Ouch! Stung on the scalp.

Ouch! Stung on the hand.

Ouch! Stung on the leg.

Ouch! Ouch! Stung TWICE on the lips.

Those nasty, nasty hornets.  During the hot days of August, they become more and more territorial and attack anything near their nests.  Today, in my yard, hornets mercilessly chased and attacked a fourth grader named Dan.  As everyone knows, you’d rather have something happen to yourself than have something negative happen to a child who is under “your watch.” As I rolled out the Slip and Slide, I was relieved not to see any wasps hovering above nests buried in the lawn.  I was also falsely reassured by the fact that our lawn had been recently mowed.  I reasoned that anything lurking would have already attacked a lawn mower.  Unfortunately, I failed to see the basketball sized grey wasp nest dangling insidiously above our heads in a tree.  So, when a wayward ball shook the tree, the hornets found Dan.

What will you do in the same  situation?

Assess the airway- signs of impending airway compromise include hoarseness, wheezing (whistle like sounds on inhalation or expiration), difficulty swallowing, and inability to talk.  Ask if the child feels swelling, itchiness or burning (like hot peppers) in his or her mouth/throat.  Watch for labored breathing.  If you see the child’s ribs jut out with each breath, the child is struggling to pull air into his/her body.    If you have Epinephrine (Epi-Pen or Twin Jet)  inject  immediately- if you have to, you can inject  through clothing.  Call 911 immediately. 

Calm the panic- being chased by a hornet is frightening and the child is more agitated  over the disruption to his/her sense of security than over the pain of the sting.  Use pain control /self calming techniques such as having the child breath slowly in through the nose and out through the mouth.  Distract the child by having them “squeeze out” the pain out by squeezing your hand.

If the child was stung by a honey bee, if seen, scrape the stinger out with your fingernail or a credit card.  Do not squeeze or pull with tweezers to avoid injecting any remaining venom into the site.   Hornets, and other kinds of wasps, do not leave their stingers behind.  Hence the reason they can sting multiple times.

Relieve pain by administering Ibuprofen (Motrin,Advil) or Acetaminophen (Tylenol).

As  you would with any break in the skin, to prevent infection, wash the affected areas with mild soap and water.

Decrease the swelling.  Histamine produces redness, swelling and itch.  Counter any histamine release with an antihistamine such as Diphenhydramine (Benadryl).  Any antihistamine will be helpful, but generally the older ones like Diphenhydramine, tend to work the best in these instances.  Unfortunately, sleepiness is common side effect.

To decrease overall swelling elevate the affected area.

A topical steroid like hydrocortisone 1% will also help the itch and counter some of the swelling. 

And don’t forget, ice, ice and more ice.  Fifteen minutes of indirect ice on and fifteen minutes off.

Even if the child’s airway is okay, if the child is particularly swollen, or has numerous bites, a pediatrician may elect to add oral steroids to the child’s treatment.

It is almost midnight as I write this blog post.  Now that I know all of my kids are safely tucked in their beds, and I know that Dan is fine, I turn my mind to one final matter:  Hornets beware – I know that at night you return to your nest.  My husband is going outside now with a can of insecticide.   Never, never mess with the mother bear…at least on my watch.

Naline Lai, MD and Julie Kardos, MD

©2009 Two Peds in a Pod®

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.

Also, contrary to popular belief, 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.  I 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.
• Do not use alcohol or bleach- these items will irritate the rash more than help

The biggest worry with poison ivy rashes is not the itch, but the chance of super-infection.  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, a hallmark of infection is tenderness- if there is pain associated with a poison ivy rash, think infection.  A hallmark of an allergic reaction is 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.  Infection usually occurs on the 2nd or 3rd days.  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

2012 Two Peds in a Pod®

As we are in the middle of Lyme disease season here in the Northeastern United states, I thought I should address Lyme disease. I have diagnosed 8 cases so far this summer, seven in my office and one at a picnic, and what struck me in each case was how relieved the parents were to find out how easy it is to treat the disease when it is diagnosed early. It is important to treat Lyme disease in the early phase because this treatment prevents later manifestations of the illness (arthritis, meningitis, etc.).

 Lyme disease is spread to people by deer ticks. Any one deer tick that you pull off your child has only a 1% chance of transmitting Lyme disease, but the reason so many people get Lyme disease is that there are an awful lot of deer ticks out there.

In areas where Lyme disease is prevalent (New England and Mid-Atlantic states, upper Midwest states, 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 axillas (armpits), but can occur anywhere. I shower my kids 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.

Most kids do 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 typically red. It can have some central clearing. The key is that the rash expands and becomes larger than 5cm. Untreated, it can become quite large as seen in the above photo. The rash does not itch or hurt. This finding is helpful because if you think you are seeing the primary rash of Lyme disease on your child, you can safely wait a day or two before bringing your child to his health care provider because the rash will continue to grow. The Lyme disease rash does not come and then fade in the same day. In fact, the history of a rash that enlarges over a few days is helpful in diagnosing the disease. Some kids have fever, headache, or muscle aches at the same time that the rash appears.

The second phase of Lyme disease occurs if it is not treated in the primary phase. It occurs about one month from the time of tick bite. Children develop a rash that looks like the primary rash but 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 primary rash but typically 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 the fever but no rash. Some kids get one-sided facial weakness. This stage is called Early Disseminated disease and is treated similarly to the way that Early Lyme disease is treated.

If your child has primary Lyme disease (enlarging red round rash), the diagnosis is made on clinical presentation alone. No blood work is needed because it takes several weeks for a person’s body to make antibodies to the disease, and blood work tests for antibody response. In other words, the test can be negative when a child does have early Lyme disease. Therefore, treatment begins after taking a history and performing a visual diagnosis.

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 prescribed by your child’s health care provider. This treatment prevents later complications of the disease. While the disease can progress if no treatment is undertaken, in children there is no evidence of “chronic Lyme disease” despite claims to the contrary. Once treatment is started, the rash fades over several days. Sometimes at the beginning of treatment the child experiences chills, aches, or fever for a day or two. This reaction is normal but your child’s health care provider should be contacted if it persists for longer.

If not treated early, then treatment starts when diagnosis is made during later stages of Lyme disease and may include 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, painful joint) of a large joint such as a knee, hip, shoulder. Some kids just develop joint swelling without pain. The arthritis can come and go. This stage is prevented by early treatment but is also can be treated with antibiotics.

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.

Misinformation about this disease abounds, and self proclaimed “Lyme disease experts” play into people’s fears. If you feel that you need another opinion about your child’s Lyme disease, the “expert” that you could consult would be a pediatric infectious disease specialist.

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

Julie Kardos, MD with Naline Lai, MD

2009 Two Peds in a Pod, updated 2015