What is the recommended treatment for a pediatric patient presenting to the emergency department (ED) with a tick bite?

Tick Bite Treatment in Pediatric Emergency Department

Immediate Tick Removal

Remove the attached tick immediately using fine-tipped tweezers or a commercial tick removal device by grasping the tick's head as close to the skin as possible and pulling upward with steady, even pressure. 1

• Time is critical—the risk of disease transmission increases with duration of attachment, particularly after 36 hours 2, 3
• Use clean fine-tipped tweezers or comparable commercial tick removal devices 4
• Grasp as close to the skin surface as possible to avoid leaving mouthparts embedded 1
• Pull upward with steady, constant pressure—avoid twisting or jerking motions 4

What NOT to Do During Removal

• Never use burning methods, matches, petroleum jelly, nail polish, gasoline, or other chemicals—these are ineffective and potentially harmful 1, 2, 4
• Avoid crushing the tick with fingers or handling with bare hands as tick fluids may contain infectious organisms 4
• Do not attempt aggressive removal of retained mouthparts if they break off—clean the site and leave them alone as they will be expelled naturally without increasing infection risk 2

Post-Removal Care

• Clean the bite site thoroughly with soap and water, alcohol, or iodine scrub 1, 2, 4
• Wash hands thoroughly after handling ticks, especially before touching face or eyes 1, 4
• Document the date and location of the tick bite for future reference 2

Antibiotic Prophylaxis Decision Algorithm

Prophylactic antibiotics should ONLY be given if ALL three high-risk criteria are met within 72 hours of tick removal: 2, 4, 3

High-Risk Criteria (ALL must be present):

1. Tick species: Identified as Ixodes scapularis (deer tick) 2, 3
2. Geographic location: Bite occurred in highly endemic Lyme disease area (parts of New England, mid-Atlantic states, Minnesota, Wisconsin with ≥20% tick infection rates) 2, 3
3. Duration of attachment: Tick was attached ≥36 hours (estimated by degree of engorgement) 2, 3

Prophylaxis Dosing (if ALL criteria met):

• Children ≥8 years: Single dose of doxycycline 4.4 mg/kg (maximum 200 mg) orally 2, 4, 3
• Adults: Single dose of doxycycline 200 mg orally 4, 3
• Must be given within 72 hours of tick removal 2, 4, 3

Contraindications to Doxycycline Prophylaxis:

• Children <8 years of age 2, 3
• Pregnant women 2, 3

Important Caveat:

If the tick bite cannot be classified with high certainty as meeting ALL three high-risk criteria, use a "wait-and-watch" approach rather than empiric antibiotics. 3 Most tick bites do NOT require prophylactic antibiotics 2, 4

Post-Bite Monitoring Instructions

• Monitor the bite site for 30 days for development of erythema migrans (expanding "bullseye" rash) 2, 4, 3
• Watch for systemic symptoms including fever, headache, muscle pain, joint pain, or swollen lymph nodes 4, 3
• For Rocky Mountain Spotted Fever, be alert for petechial rash starting on wrists, forearms, and ankles 2
• Instruct parents/caregivers to seek immediate medical attention if erythema migrans develops at any time 2

When to Seek Follow-Up Care

• Prompt consultation within 72 hours after removal of an engorged tick in high-prevalence Lyme disease regions 2
• Immediate return if expanding rash develops at bite site 2
• Return for any systemic symptoms suggesting tick-borne illness 4

Common ED Pitfalls to Avoid

• Delaying tick removal—every hour counts in reducing transmission risk 2, 4
• Over-prescribing prophylactic antibiotics—only high-risk bites meeting ALL three criteria warrant prophylaxis 2, 4
• Assuming prophylaxis prevents all tick-borne diseases—single-dose doxycycline may prevent Lyme disease but not necessarily ehrlichiosis, anaplasmosis, or Rocky Mountain Spotted Fever 2, 4
• Failing to provide clear monitoring instructions—parents must understand the 30-day observation period and warning signs 2, 4

Prevention Education for Discharge

• Use EPA-registered tick repellents containing DEET, picaridin, IR3535, oil of lemon eucalyptus, p-methane-3,8-diol, or 2-undecanone on exposed skin 2, 4, 3
• Apply permethrin to clothing for additional protection 2, 4
• Wear protective clothing including long-sleeved shirts, pants, socks, and closed-toe shoes in tick-infested areas 2, 4
• Perform daily full-body tick checks after outdoor activities 4, 3