Itching to know: how to treat poison ivy


Teach your child to recognize poison ivy: “leaves of three, let’em be!”

Recently we’ve had a parade of itchy children troop through our office.  The culprit: poison ivy.

Myth buster: Fortunately, poison ivy is NOT contagious. You can catch poison ivy ONLY from the plant, not from another person.

Another myth buster: You can not spread poison ivy on yourself through scratching.  However, where  the poison (oil) has touched  your skin, your skin can show a delayed reaction- sometimes up to two weeks later.  Different  areas of skin can react at different times, thus giving the illusion of a spreading rash.

Some home remedies for the itch:

Hopping into the shower and rinsing off within fifteen minutes of exposure can curtail the reaction.  Warning, a bath immediately after exposure may cause the oils to simply swirl around the bathtub and touch new places on your child.

Hydrocortisone 1%-  This is a mild topical steroid which decreases inflammation.  We suggest the ointment- more staying power and unlike the cream will not sting on open areas, use up to four times a day

Calamine lotion – a.k.a. the pink stuff- This is an active ingredient in many of the combination creams.  Apply as many times as you like.

Diphenhydramine (brand name Benadryl)- take orally up to every six hours. If this makes your child too sleepy, once a day Cetirizine (brand name Zyrtec) also has very good anti-itch properties.

Oatmeal baths – Crush oatmeal, place in old hosiery, tie it off and float in the bathtub- this will prevent oat meal from clogging up your bath tub. Alternatively buy the commercial ones (e.g. Aveeno)

Do not use alcohol or bleach– these items will irritate the rash more than help

The biggest worry with poison ivy rashes is the chance of infection.  Just like with an itchy insect bite, with each scratch, your child is possibly introducing  infection into an open wound.  Unfortunately, it is sometimes difficult to tell the difference between an allergic reaction to poison ivy and an infection.  Both are red, both can be warm, both can be swollen.

However, infections cause pain – if there is pain associated with a poison ivy rash, think infection.  Allergic reactions cause itchiness- if there is itchiness associated with a rash, think allergic reaction.  Because it usually takes time for an infection to “settle in,” an infection will not occur immediately after an exposure to poison ivy.  Infection usually occurs on the 2nd or 3rd day of scratching.  If you have any concerns take your child to her doctor.

Generally, any poison ivy rash which is in the area of the eye or genitals (difficult to apply topical remedies), appears infected, or is just plain making your child miserable needs medical attention.

When all else fails, comfort yourself with this statistic: up to 85% of people are allergic to poison ivy.  If misery loves company, your child certainly has company.

Naline Lai, MD and Julie Kardos, MD
©2017, 2016, 2015 Two Peds in a Pod®, updated from 2012




Eight is Great! All about eight-year-olds


eight year old development

Photo by Lexi Logan

Happy 8th Birthday Two Peds in a Pod!

If our blog had a “face” we would put a party hat on a smiling head with disproportionately large emerging adult teeth and a body with gangly legs and arms.  In honor of our blog’s eighth birthday  (read our very first post here) today’s post celebrates your eight-year-old.

Typical eight-year-olds are no longer squishy-faced babies and no longer adoring young elementary school students who still think of their parents as heroes. Now you have an emerging friend-seeking, active child.

Eight-year-olds understand logic and are less apt to believe in “real” magic but are interested in spotting the “trick.” Parents may find that eight is the year that their child stops believing in Santa or the tooth fairy. If they do believe in Santa, expect them to question how Santa reaches all the children in one night, or how he can fit down a chimney.

This is an academic leap year. There is less hand holding in school. The switch-over from “learning how to read” to “reading in order to learn”  begins. Instead of rote memorization of individual words, reading comprehension increases and children now gain knowledge from books. Some eight-year-olds may prefer to read to themselves before bedtime because they can read to themselves faster than you can read to them. Even if they are reading on their own, continue to share books together at bedtime.  For many kids, this is the age when they begin to struggle academically if they have a previously unrecognized learning disability.

Eight-year-olds begin to notice kids who stand out, especially kids who act or look different from the other kids, and can be cruel with their observations and exclusions. Teach your child about differences and the importance of tolerance. As Dr. Lai tells her kids, “You don’t have to be friends with everyone, you just have to be nice.”

