The Challenge of Diagnosing Lyme Disease
July 29, 2019
From The New York Times:
Lyme disease is on the rise. The 30,000 cases reported annually to the Centers for Disease Control and Prevention by state health departments represent only a fraction of the cases diagnosed and treated around the country. About half the cases occur in people under the age of 21, and boys from 5 to 9 years old are the most commonly affected group, possibly because they spend a good deal of time outdoors.
A recent article in The New York Times about a child who was treated for Lyme disease and did well, offering a reassuring message about relatively straightforward cases of the infection, drew more than 700 reader comments, many of them angrily denouncing the author and predicting medical complications to come for her son. Some responses reflect the frustrations of people who feel they have struggled for years with persistent and recalcitrant symptoms from the infection.
The condition can be challenging to treat, in part because it is not always easy to get the diagnosis right the first time around. The biggest problem is that there is no reliable biomarker for Lyme, no way to test, unequivocally, for the presence of the bacteria, Borrelia burgdorferi, which are transmitted by tick bite and cause the disease.
You can make a diagnosis of acute Lyme disease by seeing the characteristic rash, erythema migrans, which at its most classic looks like a target. But it doesn't always look like that, and it can be hidden in the hair, and it doesn't show up nearly as clearly on darker-skinned people. "A large number of affected patients don't have the rash," said Dr. Lise Nigrovic, a pediatric emergency physician at Boston Children's Hospital.
The blood tests we have don't test directly for the bacteria, but instead test for the body's antibody response. When you hear people talk about sending a "Lyme test" or a "Lyme titer," what they are sending is a two-tiered test, looking to see whether the body is making antibodies to that bacteria. For that reason, the test will be negative early on during the infection, because it takes time for the immune system to mount this defense.
So the Lyme test is not helpful in the earliest stages of infection -- which is when you would ideally like to start treatment. Not only that, it takes a while to get the results.
"For me as an emergency room physician, none of the tests come back in rapid enough time to make a decision," Dr. Nigrovic said. She makes treatment decisions on the basis of symptoms, such as meningitis or swollen joints, she said, and that also means deciding how aggressively to pursue alternative diagnoses -- for example, deciding whether a swollen knee needs to be surgically drained or looking for other possible infections: "In my world, it's like, O.K., do I tap the knee, let the orthopedist take the kid to the O.R. when it's probably just Lyme?"
And the increase in Lyme should remind us that ticks can carry other infections as well.
Sun Safety and Protection Tips
July 16, 2019
From the American Academy of Pediatrics:
Spending time outdoors is a common activity on spring breaks or summer vacations, but remember to protect against the sun's rays. Everyone is at risk for sunburn. Children especially need to be protected from the sun's burning rays, since most sun damage occurs in childhood. Like other burns, sunburn will leave the skin red, warm, and painful. In severe cases, it may cause blistering, fever, chills, headache, and a general feeling of illness. The American Academy of Pediatrics offers tips to keep children safe in the sun.
Sun Safety for Babies Under 6 Months
- Babies under 6 months of age should be kept out of direct sunlight. Move your baby to the shade under a tree, umbrella or stroller canopy. Dress babies in lightweight clothing that covers the arms and legs and use brimmed hats that shade the neck to prevent sunburn.
- When adequate clothing and shade are not available, parents can apply a minimal amount of sunscreen with at least 15 SPF (sun protection factor) on infants under 6 months to small areas, such as the infant's face and the back of the hands. Remember it takes 30 minutes to be effective.
- If an infant gets sunburn, apply cool compresses to the affected area.
Sun Safety for Kids
- The first, and best, line of defense against harmful ultraviolet radiation (UVR) exposure is covering up. Stay in the shade whenever possible, and limit sun exposure during the peak intensity hours - between 10 a.m. and 4 p.m.
- Select clothes made of tightly woven fabrics. Cotton clothing is both cool and protective.
- Try to find a wide-brimmed hat that can shade the cheeks, chin, ears and back of the neck. Sunglasses with ultraviolet (UV) protection are also a good idea for protecting your child's eyes.
- Apply sunscreen with an SPF 15 or greater to areas of your child's skin that aren't covered by clothing. Before applying, test the sunscreen on your child's back for an allergic reaction. Apply carefully around the eyes, avoiding eyelids. If a rash develops, talk with your pediatrician.
- Be sure to apply enough sunscreen -- about one ounce per sitting for a young adult.
- Reapply sunscreen every two hours, or after swimming or sweating.
- If your child gets sunburn that results in blistering, pain or fever, contact your pediatrician.
Sun Safety for the Family
- The sun's rays are the strongest between 10 a.m. and 4 p.m. Try to keep out of the sun during those hours.
- The sun's damaging UV rays can bounce back from sand, water, snow or concrete; so be particularly careful of these areas.
- Wear commercially available sun-protective clothing, like swim shirts.
- Most of the sun's rays can come through the clouds on an overcast day; so use sun protection even on cloudy days.
- When choosing a sunscreen, look for the words "broad-spectrum" on the label - it means that the sunscreen will protect against both ultraviolet B (UVB) and ultraviolet A (UVA) rays. Choose a water-resistant sunscreen and reapply every two hours or after swimming, sweating or towel drying. You may want to select a sunscreen that does not contain the ingredient oxybenzone, a sunscreen chemical that may have hormonal properties.
- Zinc oxide, a very effective sunscreen, can be used as extra protection on the nose, cheeks, top of the ears and on the shoulders.
- Use a sun protection factor (SPF) of at least 15. The additional benefits of using sunscreen with SPF 50+ are limited.
- Rub sunscreen in well, making sure to cover all exposed areas, especially the face, nose, ears, feet and hands, and even the backs of the knees.
- Put on sunscreen 30 minutes before going outdoors - it needs time to work on the skin.
- Sunscreens should be used for sun protection and not as a reason to stay in the sun longer.