Doxycycline for Children With Lyme Disease: Pros and Cons

Doxycycline is commonly used to treat Lyme disease in adults, but its use in young children remains controversial. Physicians must weigh the benefits of doxycycline against the potential risk of permanent tooth staining associated with tetracycline antibiotics. Several recent studies and updated pediatric guidelines have reexamined whether doxycycline may be appropriate for some children with Lyme disease.

Tetracyclines, including doxycycline, are typically not recommended for treating young children with Lyme disease because the antibiotic may cause permanent staining of the teeth, explains Wormser and colleagues in a recently published article, “Is Doxycycline Appropriate for Routine Treatment of Young Children With Erythema Migrans?” [1]

For a broader overview, see Lyme disease in children and Managing Lyme disease in children.

Why Doxycycline Is Used for Lyme Disease

Doxycycline is effective against Borrelia burgdorferi, the bacterium responsible for Lyme disease. The antibiotic is also active against several tick-borne coinfections, including Anaplasma and Ehrlichia, which may occur in the same geographic regions.

Because of this broader coverage, doxycycline is sometimes preferred when coinfection is suspected.

Risk of Tooth Staining in Young Children

Doxycycline for Children With Lyme Disease: Pros and Cons

Doxycycline is commonly used to treat Lyme disease in adults, but its use in young children remains controversial. Physicians must weigh the benefits of doxycycline against the potential risk of permanent tooth staining associated with tetracycline antibiotics. Several recent studies and updated pediatric guidelines have reexamined whether doxycycline may be appropriate for some children with Lyme disease.

Tetracyclines, including doxycycline, are typically not recommended for treating young children with Lyme disease because the antibiotic may cause permanent staining of the teeth, explains Wormser and colleagues in the article “Is Doxycycline Appropriate for Routine Treatment of Young Children With Erythema Migrans?” [1]

For a broader overview, see Lyme disease in children and Managing Lyme disease in children.

Why Doxycycline Is Used for Lyme Disease

Doxycycline is effective against Borrelia burgdorferi, the bacterium responsible for Lyme disease. The antibiotic is also active against several tick-borne coinfections, including Anaplasma and Ehrlichia, which may occur in the same geographic regions.

Because of this broader coverage, doxycycline is sometimes preferred when coinfection is suspected.

Risk of Tooth Staining in Young Children

In the article, Wormser discusses the risk-to-benefit ratio of prescribing doxycycline. “Tetracycline-induced dental staining does not spontaneously resolve, may have adverse psychological effects, and families may incur considerable expense to correct the problem.”

The risk of tetracycline-related tooth staining is greatest in children younger than 5 to 6 years of age because permanent teeth are still developing during this period.

“Because calcification of permanent teeth is largely complete by 5–6 years of age, children who are <4 years of age are at highest risk,” Wormser explains.

Doxycycline Compared With Older Tetracyclines

The risk of dental staining was expected to be lower after doxycycline, a tetracycline derivative, was introduced.

“Doxycycline was reported to bind calcium less avidly than tetracycline, which could explain why doxycycline may be less likely to cause dental staining,” writes Wormser.

In two small studies involving 89 children, doxycycline did not lead to dental staining. However, the studies were short in duration and used lower doses than those typically prescribed for tick-borne illnesses.

American Academy of Pediatrics Guidance

New evidence led the American Academy of Pediatrics (AAP) Committee on Infectious Diseases to update guidance in 2018. The committee stated that doxycycline may be prescribed for up to 21 days in young children with infections responsive to the drug, including early Lyme disease.

Is Doxycycline Recommended for Children With Lyme Disease?

“The recommendation to use doxycycline in young children with early Lyme disease should be based on assessment of the risk-to-benefit ratio of this drug compared with other recommended antibiotics,” writes Wormser.

The decision to prescribe doxycycline should therefore be individualized based on clinical factors.

Wormser also notes that the risk of dental staining may depend on cumulative exposure to tetracycline antibiotics.

“The recommendation to use doxycycline in children <8 years of age should require an assessment of how much doxycycline had previously been taken by a patient, including total dosage,” he explains.

Based on Lyme disease case estimates, Wormser suggests that more than 30,000 children under age 8 could potentially receive doxycycline each year.

If the risk of dental staining were even 1 in 1000 (0.1%), this could result in more than 30 children annually developing dental staining from treatment of erythema migrans.

Use of doxycycline is clearly indicated for serious infections such as Rocky Mountain Spotted Fever, where doxycycline is considered the preferred treatment.

Alternative Antibiotics for Children

For many children with Lyme disease, antibiotics such as amoxicillin or cefuroxime may be considered alternatives when doxycycline is not the preferred option.

These antibiotics are commonly used when coinfections such as Rocky Mountain Spotted Fever, Ehrlichia, or Anaplasma are not suspected.

Single Dose of Doxycycline for a Tick Bite

The authors also discuss using a single dose of doxycycline after a deer tick bite to prevent Lyme disease.

“It seems unlikely that one dose would cause dental staining in young children,” writes Wormser.