The long march through adolescence starts now. Some girls start to show the initial  sign of puberty called breast-budding (chest development). Teach your daughters about periods at this age because some girls begin to menstruate in the next couple of years, and girls who are caught unawares can become quite frightened by unexpected blood coming out of them. You can refresh your memories and check your facts about periods from our prior post on this subject.

Many eight-year-olds, even those who seem years away from puberty, become stinky. Trust us, you will notice, and so will others, so encourage them to wash their entire body, INCLUDING ARMPITS, every day WITH SOAP and to use deodorant daily. We do not have a favorite brand but you could look initially for a deodorant alone rather a deodorant/antiperspirant combination product as they may irritate young skin. Note that even though they may smell like adults, their brains are only eight years old, so you will have to remind your eight-year-olds to use the deodorant. One trick is to keep the deodorant next to the toothbrush so when they brush their teeth every morning, they will remember to incorporate deodorant into their morning routine.

Other self-care tasks also will need reminders. After years of tracking your child’s pee and poop pattern, you now probably don’t know when the last time your child moved her bowels. No need to follow your child into the bathroom, but every once in a while ask about their bowel and bladder habits. During the school year, be aware that eight-year-olds may avoid school bathrooms and don’t urinate all day, which can lead to problems with leaking urine (accidents) and urinary tract infections.

Eight-year-olds continue to  improve their concentration spans and have a greater interest in learning new skills. For many, this is the age of active sport participation (playing “real” sports games), the start of learning a musical instrument or foreign language, and club participation such as 4H or scouts. Some eight-year-olds begin to spend many hours a week in a chosen activity such as gymnastics (however, please note that the American Academy of Pediatrics recommends against home trampolines for all kids). Eight years is when they can handle the toys and art equipment that are labeled “for eight and above.” You will be impressed at the attention to detail that an eight-year-old can display in art projects.

Children this age often prefer to spend time with a friend rather than a younger sibling or parents. It is fun and also good for self-esteem for your child to host a friend at your home and to spend time with friends at their homes. While eight-year-olds are fully capable of entertaining themselves, they still require adult supervision, even if that supervision is from another room or floor of the house. Eight-year-olds do not yet need their own phones: an adult should always be present in case trouble arises. However, it is appropriate to teach your eight-year-old to use a phone and to arrange a get-together or a car pool after first checking with parents. Screen-addiction (to television, computers, and hand-held devices) starts early; set screen time rules now so that you won’t be frustrated later.

Speaking of self-reliance, by all means teach your eight-year-old to cook a simple meal, use the microwave and toaster oven, set and clear the table, do dishes, load and unload a dishwasher and washing machine, and take out the trash. Again, parents should supervise, but the goal is to create an independent adult. Eight-year-old egos enjoy a good boost when you acknowledge their increased sense of responsibility and contributions to running the household.

Last tip: if you are driving your child and an eight-year-old friend, be sure to have enough booster seats in the car for everyone (US law requires booster seats through age 8 years-see our post on car safety).

Yes, eight is great, and Two Peds is thrilled to celebrate this birthday.  Your eight-year-old celebrates this birthday smack dab in the middle of the “golden years” of parenting. During these years, they are too young to drive and too old to take a nap. The typical blog lasts less than 6 months, so keep us going by reading, sharing, sending us your post ideas, and inviting us to speak (twopedsinapod@gmail.com). Our information is only good if others read it and share it! Please “follow” us on Facebook, tweet about us, email subscribe, and continue to get the word out. Pediatric colleagues: we welcome guest bloggers, so if you have something to share that we haven’t already said, please contribute.

Cheers,
Julie Kardos, MD and Naline Lai, MD
Ⓒ2017 Two Peds in a PodⓇ

 




Is your car seat up to snuff? And how about planes?


This photo above is a horrific yet terrific reminder of why we strap our kids into car seats. This child was buckled into a car seat when the unthinkable happened— a potentially lethal car accident. As you can see, the child’s bruises directly line up with properly-applied car seat restraints. Thankfully, the injuries to this child are only skin-deep. On the other hand, the photo below shows what happened to the car.

Please remember always to travel with your children properly restrained.

