Objective To investigate the predictive value of erythrocyte sedimentation rate (ESR) on coronary artery lesions (CAL) in Kawasaki disease (KD). Methods Clinical data of children with KD admitted to the hospital from May 2017 to June 2021 were collected to analyze the predictive value of ESR on the occurrence of CAL in children with KD. Results Of the 272 enrolled children with KD, 70 children with CAL and 202 children without CAL. ESR was significantly higher in children with KD. Univariate analysis suggested that ESR was lower in the CAL group than in the non-CAL group, and the difference was statistically significant (P<0.05). The area under the ROC curve was 0.586, suggesting that ESR could be a predictor of CAL (P<0.05). The critical value of ESR for predicting the occurrence of CAL in KD was 76.5 mm/h. Dichotomous Logistic regression analysis showed that ESR was an independent risk factor for the development of CAL in children with KD (P<0.05), and the risk of CAL in children with KD was significantly increased when ESR was<76.5 mm/h. (OR = 2.38, 95% CI: 1.25-4.53). Conclusions ESR levels in the acute phase of KD can be used to predict the development of CAL in children with KD, and ESR <76.5 mm/h suggests that children with KD may develop CAL.