Introduction

Lyme disease is a bacterial infection caused by the bacterium Borrelia burgdorferi.¹ The infection occurs when an infected tick bites a human.² Ticks exist in various outdoor areas but are very common in grassy woodland areas. They are present throughout all seasons, however, they are most active between April and July. Consequently, people taking part in outdoor activities such as cycling, hiking or camping have a higher risk of exposure to ticks.³ 

With children spending more time outdoors in the summer months, parents may become concerned about their child's risk of exposure to ticks. Early treatment and diagnosis are important to prevent the disease from progressing to more severe manifestations. With effective and early treatment, children generally make a full recovery.⁴ We need to remember that not all ticks are infected with the bacteria, so you won’t necessarily get Lyme disease if you are bitten by one. However, it is important to understand how to safely remove ticks and to know what signs and symptoms to look out for. 

Symptoms of lyme disease in children

If a child has been bitten by an infected tick, their symptoms may confuse parents/carers, as they are non-specific. Symptoms may appear days or months after your child has been bitten by a tick.⁵ The symptoms of Lyme disease may be categorised into two stages; early symptoms and later symptoms. 

Early symptoms

In the first few weeks after the tick bite, your child may appear to have:

• Erythema migrans - 70-80% of people with Lyme disease present with this symptom. Erythema migrans is a circular or ring-shaped area of red and damaged skin which has a characteristic bulls-eye appearance. The area of affected skin may vary in colour and size, and can often mimic other skin conditions - making it difficult to diagnose. Some people may experience itching, whereas others don’t feel anything at all. Erythema migrans can last for up to a few weeks before disappearing
• Flu-like symptoms such as:^4,5
  • Fever
  • Headache
  • Fatigue
  • Muscle ache
  • Joint pain
  • Swollen lymph nodes

Late symptoms

If left untreated the infection can spread, which may result in severe symptoms. These include:⁵

• Severe headaches and neck stiffness
• Additional erythema migrans or bulls-eye-like rashes on other parts of the body
• Joint pain and swelling in the knees 
• Bell’s palsy - a neurological condition that causes the face to droop
• Nerve pain
• Short-term memory problems.
• Lyme carditis - which can cause heart palpitations or an irregular heartbeat

Diagnosis of lyme disease in children

The diagnosis of Lyme disease can sometimes be tricky due to its symptoms being quite similar to other conditions. A detailed medical history and a thorough physical examination is usually common practice in the early stages of the disease. The assessment is mainly focused on the child’s risk of exposure to ticks and the presence of erythema migrans (the bulls-eye skin rash). 

Testing for lyme disease

Doctors may order blood tests if they suspect a patient has Lyme disease. These blood tests look for the antibodies that the body produces to target and fight off Borrelia burgdorferi. An ELISA (Enzyme-linked Immunosorbent Assay) test may also be used to detect any antibodies against Borrelia burgdorferi. However, blood tests are usually most effective - but only two to six weeks after the tick bite (as this is how long it takes the body to produce detectable quantities of antibodies). A western blot test can be considered to confirm the presence of antibodies.^5,6

Differential diagnosis of lyme disease

Common causes of skin rashes that may be mistaken for erythema migrans include:⁷

• Insect bites
• Cellulitis
• Ringworm
• Granuloma annulare
• Erythema multiforme
• Nummular eczema

Neurological Lyme disease refers to when the bacteria infects the peripheral and central nervous system. Neurological Lyme disease may mimic other neurological conditions such as:

• Tumours
• Multiple sclerosis
• Motor neuron disease

If neurological Lyme disease is suspected, the cerebrospinal fluid must be tested for antibodies to Borrelia burgdorferi. 

Other conditions to consider during differential diagnosis of Lyme disease include:

• CMV (Cytomegalovirus)
• EMV (Epigone migraine vertigo)
• Hepatitis
• HIV
• Tumours
• Encephalitis
• Arthritis
• Heart disease

Treatment of lyme disease in children

Treatment of Lyme disease depends on whether the disease is in its early stages, or whether it has progressed to the late stages where the symptoms are more severe. Early and accurate treatment of Lyme disease is essential in preventing progression to the later stages. Given that the patient follows and completes the treatment prescribed, they generally are expected to have a full recovery.