For maximum safety in cars:

  • Keep children in rear facing car seats until age two years. Usually they will outgrow the baby car seat that you brought them home in and you will need to install a new rear facing car seat before they reach two years.  Check the weight/height limits for the seat.
  • Keep them in the car seat until age five years, or until they outgrow the weight or height limits set forth by the car seat manufacturer.
  • Use a booster until your children are 4 feet 9 inches or until the car’s shoulder seatbelt falls naturally across the chest (not the neck) and the lap belt lies low across their hip bones (some kids are in boosters to age 10 years and beyond).
  • Keep infants and children in the back seat until at least age 13 years.
  • Don’t drive while distracted or sleep deprived. Children learn from watching their parents. Emulate now the way you want your 16-year- old to drive.

Your can read more details on car seats and seat belts on the CDC (Centers for Disease Control) website here.

Read about guidelines for child safety restraints on airplanes here.

Julie Kardos, MD and Naline Lai, MD

© 2017 Two Peds in a Pod®, photos used with permission




Summertime ear pain? It might be swimmer's ear


These lucky fish don't have to worry about swimmer's ear... they don't have any ears!

These lucky fish don’t have to worry about swimmer’s ear… they don’t have any ears! –Photo by Dirk Peterson, MD

It’s the type of ear pain that usually creeps up on a school-aged summer camper. One night he may notice discomfort when his ear is against his  pillow. The next night, the pain gets worse. Eventually, even touching the ear is painful. The ear is probably infected, but infected with “the other kind” of ear infection—swimmer’s ear.

Ear infections are divided into two main types: swimmer’s ear (otitis externa) and middle ear infections (otitis media). An understanding of the anatomy of the ear is important to understanding the differences between the two types of infection.  Imagine you are walking into someone’s ear. When you first enter, you will be in a long tunnel. Keep walking and you will be faced with a closed door. The tunnel is called the external ear canal and the door is called the ear drum.

Swimmer’s ear occurs in the ear canal. Dampness from water, and it can be water from any source- not just the pool, sits in the ear canal and promotes bacterial infection.  

Next, open the door. You will find yourself in a room with a set of three bones. Another closed door lies at the far end.  Look down.  In the floor of the room there is an opening to a drainage pipe. This room is called the middle ear. This is where middle ear infections occur.

During a middle ear infection, fluid, such as during a cold, can collect in the room and promote bacterial infection.  Think of the sensation of clogged ears when you have a cold. Usually the drainage pipe, called the eustachian tube,  drains the fluid.  But, if the drain is not working well, or is overwhelmed, fluid gets stuck in the middle ear and become infected. 

Because a swimmer’s ear infection occurs in the external canal, the hallmark symptom of swimmer’s ear is pain produced by pulling the outside of the ear.  Since middle ear infections occur farther down in the ear, pain is not reproduced by pulling on the outer ear.

Swimmer’s ear is treated topically by your doctor with antibiotic drops.  To avoid dizziness and discomfort when putting drops in, first bring the ear drop medicine up to body temp by holding the bottle in your hand.

Home remedies to prevent swimmer’s ear:

  • After immersion in the water, tilt your child’s head to the side and towel dry what leaks out.
  • Mix rubbing alcohol and vinegar in equal parts. After swimming, place a couple drops in the ear.  Do not put these drops in if there is a hole in your child’s eardrum. 
  • Prior to swimming put a drop of mineral oil or olive oil in each ear. This serves as a barrier protection against the water as well an ear wax softener. Do not put in if there is a hole in your child’s eardrum.

Although it’s tough to remind children to dry their ears well, take heart.  Dr. Lai once spent two hours trying to get a cockroach out of a child’s ear canal.   We  suspect those parents would have been happier if instead, water had gotten into their child’s ear.

Naline Lai, MD and Julie Kardos, MD

©2017 Two Peds in a Pod® 
updated from 2016




Happy Father's Day 2017 from your Two Peds


father's day cartoonA few years ago, we asked our dad readers to help us write our Father’s Day post.  We thought you would enjoy hearing from them again. The dads completed this thought: “Before I became a dad, I never thought I’d…”

…Learn to curl hair for cheerleading competitions

 

…BE RESPONSIBLE

 

…Become a stay at home dad AND love it so much after everything I’ve been through!!

 

…Learn all of the names of Thomas The Tank Engine’s friends and the many songs associated with them.