However, the authors do not mention that no studies have demonstrated the effectiveness of a single dose of doxycycline in preventing chronic manifestations of Lyme disease.

Clinical Perspective

In my practice, treatment decisions for children with Lyme disease are based on an individualized assessment of risks and benefits. Age, symptom severity, possible coinfections, and prior antibiotic exposure all influence the choice of therapy.

When treating children with Lyme disease, physicians must carefully weigh the benefits of doxycycline against potential risks. Treatment decisions should be individualized based on age, clinical presentation, and the possibility of coinfections such as Babesia and Bartonella in children.

Frequently Asked Questions

Is doxycycline safe for children with Lyme disease?

Short courses of doxycycline may be used in some children when the benefits outweigh the risks, particularly for early Lyme disease or when coinfections are suspected.

Can doxycycline stain children’s teeth?

Tetracycline antibiotics can cause permanent tooth staining in young children. Doxycycline appears to bind calcium less strongly, but the risk may still depend on cumulative exposure.

What antibiotics are used for children with Lyme disease?

Common treatments include amoxicillin, cefuroxime, and in some cases doxycycline.

In the article, Wormser discusses the risk-to-benefit ratio of prescribing the antibiotic. “Tetracycline-induced dental staining does not spontaneously resolve, may have adverse psychological effects, and families may incur considerable expense to correct the problem.”

The risk of tetracycline-related tooth staining is greatest in children younger than 5 to 6 years of age because permanent teeth are still developing during this period.

This risk is greatest for younger children, he explains. “Because calcification of permanent teeth is largely complete by 5–6 years of age, children who are <4 years of age are at highest risk.”

Doxycycline Introduced

However, the risk of dental staining was expected to be less after doxycycline, a tetracycline derivative, was introduced to the market.

“Doxycycline was reported to bind calcium less avidly than does tetracycline, which could explain why doxycycline may be less likely to cause dental staining,” writes Wormser.

In 2 small studies, which enrolled 89 children, doxycycline did not lead to dental staining. However, the studies were of short duration and used lower doses of the antibiotic than is typically prescribed for tick-borne illnesses.

American Academy of Pediatrics Guidance

These new studies led to the recommendation in 2018 by the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP) that a course of treatment with doxycycline (for up to 21 days) is safe to prescribe for young children with any infection responsive to this agent, specifically including early Lyme disease.

Is Doxycycline Recommended for Children With Lyme Disease?

“The recommendation to use doxycycline in young children with early Lyme disease should be based on assessment of the risk to benefit ratio of use of this drug compared with that of other recommended antibiotics,” writes Wormser.

The decision to prescribe doxycycline for children with Lyme disease should be based on careful evaluation of risks and benefits.

“The recommendation to use doxycycline in children <8 years of age should require an assessment of how much doxycycline had previously been taken by a patient, including total dosage, because the risk of dental staining is directly related to cumulative exposure,” he adds.

Based on the number of Lyme disease cases reported each year and the percentage of children likely affected, Wormser estimates that “more than 30,000 children <8 years of age could potentially be treated with doxycycline each year.”

If the risk of dental staining were even just 1 in 1000 (0.1%),” he explains, “this would translate to >30 children annually who would develop dental staining from taking doxycycline for erythema migrans.”

Use of doxycycline clearly is indicated to treat young children with Rocky Mountain Spotted Fever or with other very serious infections for which doxycycline is preferred, he adds.

Alternative Antibiotics for Children

For many children with Lyme disease, antibiotics such as amoxicillin or cefuroxime may be considered alternatives when doxycycline is not the preferred option.

Other antibiotics, including amoxicillin, remain an alternative for children with Lyme disease who do not have Rocky Mountain Spotted Fever, Ehrlichia, or Anaplasmosis.

Single Dose of Doxycycline for a Tick Bite

In addition, the authors discuss treating a deer tick bite with a single dose of doxycycline to prevent Lyme disease. “It seems unlikely that one dose would cause dental staining in young children,” writes Wormser.

However, the authors fail to mention that no studies have demonstrated the effectiveness of a single dose of doxycycline in preventing chronic manifestations of Lyme disease.

Clinical Perspective

In my practice, treatment decisions for children with Lyme disease are based on an individualized assessment of risks and benefits. Age, symptom severity, possible coinfections, and prior antibiotic exposure all influence the choice of therapy.

When treating children with Lyme disease, physicians must carefully weigh the benefits of doxycycline against potential risks. Treatment decisions should be individualized based on age, clinical presentation, and the possibility of coinfections such as Babesia and Bartonella in children.

Frequently Asked Questions

Is doxycycline safe for children with Lyme disease?

Short courses of doxycycline may be used in some children when the benefits outweigh the risks, particularly for early Lyme disease or when coinfections are suspected.

Can doxycycline stain children’s teeth?

Tetracycline antibiotics can cause permanent tooth staining in young children. Doxycycline appears to bind calcium less strongly, but the risk may still depend on cumulative exposure.

What antibiotics are used for children with Lyme disease?

Common treatments include amoxicillin, cefuroxime, and in some cases doxycycline.

Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention