Lyme Disease in Children: Symptoms, Diagnosis, and Treatment

Lyme disease in children can affect the joints, brain, and nervous system
Symptoms may include fatigue, headaches, learning difficulties, and joint pain
Early recognition and treatment may reduce the risk of long-term complications

Welcome to another selection from my book An Expert’s Guide on Navigating Lyme Disease. This chapter highlights Lyme disease in children and summarizes findings from many of my Lyme disease science blogs. Children often present differently than adults, and early recognition may help prevent unnecessary disability and prolonged illness.

Lyme disease symptoms in children extend beyond the classic bull’s-eye rash. While many children recover with prompt antibiotic treatment, others develop neurological, cognitive, psychiatric, or musculoskeletal symptoms that interfere with school, sports, and daily life. Because the early symptoms may resemble viral illnesses or other common childhood conditions, diagnosis can sometimes be delayed.

Throughout this article, I review published pediatric studies and case reports illustrating the broad spectrum of Lyme disease in children, including learning difficulties, Lyme arthritis, infants with tick-borne infections, congenital babesiosis, and uncommon neurologic presentations.

How Lyme disease affects children

Lyme disease is one of the most common tick-borne illnesses affecting children in the United States. Early symptoms may include fever, fatigue, headache, muscle aches, swollen lymph nodes, and an expanding erythema migrans rash. If treatment is delayed, the infection may involve the joints, nervous system, heart, or other organs.

Children often experience Lyme disease differently than adults. Some primarily develop arthritis, while others present with facial palsy, severe headaches, dizziness, cognitive changes, mood symptoms, or declining school performance. Because these symptoms overlap with many common childhood illnesses, maintaining clinical suspicion remains important in endemic areas.

According to the Centers for Disease Control and Prevention (CDC), children between approximately 5 and 14 years of age are among the age groups at greatest risk for Lyme disease because of frequent outdoor exposure in wooded and grassy environments.

How Lyme disease can affect learning and school performance

Children with persistent Lyme disease symptoms may struggle academically as well as physically. Neurological, psychiatric, and cognitive symptoms can impair learning, concentration, memory, classroom performance, and participation in extracurricular activities.

Tager and colleagues (2001) described 20 children between 8 and 16 years of age who continued to experience significant symptoms despite antibiotic treatment. These included marked fatigue (100%), arthralgias (100%), severe headaches (100%), irritability or depression (94%), short-term memory problems (94%), schoolwork deterioration (94%), myalgias (88%), brain fog (88%), neck pain (88%), insomnia (82%), distractibility (82%), word-finding difficulty (82%), sensory sensitivity to light and sound, and radicular pain.

These findings illustrate that Lyme disease may affect far more than the joints and emphasize the importance of considering Lyme disease when a child develops otherwise unexplained cognitive decline, memory problems, or worsening school performance.

Learn more about how Lyme disease can affect school performance.

Children with Lyme disease may need school accommodations

Persistent symptoms may interfere with learning, attention, attendance, and emotional well-being. Tager and colleagues reported increased learning and attention problems together with mood disturbances in children with Lyme disease compared with healthy controls. McAuliffe and colleagues later described adolescents with significant deficits in visual memory, verbal memory, recognition memory, attendance, grades, and subjective memory complaints.

Children recovering from Lyme disease may qualify for educational accommodations through Section 504 plans or an Individualized Education Program (IEP), depending on the severity of their symptoms. Helpful accommodations may include:

• Shortened school days
• Untimed examinations
• Quiet testing environments
• Modified homework expectations
• Temporary home instruction when medically necessary
• Flexible attendance policies during recovery

Read more about Lyme disease and school accommodations.

A teenager’s journey from martial arts to a wheelchair

A published case described an athletic 18-year-old woman who developed a bull’s-eye rash followed by Bell’s palsy. During the next four years she progressively deteriorated and eventually required a wheelchair.

Her symptoms included cognitive impairment involving attention, concentration, memory, processing speed, tactile hypersensitivity, orthostatic hypotension, fatigue, non-restorative sleep, headaches, peripheral neuropathy, muscle atrophy, cervical radiculopathy, pelvic pain, difficulty urinating, costochondritis, generalized pain, and seizures.

