For most people, an insect sting or bite is just a painful or irritating problem. But there are those whose immune systems are such that they have severe, sometimes life-threatening, reactions.

Such reactions can be dangerous and cause a person to become incapacitated or even die within minutes. Childcare providers should know how to treat a severe reaction until emergency medical help arrives.

The most common reaction to an insect bite or sting is a local reaction. This type of reaction consists of redness, itching, pain, and swelling at the site of the sting or bite. This type of reaction may look serious, and the child may be screaming in pain and fear if bitten or stung; but the reaction is localized and generally not serious.

A reaction called anaphylaxis is a profoundly serious problem caused by a severe allergic reaction to a substance. This reaction may be triggered by many sources of allergies, such as medications, peanuts or other food items, or the bite or sting of an insect.

The insects most commonly associated with severe allergic reactions are those that belong to the order Hymenoptera, which means “membranous wing.” This order of insects includes ants, hornets, bees, wasps, and yellow jackets.

Hornets, wasps, and bees sting, while ants bite. A hornet or wasp can sting the victim repeatedly. A bee has a barb at the end of the stinger, so after it stings its unfortunate victim, the stinger remains in the skin after the bee flies away.

Therefore, a bee can only sting once; however, the venom sac may remain attached to the stinger and can continue to pump venom into the person for several minutes. Ants, such as fire ants, may swarm a child and quickly cause multiple bites.

About 0.5-5 percent of the U.S. population, or about 13 million people, have serious reactions to insect stings or bites. In the U.S., more than 500,000 emergency room visits each year are due to people suffering from insect bites or stings, resulting in an estimated 40 deaths due to anaphylaxis. About half of these deaths are due to bites by fire ants, which are becoming an increasingly common problem as they spread throughout the southern U.S.

So, what should you do when a child comes to you crying that she has been “bitten by a bee?” First, calm the child while you do a quick visual inspection. Look for hives (an itchy, red rash that appears at sites distant from the sting or bite); wheezing or breathing difficulties; swelling of the face, lips, or throat; or dizziness or restlessness. Flushing, abdominal cramps, nausea, and vomiting also are common signs of anaphylaxis.

These are signs that anaphylaxis is developing and indicate a true emergency. Have someone call 911. Treatment must be administered immediately.

If the child is known to be severely allergic to insect stings or other substances, his or her doctor may have prescribed an EpiPen Jr. This injectable epinephrine will temporarily block the receptors that cause the reaction. If a child in your care has a prescribed EpiPen Jr., then you should always have it available and should be trained in its use. Also, be prepared to perform CPR if necessary, and continue until emergency help arrives.

Do not use an EpiPen on a child who had not been prescribed the pen. If a child has a reaction and has not been prescribed an EpiPen (or you have not been provided on by the parents), call 911 and wait for help.

Be aware that while most serious reactions occur within minutes, anaphylactic reactions may take several hours to develop, so watch the child carefully, even if the reaction initially appears to be localized.

Assuming the reaction is not life-threatening, local treatment is in order. If the stinger is still attached, remove it by gently scraping it from the skin with a credit card or similar object. Scrape in the opposite direction of the stinger so it will come out the same way it went in. Do not attempt to remove the stinger with tweezers or your fingers. If the venom sac is still attached, squeezing it may inject more venom into the child.

Wash the area with soap and water and apply a bandage. An ice pack may help reduce itching or swelling. Do not apply ice directly to the skin; place a soft cloth between the ice and the child’s skin. A paste of baking soda and water applied to the area also may help.

Contact the child’s parent or guardian and inform them of the situation. Ask them if the child has had previous reactions to a sting or bite. Even though you should have this information in the child’s file, it is a good idea to double-check.

If the child is in pain or discomfort, encourage the parent to pick up the child. You also may suggest that they ask their pediatrician or pharmacist about over-the-counter medications to relieve the symptoms.

Routinely inspect children’s play areas for nests. Hornets construct dull-colored, paper-like nests that are anywhere from five to ten feet above the ground. Wasps usually live in trees or construct nests on or in buildings or on wooden playground equipment. Some wasps, such as yellow jackets, have underground nests that may be disturbed by a child walking or playing nearby. Most insect repellants do not work against wasps or bees.

Fire ant nests are underground and have a small dirt mound above ground. Bees generally construct a hive or live in hollow trees. If you spot an insect nest, keep children far away from the area until it can be removed by a pest control specialist. Never expose children to areas being treated with pesticides.

The risk of bites or stings can be minimized by following these recommendations:

• Avoid wearing sweet-smelling perfume or hair spray that may attract insects.
• Children should always wear shoes. Closed shoes are best, not only to prevent stings and bites, but also to avoid tripping or other hazards.
• If eating outside, keep food and beverages covered. An insect may enter a beverage container, resulting in a sting to the mouth or throat. Such stings can cause life-threatening swelling.
• Tightly close all garbage cans.

Outdoor play should be a fun time for children, but inevitably someone will be stung or bitten by an insect. All caregivers should know how to handle either mild or severe reactions caused by our insect friends. Remember, children known to be severely allergic to insect stings or other substances (such as food allergies) should have an EpiPen Jr. with them; and the caregiver should be trained in its proper use.

Joe Knight
Family Practice Physician Assistant and medical writer, Fresno, California.

American Academy of Allergy, Asthma & Immunology, 555 E. Wells St., Ste. 1100, Milwaukee, WI 53202-3823; 414-272-6071; www.aaaai.org

EpiPen, www.epipen.com

Kids Health, www.kidshealth.org/parent/firstaid_safe/emergencies/insect_bite.html

Mayo Clinic, www.mayoclinic.com/health/first-aid-insect-bites/FA00046

MedLine, www.nlm.nih.gov/medlineplus/insectbitesandstings.html