WHEN TO SUSPECT LYME DISEASE IN CHILDREN

Nurses are in a Unique Position to see the Red Flags

By Ginger Savely, FNP-C

As published in the Lyme Times, Pediatric Issue, Fall 2005

One of the major complaints about modern, rushed, managed-care

medicine is that not enough time is spent with the patient. Time is
invaluable for a correct diagnosis for noticing clues, picking up on
off-handed comments, asking directed questions, and having the
luxury to listen. Time allows you to see the red flags.

Adequate time is particularly important in the assessment of a child.

Children are not apt historians, frequently omitting what might be
important or feeling that whatever symptoms they are having are
normal and shouldnt be mentioned. With more time, a provider can
pick up on subtle cues that could be crucial for the correct diagnosis.

In a pediatric 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 tick-borne diseases. Since
most doctors do not think to include these diseases in their differential
assessment, heightened awareness on the part of the nurse could
make the difference in determining a 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 Lyme disease in children are subtle and can be easily
missed or confused with other illnesses. These children often present
with a history of such diagnoses as juvenile rheumatoid arthritis (JRA),
hypercholesterolemia, migraines, Crohns disease, gastritis, maturation
delay, attention deficit/hyperactivity disorder (ADHD) and learning
disabilities. The nurse should always be suspect of a previous
diagnosis of JRA, especially if the child has also been diagnosed with
ADHD and/or migraines.

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 infection; visual problems with a normal ophthalmologic
exam; 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 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 dont 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 will bring home notes
for poor behavior. The child with tick-borne 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 suspect.

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 childs usual
behavior.

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! Lyme and tick-borne co-infections are found in
every state. 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 childs 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 wont 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 dont sound suspect for tick exposure,
inquiries should be made regarding the mothers health status. If the
mother says that she has been diagnosed with fibromyalgia or chronic
fatigue syndrome, or that shes had vague complaints of joint pain and
fatigue since before the child was born, a congenital Lyme case may
be a possibility.

In the assessment of the child the nurse may notice a tendency

towards distractibility and hyperactivity. 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 hyper-sensitive to touch and may wince when the
blood pressure is taken. He may avert his eyes to the light of an
ophthalmoscope or complain that the lights in the room are too bright.
Reflexes may be so hyper that even brushing against the leg will cause
the childs lower leg to kick forward.

Nurses are the parents and childs first contact in the doctors office.
They can form a strong relationship with the parent and bond with the
child. They are the childs 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.