouth parts may very well come out on their own or may remain and not cause a problem. Of course these areas can become secondarily infected ( as any cut or abrasion might) with bacteria and that would result in redness, swelling, warmth over the area and pain or tenderness Since ticks actually breathe very infrequently the idea of smothering them with petroleum jelly or other thick substance would not be practical. Do not try to burn them off with a heated pin or freshly lit match head as the only thing you will probably burn is your child’s skin.

If the disease is transmitted to your child (let me point this out again, this is rare) a mild illness with feverinitially might occur in some, this is more likely not the case however, and chronic long term vague illness is also not necessarily what you will see. The rash of Lyme’s disease also does not occur in all cases and is fairly characteristic: initially a reddened bump that subsequently clears in the middle leaving a red ring that slowly and inexorably enlarges. Sometimes there is more than one ring and other times that ring may enlarge significantly to cover entire body parts and extend to others. As a result, it is sometimes difficult to recognize this as a ring. There are blood tests that can detect the presence of Lyme disease but these might not be positive for several weeks. Treatment is easily accomplished through the use of an antibiotic for 21 – 28 days and there is time to begin treatment, up to a week to 10 days without fear of the disease progressing. The antibiotics used are common to everyone generally without side effects: Amoxicillin for young children and doxycycline (a form of tetracycline) for children 8-10 years and older.

This is a diagnoses made usually on clinical grounds; that is as a result of your child’s doctor’s experience in light of a certain constellation of signs and symptoms. Checking the tick for the presence of Lyme disease (if you have the tick) is not recommended and neither is preventive treatment if living in a high density tick area. There are reports of “chronic Lyme disease” and the treatment of such a suspected occurrence is not clear- probably the services of a specialist (infectious disease) should be sought.

Summary– Lyme disease is not very common even though you may hear of cases in your area. If you are concerned after a tick bite take your child to his/her doctor and he/she will make the diagnosis and suggest treatment if necessary. Check your child twice a day for the presence of any ticks and remove as described above. There is plenty of time to begin treatment and the antibiotics used are well tolerated; once treated it is not recommended to repeat lab work if done originally, and it can be assumed that the illness is gone and will not leave long lasting problems.

Is My Child’s “Barky Cough” CROUP and How Can I Help?

Croup, or laryngotracheobronchitis, is caused by many viral infections and falls into the category of upper respiratory infection along with the common cold. Croup tends to occur in the autumn and early winter months. In croup, the major areas affected are the ones referred to in the long name of this illness (above); the larynx, trachea and bronchi, which are all structures that convey air from the mouth and nose down toward the lungs. As with all colds or upper respiratory infections there is inflammation of the mucosa (most superficial covering) of the inside of the nose, mouth, throat and upper respiratory tract, leading to mucous production and irritation of those sites.

In croup, the area of the upper respiratory tract most prominently affected is the larynx, or the voice box area located very close to the firm lump in the front of your neck, the “adam’s apple”. When vocal cords are irritated and swollen, adults merely get hoarse or raspy talking and a “normal” sounding cough. Children have a much narrower windpipe and therefore with even the slightest swelling of their vocal cords, there is less room for air to get by and they also get hoarseness along with a cough and raspy breathing. There is also a characteristic barky (yes sounds like a animal barking) kind of cough and occasional difficulty breathing. All symptoms tend to be worse at night, a time when all illnesses seem to worsen.

For the most part this illness remains mild and the only treatment needed is a cool mist humidifier, fluid intake, elevated head at night and reassurance for the child and parents.

Rarely a child may progress to real difficulty breathing, with a characteristic whooping noise when taking a breath in versus a wheezing sound when breathing out found more commonly in those with asthma. So if your child exhibits difficulty breathing along with the above symptoms, call your doctor for further instructions.

Once a child has had croup, parents seldom forget what the barky cough sounds like and can make the diagnosis themselves. Usually, as with other upper respiratory viral infections there is a mild amount of fever and the child is not real sick.