Initially, clinicians diagnosed fibromyalgia, chronic fatigue syndrome, hypoglycemia, and “pseudoseizures.” Eventually, Bransfield and Friedman diagnosed late-stage Lyme borreliosis with multisystem involvement together with additional medical conditions contributing to her illness. Further evaluation demonstrated complex partial seizures rather than psychogenic events.

According to the authors, appropriate treatment ultimately allowed the patient to become physically active, marry, and resume a productive life.

Read more about psychiatric and neurological manifestations of Lyme disease.

When Lyme disease is mistaken for child abuse

Pan and colleagues described a 4-year-old boy evaluated after an unwitnessed fall. He presented with a swollen knee, a forearm fracture, and what initially appeared to be extensive bruising over the buttock.

Concerned about possible non-accidental trauma, clinicians reported the family to child protective services. Subsequent evaluation revealed that the apparent bruising represented erythema migrans, the characteristic Lyme disease rash. Lyme testing was positive, and the child improved after treatment with oral amoxicillin.

The child was released from foster care after authorities concluded that Lyme disease explained the rash and knee findings, while the forearm fracture was unrelated.

This case illustrates how Lyme disease can occasionally mimic other conditions and why maintaining an appropriate diagnostic perspective remains important in endemic regions.

Read the complete case report.

Lyme disease in a 5-week-old baby

Handel and colleagues described an otherwise healthy 5-week-old girl diagnosed with Lyme disease. The infant lived on Long Island, New York, an area where Lyme disease is endemic. Although she was rarely outdoors, clinicians suspected that the family dog may have carried a tick into the home.

Because of concern for possible Lyme meningitis, doctors attempted a lumbar puncture. The procedure was unsuccessful, but the medical team elected to treat the infant for possible neurologic Lyme disease.

She received intravenous ceftriaxone for two weeks and was subsequently discharged from the hospital.

This case demonstrates that Lyme disease can occasionally occur even in very young infants without a recognized tick bite or clear history of outdoor exposure.

Read more about Lyme disease in this 5-week-old infant.

Babesiosis in three premature infants

Lyme disease is not the only tick-borne infection that can affect children. Glanternik and colleagues described three premature infants in a neonatal intensive care unit who developed babesiosis after receiving blood products from the same 24-year-old donor.

The donor lived in Connecticut and had been considered eligible for donation. At the time, routine blood-bank screening did not identify the donor’s Babesia infection.

Two infants developed high levels of parasitemia, reaching 13.4% and 12.5%. Parasitemia in the third infant peaked at 6.8%.

All three infants were treated with azithromycin and atovaquone rather than clindamycin and quinine. The authors noted practical concerns regarding quinine use in very small children, including its narrow therapeutic index, potential adverse effects, and uncertainty regarding the stability of compounded oral preparations.

The infants received 14 days of treatment. However, one child experienced a relapse 48 days later and required an additional 23-day course of azithromycin and atovaquone.

This report highlights the possibility of transfusion-associated babesiosis and the importance of follow-up after treatment, particularly in premature or medically vulnerable infants.

Read more about transfusion-associated babesiosis in premature infants.

Delayed babesiosis in two newborns

Hoversten and Bartlett described two newborn infants diagnosed with babesiosis several weeks after their mothers had been treated for Lyme disease during pregnancy.

Infant 1: A baby boy was diagnosed with babesiosis at approximately 4½ weeks of age. His mother had been diagnosed and treated for early Lyme disease at 32 weeks of pregnancy.

Infant 2: A baby girl was diagnosed with babesiosis at 18 days of age. Her mother had been diagnosed and treated for early Lyme disease at 37 weeks of pregnancy.

The delayed presentation illustrates how congenital babesiosis may not become apparent immediately after birth. Symptoms can emerge days or weeks later as parasitemia increases and maternal antibodies decline.

These cases also raise an important clinical question: when a pregnant patient is diagnosed with Lyme disease after a tick bite, should clinicians also consider possible exposure to Babesia microti?

