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Lyme Disease in Children

Lyme Disease in Children

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Published by Virginia Savely DNP

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Published by: Virginia Savely DNP on Jun 17, 2010
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LYME DISEASE IN CHILDREN Nurses can learn to see the “Red Flags” By Ginger Savely, FNP-C Lyme disease

, a tick-borne disease named for the town of Lyme, Connecticut where the first U.S. outbreak occurred, is present in every state and is more prevalent than most people realize. Ticks that transmit the infection are so tiny that they are frequently not detected by unsuspecting victims. Only approximately 40% of bites are followed by the tell-tale “bull’s eye” rash and consequently the early, acute and easily treatable phase of the illness is often missed.[5] Months to years later, children can present with a host of seemingly unrelated and puzzling symptoms that parents and doctors do not associate with past exposure to ticks. Thus the possibility of chronic disseminated Lyme disease is usually not entertained. [2] In an ambulatory care setting the nurse often spends as much or more time with the child than does the physician. While taking vital signs and gathering preliminary information from the parent, the nurse is in a unique position to pick up on “red flags” for chronic disseminated Lyme disease. Since most doctors do not think to include this disease in their differential assessment, [2] heightened awareness on the part of the nurse could make a significant difference in determining the correct diagnosis. The nurse should put up her “Lyme radar” when a child is a frequent visitor to the office, has many and varied complaints, or has symptoms that have eluded diagnosis by other health care providers. The symptoms of chronic Lyme disease in children are subtle and can be easily missed or confused with other illnesses. [1] These children often present with a history of such diagnoses as juvenile rheumatoid arthritis (JRA), hypercholesterolemia, migraines, Crohn’s disease, gastritis, maturation delay, attention deficit/hyperactivity disorder (ADHD) and learning disabilities. The nurse should always be skeptical of a previous diagnosis of JRA, especially if the child has also been diagnosed with ADHD and/or migraines. [6] Children with tick-borne diseases also have a history of symptoms that do not neatly fit into any diagnostic category. A few of these are: low energy in the absence of anemia; frequent urination in the absence of a urinary tract infection; visual problems with a normal ophthalmologic exam; stomach pains, vomiting and abdominal cramping without

obvious pathology [3]; clumsiness; frequent “growing pains” and insomnia unresponsive to the usual treatments. When questioning a child about symptoms, the nurse should always be suspicious when the parent reports that the child has frequent and significant symptoms but the child claims he does not. Children who have been sick for a long time, and especially those who have been sick their entire lives (such as children with congenital Lyme disease), do not recognize pain and other discomforts as abnormal. If your knees have always hurt, you really don’t know what it means for them NOT to. The parent may say “he vomits three or four times a week.” The child may neglect to mention this because he has become accustomed to it and thinks that this is normal. The parent may report that the child is moody and unpredictable and that he has frequent headaches and stomach aches. He will often report to the school nurse not feeling well and bring home notes for poor behavior. The child with Lyme disease usually has a high number of school absences. If a child is sick frequently and the parent reports “he comes down with everything that goes around”, immune suppression due to chronic infection should always be suspected. The parent may also report that the child has had a sudden change of behavior. The quiet child has become loud and aggressive, the active child has become passive, the happy child has become weepy and sad, the calm child has started throwing fits and tantrums. The nurse should always take note when there is a change in the child’s usual behavior. [2] The parent should be asked if the child has ever had a tick attachment, even if the popular belief is that the area does not have ticks that carry disease. If the child has ever had rashes of any kind, the parent should be asked to describe these in detail. The nurse should be sure to ask about the child’s environment, habits and activities. Questions may include: are there wooded areas near the home, are there deer around, does the child play out in the grass, does the family go camping, do they have pets, are tick checks routinely done, has the family traveled to highly tick-endemic areas? Often parents won’t recall a tick bite, but if there is exposure potential, there may have been a bite that went unnoticed because it was in the hair or another part of the body that was difficult to see.

If environmental factors don’t sound suspect for tick exposure, inquiries should be made regarding the mother’s health status. If the mother says that she has been diagnosed with fibromyalgia or chronic fatigue syndrome, or that she’s had vague complaints of joint pain and fatigue since before the child was born, a congenital Lyme case may be a possibility.[4] In the assessment of the child the nurse may notice a tendency towards distractibility and hyperactivity. [1]It is often difficult to get the child to stop talking or sit still long enough for vital signs to be taken. The child may be hypersensitive to touch and may wince when the blood pressure is taken. He may avert his eyes to the light of an opthalmoscope or complain that the lights in the room are too bright. Reflexes may be so brisk that even brushing against the leg will cause the child’s lower leg to kick forward. Nurses are the parent’s and child’s first contact in the doctor’s office. They can form a strong relationship with the parent and bond with the child. They are the child’s advocate. Since nurses have acute observation skills, they would do well to become vigilant to the “red flags” of Lyme disease. They can then encourage the physician to take note of relevant history and symptoms and to pursue the possibility of tick-borne disease.
The author specializes in treating patients with tick-borne diseases in her practices in Austin, TX and San Francisco, CA. She is a member of the International Lyme and Associated Diseases Society and has treated hundreds of children and adults with chronic Lyme and other tick-borne diseases.

References: 1. Adams WV, Rose CD, Eppes SC, Klein JD. Long-term cognitive effects of Lyme disease in children. Appl Neuropsychol 1999;6:39-45. 2. Fallon BA, Kochevar JM, Gaito A, Nields JA. The underdiagnosis of neuropsychiatric Lyme disease in children and adults. Psychiatr Clin North Am 1998;21:693-703, viii. 3. Fried, MD, Duray, PH, Pietrucha, D. Gastrointestinal pathology in children with Lyme disease. J Spiro Tick Diseases 1996;3:101104.

4. Gardner, T. Infectious Diseases of the Fetus and Newborn Infant. Chapter 11: Lyme Disease. 2000. WB Saunders: Philadelphia, PA. 5. Johnson L, Stricker RB. Treatment of Lyme disease: A medicolegal assessment. Expert Rev Anti-Infect Ther 2004;2:533-57. 6. Steere AC, Malawista SE, Snydman DR, et al. Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three Connecticut communities. Arthritis Rheum 1977;20:7-17.

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