A 9-month-old female came to clinic for her health supervision visit.
The mother had just been diagnosed with Lyme disease after having fatigue, mild headache, muscle aches, and joint aches that were initially attributed to being a new mother. She did not remember having a rash.
She had been started on antibiotics a few days ago, and wanted to know if she could pass the infection to her daughter because she was breastfeeding.
The child herself did not have a history of a tick bite or rash, but did have a couple of colds in the past. She was doing well per her mother.
The pertinent physical exam showed a smiling, interactive female. Growth parameters were between 5th and 25th percentiles, and her examination was normal.
The diagnosis of a healthy infant was made. The physician reviewed Lyme disease in the American Academy of Pediatrics RedBook Online® which said that Lyme disease is not transmitted by breast milk.
The mother was reassured with this information.
Lyme disease, also referred to as Lyme borreliosis, is caused by the spirochete Borrelia burgdorferi. It is spread by the tick Ixodes scapularis which is about the size of a pencil point.
In the United States it occurs mainly in the New England states, upper Midwest especially in Wisconsin and Minnesota, and in northern California. Cases occur during warm months (April-October) with ~ 50% of the cases occurring in June and July.
All ages can be affected but incidence is highest in 5-9 year olds and 45-54 year olds.
For children, the most common symptoms are erythema migrans, arthritis, facial nerve palsy, aseptic meningitis, and carditis. Symptoms depend on the timing though.
Early localized disease
- Erythema migrans at site of lesion – red macule or papule that appears to migrate over time forming a painless, non-pruritic, annular, erythematous lesion sometimes with central clearing.
The spreading occurs over days to weeks. This can appear 1-55 days after the tick bite, with a median of 11 days.
- Lymphadenopathy, regional
- Neck stiffness, mild
Doxycycline 100 mg orally, twice a day for 14-21 days is recommended for all children 8 years or older. Alternatively for all ages, Amoxicillin 50 mg/kg/day orally, divided three times per day for 14-21 days (maximum dose is 1.5 g/day)
or Cefuroxime 30 mg/kg/day orally, divided twice per day for 14-21 days (maximum dose 1000 mg/day) or Cefuroxime 1.0 g/day orally for 14-21 days.
- Erythema migrans, multiple lesions
- Cranial nerve palsies, especially cranial nerve VII
- Lymphadenopathy, regional
- Meningitis, aseptic
In untreated children, 50% will develop arthritis, 10% will develop central nervous system involvement, and 5% will develop cardiac involvement.
Recommended treatment depends on symptomatology:
- For multiple erythema migrans, follow early localized disease treatment for 21 days
- For Isolated facial palsy follow early localized disease treatment for 21-28 days
- For arthritis, follow early localized disease treatment for 28 days
- For arthritis that is persistent or recurrent, Ceftriaxone sodium 75-100 mg/kg intravenously or intramuscularly, once per day for 14-28 days (maximum dose 2 g/day)
or Penicillin 300,000 Units/kg/day intravenously, given in divided doses every 4 hours for 14-28 days (maximum 20 million Units/day)
or same regimen as early localized disease
- For carditis, follow persistent or recurrent arthritis treatment
- For encephalitis or meningitis, follow persistent or recurrent arthritis treatment for 14-28 days
- Arthritis, particularly large joints and is recurrent
- Peripheral neuropathy
Early disseminated disease
Late disease – can occur months to years later
Treatment usually prevents development of later stages but successfully treated patients may have persistent symptoms for weeks.
The diagnosis is made by history and physical examination, particularly the characteristic erythema migrans rash.
A step-wise approach to laboratory testing is recommended. The first step is screening by an enzyme immunoassay or immunofluorescent antibody assay. Positive or equivocal results should then be confirmed by Western immunoblot for IgG and IgM if confirming early disease and for IgG for late disease.
Other testing can be done but can be complex or is not necessarily better than the step-wise approach.
The risk of developing Lyme disease after a tick bite even in an endemic area is low enough that prophylactic antibiotics are not indicated for most people.
Some experts recommend treatment after 72 hours of suspected attachment to the skin by the tick using Doxycycline 200 mg orally once or 4.4 mg/kg for body weight <45 kg in people older than 12 years of age. A vaccine was licensed by the FDA from 1998-2002, but is not currently available.
Lyme disease is not transmitted by breast milk. The American Academy of Pediatrics RedBook® states that no causal relationship between maternal Lyme disease and pregnancy complications or congenital abnormalities has been conclusively documented.
Questions for Further Discussion
1. What are other tick-borne diseases?
2. Why is it called Lyme Disease?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
Foy AJ. Diagnosis of lyme disease. Am Fam Physician. 2005;72(2):297-304. Available from the Internet at http://www.aafp.org/afp/20050715/297.html (rev. 7/15/2006, cited 3/8/07).
American Academy of Pediatrics. Lyme Disease, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;428-433.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
April 23, 2007