My child's been bitten by a tick: now what?

**This article was inspired after a friend of mine went through the process of discovering a tick on her child, and the subsequent steps she had to take. I then contacted Dr. Gina Neto, head of Emergency Medicine at CHEO. All information below is from my conversations with Dr. Neto, Christine, and the Public Health Agency of Canada, with sources referenced throughout. I acknowledge there is conflicting advice/evidence when it comes to tick bites and prevention/treatment of Lyme disease - at the end of this article I have included a list of guidelines and resources for parents to review. I also validate that YOU, as parent, need to make the right choice for your child.

It was after a swim in the pool when Christine Karpinski found the tick embedded in the back of her son's neck. During the long drive from Toronto earlier that day, the family had made a pit stop at the Odessa ONroute service centre. Looking for an opportunity to stretch their legs, they headed out to play a bit of geocaching in the treed area behind the highway stop. This is where Christine's five year-old son picked up the black-legged tick, which is the species that can carry the Lyme bacteria.

Tick2.jpg

"It's been a stressful few days," says Christine. Once they had removed the tick (using tick tweezers from MEC,) they headed over to the Children's Hospital of Eastern Ontario (CHEO) emergency department to inquire about potential treatment and testing.

According to Dr. Manisha Kulkarni, 1 in 3 ticks in the west end of Ottawa is carrying the Lyme disease bacteria. There has been a 145% increase in the tick population in this city between 2016 and 2017 and this number is expected to rise. In the Odessa area where Christine's son got the tick bite, there is a 40-45% chance that the bug is carrying Lyme.

By now, most folks have learned about ways to protect themselves against tick bites, but it's always helpful to review the proper methods for removal (tick keys or tick tweezers are best, but in a pinch you can use flat-edged tweezers.) It's important not to stress the tick, so no dousing it in oils or other substances, and no squeezing or twisting the body. Grip firmly at the base and pull.

Once the tick was removed, Christine's journey into the murky world of ticks and Lyme disease began. Upon arrival at CHEO, Christine learned that not only would her son not be a good candidate for preventative antibiotics, but that the tick itself could not be sent away for testing.

"There is a role for preventative antibiotics (which is different from treatment,) if the tick was engorged (attached for > 36 hours) and the child is more than 8 years old," says Dr. Gina Neto, head of Emergency Medicine at CHEO. In kids under eight years of age, it’s still controversial** as to whether or not there’s a benefit in doing preventative antibiotics, mainly because it's not been well studied and carries potential risks.

Preventative antibiotics need to be administered within 72 hours to be effective. This means that many tick bites could be treated by a primary care physician, as long as the patient has access to timely care.

However, CHEO knows that sometimes seeing your family doctor is not practical. "We understand if families come to the emergency department," says Dr. Neto. "We accept that and we know that they’re worried." (Another alternative would be a visit to your local urgent care clinic as opposed to emerg.)

When antibiotics within 72 hours are not advisable (as in Christine's case) or when the window has been missed, then the next step is to watch for symptoms of Lyme disease. These typically include flu-like symptoms, such as body aches, fever and lack of energy. Symptoms generally present between 7 - 14 days, but parents should be vigilant up to 30 days after the bite. Also, the typical "bulls eye" rash that is a possible sign/symptom doesn't show up in all cases - when it does, it usually pops up several days after the bite.

The treatment for Lyme disease** is similar to the treatment a child would receive for an ear infection - a course of amoxicillin, as well as rest and recovery. "[Early stage] Lyme disease isn’t something that makes you really, really sick," says Dr. Neto.

With prompt treatment, patients can avoid more severe symptoms that may arise with second or third-stage Lyme disease. Dr. Neto is quick to point out how rare it is to struggle with long-term Lyme disease symptoms. "It gets portrayed a lot in the media and that’s where people get scared," she says.

tick1.jpg

And what about testing the tick that has bitten your child? As Christine discovered, that's not so easy. "CHEO doesn't send ticks for testing, nor does OTTAWA Public Health; but our pediatrician was able to send it through a lab requisition to ONTARIO Public Health (sent via gammacare) and then it's being sent to the National Microbiology Lab in Winnipeg," says Christine. Ottawa Public Health does test ticks, but only for surveillance on Lyme disease.

In the end, given the age of Christine's son and the fact that the tick was not engorged (it had been attached for about 4-5 hours,) testing is rather pointless - even if the tick is found to have Lyme disease, the chance of Christine's son developing Lyme is extremely low. This is because of how tick biology works. In most cases, they need to have been feeding for a certain length of time (all guidelines point to 24-36 hours) before they start to pass the Lyme bacteria on to the host. 

Speculation is that individuals who find a tick and have gotten Lyme disease after it was attached for less than 24 hours probably had another nymph attached to them somewhere that they never discovered. Nymphs are the "baby" ticks, and can be as small as a poppy seed. This is a good reason why a nice warm shower and a thorough "tick check" is a great idea before bedtime!

To recap, the following are some of the things to do/watch for if you discover your child has been bitten by a tick:

  • Remove the tick with a tick key or special tick tweezers
  • Think back and try to figure out when your child could have gotten the tick (if you're camping, this will be easy!)
  • Assess whether the tick is "engorged" (see picture below.) This means the body will be fat and round, and not flat. An engorged tick has most likely been feeding for a while, and could require more prompt treatment for your child.
  • If your family doctor is accessible, make that your first point of contact. If you do not have a family doctor or think you're running out of time (72 hours) for preventative antibiotics, consider an urgent care clinic or your local emergency department.
  • Children under 8 are not usually given preventative antibiotics here in Ottawa. In these cases, you will need to watch for signs or symptoms of Lyme disease, but this needs to be discussed with a physician**
  • Your physician will be able to best guide you in your decision about preventative antibiotics OR a course of antibiotics for treatment if signs/symptoms of Lyme have occurred.** That said, you are the parent, and need to make an informed choice based on your research - which is exactly what Christine did!
  • You CAN send your tick for testing, but it's not necessary for diagnosis or treatment
 A GOOD VISUAL OF WHAT AN ENGORGED TICK LOOKS LIKE

A GOOD VISUAL OF WHAT AN ENGORGED TICK LOOKS LIKE

 

**most prevention and treatment guidelines are conflicting, poorly conducted and often out-of-date. Many Lyme disease advocates argue that current guidance is not accurate. Furthermore, some doctors choose to delay treatment or can outright dismiss claims of Lyme, making it very difficult for patients to navigate the system. Below are three guidelines I have found in my research, which all state various recommendations based on low-quality evidence:

ILADS Guidelines

IDSA Guidelines

NICE Guidelines

In addition, I'd like to draw your attention to the Ministry of Health and Long-Term Care's Lyme Disease and Tick-borne Illnesses Task Force report. This contains some recommendations for improving prevention and care, including a call for a full review of all available guidelines. It is my sincere hope that we move forward as a province to ensure adults and children are getting timely and compassionate care.

Misty Pratt is a Research Assistant at the Ottawa Hospital Research Institute, and co-Community Manager for Kids in the Capital. She lives in Orleans and enjoys regular walks in the ravine behind her house, and isn't planning to stop just because of ticks.

Has your child been bitten by a tick? Share your experience with us in the comments below.