Lyme Disease Symptoms in Children: Behavior Changes and Early Signs
Symptoms may include physical, cognitive, and behavioral changes
Irritability or school difficulties may accompany a broader illness pattern
Recognizing evolving signs may support earlier diagnosis
Lyme disease symptoms in children may include an expanding rash, fever, fatigue, headaches, muscle or joint pain, facial palsy, and swelling of a large joint—particularly the knee. Some parents also report irritability, concentration problems, or other behavior changes as part of a broader pattern of illness.
Lyme disease does not present the same way in every child. Some children develop recognizable physical signs, while others initially have fatigue, headaches, pain, or changes in their usual activity and behavior.
Over the years in clinical practice, I have evaluated children and adolescents whose symptoms became more recognizable only as the illness evolved. Because many individual symptoms are nonspecific, exposure history, objective findings, and the pattern over time remain important.
Many of the younger patients I evaluate are adolescents whose symptoms fall somewhere between pediatric and adult patterns of Lyme disease. In these cases, the clinical picture may evolve gradually before the diagnosis becomes clear.
For a broader overview of diagnosis and treatment considerations, see Pediatric Lyme Disease.
Early Lyme Disease Symptoms in Children Can Be Subtle
Early Lyme disease symptoms in children may include an expanding erythema migrans rash, fever, fatigue, headache, muscle and joint aches, and swollen lymph nodes.1 Some children have mild symptoms that come and go, while others develop more noticeable signs as the illness progresses.
Parents sometimes describe a child who “just doesn’t seem like themselves.” The child may appear unusually tired, irritable, less active, or less able to concentrate at school. These changes are nonspecific and can occur with many illnesses, but they may warrant closer attention when accompanied by physical symptoms or possible tick exposure.
In toddlers, Lyme disease symptoms may be more difficult to recognize because young children cannot always describe headaches, pain, dizziness, or fatigue. Parents may instead notice irritability, sleep changes, reduced activity, limping, or reluctance to use an arm or leg.
For a more focused discussion, see Early Signs of Lyme Disease in Children.
Lyme Disease Rashes Can Be Misleading
Although erythema migrans is considered a hallmark sign of Lyme disease, it does not always appear as a classic bull’s-eye. The rash may be uniformly red, oval, irregularly shaped, or have darker or lighter areas. It typically expands gradually over several days.
In a case reported by Banadyha and colleagues, an 11-year-old girl developed several evolving rashes before a more recognizable erythema migrans lesion appeared.2 Her illness began with small rashes on the feet that temporarily resolved. Larger rashes later appeared on the trunk and limbs.
The changing appearance complicated the initial evaluation. This case illustrates why Lyme disease may not be suspected early when a rash has an atypical or evolving presentation.
For additional discussion of rash variability, see Erythema Migrans Rash Doesn’t Always Have a Bull’s-Eye Appearance.
Behavior Changes May Accompany Lyme Disease in Children
Behavioral, emotional, and cognitive changes have been described in some children with Lyme disease. Reported concerns include irritability, anxiety, emotional outbursts, difficulty concentrating, memory problems, sleep disturbances, and declining school performance.3 However, the available evidence is limited, and these symptoms are not specific for Lyme disease.
When these symptoms occur without recognizable physical findings, a child may initially be evaluated for an attention disorder, mood condition, learning problem, or another behavioral diagnosis.
Behavior changes alone should not be used to establish a Lyme disease diagnosis. However, they may be clinically relevant when they begin abruptly or occur alongside fatigue, headaches, pain, neurologic findings, an evolving rash, joint swelling, or a history of possible tick exposure.
For more on this topic, see Behavioral Changes in Children With Lyme Disease.
How Lyme Disease Symptoms May Affect School Performance
Fatigue, headaches, sleep disruption, pain, and difficulty concentrating may interfere with a child’s ability to attend school or complete academic work. Parents may notice falling grades, increased absences, difficulty finishing assignments, or a reduced ability to participate in activities.
These problems can be mistaken for a lack of motivation or an isolated learning or behavioral issue. The broader clinical pattern should be considered, particularly when school difficulties develop alongside new physical symptoms.
Joint Swelling May Bring Children to Medical Attention
Lyme arthritis typically develops later than the initial rash or flu-like illness. It often causes obvious swelling of one or a few large joints and most commonly affects the knee.4
A child with Lyme arthritis may appear otherwise well despite substantial swelling. Pain can vary, and some children continue walking even when the affected knee is visibly enlarged.
Earlier signs of Lyme disease may have been mild, overlooked, or absent. As a result, joint swelling may be the first manifestation that leads to medical evaluation.
Neurologic and Other Disseminated Symptoms
Untreated Lyme disease can spread beyond the skin and involve the nervous system, heart, or joints. Neurologic manifestations may include facial palsy, severe headache, neck stiffness, nerve pain, numbness, tingling, or inflammation involving the brain or spinal cord.1
Episodes of dizziness, shortness of breath, heart palpitations, or an irregular heartbeat may also occur when Lyme disease affects the heart. These symptoms warrant prompt medical evaluation.
