What are the recommended treatments for Lyme disease in pediatric patients?

Treatment Recommendations for Lyme Disease in Pediatric Patients

For pediatric patients with Lyme disease, amoxicillin is the preferred first-line treatment for children under 8 years of age, while doxycycline is recommended for children 8 years and older. 1

First-Line Treatment Options by Age

Children Under 8 Years

• Amoxicillin: 50 mg/kg/day in 3 divided doses (maximum 500 mg per dose) for 14 days 1, 2
• Cefuroxime axetil: 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose) for 14 days as an alternative 1, 3
• Macrolides (e.g., azithromycin): Only if patient cannot tolerate first-line agents, as they are less effective 3, 1

Children 8 Years and Older

• Doxycycline: 4 mg/kg/day in 2 divided doses (maximum 100 mg per dose) for 10-14 days 1, 4
• Amoxicillin or cefuroxime axetil at doses listed above are alternatives 3, 1

Treatment by Clinical Manifestation

Early Localized Disease (Erythema Migrans)

• Oral antibiotics for 14 days (10 days if using doxycycline) 1, 5
• Most patients respond promptly and completely to appropriate therapy 1, 3

Early Disseminated Disease

• For isolated facial nerve palsy without meningitis: oral therapy as above 3, 5
• For meningitis or other neurological involvement: parenteral therapy with ceftriaxone 50-75 mg/kg/day IV once daily (maximum 2g) for 14 days 1, 3
• Recent research suggests oral doxycycline may be effective for Lyme meningitis in children, though parenteral therapy remains the standard recommendation 6

Lyme Arthritis

• Amoxicillin or doxycycline (age-appropriate) for 28 days 3
• For persistent arthritis after initial therapy: second course of oral antibiotics or 2-4 weeks of IV ceftriaxone 3, 7
• For antibiotic-refractory arthritis: NSAIDs, intra-articular corticosteroids, or DMARDs may be needed (consult rheumatology) 7, 3

Important Considerations

Medication Administration

• Doxycycline should be taken with 8 ounces of fluid and with food to reduce esophageal irritation and gastrointestinal intolerance 1, 4
• Patients on doxycycline should avoid sun exposure due to photosensitivity risk 1
• Amoxicillin should be taken at the start of a meal to minimize gastrointestinal intolerance 2

Treatment Duration

• Standard duration for early Lyme disease: 14 days for amoxicillin or cefuroxime; 10 days for doxycycline 1
• For Lyme arthritis: 28 days of oral therapy 3
• For neurological manifestations: 14 days of parenteral therapy 1, 3

Monitoring and Follow-up

• Most patients respond well to appropriate therapy, but <10% may not respond as evidenced by persistent clinical manifestations 3, 1
• Patients who are more systemically ill at diagnosis may take longer to have a complete response 3
• For Lyme arthritis, resolution may take several months after antibiotic completion 7, 3

Common Pitfalls to Avoid

• Using first-generation cephalosporins like cephalexin, which are ineffective against B. burgdorferi 1, 3
• Prescribing fluoroquinolones, carbapenems, or other antibiotics not recommended for Lyme disease 1, 3
• Multiple, repeated, or prolonged courses of antibiotics beyond recommended durations, which lack supporting data and may cause harm 3, 1
• Using amoxicillin with probenecid in patients with neurologic symptoms, as probenecid may impair penetration of β-lactam antibiotics into brain parenchyma 3
• Assuming that persistent symptoms after appropriate treatment always require additional antibiotics; some may represent post-Lyme disease syndrome or other conditions 5, 7