Dr. Greene, My son (along with several of his classmates) was recently stung by bees. The sting was on his foot, and the next morning, the entire foot was swollen. Is this serious? How do you treat bee stings? What insect repellents work the best at preventing them?
While it may not be readily apparent in the insulated, air-conditioned society most of us are accustomed to in the U.S., the fact of the matter is that the survival of bees and human beings is inextricably linked. It is estimated that one in every three bites of food we eat exists because of animal and insect pollinators, including 3,500 species of native bees! This means that one-third of our food is created by these industrious little beings.
Bees are intelligent creatures with highly developed social cultures. They are not aggressive in nature, but sting when frightened or startled as a mechanism of defense. Honeybees in particular die after engaging their stingers. In light of recent threats such as colony collapse, it is in the best interest of both bees and humans to support their longevity as best we can.
Bees are never on the hunt for victims to sting, but nevertheless it does happen when they feel threatened. While bee stings are fairly common, extreme cases of allergic reaction are rare. Of the 60 or so people who die as a result of hornet, wasps, or bee stings each year, the vast majority are adults. After being stung most children and adults experience a case of innocuous, if painful, red bumps that subsides within about 2 hours. Swelling may appear into the following day, but is not generally a cause for concern.
Bee venom contains more than nine components that work in concert to cause the physical reactions we humans experience at the onset of a bee sting. A bee’s stinger is barbed along the sides. When stinging, it is torn away from the body of the bee, along with the venom sac, as well as any attached muscles. The barbs then work their way a bit deeper into the skin, and continue to inject venom for a few more moments.
It is possible to have an immediate reaction that occurs within 4 hours of being stung, a delayed reaction that begins at least 4 hours after initial contact, or both. Classifying what type of reaction your child has is important for both immediate management as well as assessing for the severity of future encounters. Additionally, types of reactions can be determined as follows: local, large local, systemic, toxic, and delayed.
Local: Local reactions are the most common type of reaction to bee stings. There may be an area of swelling 2-3 inches across in the immediate area of the sting. Inflammation, redness and pain generally dissipate in less than 24 to 48 hours. Note that this is a natural response to the venom conveyed in a bee sting, and not an allergic reaction.
Large Local: A larger local reaction can affect an entire limb with swelling and redness, but is consistently near or adjacent to the stinging site. These types of reactions generally come on about 12-36 hours after a sting, and persist for up to a week. While it may be uncomfortable or unsightly, large local reactions are not a serious threat to the health and wellbeing of your child. If, however, such a reaction lasts longer than a week, or it spreads to other parts of the body, contact your pediatrician. For example, a sting on the forehead accompanied by the swelling of the eyelids is considered a “large local” reaction. A sting on the foot accompanied by the swelling of eyelids is considered systemic and presents a warning sign of a more severe allergic response.
Systemic: Unlike local and most large local reactions, systemic responses are allergic in nature, meaning the body overcompensates in its attempt to manage the presence of bee venom within the body. This may include swelling, redness, and pain in parts of the body nowhere near the original site of the sting such as hives, generalized itching and/or swelling, nausea, stomach pain, vomiting, dizziness, hoarseness, difficulty breathing, and low blood pressure. Severe reactions include most or all of these symptoms and may induce anaphylactic shock.
Such severe reactions to bee stings occur in only about 1-3% of children, and only 0.8% experience anaphylactic shock. See a doctor immediately if your child displays any symptoms listed in this section. Children who fall into this category should follow protocols set forth by their doctor, including carrying an injectable epinephrine and possibly wearing a medical bracelet.
Toxic: Toxic reactions, while not as frightening as the name implies, are still unpleasant. Toxic reactions occur immediately upon stinging, usually as a result of multiple stings. The term “toxic” refers to the fact that the body is responding to the presence of high levels of bee venom, and not as an allergic reaction. Toxic responses are not medically dangerous but may include fever, weakness, nausea, vomiting, and pain within the body. It is also possible that such an experience can predispose a child to future bee venom allergies.
It is best to see a doctor if a child experiences 10 or more bee stings at once, or if there are any stings inside the nose or mouth, as ensuing swelling can interfere with the ability to breathe.
Delayed: Delayed responses to bee stings are generally the result of the body’s attempt to over-prepare for future stings due to an unpleasant sting encounter in the past. In doing so the body unknowingly turns against itself with the onset of the next bee stings.
Delayed reactions include serum sickness (fever, weakness, rash, swelling, and/or intense itching which begin a week after the sting), nephrotic syndrome (inflammation of the kidney), neuritis (inflammation of the nerves), or inflammation of other parts of the body.
Remove the stinger as quickly and safely as possible. The longer a stinger stays in the skin, the larger the resulting welt, or wheal, will be. A credit card or dull butter knife scraped horizontally across the skin can usually dislodge the stinger effectively. Historically, medical professionals discouraged the use of tweezers for removal of stingers under the assumption that it would express more venom into the skin, but recent experiments have debunked that concern. Removing the stinger more quickly, as opposed to how it is removed, plays a bigger role in resulting swelling. If you observe a black dot in the skin, it likely means a part of the stinger is still embedded in the tissue.
To help prevent secondary infection, gently wash the area with soap and water. Do not break any blisters that may appear.
