POTS in Children With Lyme Disease: A Hidden Autonomic Disorder
Pediatric autonomic dysfunction can be overlooked
POTS has been reported following Lyme disease
Symptoms may interfere with school and daily function
POTS in children with Lyme disease may involve dizziness when standing, a rapid heart rate, fatigue, brain fog, and exercise intolerance. However, research specifically examining Lyme disease and POTS in children remains limited.
These symptoms may be attributed to anxiety, behavioral problems, school avoidance, or deconditioning before an underlying physiologic problem is identified.
A child may complain of dizziness when standing, experience a racing heart during gym class, feel exhausted after a shower, struggle to concentrate in school, or need to lie down after routine activity.
When symptoms consistently worsen while upright and improve with sitting or lying down, POTS or another form of orthostatic intolerance may warrant consideration.
This pattern may fit within the broader spectrum of POTS in Lyme disease. It also reflects the diagnostic challenges surrounding pediatric Lyme disease, in which children may have difficulty describing complex or fluctuating symptoms.
What Is POTS in Children?
POTS, or postural orthostatic tachycardia syndrome, is a form of autonomic dysfunction characterized by chronic orthostatic symptoms and an excessive increase in heart rate after standing.
For adolescents ages 12 through 19, commonly used diagnostic criteria include a sustained heart rate increase of at least 40 beats per minute within 10 minutes of standing, without orthostatic hypotension. Symptoms generally must persist for at least three months, and other conditions that could explain the tachycardia must be excluded.3
A heart rate increase alone is not sufficient to diagnose POTS. The child must also have symptoms associated with being upright, and clinicians should evaluate potential alternative explanations.
POTS Symptoms in Children With Lyme Disease
Children do not always describe orthostatic symptoms clearly. Instead, they may report vague, intermittent, or seemingly unrelated complaints such as:
- Lightheadedness or feeling faint
- Rapid heartbeat or palpitations
- Fatigue and exercise intolerance
- Headaches
- Nausea or abdominal discomfort
- Blurred vision
- Weakness or shakiness
- Difficulty concentrating or brain fog
Symptoms often become more noticeable during prolonged standing, hot weather, showers, sports, dehydration, illness, or periods of inadequate sleep.
Can Lyme Disease Cause POTS in Children?
POTS has been reported following Lyme disease, but the evidence is limited. In a 2011 case series, Kanjwal and colleagues described five patients who developed symptoms consistent with POTS after treated Lyme disease.1 The report involved adults and did not establish how often this occurs or prove that Lyme disease directly caused POTS.
A 2024 review discussed dysautonomia as a possible contributor to persistent symptoms following Lyme disease. The authors emphasized that research remains scarce and that dysautonomia has not yet been firmly established as a complication of Lyme disease in the medical literature.2
Proposed mechanisms include infection-associated inflammation, immune changes, small-fiber nerve involvement, and impaired regulation of blood flow. These mechanisms remain under investigation, particularly in children.
Therefore, an association may be considered in an individual child, but Lyme disease should not automatically be assumed to be the cause of every case of POTS, dizziness, or tachycardia.
Orthostatic Symptoms Parents May Notice
Parents may recognize an upright pattern before a child can explain it. A child may feel worse while standing in line, walking between classrooms, participating in sports, shopping, or taking a hot shower.
Other clues may include:
- Needing to sit or lie down during ordinary activities
- Feeling better after returning to a horizontal position
- Difficulty getting ready in the morning
- Worsening symptoms after standing still
- Exhaustion after a full school day
- A racing heart after minor physical activity
These observations can help clinicians determine whether symptoms follow an orthostatic pattern rather than occurring randomly.
Looking Beyond POTS: Other Forms of Autonomic Dysfunction
POTS is only one form of dysautonomia. Some children experience significant orthostatic symptoms without meeting formal POTS criteria.
Other possible autonomic problems include:
- Orthostatic intolerance without the required heart rate increase
- Orthostatic hypotension
- Neurally mediated hypotension
- Vasovagal syncope
- Temperature regulation problems
- Sweating abnormalities
- Gastrointestinal dysmotility
- Possible autonomic or small-fiber neuropathy
A child may therefore have dizziness, heat intolerance, gastrointestinal symptoms, exercise intolerance, cognitive slowing, or sweating changes without having classic POTS.
Focusing exclusively on POTS could cause other contributors to a child’s symptoms to be overlooked.
School Performance and Daily Function Can Be Affected
POTS and other forms of orthostatic intolerance can interfere with school attendance, concentration, physical education, and participation in ordinary activities.
A child may struggle with prolonged standing, walking between classrooms, climbing stairs, carrying books, participating in sports, or remaining alert through a full school day.
Brain fog may become worse after standing for an extended period or trying to push through fatigue. The child may need additional time, rest periods, access to fluids, or other individualized school accommodations.
These limitations should not automatically be interpreted as anxiety, poor motivation, behavioral problems, or school avoidance.
Why POTS Symptoms May Fluctuate
One of the most confusing features of pediatric autonomic dysfunction is that symptoms may vary from day to day.
