What is the recommended treatment for Bell's palsy in children?

Treatment of Bell's Palsy in Children

Primary Treatment Recommendation

Oral corticosteroids may be offered to children with Bell's palsy within 72 hours of symptom onset, but the evidence for benefit is weak and children have excellent spontaneous recovery rates (90-99%) regardless of treatment. 1, 2, 3

The decision to treat should involve substantial caregiver participation in shared decision-making, as the benefit-harm ratio in pediatric patients remains uncertain despite the generally favorable safety profile of short-term corticosteroids. 4

Evidence Quality and Strength

Why the Evidence is Weak in Children

• No high-quality pediatric-specific trials exist: Most Bell's palsy treatment trials excluded children entirely, and the few that included pediatric patients did not analyze them separately. 4

• The largest pediatric RCT showed no benefit: A 2022 double-blind, placebo-controlled trial of 187 children found no significant difference in complete recovery at 1 month (49% prednisolone vs 57% placebo), though the study was underpowered. 3

• Observational studies consistently show no difference: Multiple retrospective studies found no significant difference in recovery rates or duration between steroid-treated and untreated children. 2, 5

Pediatric Prognosis is Excellent Without Treatment

• Children demonstrate 90-99% complete spontaneous recovery rates, substantially higher than the 70% rate seen in adults with complete paralysis. 1, 6, 2

• Recovery typically begins within 2-3 weeks and completes within 3-4 months in most pediatric cases. 1

• One study of 100 children showed 100% recovery regardless of steroid use, with no statistically significant difference in symptom duration (median 5 weeks treated vs 6 weeks untreated, p=0.86). 5

Treatment Algorithm for Pediatric Bell's Palsy

Within 72 Hours of Symptom Onset

Option 1 (Preferred for most cases): Supportive care alone with close monitoring

• Appropriate given excellent spontaneous recovery rates 2, 3
• Avoids medication side effects in a population with unclear benefit 4

Option 2: Oral corticosteroids (shared decision-making with caregivers)

• Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days, followed by 5-day taper 6
• Consider for severe/complete paralysis cases where caregivers prefer intervention 4
• Extrapolated from adult data showing benefit, though pediatric applicability uncertain 4, 1

Beyond 72 Hours of Symptom Onset

Do not initiate corticosteroids - no evidence supports benefit after this window, even in adults. 1, 7

Antiviral Therapy

Never prescribe antiviral monotherapy - it is ineffective and not recommended. 4, 1

Combination antiviral + steroid therapy may be considered within 72 hours, though evidence is even weaker in children than steroids alone. 4, 6

Essential Supportive Care (All Patients)

Eye Protection (Critical Priority)

Implement aggressive eye protection immediately for any child with impaired eye closure to prevent potentially permanent corneal damage. 1

• Daytime: Lubricating ophthalmic drops applied frequently 1
• Nighttime: Ophthalmic ointments for superior moisture retention 1
• Mechanical protection: Eye patching/taping (with careful instruction to avoid corneal abrasion), moisture chambers, sunglasses outdoors 1
• Urgent ophthalmology referral if severe lagophthalmos, eye pain, vision changes, or persistent symptoms develop 1

Monitoring and Follow-Up

• Reassess at 2-3 weeks to confirm recovery is beginning 1
• Mandatory reassessment or specialist referral at 3 months if incomplete facial recovery persists 1
• Refer immediately if new/worsening neurologic findings or ocular symptoms develop at any point 1

Critical Diagnostic Considerations

When to Question the Diagnosis

Order MRI with and without contrast and refer to specialist immediately if: 1

• Recurrent facial paralysis on the same side (raises concern for tumor, sarcoidosis, Lyme disease) 1, 8
• Bilateral facial weakness (extremely rare in Bell's palsy) 1
• Isolated branch paralysis rather than complete hemifacial involvement 1
• Other cranial nerve involvement 1
• No recovery after 3 months 1

Do NOT Order Routine Testing

• Routine laboratory testing is not recommended for typical Bell's palsy presentation 1
• Diagnostic imaging is not indicated for straightforward cases 1

Common Pitfalls to Avoid

• Failing to provide adequate eye protection: This is the most important intervention to prevent permanent morbidity, regardless of whether steroids are used. 1

• Overestimating steroid benefit in children: Unlike adults where steroids show clear benefit (83% vs 63.6% recovery at 3 months), pediatric data does not support this advantage. 4, 3

• Starting steroids after 72 hours: No evidence supports delayed treatment and exposes children to medication risks without benefit. 1, 7

• Using antiviral monotherapy: This is ineffective and should never be prescribed. 4, 1

• Missing atypical features: Recurrent or bilateral cases require immediate imaging and specialist referral to exclude serious pathology. 1, 8

• Inadequate caregiver counseling: Families need clear information that most children recover completely without treatment, and that steroid benefit remains unproven in pediatrics. 4, 2, 3