A school-aged child comes in with a droopy face. No trauma. No fever. Your gut says Bell’s palsy. Maybe. Before you write for steroids, make sure you’re not missing a mimic.
1. Start with the forehead – but don’t stop there
Can the child wrinkle their forehead and fully close the affected eye?
● Can’t wrinkle the forehead + can’t close the eye → Think a peripheral CN VII palsy.
● Forehead movement is preserved with weakness only in the lower face → Think a central lesion until proven otherwise.
Clinical pearl: Forehead sparing is a clue, not a rule – early or evolving facial palsy may not follow a textbook pattern.
But peripheral doesn’t always mean Bell’s palsy. Lyme disease, acute otitis media, pontine lesions, and Guillain-Barré can all present this way. Additional cranial nerve deficits, bilateral weakness, or progression beyond the expected course should prompt further evaluation.
2. Think Lyme disease as a cause before calling it idiopathic
Lyme disease is an important identifiable cause of acute peripheral facial palsy in children, particularly in endemic regions.
Suspect Lyme with:
● Fever, malaise, myalgias, or arthralgias
● Summer/early fall presentation
● Recent outdoor exposure or travel to an endemic area
● Bilateral facial palsy
Don’t be reassured by the absence of a remembered tick bite or erythema migrans, as many children have neither.
If Lyme disease is clinically suspected, obtain Lyme serology and consider antibiotic therapy based on clinical presentation, epidemiology, and current guidelines. Routine neuroimaging is generally unnecessary in an isolated peripheral facial palsy without additional neurologic findings. Lumbar puncture should be guided by concern for meningitis, another neurologic process, or an alternative diagnosis.
Clinical pearl: Take 10 seconds to look in the ears. Acute otitis media is another important, less common cause, of pediatric facial nerve palsy.
3. Steroids: Evidence is strong in adults but less definitive in kids – and eye care is essential
In adults, oral corticosteroids started within 72 hours clearly improve outcomes.
In children, the evidence is less definitive. Pediatric recovery rates are generally excellent, but studies have not shown the same clear steroid benefit seen in adults.
Many clinicians still consider early corticosteroids for presumed idiopathic Bell’s palsy, but the decision should be individualized. When corticosteroids are chosen, many clinicians use a short course of oral prednisolone (commonly 1-2 mg/kg/day, maximum 60 mg/day; consider tapering depending on treatment duration) starting within 72 hours of symptom onset.
Antivirals are not routinely recommended for Bell’s palsy. Consider antiviral therapy when Ramsay Hunt syndrome is suspected (facial palsy with otalgia and vesicular lesions).
Don’t forget the eye: Artificial tears by day, ointment and eyelid closure/taping at night help reduce the risk of exposure keratopathy in children who can’t fully close the affected eye.
The Bottom Line
Not every droopy face is Bell’s palsy. Confirm it’s peripheral, think Lyme before calling it idiopathic, and protect the cornea. Steroid benefit in kids stays uncertain – but missing an alternative diagnosis is the mistake that matters most.
References
1. Ohira S, Yamaguchi Y, Yui R, Wada K. “Precursory Symptoms, Awareness or Progression of Facial Palsy” Are More Useful Than “Forehead Wrinkling Ability” in Differentiating Central Facial Palsy Examined in the Emergency Department. Acta Oto-Laryngologica. 2024.
2. Guez-Barber D, Swami SK, Harrison JB, McGuire JL. Differentiating Bell’s Palsy From Lyme-Related Facial Palsy. Pediatrics. 2022.
3. Babl FE, Herd D, Borland ML, et al. Efficacy of Prednisolone for Bell Palsy in Children: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial. Neurology. 2022. (RCT)
4. Madhok VB, Gagyor I, Daly F, et al. Corticosteroids for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2016;(7):CD001942.
5. Dalrymple SN, Row JH, Gazewood J. Bell Palsy: Rapid Evidence Review. American Family Physician. 2023. (Review)
6. Jančić J, Zeković J, Ćetković M, et al. Acute Peripheral Facial Nerve Palsy in Children and Adolescents: Clinical Aspects and Treatment Modalities. CNS & Neurological Disorders Drug Targets. 2022.
Dr. Anum N. Mitha, D.O., is a second-year Pediatric Emergency Medicine fellow at Maimonides Medical Center in Brooklyn, New York. She can be reached at amitha@maimo.org.