If there is sudden high fever with the onset of “croup” and your child is drooling, cannot swallow or speak, and is very anxious, you must call your doctor immediately or call 911.

This symptom complex describes a rare but life threatening illness called epiglotitis which can be very dangerous. I stress that this is a rare illness which used to be far more common before we were able to vaccinate against the bacteria which causes this illness.

How to Treat Your Child’s Infectious Disease

Chickenpox

Incubation period: One to three weeks
Infectious period: The most infectious time is one to two days before the rash appears, but it continues to be infectious until all the blisters have crusted over.

Symptoms

Chickenpox is a mild infectious disease that most children catch at some time. It starts with feeling unwell, a rash and, usually, a fever.

Spots develop, which are red and become fluid-filled blisters within a day or two. They eventually dry into scabs, which drop off. The spots first appear on the chest, back, head or neck, then spread. They don’t leave scars unless they’re badly infected or picked.

What to do

You don’t need to go to your GP(*physician) or accident and emergency (A&E) department(*emergency room) unless you’re unsure whether it’s chickenpox, or your child is very unwell or distressed.

• Give your child plenty to drink.
• Use the recommended dose of paracetamol to relieve any fever or discomfort. Ibuprofen isn’t recommended for children who have chickenpox as, in rare cases, it can cause skin complications.
• Taking baths, wearing loose, comfortable clothes and using calamine lotion can all ease the itchiness.
• Try to discourage or distract your child from scratching, as this will increase the risk of scarring. Keeping their nails short will help.
• Let your child’s school or nursery know they are ill, in case other children are at risk.
• Keep your child away from anyone who is pregnant or trying to get pregnant. If your child had contact with a pregnant woman just before they became unwell, let the woman know about the chickenpox and suggest that she sees her GP or midwife. For women who have never had chickenpox, catching the illness in pregnancy can cause miscarriage, or the baby may be born with chickenpox.

For more information, see our page on chickenpox.

See our visual guide to rashes in babies and children.

Measles

Incubation period: 7 to 12 days
Infectious period: From around 4 days before the rash appears until 4 days after it’s gone.

Symptoms

• Measles begins like a bad cold and cough with sore, watery eyes.
• Your child will become gradually more unwell, with a fever.
• A rash appears after the third or fourth day. The spots are red and slightly raised. They may be blotchy, but not itchy. The rash begins behind the ears and spreads to the face and neck, then the rest of the body.
• The illness usually lasts about a week.

Measles is much more serious than chickenpox, german measles, or mumps. It’s best prevented by the MMR vaccination. Serious complications include pneumonia and death.

What to do

• Make sure your child gets plenty of rest and plenty to drink. Warm drinks will ease the cough.
• Give them paracetamol or ibuprofen to relieve the fever and discomfort.
• Put Vaseline around their lips to protect their skin.
• If their eyelids are crusty, gently wash them with warm water.
• If your child is having trouble breathing, has a seizure, is coughing a lot or seems drowsy, seek urgent medical advice.

For more information, read see our page on measles.

Mumps

Incubation period: 14 to 25 days
Infectious period: From a few days before starting to feel unwell until a few days afterwards.

Symptoms

• A general feeling of being unwell.
• A high temperature.
• Pain and swelling on the side of the face (in front of the ear) and under the chin. Swelling usually begins on one side, followed by the other side, though not always.
• Discomfort when chewing.

Your child’s face will be back to normal size in about a week. It’s rare for mumps to affect boys’ testes (balls) – this happens more often in adult men with mumps. If you think your child’s testes are swollen or painful, see your GP.

What to do

• Give your child paracetamol or ibuprofen to ease pain in the swollen glands. Check the pack for the correct dosage.
• Give your child plenty to drink, but not fruit juices, as they make the saliva flow, which can worsen your child’s pain.
• There’s no need to see your GP, unless your child has other symptoms, such as a severe headache, vomiting, rash or, in boys, swollen testes.
• Mumps can be prevented by the MMR vaccine.

