What is the management approach for newborn facial palsy (facial nerve palsy)?

Management of Newborn Facial Palsy

The management of newborn facial palsy should primarily involve watchful waiting with supportive care, as most cases caused by birth trauma resolve spontaneously within weeks to months, with surgical exploration only considered for complete paralysis showing no improvement by 5 weeks of age. 1

Differential Diagnosis and Initial Assessment

When evaluating a newborn with facial palsy, it's crucial to differentiate between:

1. Birth trauma-related palsy (most common)

   • Associated with forceps delivery, large infant size, or difficult labor
   • Usually unilateral and resolves spontaneously

2. Developmental/congenital facial palsy

   • Due to aplasia or hypoplasia of the facial nerve
   • Often permanent and may require surgical intervention
   • May be isolated or part of a syndrome 2

Key Assessment Points:

• Complete neurological examination to assess severity using House-Brackmann scale 3
• Evaluate for eye closure, oral competence, and forehead involvement
• Document timing of onset (present at birth vs. developing later)
• Review birth history for trauma, forceps use, or difficult delivery

Management Algorithm

1. Initial Management (0-4 weeks)

• Eye protection is mandatory for patients with impaired eye closure 3

  • Artificial tears during the day
  • Lubricating ointment at night
  • Taping eyelids closed if necessary

• Monitor for feeding difficulties

  • Assess all phases of swallowing 3
  • Consider specialized feeding techniques if needed

• Parent education and reassurance

  • Explain high likelihood of spontaneous recovery in traumatic cases
  • Discuss expected timeline for improvement

2. Evaluation at 4-5 Weeks

• If improvement is observed: Continue supportive care and monitoring

• If no improvement by 5 weeks:

  • Consider electrophysiologic testing to assess nerve integrity 4
  • Imaging studies:
    • MRI of posterior fossa
    • CT of temporal bone to evaluate facial nerve course 2

3. Management Based on Etiology

For Birth Trauma-Related Palsy:

• Continue supportive care
• Most cases resolve spontaneously with excellent prognosis 1
• Follow-up until complete resolution

For Developmental/Congenital Palsy:

• Multidisciplinary approach involving ENT, neurology, and ophthalmology 2
• Consider surgical options if imaging confirms nerve aplasia/hypoplasia
• Discuss reanimation procedures for permanent cases 4, 5

Surgical Considerations

Surgical exploration should be considered only in specific circumstances:

• Complete paralysis with no improvement by 5 weeks
• Electrophysiologic evidence of nerve disruption
• Imaging evidence of facial nerve abnormality 1, 4

Follow-up Recommendations

• Regular follow-up to monitor recovery progress
• Referral to facial nerve specialist if incomplete recovery after 3 months 3
• Consider reconstructive procedures for persistent cases:
  • Eyelid weights
  • Brow lifts
  • Static or dynamic facial slings 3

Important Caveats

1. Avoid unnecessary interventions in traumatic cases, as most resolve spontaneously
2. Don't delay imaging in cases with no improvement by 5 weeks, as early intervention may improve outcomes in developmental cases
3. Psychological support for parents is essential, as facial asymmetry in infants can cause significant parental anxiety
4. Unlike adult Bell's palsy, corticosteroids are not routinely recommended for newborn facial palsy, particularly for birth trauma cases 6, 3

The management approach differs significantly from adult Bell's palsy, where early corticosteroid administration is strongly recommended 6, 3. In newborns, the watchful waiting approach with appropriate supportive care yields excellent outcomes in most cases of birth trauma-related facial palsy.