Symptoms can worsen with dehydration, heat, infection, inadequate sleep, emotional stress, rapid growth, prolonged inactivity, or overexertion. A child may appear relatively well on one day but be unable to tolerate the same activities on another.
Recognizing this fluctuating pattern can help families and schools understand that inconsistent function does not necessarily mean the symptoms are voluntary.
Evaluating POTS Symptoms in Children With Lyme Disease
Evaluation typically begins with a careful history of symptoms, including whether they worsen while standing and improve when sitting or lying down.
Heart rate and blood pressure may be measured after the child has rested lying down and again during up to 10 minutes of standing. Some children undergo formal tilt-table testing or evaluation by a clinician experienced in pediatric autonomic disorders.
The evaluation should also consider other possible causes of dizziness or tachycardia, including:
- Dehydration
- Anemia or iron deficiency
- Thyroid disease
- Medication effects
- Cardiac rhythm abnormalities
- Prolonged bed rest or deconditioning
- Other infections or inflammatory conditions
- Sleep disruption
- Nutritional deficiencies
Chest pain, fainting during exercise, severe shortness of breath, or a sustained abnormal heart rhythm require prompt medical evaluation.
The goal is not simply to attach a POTS label to the child. It is to identify the physiologic pattern, exclude other explanations, and understand how the symptoms affect daily function.
Management Considerations
Management depends on the child’s symptoms, examination, underlying conditions, and tolerance of activity.
Strategies may include adequate hydration, increased dietary salt when medically appropriate, compression garments, sleep optimization, avoiding prolonged standing, pacing daily activity, and a carefully structured physical-conditioning program.
Salt supplementation or major changes in fluid intake should be discussed with the child’s clinician, particularly when kidney disease, high blood pressure, heart disease, or another medical condition is present.
Some children require medication when nonpharmacologic strategies are insufficient. Medication choices should be individualized and supervised by a clinician familiar with pediatric POTS or autonomic disorders.
When Lyme disease and autonomic symptoms occur together, each problem requires an appropriate evaluation. Identifying POTS does not by itself establish whether infection remains active, and additional antibiotic treatment should not be based on an elevated standing heart rate alone.
For a broader discussion, see the overview of autonomic dysfunction in Lyme disease.
Frequently Asked Questions
Can Lyme disease cause POTS in children?
POTS has been reported following Lyme disease, but pediatric-specific evidence is limited. Lyme disease may be considered as one possible contributor when symptoms begin during or after the infection, but an association does not prove direct causation.
What are common POTS symptoms in children with Lyme disease?
Symptoms may include dizziness when standing, a rapid heartbeat, fatigue, headaches, nausea, weakness, exercise intolerance, blurred vision, and brain fog.
How is POTS diagnosed in children?
Diagnosis requires chronic orthostatic symptoms together with an excessive, sustained heart rate increase after standing and the exclusion of other causes. For adolescents ages 12 through 19, the commonly used heart rate threshold is an increase of at least 40 beats per minute within 10 minutes.
Can Lyme disease cause dizziness and brain fog in children?
Children with Lyme disease may experience dizziness, fatigue, and cognitive symptoms for several possible reasons. When these symptoms consistently worsen while upright, POTS or another form of orthostatic intolerance may be considered.
Can POTS symptoms be mistaken for anxiety?
Yes. A racing heart, shakiness, nausea, dizziness, and difficulty concentrating can resemble anxiety. Anxiety and POTS can also occur together, so the presence of anxiety should not prevent an appropriate evaluation of orthostatic symptoms.
Does every child with Lyme disease and dizziness have POTS?
No. Dizziness can have many causes, and some children have orthostatic intolerance or another autonomic disorder without meeting formal POTS criteria.
Clinical Takeaway
POTS and other forms of autonomic dysfunction may be overlooked in children with Lyme disease, particularly when symptoms fluctuate or resemble anxiety, deconditioning, or behavioral difficulties.
The published evidence linking Lyme disease to POTS remains limited, and research specifically involving children is especially sparse. Clinicians should therefore consider the possible association without assuming that Lyme disease is responsible for every case of pediatric orthostatic intolerance.
When dizziness, fatigue, rapid heart rate, and brain fog consistently worsen with standing, an evaluation for POTS and other causes of autonomic dysfunction may be appropriate.
Related Articles
Lyme disease dizziness and foggy feeling
Exercise intolerance in Lyme disease
Persistent Lyme disease symptoms
Why Lyme symptoms come and go
References
- Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Postural orthostatic tachycardia syndrome following Lyme disease. Cardiol J. 2011;18(1):63-66.
- Adler BL, Chung T, Rowe PC, Aucott JN. Dysautonomia following Lyme disease: a key component of post-treatment Lyme disease syndrome? Front Neurol. 2024;15:1344862.
- Boris JR, Bernadzikowski T. Pediatric postural orthostatic tachycardia syndrome. Pediatrics. 2022;150(1):e2021054945.
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