 

…Have a toys r us in my house.

 

…Go food shopping at midnight.

…Make so many pancakes on Sunday mornings.

…Volunteer in a dunk tank and have pie thrown at me.

 

One of our readers summed up his thoughts on becoming a dad:

Since I’ve become a father, nearly seven years and two beautiful daughters later, my life has become a series of jobs that I never thought I would have to tackle. These include:

Beautician: I never thought in a million years that I would be learning how to do pony tails, side pony’s, braids (not that I can braid yet), and painting little finger and toe nails.

Disney Princess Aficionado: At one point in my life I thought I was cool because I knew a lot about beer, how it was made, where it was from, where the best IPA’s were being poured. Now I am “cool” because I know where Mulan lived, and because I know the story about Ariel falling in love with Prince Eric.

Doctor: I am well versed here and can cover almost everything from the simple band-aid application and boo-boo kissing, to the complex answering of why daddy is different and why he gets to go to the bathroom standing up.

Cheerleader: Both of my daughters enjoy participating in sports. It’s been such a great experience to cheer them both on from the side line. I enjoy watching them grow with the sport and gain confidence game after game.

Becoming a father was one of the best choices I have made with my life. I love being a dad, and I look forward to the future dad challenges, good and bad, and being the best mentor I can be.

Thank you to our readers for contributing to this post.

Happy Father’s Day!

Julie Kardos, MD and Naline Lai, MD

©2014, 2017 Two Peds in a Pod®




A guide for parents of one-year-olds


When your baby turns one, you’ll realize he has a much stronger will. My oldest threw his first tantrum the day he turned one. At first, we puzzled: why was he suddenly lying face down on the kitchen floor? The indignant crying that followed clued us to his anger. “Oh, it’s a tantrum,” my husband and I laughed, relieved.

Parenting one-year-olds requires the recognition that your child innately desires to become independent of you. Eat, drink, sleep, pee, poop: eventually your child will learn to control these basics of life by himself. We want our children to feed themselves, go to sleep when they feel tired, and pee and poop on the potty. Of course, there’s more to life such as playing, forming relationships, succeeding in school, etc, but we all need the basics. The challenge comes in recognizing when to allow your child more independence and when to reinforce your authority.

Here’s the mantra: Parents provide unconditional love while they simultaneously make rules, enforce rules, and decide when rules need to be changed. Parents are the safety officers  and provide food, clothing, and a safe place to sleep. Parents are teachers. Children are the sponges and the experimenters. Here are concrete examples of how to provide loving guidance:

Eating: The rules for parents are to provide healthy food choices, calm mealtimes, and to enforce sitting during meals. The child must sit to eat. Walking while eating poses a choking hazard. Children decide how much, if any, food they will eat. They choose if they eat only the chicken or only the peas and strawberries. They decide how much of their water or milk they drink. By age one, they should be feeding themselves part or ideally all of their meal. By 18 months they should be able to use a spoon or fork for part of their meal.

If, however, parents continue to completely spoon feed their children, cajole their children into eating “just one more bite,” insist that their child can’t have strawberries until they eat  their chicken, or bribe their children by dangling a cookie as a reward for eating dinner, then the child gets the message that independence is undesirable. They will learn to ignore their internal sensations of hunger and fullness.

For perspective, remember that newborns eat frequently and enthusiastically because they gain an ounce per day on average, or one pound every 2-3 weeks. A typical one-year-old gains about 5 pounds during his entire second year, or one pound every 2-3 months. Normal, healthy toddlers do not always eat every meal of every day, nor do they finish all meals. Just provide the healthy food, sit back, and enjoy meal time with your toddler and the rest of the family.  

A one-year-old child will throw food off of his high chair tray to see how you react. Do you laugh? Do you shout? Do you do a funny dance to try to get him to eat his food? Then he will continue to refuse to eat and throw the food instead. If you say blandly,” I see you are full. Here, let’s get you down so you can play,” then he will do one of two things:

1)      He will go play. He was not hungry in the first place.

2)      He will think twice about throwing food in the future because whenever he throws food, you put him down to play. He will learn to eat the food when he feels hungry instead of throwing it.