Oral antibiotics are commonly used in treating Lyme disease. These are generally prescribed as part of a 10-14 day course. These include:

• Doxycycline
• Amoxicillin
• Cefuroxime

Lyme disease should typically clear up after treatment with antibiotics. However, if the disease persists, a second course of antibiotics may be necessary. Children with neurological Lyme disease or Lyme carditis may require IV antibiotics. They will also require monitoring and follow-up appointments.

Symptoms may take several months or even years for some people to subside. For some people symptoms may persist. They are described as being similar to chronic fatigue syndrome or fibromyalgia. There is no agreed treatment for chronic symptoms. Patients must be assessed by specialists or doctors to determine the best way to manage their symptoms.

Blood tests cannot be used to assess the child’s response to treatment. This is because the body will continue to produce antibodies to protect against Lyme disease, long after treatment. This does not mean that your child is still infected.^2,5

If you are concerned about your child’s symptoms or you feel that they have come back, contact your doctor for support. 

Prevention and awareness

Whilst there is no vaccination offering immunity against Lyme disease, it is possible to avoid tick bites by taking precautionary measures. Here are some tips to help protect your family:

• Walk on paths and pavements and avoid walking through grassy areas as ticks are drawn to low-level shrubs and grass
• When you are outdoors, wear protective clothing such as hats, tops with long sleeves and long pants. This is particularly important when walking through wooded, grassy areas.
• Use a child-friendly insect repellent on your child’s clothes and skin. Insect repellents containing DEET are best, as they are effective against ticks
  • Be careful when using products containing DEET - do not apply to children’s hands, around the eyes or the mouth. DEET is toxic if swallowed, so ensure that your child does not inhale or ingest the product
• Encourage your child to take a shower when coming inside. This will help to wash away any unattached ticks

Regularly and thoroughly check your child’s body for ticks. This is particularly important if you live in an area where ticks or cases of Lyme disease are common. Common areas of the body to check for ticks include:

• Part of the body that you can bend, such as underarms, behind the knees, groin, and between fingers and toes
• The belly button, ears, neck, hairline, armpits and scalp
• Areas where clothing pressures the skin, for example, the waistband

How to safely remove ticks

It’s best to remove any ticks attached to the body as soon as possible. The safest way to do this would be to:

• Use a tick removal tool or a fine-tipped tweezer. Grasp the tick close to the skin by either the head or mouth and carefully pull upwards and outwards
• Dispose of the tick and clean the area. It is best to wash the area with antiseptic soap and water. You can also apply an antiseptic lotion

This does not mean that your child will get Lyme disease, however, keep checking for a rash or any symptoms that may indicate Lyme disease.^2,4,5

Summary

Lyme disease is a condition caused by the bacterium Borrelia burgdorferi and may occur in children after being bitten by an infected tick. People are at a higher risk of exposure when they are outdoors and/or in woodland and grassy areas. Symptoms of Lyme disease can appear within weeks or even months of a tick bite. Because the symptoms of Lyme disease may mimic flu-like symptoms, it is important to take a detailed medical history and conduct a thorough physical examination. The characteristic symptom of Lyme disease is erythema migrans, which is a bulls-eye or target-like rash on the skin.  

When diagnosed and treated early, we can prevent the progression of Lyme disease to more serious conditions such as neurological Lyme disease or Lyme carditis. Some patients have described chronic symptoms of Lyme disease, which have been described as being similar to chronic fatigue syndrome or fibromyalgia. Treatment includes a course of antibiotics and for those whose symptoms persist, a course of IV antibiotics may be given. You can take precautionary measures, such as ensuring your children wear appropriate, protective clothing and use insect repellent, to decrease your child’s risk of tick bites and Lyme disease. 

Going forward, research into a vaccination for Lyme disease could be very useful in preventing Lyme disease cases. Additionally, further research into chronic Lyme disease is needed to fully understand why some patients experience persistent symptoms. Combined with educational programmes in schools, these measures could be very useful in making children and adults aware of the risks of tick exposure when outdoors - particularly in areas where tick exposure or Lyme disease is common.