Read more about delayed babesiosis in newborns.

Babesia can be transmitted during pregnancy

Babesia may be acquired through a tick bite, blood transfusion, or transmission from mother to infant during pregnancy. Congenital babesiosis is uncommon, but published cases demonstrate that it can occur.

Important unanswered questions include:

• How often do pregnant women acquire babesiosis following a tick bite?
• How can clinicians recognize babesiosis during pregnancy when symptoms are mild or nonspecific?
• Which treatments are both effective and safe during pregnancy?
• Should pregnant patients with Lyme disease or a known tick bite also be evaluated for babesiosis?
• How long should newborns be monitored when congenital exposure is possible?

Because symptoms in the newborn may be delayed, follow-up may be important even when the infant initially appears healthy.

Read more about congenital babesiosis.

Four children developed Lyme disease after attending camp

A report in the Morbidity and Mortality Weekly Report described four children who developed Lyme disease after attending a wilderness day camp in North Carolina.

Investigators collected 35 ticks from the camp. Six were infected with Borrelia burgdorferi sensu stricto, the primary cause of Lyme disease in the United States. The estimated infection prevalence among collected nymphal ticks was 17%.

One of the infected ticks also tested positive for Borrelia miyamotoi, another tick-borne bacterium transmitted by Ixodes ticks.

This investigation demonstrated that children may encounter infected ticks even outside regions traditionally considered highly endemic. Parents, schools, and camp personnel should remain alert for expanding tick habitats and changing geographic patterns of Lyme disease.

Read more about the Lyme disease cases linked to this wilderness camp.

A child’s Lyme rash was initially dismissed

Banadyha and colleagues described a 6-year-old girl who developed a circular rash on the left side of her face. Her physician initially diagnosed allergic dermatitis and prescribed topical corticosteroids.

The rash failed to improve. Over the following 1½ months, it expanded toward the back of her head, and the child developed malaise and a low-grade fever.

Although she lived in an endemic area, there was no known tick bite, and initial Lyme disease testing was not positive. Based on the clinical appearance and progression of the rash, the treating physician prescribed oral cefuroxime.

Two weeks after treatment began, Lyme disease was confirmed by a positive IgG Western blot. The child remained asymptomatic at 1½-year follow-up.

This case illustrates why a negative early test or absent history of a tick bite should not automatically exclude Lyme disease when the clinical findings are suggestive.

Read more about the role of clinical judgment in this pediatric Lyme disease case.

The emotional and financial burden of pediatric Lyme disease

Lyme disease can affect far more than a child’s physical health. Persistent symptoms may disrupt family life, education, employment, and finances. Parents often face repeated medical visits, uncertainty regarding diagnosis, and significant out-of-pocket expenses while searching for answers.

DeLong and colleagues noted that the absence of a universally accepted definition for post-treatment Lyme disease means many patients receive limited insurance coverage for prolonged care. As a result, families frequently bear the financial burden themselves.

Because children between 5 and 14 years of age are among the highest-risk groups for Lyme disease, persistent illness can create substantial emotional, educational, and financial challenges for both families and school systems.

Parents describe the challenges of raising a child with Lyme disease

To better understand the family experience, Gaudet and colleagues analyzed correspondence from 23 parents of children diagnosed with Lyme disease who were recruited through two Canadian Lyme disease support groups.

Lack of awareness

One parent recalled:

“My youngest child, who was 10 at the time, had TWO BULL’S-EYE RASHES on her body … the doctor said, ‘It can’t be Lyme. There’s no Lyme in British Columbia.’”

This experience illustrates how delayed recognition may occur when Lyme disease is considered uncommon in a particular geographic area.

Persistent suffering

“He continued to get worse … crying all day, sad about being unable to play with his brother, and sad from the pain in his head.”

Parents frequently described ongoing pain, fatigue, headaches, and cognitive problems that affected daily life long after symptoms first appeared.

Missing childhood milestones

“She was not able to undertake the many extracurricular activities that often define the teenage years… she has missed out on a lot and will never be able to get those years back.”