Sleep: The rule is that parents decide on reasonable bedtimes and naptimes. The toddler decides when he actually falls asleep. Singing to oneself or playing in the crib is fine. Even cries of protest are fine. Check to make sure he hasn’t pooped or knocked his binky out of the crib. After you change the poopy diaper/hand back the binky, LEAVE THE ROOM! Many parents tell me that “he just seems like he wants to play at 2:00am or he seems hungry.” Well, this assessment may be correct, but remember who is boss. Unless your family tradition is to play a game and have a snack every morning at 2:00am, then just say “No, time for sleep now,” and ignore his protests.

Pee/poop: The rule is that parents keep bowel movements soft by offering a healthy diet. The toddler who feels pain when he poops will do his best not to have a bowel movement. Going into potty training a year or two from now with a constipated child can lead to many battles. 

Even if your child does not show interest in potty training for another year or two, talk up the advantages of putting pee and poop in the potty as early as age one. Remember, repetition is how kids learn.

Your one-year-old will test your resolve. He is now able to think to himself, “Is this STILL the rule?” or “What will happen if I do this?” That’s why he goes repeatedly to forbidden territory such as the TV or a standing lamp or plug outlet, stops when you say “No no!”, smiles, and proceeds to reach for the forbidden object.

When you feel exasperated by the number of times you need to redirect your toddler, remember that if toddlers learned everything the first time around, they wouldn’t need parenting. Permit your growing child to develop her emerging independence whenever safely possible. Encourage her to feed herself even if that is messier and slower. Allow her to fall asleep in her crib and resist only rocking her to sleep. Everyone deserves to learn how to fall asleep independently. You don’t want to train a future insomniac adult.

And if you are baffled by your child’s running away from you one minute and clinging to you the next, just think how confused your child must feel: she’s driven towards independence on the one hand and on the other hand she knows she’s wholly dependent upon you for basic needs. Above all else, remember the goal of parenthood is to help your child grow into a confident, independent adult… who remembers to call his parents every day to say good night… ok, at least once a week to check in…. ok, keep in touch with those who got him there!

Julie Kardos, MD with Naline Lai, MD
©2012, 2017 Two Peds in a Pod®




Graduation time and new horizons


 

This time of year is always a joy as kids graduate and move onward. Having sent off my own children and my patients to daycare, kindergarten, high school and college, I am amazed how the graduations change, but the parental emotions remain the same. In honor of Dr. Kardos’s soon-to-be high school graduate, I share with you a post from years ago… a letter I had written to my child the night before kindergarten, and pointers on easing the transition. Shhh- it’s a surprise. We’ll see when Dr. Kardos notices.— Dr. Lai

My Child,

As we sit, the night before kindergarten, your toes peeking out from under the comforter, I notice that your toes are not so little anymore.

Tomorrow those toes will step up onto to the bus and carry you away from me. Another step towards independence. Another step to a place where I can protect you less. But I do notice that those toes have feet and legs which are getting stronger. You’re not as wobbly as you used to be. Each time you take a step you seem to go farther and farther.

I trust that you will remember what I’ve taught you. Look both ways before you cross the street, chose friends who are nice to you, and whatever happens don’t eat yellow snow. I also trust that there are other eyes and hearts who will watch and guide you.

But that won’t stop me from worrying about each step you take.

Won’t stop me from holding my breath­.

Just like when you first started to walk, I’ll always worry when you falter.

I smile because I know you’ll hop up onto the bus tomorrow, proud as punch, laughing and disappearing in a sea of waving hands. I just hope that at some point, those independent feet will proudly walk back and stand beside me.

Maybe it will be when you first gaze into your newborn’s eyes, or maybe it will be when your child climbs onto the bus.

Until then,

I hold my breath each time you take a step.

Love,

Mommy

 

No matter the stage, even when they are bigger than you, aways remember the basic rules of daycare drop-off:

  • Always convey to your child that the transition is a positive experience. You give your child cues on how to act in any situation. Better to convey optimism than anxiety.
  • Take your child and place her into the arms of a loving adult- do not leave her alone in the middle of a room.
  • Do not linger. Prolonging any tears, only prolongs tears. The faster you leave, the faster happiness will start.
  • It’s ok to go back and spy on them to reassure yourself that they have stopped crying- just don’t let them see you.

