Lyme disease is a bacterial infection caused by Borrelia burgdorferi, transmitted to humans through the bite of an infected blacklegged tick (Ixodes scapularis). Children are at a particularly high risk because of their frequent outdoor activities in wooded and grassy areas where ticks thrive. The small size of the nymphal tick makes it easy to overlook, often resulting in a delayed diagnosis. Younger children may also struggle to articulate vague symptoms like fatigue or headache, which complicates early detection.
Recognizing Early Symptoms in Children
The Erythema Migrans (EM) rash develops at the site of the tick bite within three to 30 days. This rash occurs in 70 to 80 percent of cases and often expands outward, sometimes clearing in the center to create the classic “bulls-eye” appearance. The rash can also be solid, oval, or irregular, and may be missed entirely if it appears in a less visible area like the scalp, groin, or armpits.
In the early localized stage, children may also experience non-specific, flu-like symptoms that emerge days or weeks after the bite. These signs include fever, headache, chills, swollen lymph nodes, and muscle or joint aches. These vague complaints make clinical diagnosis challenging, as they can easily be mistaken for other common childhood illnesses.
As the infection enters the early disseminated stage, it can affect the nervous system and joints. One of the most common neurological manifestations is facial palsy, a weakness or droop on one or both sides of the face. This occurs when the bacteria inflame the facial nerve and requires immediate antibiotic treatment. Another later sign is Lyme arthritis, which typically involves recurrent swelling and pain in large joints, most often the knee.
Pediatric Diagnosis and Treatment Guidelines
Diagnosis of Lyme disease is primarily clinical, especially if the characteristic Erythema Migrans rash is present in a child from an endemic area. If the rash is absent or the disease has progressed, a two-step serologic testing process is recommended to detect antibodies to the bacteria. This process begins with a sensitive enzyme-linked immunosorbent assay (ELISA) or immunofluorescence assay (IFA).
If the initial screening test is positive or equivocal, it is followed by a Western blot test to confirm the presence of specific antibodies. Antibody tests can be falsely negative during the first few weeks of infection because the immune system has not yet produced a measurable response. A positive antibody test can also persist for months or years after the infection has been successfully treated.
The standard treatment involves oral antibiotics, with the choice depending on the child’s age and the stage of the disease. Common choices include amoxicillin or cefuroxime, typically administered for a course of 14 to 28 days. Recent guidelines have updated the recommendations regarding the use of doxycycline in young children, which was historically avoided due to concerns about tooth discoloration.
Current pediatric recommendations now support the use of a short course of doxycycline for children of all ages, including those under eight, especially for high-risk tick bite prophylaxis or in cases of disseminated disease like neuroborreliosis. The risk of dental staining with short courses of doxycycline is considered low, and the benefits of its efficacy against both Lyme and potential co-infections often outweigh this minimal risk.
Long-Term Health Considerations
For children who receive antibiotic treatment, the prognosis is excellent, with most achieving a full recovery. However, in a small percentage of cases, symptoms may persist or emerge after treatment completion. One potential complication is persistent Lyme arthritis, where joint swelling continues despite the initial course of treatment. This condition may require a second course of oral antibiotics or, in some cases, intravenous ceftriaxone.
Some children may experience lingering, non-specific symptoms such as muscle pain, fatigue, and memory complaints. This condition is sometimes referred to as Post-Treatment Lyme Disease Syndrome (PTLDS). While the exact cause is not fully understood, theories suggest it may be related to residual damage, an autoimmune response, or the immune system’s reaction to lingering bacterial fragments.
Studies indicate that up to 22% of pediatric patients may report one or more symptoms lasting longer than six months, though the majority do not have functional impairment. Prolonged courses of antibiotics have not been shown to be beneficial for PTLDS and are not the recommended approach. Managing PTLDS involves supportive care focused on addressing the specific symptoms a child is experiencing.
Prevention and Safe Tick Removal
Preventing Lyme disease starts with minimizing exposure to ticks, particularly during the spring and summer months when nymphs are most active. When children are in wooded or brushy areas, wearing long-sleeved shirts and tucking pant legs into socks creates a physical barrier. Applying insect repellent containing DEET to exposed skin and clothing can effectively repel ticks, with concentrations up to 30% considered safe for children.
Parents can also treat clothing and gear with permethrin, though it should never be applied directly to the skin. After spending time outdoors, a thorough “tick check” is essential, focusing on areas where ticks hide:
- The hairline
- Ears
- Armpits
- Groin
Taking a shower within two hours of coming indoors can also help wash off unattached ticks.
If a tick is found attached to the skin, it should be removed promptly and correctly, as transmission typically requires the tick to be attached for 36 to 48 hours. Use fine-tipped tweezers to grasp the tick as close to the skin’s surface as possible, ideally at the mouthparts. Pull upward with a steady, even pressure without twisting or jerking, which can cause the mouthparts to break off. After removal, the bite area should be cleaned with rubbing alcohol or soap and water.