Lyme Disease in Children: Symptoms, Early Signs, Diagnosis, and Long-Term Effects
Lyme disease in children may be difficult to recognize
A tick bite or bullseye rash is often not remembered
Early diagnosis may reduce the risk of complications
Lyme disease in children can be difficult to recognize. Some children develop an expanding erythema migrans rash, fever, headache, or joint swelling. Others never develop a recognized rash and instead experience fatigue, leg pain, facial weakness, sleep disruption, behavior changes, or difficulty concentrating.
A child may not remember being bitten by a tick, and parents may never see an attached tick. The absence of a known tick bite or classic bullseye rash does not automatically exclude Lyme disease when compatible symptoms are present.
Recognizing the symptoms of Lyme disease is particularly important in children because younger patients may have difficulty describing pain, dizziness, fatigue, or cognitive changes.
Why Lyme Disease in Children May Be Missed
Children with Lyme disease may cycle through several providers before receiving a diagnosis. Symptoms such as headaches, leg pain, irritability, fatigue, school refusal, or poor concentration may initially be attributed to a viral illness, behavioral problems, puberty, anxiety, or school stress.
Diagnosis may be especially challenging when a child does not have an obvious rash or known tick bite. In a 2026 study of 190 children with Lyme neuroborreliosis, only 43.2% had a recognized tick bite and only 17.4% had a history of erythema migrans.
Blood testing can also be negative early in the illness because antibodies may not yet be detectable. This is one reason Lyme disease remains a clinical diagnosis, particularly during the first few weeks of illness when antibodies may not yet be detectable. When symptoms and exposure are consistent with Lyme disease, the timing of testing should be considered when interpreting a negative result. Parents can learn more about why early Lyme disease tests may be negative.
Early Symptoms of Lyme Disease in Children
Early signs of Lyme disease in children vary. Symptoms may include:
- Expanding red rash or erythema migrans
- Fever or chills
- Fatigue
- Headache
- Neck discomfort
- Muscle or joint pain
- Swollen lymph nodes
- Irritability or behavior changes
- Difficulty sleeping
- Reduced attention or concentration
The Lyme disease rash does not always form a perfect bullseye. It may appear uniformly red, oval, irregular, or partly hidden beneath the hair, behind an ear, or in another difficult-to-see location.
Lyme Disease Symptoms in Toddlers
Toddlers and young children may not be able to describe headaches, fatigue, numbness, muscle pain, or dizziness. Parents may instead notice a change in behavior or activity.
Possible signs of Lyme disease in toddlers include:
- Unusual irritability or persistent crying
- Excessive sleepiness or reduced activity
- Poor appetite
- Limping or refusing to walk
- Holding or protecting an arm or leg
- Loss of interest in normal play
- New sleep problems
- Facial weakness or an uneven smile
A limp or refusal to walk can have many causes. However, Lyme arthritis should be considered when a child develops unexplained swelling or limited movement of a large joint, particularly the knee. Read more about Lyme disease and limping in children.
Neurologic Lyme Disease in Children
Lyme disease can affect the peripheral or central nervous system. Neurologic symptoms may include facial palsy, headache, meningitis, nerve pain, light sensitivity, sound sensitivity, cognitive changes, or changes in behavior.
In a 2026 study of 190 children with Lyme neuroborreliosis, meningitis was the most common presentation, occurring in 60.5%. Isolated cranial neuropathy occurred in 28.9%, and meningoradiculitis occurred in 7.9%.
Facial palsy was documented in 71.6% of the children. Headache, fatigue, meningitis, and facial palsy remain among the most common neurologic manifestations of pediatric Lyme disease. Fatigue was reported in 31.7%, while changes in behavior or personality were documented in 16.3%. Rare, severe neurologic manifestations included myelitis and cerebral vasculitis.
Children with isolated cranial neuropathy had less cerebrospinal fluid inflammation, weaker responses on several Borrelia burgdorferi-specific tests, and a shorter duration of symptoms after treatment than children with meningitis or meningoradiculitis. These findings suggest that laboratory results may vary according to the location and extent of neurologic involvement.
Facial weakness in a child living in or returning from a Lyme-endemic area should prompt consideration of Lyme disease. Learn more about Lyme disease and facial palsy in children.
Behavior and Cognitive Changes
Some children with Lyme disease develop changes that are first noticed at home or school. These may include:
- Difficulty concentrating
- Poor short-term memory
- Reduced school performance
- Irritability
- Emotional outbursts
- New anxiety
- Sleep disturbances
- Withdrawal from normal activities
These symptoms often fluctuate and may be mistaken for attention-deficit disorder, anxiety, depression, or school-related stress. They are not specific to Lyme disease and may have many possible explanations. Their significance depends on the child’s full clinical history, physical findings, possible tick exposure, and other symptoms.
When Lyme Disease Resembles PANS or PANDAS
Pediatric acute-onset neuropsychiatric syndrome, or PANS, is characterized by the abrupt onset of obsessive-compulsive symptoms or severe food restriction accompanied by other sudden neuropsychiatric changes.
Some infections and inflammatory conditions have been investigated as possible triggers. Lyme disease and other tick-borne infections have been reported in some children evaluated for PANS, but the relationship remains an area of ongoing research.
Lyme disease should not be assumed to explain every case of sudden anxiety, tics, obsessive behavior, rage, or food restriction. Children with abrupt neuropsychiatric symptoms require a careful medical and psychiatric evaluation to consider infectious, neurologic, autoimmune, metabolic, and other potential causes.
Learn more about the proposed relationship between Lyme disease, PANS, and PANDAS.
Can Symptoms Persist After Treatment?
Most children improve following appropriate antibiotic treatment, but recovery is not always immediate.