To reduce pain, a solution of one part meat tenderizer and 4 parts water can be applied to the site. Meat tenderizer contains papain, an enzyme found in papaya, that breaks down protein – in this case, the protein in bee venom that causes pain and itching. If you decide to use this method, be sure to rinse the solution from the skin within 30 minutes to reduce the chances of skin irritation. An antiperspirant can also be applied, as aluminum carbohydrate will also mitigate the effects of bee venom, but not to the same degree as papain.
Cold applications can feel soothing to inflamed areas of the skin. Applying an ice pack or rag soaked in cool water for 10-30 minutes at a time will lessen allergic reactions. An antihistamine such as Benadryl can also prevent a systemic response from spreading, and calamine lotion or a paste of water and baking soda can help reduce itching. Raising the limb (if that is where the sting is located) may also help reduce the inflammation.
Topical hydrocortisone may be helpful for treating bee stings that are more virulent, as well as an antibiotic ointment applied to sting sites to reduce the chances of infection.
For generalized discomfort, the appropriate dose of acetaminophen or ibuprofen can provide some relief for your child.
If you know your child is allergic to bee stings, it is likely they will need to carry injectable epinephrine, such as an Epi-pen, with them during the warmer months. These are injected immediately after a bee sting to stop symptoms of dizziness, difficulty breathing, and/or the swelling of the lips and tongue.
Additionally, treating bee stings include options for children with more severe allergic response include corticosteroids, antihistamines, and possibly allergy shots. The correct type of allergy shot can help to desensitize a child to bee stings, but will first need to be assessed using either a positive skin or RAST test. Test results indicate the specific type of bee allergy shot to administer. (See more on testing below). Ask your pediatrician about the best methods to manage your child’s symptoms.
When it comes to bee stings, prevention means not attracting bees, to begin with, and not frightening them when they are present. More bee stings occur in fall as the proliferation of flowers begin to dwindle, so it’s helpful to carry the following practices of prevention well into autumn.
Avoid fragrances, including those found in hair spray, soap, lotions, and oils. Try your best not to smell like a flower!
Skip floral patterns and bright colors in favor of more muted and neutral tones. Avoid black light activated fabrics – bees are able to see in the ultraviolet range, so these sorts of colors are especially appealing to them.
If you’re going to be in a place where you expect to encounter bees, wear solid shoes that cover the whole foot, and long pants that keep the legs covered. Hats are also helpful as they keep hair contained. Bees recognize that bears and other furry animals have an interest in their honey, and are therefore more alert to defend themselves around hair and fur.
Take extra caution when eating outside, especially sweet foods and beverages. Bees love to climb into open soda cans. They then become jostled and afraid when a person goes to drink and may end up stinging the mouth, which is especially unpleasant. Be very observant at your picnics, and try to wipe away food from your child’s hands, face, and clothing so as not to appear like a tasty treat!
When bees do land on yourself or your child, do your best not to frighten them. Stay still, even turning it into a game of “playing statue.” Unless you have inadvertently disturbed a beehive, when a bee has landed on you it believes you are a safe place; it wouldn’t hang out somewhere it felt threatened. Rather than gesturing wildly and causing the bee to become startled, gently blow in its direction, or simply wait until it flies away on its own. Once it realizes you’re not filled with nectar, it will happily be on its way.
If a bee comes into your vehicle, stop the car slowly and open all windows. Allow the insect to fly out on its own, if possible, to avoid making it agitated and more likely to sting.
There are two main ways to test for bee venom allergies. Neither test is completely perfect, and in some cases it may be beneficial to engage in both types of testing.
The most common method is skin testing. However, it is important to perform the skin test at least 1-6 weeks after being stung to obtain the most accurate results. A positive skin test is a good indicator of allergy if the child has a history of reactions to bee stings that suggest systemic response or other severe symptoms. However, up to 50% of non-allergic participants will also test positively, so skin test results must be taken in context with other factors.
If your child has a history of anaphylaxis related to bee stings and has resulted in a negative skin test, it is highly suggested to order a blood test (RAST), and repeat the skin test in 3-6 months. Skin testing requires careful precision to prevent systemic reactions in very sensitive individuals. It is also important to be aware that the degree of a positive skin test does not necessarily correlate to the severity of an allergic reaction in real-time.
RAST testing, while more reliable than a skin test, does present 20% false-negative or false-positive results. Again, the level of positivity does not accurately indicate the degree of allergy present.
A final word about allergy testing: it is only necessary to test for bee venom allergy if your child has sustained symptoms indicative of a systemic reaction. Large local reactions, while unpleasant, are not suggestive of allergies.
Aside from the fact that most children experience normal, mild reactions to bee stings, the good news is that even children who are allergic tend to grow out of their allergies. A study followed 174 kids, age 3-16, for 4 years. All had previously experienced a systemic reaction to bee stings before the onset of the study. Of the 196 stings experienced by the group in the following years, only 9.2% produced systemic reactions once again, and none more severe than the first encounter. It is likely that most children with a bee venom allergy will eventually cease to have such extreme reactions.
No one wants to get stung by bees, and as far as we can tell, they don’t want to sting anyone, either! It takes 2 million visits to flowers to make just one pound of honey. Bees are far too busy tending their hives to want to go out of their way to harm anyone. With careful measures in place, you can reduce the chances of stinging, making for happy children and happy bees alike.
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Valentine et al. The value of immunotherapy with venom in children with allergy to insect stings. N Engl J Med 323(23):1601‐1603, 1990.