©2017, originally posted 2009 Two Peds in a Pod®




Discussing suicide: how much should I tell my kids?


how to breech the topic of suicide

“Hi, it’s me, Hannah.  Hannah Baker.” So begins the first episode of 13 Reasons Why, a thirteen installment Netflix series that focuses on the aftermath of the suicide of a 17-year-old high school student.  Based on the novel by Jay Asher, the series has sparked quite a bit of debate and concern among parents and mental health professionals.  At its best, the series has served as a conversation starter; at its worst, it has glamorized suicide and the fantasy of revenge.  At the end of the day, however, an important question remains:  How do we talk with our kids about suicide?  While many difficult topics have become increasingly safer to discuss, suicide is one that is still shrouded in secrecy and shame. In fact, it is so difficult to talk about that I had a hard time writing this post.  Finding the right words about something that often remains unspoken is not an easy task.  So if circumstances require it, how are we to explain suicide to our children?

According to the American Foundation for Suicide Prevention, research has shown that over 90% of people who died by suicide had a diagnosable, though not always identified, brain illness at the time of their death.  Most often this illness was depression, bipolar disorder, or schizophrenia, and was complicated by substance use and abuse.  Just as people die from physical illnesses, they can die as the result of emotional ones.  If we can change the narrative about suicide from talking about it as a weakness or character flaw to the unfortunate outcome of a serious, diagnosable, and treatable illness, then it will become easier for us to speak with honesty and compassion.

Telling the truth about any death is important. While it is natural for us adults to want to protect our children from pain, shielding them from the truth or outright lying will undermine their trust and can create a culture of secrecy and shame that can transcend generations.  We can protect our children best by offering comfort, reassurance, and simple, honest answers to their questions. It is important to recognize that we adults typically offer more information than our children require.  We should start by offering basic information, then let them take the lead on how much they actually want to know.

For young children, your statements may look something like this: “You have seen me crying, that is because I am sad because Uncle Joe has died.”  They may not even ask how the death occurred, but if they do, you can say “He died by suicide. That means he killed himself.”  The rest of the conversation will depend on the child’s response.  With older children, the narrative can follow a similar theme yet use more sophisticated language.  The older the child, the more likely they are to ask direct questions.  Some examples of honest answers are “Do you know how people have illness in their bodies, like when Grandma had a heart attack and our neighbor had cancer?  People can get illness in their brains too, and when that happens, they feel confused, hopeless, and make bad decisions. Uncle Joe didn’t know how to get himself help to stop the pain.”  If they ask how the suicide occurred, you can say “With a gun” or “She cut herself.”  Sometimes you will have to say “I don’t know. I wish I knew the answer.”  Whatever the age of your child, do your best to use simple, truthful language.

Regardless of age, children converse about and process death differently than adults.  If you tell your child about a suicide, it is likely that he/she will want to talk about multiple times over the course of days, weeks, or even years.  Keep the dialogue open, and check in with them periodically if they have questions.  If you find that you or your family is in need of the support of a professional, you might want to consider a bereavement group or a trained professional who specializes in grief.  These resources are available through online directories, local hospitals, and the Psychology Today therapist finder.  Overall, be aware that providing truthful information, encouraging questions, and offering loving reassurance to your children can allow your family to find the strength to cope with terrible loss.

(Excerpts taken from The American Foundation for Suicide Prevention’s “Talking to Children about Suicide”, www.afsp.org.)

Links:

Sesame Sreet Workshop’s When Families Grieve
The Dougy Center for Grieving Children and Families
The American Foundation for Suicide Prevention
Hands Holding Hearts (Bucks County, PA)
The Jed Foundation

Dina Ricciardi, LSW, ACSW

©2017 Two Peds in a Pod®

Guest blogger Dina Ricciardi is a psychotherapist in private practice treating children, adolescents, and adults in Doylestown, PA. She specializes in disordered eating and pediatric and adult anxiety, and is also trained in Sandtray Therapy. Ricciardi is a Licensed Social Worker and a member of the Academy of Certified Social Workers. She can be reached at dina@nourishcounseling.com.