Many families described missed school activities, sports, friendships, and important developmental experiences resulting from prolonged illness.

Frustration with diagnostic testing

“I found myself hoping something would show up on the tests so they would have no choice but to address it.”

Several parents expressed frustration when laboratory testing failed to explain symptoms despite ongoing functional impairment.

Feeling dismissed

“She was dismissed from countless medical appointments… ‘Take some Tylenol and get on with your life’ … ‘Your lab work is normal.’”

Parents frequently described feeling that the combination of physical, neurological, cognitive, and psychological symptoms made diagnosis particularly challenging.

Read more about parents’ experiences caring for children with Lyme disease.

Is doxycycline safe for young children?

Many physicians have historically avoided prescribing doxycycline to children younger than 8 years because of concerns regarding permanent tooth discoloration.

More recent evidence has challenged this long-standing concern. Two studies involving 89 children found no permanent dental staining after short courses of doxycycline, although both studies involved relatively small numbers of patients and shorter treatment durations than may sometimes be used for tick-borne illnesses.

Based on available evidence, the American Academy of Pediatrics (AAP) concluded in 2018 that doxycycline may be used for up to 21 days in young children when treating infections that respond to this antibiotic, including early Lyme disease.

Treatment decisions should still be individualized after considering the child’s age, clinical presentation, the likelihood of Lyme disease, and the risks and benefits of therapy.

Read more about doxycycline use in children with Lyme disease.

Tick bites in children may transmit more than Lyme disease

According to the Centers for Disease Control and Prevention (CDC), children account for approximately one-quarter of reported Lyme disease cases in the United States. Children between 5 and 14 years of age remain among the highest-risk groups because of frequent outdoor activities.

Ticks may carry more than one infection. Xu and colleagues found that human-biting ticks contained:

• 29.6% infected with Borrelia burgdorferi
• 4.6% infected with Anaplasma phagocytophilum
• 1.8% infected with Babesia microti

Coinfections were also identified:

• 1.8% carried both Borrelia burgdorferi and Anaplasma phagocytophilum
• 1.0% carried both Borrelia burgdorferi and Babesia microti
• 0.4% carried both Anaplasma phagocytophilum and Babesia microti
• 0.3% carried all three pathogens.

These findings remind clinicians that children with persistent symptoms following a tick bite may occasionally have more than one tick-borne infection. Coinfections may influence the clinical presentation and should be considered when symptoms are more severe than expected or fail to improve as anticipated.

Read more about tick bite prevention and pediatric coinfections.

Some children with Lyme arthritis undergo surgery

Tout and colleagues reviewed 149 children hospitalized with Lyme arthritis at a tertiary pediatric hospital in Pennsylvania.

The authors found:

• Approximately one-third of children underwent surgery.
• Two-thirds of surgical procedures were open operations.
• The remaining children underwent arthroscopic procedures.
• More than half ultimately required synovectomy.

Two children required readmission because of surgical complications. One experienced wound dehiscence, while another continued to have arthritis after initially receiving an inappropriate antibiotic. A third child required therapeutic arthrocentesis despite appropriate doxycycline treatment.

Although most children with Lyme arthritis recover with antibiotic therapy, these cases illustrate that delayed diagnosis or persistent joint inflammation may occasionally require orthopedic intervention.

Read more about Lyme arthritis and surgery in children.

Why Lyme disease in children is sometimes diagnosed late

Not every child with Lyme disease develops the classic bull’s-eye rash or recalls a tick bite. As a result, diagnosis may be delayed for months—or occasionally years—while symptoms are attributed to viral illnesses, sports injuries, anxiety, migraines, or other common childhood conditions.

Children with persistent fatigue, headaches, joint pain, abdominal pain, dizziness, declining school performance, or otherwise unexplained neurological symptoms deserve careful evaluation, particularly if they live in or have traveled to a Lyme-endemic region.

Parents should also pay attention to changes in behavior, reduced participation in sports or social activities, increasing school absences, or cognitive difficulties that seem out of proportion to a routine viral illness.

One important misconception is that a known tick bite is required before considering Lyme disease. In reality, many children never notice the bite because immature nymphal ticks are extremely small and their bites are typically painless.