See our page on mumps for more information.

Slapped cheek disease (also known as fifth disease or parvovirus B19)

Incubation period: 1 to 20 days
Infectious period: A few days before the rash appears. Children are no longer contagious when the rash appears.

Symptoms

• It begins with a fever and nasal discharge.
• A bright red rash, like the mark left by a slap, appears on the cheeks.
• Over the next two to four days, a lacy rash spreads to the trunk and limbs.
• Children with blood disorders such as spherocytosis or sickle cell disease may become more anaemic. They should seek medical care.

What to do

• Make sure your child rests and drinks plenty of fluids.
• Give them paracetamol or ibuprofen to relieve any discomfort and fever.
• Pregnant women or women planning to become pregnant should see their GP or midwife as soon as possible if they come into contact with the infection or develop a rash.

Go to our page on slapped cheek syndrome for more information.

German measles (rubella)

Incubation period: 15 to 20 days
Infectious period: From one week before symptoms develop until up to four days after the rash appeared.

Symptoms

• It starts like a mild cold.
• A rash appears in a day or two, first on the face, then on the body. The spots are flat and are pale pink on light skin.
• Glands in the back of the neck may be swollen.
• Your child won’t usually feel unwell.

It can be difficult to diagnose rubella with certainty.

What to do

• Give your child plenty to drink.
• Give them paracetamol or ibuprofen to relieve any discomfort or fever.
• Keep them away from anybody who’s in the early stages of pregnancy (up to four months) or trying to get pregnant. If your child has had contact with any pregnant women before you knew about the illness, you must let the women know, as they’ll need to see their GP.
• Rubella can be prevented by the MMR vaccine.

For more information, go visit our page on rubella.

Whooping cough

Incubation period: 6 to 21 days
Infectious period: From the first signs of the illness until about three weeks after coughing starts. If an antibiotic is given, the infectious period will continue for up to five days after starting treatment.

Antibiotics need to be given early in the course of the illness to improve symptoms.

Symptoms

• The symptoms are similar to a cold and cough, with the cough gradually getting worse.
• After about two weeks, coughing fits start. These are exhausting and make it difficult to breathe.
• Younger children (babies under six months) are much more seriously affected and can have breath-holding or blue attacks, even before they develop a cough.
• Your child may choke and vomit.
• Sometimes, but not always, there will be a whooping noise as the child draws in breath after coughing.
• The coughing fits may continue for several weeks, and can go on for up to three months.

What to do

• Whooping cough is best prevented through immunisation.
• If your child has a cough that gets worse rather than better, and starts to have longer fits of coughing more often, see your GP.
• It’s important for the sake of other children to know whether or not your child has whooping cough. Talk to your GP about how to look after your child. Avoid contact with babies, who are most at risk from serious complications.
• Whooping cough can be prevented by childhood vaccinations.

For more information, go to our page on whooping cough.

Editor’s Note: *clarification provided for our US readers.

What is Strep and How Can it Affect Your Family?

Why is my Child’s Flu so Hard to Treat?

Unique Influenza:

I. First – You need to know a little about what makes this such a tough bug to prevent….

a) To do that you need to understand the nature of this virus – in particular that it is continuously changing / evolving.

Before we discuss the Flu virus and its effects on human beings it is important to know some basic background information. The Influenza viral particle at the microscopic level is unique in that its many protein particles are attached in random order to receptor cells on the surface of the viral particle itself and each one is capable of changing the characteristics of the particle in such a way that it will have altered effects on the host (humans). A virus causes its effects on the host by attaching to the host’s respiratory cells and in some way alters the function or structure of the cell so that the invading virus can replicate using the host cells’ capabilities. Replication of a species is a common goal for all living creatures no matter how large or small.