Lyme Disease...it's back


lyme rash photo

The classic bullseye rash of Lyme

Just like last year, experts are predicting more Lyme disease. While it used to be a pesky disease only in our midatlantic/Lyme Connecticut area of the world, Lyme continues to appear across the northeast and has been reported on the west coast of the United States. According to the American Academy of Pediatric’s Redbook,  about fifty percent of reported Lyme disease is during June and July.  We’ve already had children come  to our office with tick bites concerns, so here’s an update:

Lyme disease is spread to people by blacklegged ticks. Take heart- even in areas where a high percentage of blacklegged ticks carry the bacteria that causes Lyme disease, the risk of getting Lyme from any one infected tick is low. Most of the little critters DON’T carry Lyme disease… but there are an awful lot of ticks out there. Blacklegged ticks are tiny and easy to miss on ourselves and our kids. In the spring, the ticks are in a baby stage (nymph) and can be as small as a poppy seed or sesame seed. In order to spread disease, the tick has to be attached and feeding on human blood for more than 36 hours, and engorged.

In areas in the United States where Lyme disease is prevalent (New England and Mid-Atlantic states, upper Midwest states such as Minnesota and Wisconsin, and California), parents should be vigilant about searching their children’s bodies daily for ticks and for the rash of early Lyme disease. Tick bites, and therefore the rash as well, especially like to show up on the head, in belt lines, groins, and armpits, but can occur anywhere. When my kids were young, I showered them daily in summer time not just to wash off pool water, sunscreen, and dirt, but also for the opportunity to check them for ticks and rashes. Now that they are older I call through the bathroom door periodically when they shower: “Remember to check for ticks!” Read our post on how to remove ticks from your kids.

“I thought that Lyme is spread by deer ticks and deer are all over my yard.”  Nope, it’s not just Bambi that the ticks love. Actually, there are two main types of blacklegged ticks, Ioxdes Scapularis and Ioxdes Pacificus, which both carry Lyme and feed not only on deer, but on small animals such as mice.  (Fun fact: Ioxdes Scapularis is known as a deer tick or a bear tick.)

Most kids get the classic rash of Lyme disease at the site of a tick bite. The rash most commonly occurs by 1-2 weeks after the tick bite and is round, flat, and red or pink. It can have some central clearing. The rash typically does not itch or hurt. The key is that the rash expands to more than 5 cm, and can become quite large as seen in the above photo.  This finding is helpful because if you think you are seeing a rash of Lyme disease on your child, you can safely wait a few days before bringing your child to the pediatrician because the rash will continue to grow. The Lyme disease rash does not come and then fade in the same day, and the small (a few millimeters) red bump that forms at the tick site within a day of removing a tick is not the Lyme disease rash. Knowing that a rash has been enlarging over a few days helps us diagnose the disease. Some kids have fever, headache, or muscle aches at the same time that the rash appears.

If your child has early localized Lyme disease (just the enlarging red round rash), the diagnosis is made by having a doctor examine your child. Your child does not need blood work because it takes several weeks for a person’s body to make antibodies to the disease, and blood work checks for for antibodies against Lyme disease, not actual disease germs. In other words, the test can be negative (normal) when a child does in fact have early localized Lyme disease.

Other symptoms of early Lyme disease may accompany the rash or can occur even in the absence of the rash. This stage is called Early Disseminated disease.   Within about one month from the time of the tick bite, some children with Lyme develop a rash that appears in multiple body sites all at once, not just at the site of the tick bite. Each circular lesion of rash looks like the rash described above,  but usually is smaller. Additional symptoms include fever, body aches, headaches, and fatigue without other viral symptoms such as sore throat, runny nose, and cough. Some kids get one-sided facial weakness. Blood testing at this point is more likely to be positive. 

The treatment of early Lyme disease is straightforward. The child takes 2-3 weeks of an antibiotic that is known to treat Lyme disease effectively such as amoxicillin or doxycycline. Your pediatrician needs to see the rash and evaluate other symptoms to make the diagnosis. Treatment prevents later complications of the disease. Treated children fortunately do not get “chronic Lyme disease.” Once treatment is started, the rash fades over several days and other symptoms, if present, resolve. Sometimes at the beginning of treatment the child experiences chills, aches, or fever for a day or two. This reaction is normal but you should contact your child’s doctor if it persists for longer.