Nigrovic and colleagues reported that fewer than one in five children with early Lyme disease recalled a tick bite. This finding highlights why clinicians should rely on the complete clinical picture rather than waiting for a remembered tick exposure.

Early recognition and appropriate treatment remain the best strategy for preventing complications and helping children return to normal school, sports, and daily activities.

Read more about why most children do not remember a tick bite.

Clinical perspective

In my practice, children with Lyme disease often present differently than adults. While many recover promptly with appropriate treatment, others come to my office after months of unexplained fatigue, headaches, dizziness, joint pain, cognitive difficulties, or declining school performance.

One of the biggest challenges is that many children never recall a tick bite and may not develop a recognized bull’s-eye rash. Instead, their symptoms are initially attributed to viral illnesses, growing pains, anxiety, migraines, concussion, attention-deficit disorders, or other common pediatric conditions.

When multiple symptoms involve different body systems—such as fatigue, headaches, dizziness, musculoskeletal pain, and cognitive changes—I encourage parents and clinicians to consider Lyme disease as part of the differential diagnosis, particularly in children who live in or have traveled to endemic areas.

Most children improve with timely diagnosis and appropriate antibiotic treatment. Maintaining a high index of suspicion can shorten the time to diagnosis, reduce unnecessary testing, and help children return to school, sports, and normal daily activities more quickly.

Frequently Asked Questions

What are the early symptoms of Lyme disease in children?

Early Lyme disease symptoms in children may include fatigue, fever, headache, muscle aches, joint pain, swollen lymph nodes, and an expanding erythema migrans (bull’s-eye) rash. However, not every child develops the classic rash, and many children never remember a tick bite.

Can Lyme disease affect learning and behavior?

Yes. Some children with Lyme disease experience cognitive symptoms such as poor concentration, memory problems, slowed processing speed, headaches, fatigue, mood changes, and declining school performance. These symptoms deserve careful medical evaluation, particularly in children living in Lyme-endemic areas.

Can toddlers get Lyme disease?

Yes. Lyme disease can occur in infants and toddlers, although diagnosis may be more difficult because young children cannot always describe their symptoms. Parents should seek medical evaluation if a child develops an expanding rash, facial weakness, unexplained fever, limping, or persistent fatigue after possible tick exposure.

Can Lyme disease in children be missed?

Yes. Lyme disease is sometimes mistaken for viral illnesses, growing pains, migraines, sports injuries, anxiety, or other common childhood conditions. Many children never recall a tick bite, making diagnosis more challenging.

Can Lyme disease affect school performance?

Some children with Lyme disease develop fatigue, headaches, attention problems, memory impairment, and slower cognitive processing that interfere with classroom learning. Temporary school accommodations may be appropriate during recovery.

When should a child see a Lyme disease specialist?

A child with persistent symptoms following a tick bite, an expanding rash, facial palsy, recurrent joint swelling, or unexplained neurological symptoms should be evaluated promptly. Referral to a clinician experienced in diagnosing and treating Lyme disease may be appropriate when the diagnosis remains uncertain or symptoms persist despite initial treatment.

Clinical Takeaway

Lyme disease in children may present with arthritis, neurological symptoms, fatigue, cognitive changes, psychiatric symptoms, or declining school performance. Many children never develop a recognized bull’s-eye rash or remember a tick bite, making diagnosis more challenging.

Published pediatric studies demonstrate that Lyme disease can affect infants, school-aged children, and adolescents with a wide spectrum of illness ranging from uncomplicated early infection to arthritis, facial palsy, cognitive dysfunction, and uncommon neurologic complications. Coinfections such as babesiosis should also be considered in selected patients following tick exposure.

Early recognition, careful clinical evaluation, and timely treatment remain the best strategies for helping children recover and return to healthy, active lives.

Related Articles

How Lyme Disease Can Affect School Performance
Lyme Arthritis vs. Juvenile Idiopathic Arthritis
Lyme Disease Symptoms Guide
Pediatric Lyme Disease Hub
Tick Bite Prevention for Children

References

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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