In a study of 102 children with confirmed Lyme disease, most experienced complete symptom resolution. However, 22% had at least one symptom lasting longer than six months. This included 13% with persistent symptoms without functional impairment and 9% with symptoms accompanied by functional impairment.
Children with functional impairment were more likely to have significant fatigue and lower parent-reported physical quality-of-life scores. The investigators also reported that most children ultimately recovered, including children who had initially met the study definition of post-treatment Lyme disease syndrome.
A separate observational case series published in 2026 described 101 children with more than five symptoms lasting longer than six months. A history of a tick bite or rash was documented in 40%, and the author reported improvement or resolution in most children during extended antibiotic treatment.
Because that study did not include an untreated or placebo comparison group, it cannot establish whether persistent infection was responsible for the symptoms or whether extended treatment was more effective than shorter treatment. Its findings should therefore be interpreted as observational.
Why Early Recognition Matters
Children’s brains, bodies, educational skills, and social development are still changing. Prolonged illness may interfere with sleep, physical activity, school attendance, learning, emotional regulation, and participation in family or social activities.
Early recognition and treatment can reduce the risk of disseminated manifestations. However, treatment decisions should be individualized according to the child’s clinical presentation, stage of illness, examination findings, testing, and response to care.
Children with persistent or complex symptoms may require evaluation of neurologic, rheumatologic, developmental, psychiatric, sleep-related, and other possible contributors. Multidisciplinary care does not mean that symptoms are psychological. It allows clinicians to evaluate several potential mechanisms while supporting the child’s function and recovery.
Prevention and Awareness
Reducing tick exposure remains an important part of protecting children from Lyme disease. Preventive steps include:
- Using an appropriate tick repellent
- Wearing protective clothing in wooded or grassy areas
- Performing daily tick checks after outdoor activities
- Checking the scalp, hairline, ears, waist, groin, armpits, and behind the knees
- Showering after outdoor activity
- Removing attached ticks promptly and correctly
- Checking outdoor clothing, backpacks, pets, and sports equipment
Daily tick checks remain one of the most effective ways to reduce the risk of Lyme disease in children. Because ticks can be extremely small, a careful inspection is important even when a child has only been playing in a yard, park, sports field, or wooded edge.
Frequently Asked Questions
Can children get Lyme disease?
Yes. Children can develop Lyme disease after being bitten by an infected blacklegged tick. School-age children have among the highest reported rates because they often spend time playing outdoors in wooded, grassy, or brush-filled areas.
What are the early signs of Lyme disease in children?
Early signs may include an expanding rash, fever, fatigue, headache, muscle pain, joint pain, swollen lymph nodes, irritability, or changes in sleep and activity. Not every child develops a recognized rash.
Can children get Lyme disease without a rash?
Yes. Many children with Lyme disease never develop a recognized erythema migrans rash. Diagnosis may instead depend on symptoms, physical examination, possible tick exposure, and appropriate laboratory testing.
What are the symptoms of Lyme disease in toddlers?
Toddlers may become unusually irritable, sleepy, inactive, or reluctant to walk. Parents may notice poor appetite, persistent crying, limping, joint swelling, facial weakness, or a loss of interest in normal play.
Can Lyme disease cause behavior changes in children?
Behavior or personality changes have been reported in some children with neurologic Lyme disease. However, irritability, anxiety, poor concentration, and emotional changes are not specific to Lyme disease and require evaluation for other possible causes.
Can Lyme disease cause tics in children?
Tics have been reported in some children evaluated for Lyme disease or PANS, but a direct causal relationship has not been established. New tics should be assessed in the context of the child’s full neurologic, developmental, infectious, and psychiatric history.
Can Lyme disease stunt a child’s growth?
There is not strong evidence that Lyme disease directly stunts growth. However, prolonged illness may affect appetite, sleep, physical activity, school participation, and overall development until the illness and any contributing conditions are appropriately addressed.
Can a Lyme disease test be negative in a child?
Yes. Antibody tests may be negative during the early stage of infection before the immune response has become detectable. Testing results should be interpreted according to the timing of symptoms, possible exposure, clinical findings, and the type of Lyme disease being considered.
Do most children recover from Lyme disease?
Most children improve and recover after appropriate treatment. Some experience symptoms that take weeks or months to resolve, and a smaller group reports symptoms lasting longer than six months.
Clinical Takeaway
Lyme disease in children may present with a rash, fever, joint symptoms, facial palsy, headache, fatigue, behavior changes, or cognitive difficulties. A recognized tick bite or bullseye rash is frequently absent, and antibody testing may be negative early in the illness.
Most children recover after appropriate treatment, although some experience symptoms that persist for weeks or months and temporarily affect daily function.
Lyme disease should remain part of the differential diagnosis when a child develops compatible symptoms after possible tick exposure, even when no tick bite or classic rash was observed.
Related Articles
Explore these related topics for additional information on pediatric Lyme disease, diagnosis, neurologic complications, and recovery.
Pediatric Lyme disease overview
Lyme disease misdiagnosis
Lyme arthritis symptoms and diagnosis
Post-treatment Lyme disease syndrome
Persistent Lyme disease overview
References
- Monaghan M, Norman S, Gierdalski M, et al. Pediatric Lyme disease: systematic assessment of post-treatment symptoms and quality of life. Pediatr Res. 2024;95(1):174-181.
- Donta ST. Persisting Lyme disease in the pediatric population. Clin Pediatr (Phila). 2026;65(1):70-75.
- Sidorov S, Greiter BM, Osuna E, et al. Distinct clinico-pathogenic subgroups in pediatric Lyme neuroborreliosis. Open Forum Infect Dis. 2026;13(2):ofaf812.
- National Institute of Mental Health. PANS and PANDAS: Questions and Answers.
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