Later stages of Lyme disease  may be treated with  the same oral antibiotic as for early Lyme but for 4 weeks instead of 2-3 weeks. The most common symptom of late stage Lyme disease is arthritis (red, swollen, mildly painful joint) of a large joint such as a knee, hip, or shoulder. Some kids just develop joint swelling without pain and the arthritis can come and go.

For some manifestations, IV antibiotics are used. The longest course of treatment is 4 weeks for any stage. Again, children do not develop “chronic Lyme” disease. If symptoms persist despite adequate treatment, sometimes one more course of antibiotics is prescribed, but if symptoms continue, the diagnosis should be questioned. No advantage is shown by longer treatments. Some adults have lingering symptoms of fatigue and aches years after treatment for Lyme disease. While the cause of the symptoms is not understood, we do know that prolonged courses of antibiotics do not affect symptoms.

For kids eight years old or older, if a blacklegged tick has been attached for well over 36 hours and is clearly engorged, and if you live in an area of high rates of Lyme disease-carrying ticks, your pediatrician may in some instances choose to prescribe a one time dose of the antibiotic doxycycline to prevent Lyme disease. The study that this strategy was based on and a few other criteria that are considered in this situation are described here. Your pediatrician can discuss the pros and cons of this treatment.

Bug checks and insect repellent. Protect kids with DEET containing insect repellents. The Centers for Disease Control recommends 10 to 30 percent DEET- higher percent stays on longer. Spray on clothing and exposed areas and do not apply to babies under two months of age. Grab your kids and preform daily bug checks- in particular look in crevices where ticks like to hide such as the groin, armpits, between the toes and check the hair. Ticks can be tough to spot. Dr. Lai once had a elementary school patient who had a blacklegged tick in the middle of his forehead. The mother noticed it at breakfast, tried to brush it off,  thought it was a scab and sent the boy to school. Later that day the teacher called saying, “I think your son has a bug on his face.”

Misinformation about this disease abounds, and self proclaimed “Lyme disease experts” play into people’s fears. While pediatricians who practice in Lyme disease endemic areas are usually well versed in Lyme disease, if you feel that you need another opinion about your child’s Lyme disease, the “expert” that you should consult would be a pediatric infectious disease specialist.

For a more detailed discussion of Lyme disease, look to the Center for Disease Control website: www.cdc.gov.

Julie Kardos, MD and Naline Lai, MD

©2017, 2016, 2009 Two Peds in a Pod®

 

 




Mother's Day 2017: The Mother Warns the Tornado


Mother and Child

Today we bring you a fierce depiction of maternal love, written by poet Catherine Pierce PhD- who is Dr. Kardos’s sister-in-law.
We hope your Mother’s Day is full of flowers and free of tornados.
–Drs. Lai and Kardos

The Mother Warns the Tornado
I know I’ve had more than I deserve.
These lungs that rise and fall without effort,
the husband who sets free house lizards,
this red-doored ranch, my mother on the phone,
the fact that I can eat anything—gouda, popcorn,
massaman curry—without worry. Sometimes
I feel like I’ve been overlooked. Checks
and balances, and I wait for the tally to be evened.
But I am a greedy son of a bitch, and there
I know we are kin. Tornado, this is my child.
Tornado, I won’t say I built him, but I am
his shelter. For months I buoyed him
in the ocean, on the highway; on crowded streets
I learned to walk with my elbows out.
And now he is here, and he is new, and he
is a small moon, an open face, a heart.
Tornado, I want more. Nothing is enough.
Nothing ever is. I will heed the warning
protocol, I will cover him with my body, I will
wait with mattress and flashlight,
but know this: If you come down here—
if you splinter your way through our pines,
if you suck the roof off this red-doored ranch,
if you reach out a smoky arm for my child—
I will turn hacksaw. I will turn grenade.
I will invent for you a throat and choke you.
I will find your stupid wicked whirling
head and cut it off. Do not test me.
If you come down here, I will teach you about
greed and hunger. I will slice you into palm-

sized gusts. Then I will feed you to yourself.

Catherine Pierce
From The Tornado is the World (Saturnalia Books, 2016)

An associate professor and co-director of the creative writing program at Mississippi State, Dr. Pierce has authored three books of poems and won the Mississippi Institute of Arts and Letters Poetry Prize. She is a mom of two young boys.