Before we see the Influenza virus as we know it in humans it has spent several replication cycles in various animal species over time such as birds, pigs, and humans. With each pass through of a species, the virus has a chance to change or mutate into a different breed with possible different characteristics and therefore effects on the human host.

b) And you need to understand a little about how vaccines are developed – and that we need to have them ready “before” our flu season starts, but that can be problematic with a continuously changing bug..

Viral immunizations are created by using the viral particle to develop antibodies to aid our own very sophisticated immune system to function in a more effective manner and rid ourselves of the offending invader. As you can imagine, this process of developing that immunization can be a long and arduous one and effected by forces not easily seen or appreciated by us, the consumer. Economic and yes political forces are at play in developing a new immunization to be used each year. First the virus of the year needs to be isolated prior to the infection season, which is the cold weather season of the year. Often times we find that particular viral particle in countries that are in the southern hemisphere and therefore have reversed seasons; a lot of our information on the type of virus comes from the Australian experience with the illness. It then must be isolated and a viable strain must be grown near a laboratory so that it can be used in the process of developing the vaccine before the pharmaceutical companies can gear up for production.

While all this is happening and just to confuse things more, the Flu virus may continue to change and eventually present us with a different illness than the newly developed immunization will cover! And a further confusing issue is that no matter how well any vaccine is manufactured it is never 100% effective in deterring the illness; the most effective vaccines made are only about 90% effective while the Influenza vaccine is at most 60% effective (some reports of much lower than that can be found). Those who may have been immunized and still manage to get the illness should experience a much lighter case.

II. And Then Why It’s So Difficult to Treat and Cure

a) Because you can’t be sure of prevention, what you can do is lessen the effects and avoid passing it on.

OK now that we know what we are dealing with we can further discuss the illness and its prevention and treatment. The best thing one can still do is get fully immunized every year even acknowledging that it is not a perfect vaccine; all other factors are beyond our control. There are some fairly effective medicines that can treat the Flu symptoms if used early in the disease or if one is in close contact with someone who has an active case. These are also not completely effective although they can slow the length of illness. Fortunately the side effects are mainly minimal and short –lived. As with all medications there are rare significant side effects that should be reported to your Doctor such as severe headaches and vomiting (headache and vomiting can also be prominent symptoms of Flu virus infection- confusing again! ) and certain psychological symptoms such as vivid dreams and even hallucinations.

Most of the deaths that occur with Flu virus infection are found in very young children or infants, those children or infants with asthma, children with certain chronic diseases of the lungs, kidneys or heart, those individuals with immune dysfunction, and elderly people. Still, suffering through the Flu illness is no piece of cake for previously healthy individuals and can cost a week or more out of school or work.

Aside from thorough immunization every year and avoidance of those with the illness the next most effective way to reduce spread and subsequent infection is to wash hands frequently during the the Flu season with soap and water or the many anti-bacterial and antiviral solutions found in abundance in hospitals and other health care facilities and easily purchased by anyone.

b) The earlier you find it, the better the chances for EVERYONE in your family – so pay attention during flu season; even if it’s not a “traditional flu symptom” – when in doubt, ask your doctor.

Early identification of Flu –like symptoms (sudden onset of fever, chills, headache, eye pain, etc.) should be brought the attention of your Doctor as early treatment (mentioned previously) can lead to less severe symptoms and a shorter duration of illness. Remember preventing Influenza infection in one family member can help prevent the infection in all family members!

It has been mentioned that hives can be a sign of Flu even without other symptoms being present, and, as with many other viral infections, this may be possible, it is the symptoms of Flu that are debilitating and therefore worth avoiding employing all the methods mentioned above. The only significance is that if, and that is rare, hives do represent the only symptoms of Flu infection, a more preventive plan can be instituted in the family. That is why hand washing, avoidance of contact and proper immunizations should be practiced by everyone during the appropriate season of the year.

Pneumococcal Infections: What You Need to Know

Pneumococcal infections are caused by the Streptococcus pneumoniae bacteria, and range from mild to severe.