Patterns That May Raise Suspicion for Lyme Disease
In clinical practice, certain evolving patterns may raise suspicion for Lyme disease in children. These can include:
- an expanding rash that changes over several days
- fatigue accompanied by headaches, muscle aches, or joint pain
- facial weakness or other new neurologic findings
- unexplained swelling of a large joint, particularly the knee
- behavioral or cognitive changes accompanied by physical symptoms
- new difficulty concentrating or participating at school
- limping or reluctance to use an arm or leg
- dizziness, lightheadedness, palpitations, or shortness of breath
Each of these findings can occur in many conditions. Lyme disease should not be diagnosed from a single nonspecific symptom. However, when several findings occur together or evolve over time, clinicians may reconsider Lyme disease as part of the differential diagnosis.
Atypical Presentations Can Lead to Misdiagnosis
Children sometimes present with findings that resemble other medical or behavioral conditions. When symptoms do not follow a familiar pattern, clinicians may initially consider more common explanations.
In one reported case, a 4-year-old boy with knee swelling, a wrist injury, and an unusual skin lesion was evaluated for possible child abuse.5 A mark initially interpreted as a bruise was subsequently recognized as an erythema migrans rash, and the child was diagnosed with Lyme disease.
This rare case does not lessen the importance of carefully investigating possible child abuse. It illustrates the need to consider medical conditions in the differential diagnosis when a child has unexplained joint swelling, skin findings, or mobility problems.
Recognizing Lyme Disease Patterns Over Time
Lyme disease symptoms in children do not follow a single pattern. Some children develop an expanding rash or fever early in the illness. Others present later with facial palsy, joint swelling, neurologic symptoms, or a combination of physical and behavioral changes.
In some cases, the diagnosis becomes clearer only when the sequence of symptoms is considered rather than focusing on a single complaint. Careful follow-up can be especially important when symptoms evolve or new objective findings appear.
Not every child develops the same manifestations, which is one reason Lyme disease can be difficult to recognize early.
For a broader overview, see the Lyme Disease Symptoms Guide.
Frequently Asked Questions
Can Lyme disease cause behavior changes in children?
Some children with Lyme disease may develop irritability, anxiety, emotional outbursts, concentration problems, mood changes, or declining school performance as part of a broader illness pattern. These symptoms are nonspecific and should be evaluated alongside physical findings, exposure history, and other possible causes.
What are the early symptoms of Lyme disease in children?
Early symptoms may include an expanding erythema migrans rash, fever, fatigue, headache, muscle or joint aches, and swollen lymph nodes. Other manifestations, including facial palsy or joint swelling, may develop as the infection progresses.
Do all children with Lyme disease develop a bull’s-eye rash?
No. Erythema migrans does not always resemble a classic bull’s-eye. It may appear uniformly red, oval, irregular, or otherwise atypical, and the rash may not be noticed.
Can Lyme disease affect school performance?
Some children experience fatigue, headaches, pain, sleep problems, or difficulty concentrating that may interfere with attendance, classroom participation, and academic performance.
What are signs of Lyme disease in toddlers?
Possible signs include an expanding rash, fever, fatigue, irritability, reduced activity, limping, joint swelling, or reluctance to use an arm or leg. Because these findings can have many causes, a toddler with new or concerning symptoms should receive an appropriate medical evaluation.
Clinical Takeaway
Lyme disease symptoms in children may appear at different stages and can involve the skin, joints, nervous system, heart, mood, cognition, and school functioning. Behavioral changes are nonspecific, but they may provide an additional clue when they appear alongside physical symptoms or possible tick exposure.
Careful follow-up and attention to evolving findings may help clinicians recognize Lyme disease when the diagnosis is not immediately apparent.
Considering the complete pattern over time may be one of the most important steps in recognizing Lyme disease in children.
Related Articles
Why Lyme Disease Is Often Misdiagnosed
Lyme Disease Test Accuracy
Why Lyme Tests Can Miss the Diagnosis
References
- Centers for Disease Control and Prevention. Signs and symptoms of untreated Lyme disease. CDC. Updated May 15, 2024.
- Banadyha N, Rogalskyy I, Komorovsky R. Giant erythema in a child with Lyme disease. Infection and Drug Resistance. 2024;17:4343-4348.
- Rhee H, Cameron DJ. Lyme disease and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): An overview. International Journal of General Medicine. 2012;5:163-174.
- Centers for Disease Control and Prevention. Clinical care and treatment of Lyme arthritis. CDC. Updated May 15, 2024.
- Pan T, Nasreddine A, Trivellas M, Hennrikus WL. Lyme disease misinterpreted as child abuse. Case Reports in Orthopedics. 2021;2021:6665935.
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