There are more than 90 different strains of Streptococcus pneumoniae (S. pneumoniae) bacteria (known as serotypes), some of which cause more serious infection than others.

The symptoms of a pneumococcal infection can vary, depending on the type of infection you have. Common symptoms include:

• a high temperature (fever) of 38C (100.4F)
• aches and pains
• headache

Types of pneumococcal infection

Pneumococcal infections usually fall into one of two categories:

• non-invasive pneumococcal infections – these occur outside the major organs or the blood and tend to be less serious
• invasive pneumococcal infections – these occur inside a major organ or the blood and tend to be more serious

Non-invasive pneumococcal infections

Non-invasive pneumococcal infections include:

• bronchitis – infection of the bronchi (the tubes that run from the windpipe down into the lungs)
• otitis media – ear infection
• sinusitis – infection of the sinuses

Invasive pneumococcal infections

Invasive pneumococcal infections include:

• bacteraemia – a relatively mild infection of the blood
• septicaemia (blood poisoning) – a more serious blood infection
• osteomyelitis – infection of the bone
• septic arthritis – infection of a joint
• pneumonia – infection of the lungs
• meningitis – infection of the meninges (the protective membranes surrounding the brain and spinal cord)

Who is at risk?

People with a weakened immune system are most at risk of catching a pneumococcal infection. This may be because:

• they have a serious health condition, such as HIV or diabetes, that weakens their immune system
• they are having treatment or taking medication that weakens their immune system, such as chemotherapy

Other at-risk groups include:

• babies and young children under two years of age
• adults over 65 years of age
• people who smoke or misuse alcohol

Read more about the causes of pneumococcal infections.

Cases of invasive pneumococcal infection usually peak in the winter, during December and January.

Treating pneumococcal infections

Non-invasive pneumococcal infections are usually mild and go away without the need for treatment. Rest, fluids and over-the-counter painkillers such as paracetamol are usually advised.

More invasive types of pneumococcal infections can be treated with antibiotics, either at home or in hospital.

Read more about how pneumococcal infections are treated.

Pneumococcal vaccines

There are two different types of pneumococcal vaccine used. These are:

• pneumococcal conjugate vaccine (PCV) – which is given to all children as part of the childhood vaccination programme; it’s given in three separate doses at eight and 16 weeks and at one year of age
• pneumococcal polysaccharide vaccine (PPV) – which is given to people aged 65 years or over, and others who are at high risk

The PCV protects against 13 types of S. pneumoniae bacteria, and the PPV protects against 23 types. It is thought that the PPV is around 50-70% effective at preventing more serious types of invasive pneumococcal infection.

Read about pneumococcal vaccination and when pneumococcal vaccination is used.

Outlook

The outlook for pneumonia in people who are otherwise healthy is good, but the infection can lead to serious complications in people who are very young, very old or have another serious health condition.

However, due to the introduction of the PCV in 2002, the number of people dying from complications that arise from pneumonia has fallen to around 7%.

The outlook for other types of invasive pneumococcal infections such as bacteraemia is generally good, although there is about a 1 in 20 chance that bacteraemia will trigger meningitis as a secondary infection.

Multidrug-resistant Streptococcus pneumoniae (MDRSP)

During the 1990s, the increasing levels of S. pneumoniae that had developed a resistance to three or more types of antibiotics was a major concern. These types of bacteria are known as multidrug-resistant Streptococcus pneumoniae (MDRSP).

MDRSP is a real concern because it is challenging to treat and carries a higher risk of causing complications.

Since the introduction of pneumococcal vaccines, fewer cases of infection have led to antibiotics being used less and the chance of bacteria developing resistance to antibiotics becoming smaller.

The ability for bacteria to become resistant to antibiotics is the reason why GPs (*physicians) are becoming increasingly reluctant to prescribe antibiotics for mild infections.

Editor’s Note: *clarification provided for our US readers.

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