What is the evidence for using oral steroids, such as prednisone, for treating pediatric patients with Bell's (facial nerve) palsy?

Oral Steroids for Pediatric Bell's Palsy

Primary Recommendation

Oral corticosteroids may be considered for children with Bell's palsy on a case-by-case basis with substantial caregiver involvement in shared decision-making, though the evidence for benefit in pediatric patients remains inconclusive and children have excellent spontaneous recovery rates (up to 90%) without treatment. 1, 2, 3

Evidence Quality and Strength

The recommendation for pediatric steroid use differs substantially from adults due to critical gaps in evidence:

• No high-quality pediatric-specific trials exist - most Bell's palsy treatment trials excluded children entirely or did not analyze them separately 2
• The strongest pediatric evidence comes from a 2022 randomized, double-blind, placebo-controlled trial (Class I evidence) that found no significant benefit from prednisolone in children 4
• In this trial, complete recovery at 1 month occurred in 49% of prednisolone-treated children versus 57% of placebo-treated children (risk difference -8.1%, 95% CI -22.8 to 6.7), though the study was underpowered 4
• By 6 months, recovery rates were nearly identical: 99% with prednisolone versus 93% with placebo 4

Natural History in Children

Children have a fundamentally better prognosis than adults, which influences treatment decisions:

• Spontaneous recovery rates approach 90-100% in pediatric patients without any treatment 2, 3
• Complete recovery typically occurs in all children, with median duration of 5-6 weeks regardless of steroid treatment 5
• Recovery within 3 weeks occurs in approximately 69% of pediatric cases 6
• Only 3% may have partial recovery, often associated with other pathology 6

Treatment Algorithm for Pediatric Bell's Palsy

Within 72 Hours of Symptom Onset

For severe or complete paralysis where caregivers prefer intervention:

• Consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days, followed by a 5-day taper 2
• Engage in extensive shared decision-making, clearly explaining that most children recover completely without treatment and steroid benefit remains unproven 2, 3

For incomplete paralysis:

• Observation is reasonable given the excellent natural history 2, 6
• Focus on mandatory eye protection measures 2, 3

Beyond 72 Hours of Symptom Onset

• Do not initiate corticosteroids - there is no evidence to support benefit after this window 2

Antiviral Therapy

• Never prescribe antiviral monotherapy - it is ineffective 2, 3
• Combination antiviral plus steroid therapy has no established role in pediatric patients 1

Mandatory Eye Protection (All Pediatric Patients)

Regardless of steroid decision, implement aggressive eye protection immediately for impaired eye closure:

• Lubricating ophthalmic drops every 1-2 hours while awake 2, 3
• Ophthalmic ointment at bedtime for sustained moisture retention 2, 3
• Eye patching or taping at night with careful instruction on proper technique to avoid corneal abrasion 2, 3
• Sunglasses for outdoor protection against foreign particles and wind 2, 3
• Urgent ophthalmology referral for severe impairment with complete inability to close the eye 2

Contradictory Evidence and Nuances

The pediatric evidence presents a different picture than adult data:

• Adult trials show clear benefit (83% recovery at 3 months with steroids vs 63.6% with placebo) 2, 3, but this cannot be extrapolated to children
• Multiple pediatric studies found no statistically significant difference in recovery duration or rates between steroid-treated and untreated groups 5, 6, 7
• A 2001 systematic review concluded: "we do not recommend the routine use of steroids in children with Bell's palsy" 7
• The 2022 randomized trial (the highest quality pediatric evidence) was underpowered but showed a trend toward worse outcomes at 1 month with prednisolone 4

The American Academy of Otolaryngology-Head and Neck Surgery acknowledges this uncertainty, stating that oral steroids "may be considered" based on the presumed similar disease process to adults and generally favorable benefit-harm ratio, but emphasizes the large role for caregiver involvement 1, 2

Common Pitfalls to Avoid

• Overestimating steroid benefit in children - pediatric data does not support the clear advantage seen in adults 2
• Using antiviral monotherapy - this is ineffective and should never be prescribed 2, 3
• Inadequate eye protection - this can lead to permanent corneal damage and is the most critical intervention regardless of steroid decision 2, 3
• Failing to inform families that most children recover completely without treatment and steroid benefit remains unproven in pediatrics 2
• Initiating steroids beyond 72 hours - there is no evidence for benefit after this window 2

Follow-Up Requirements

• Reassess at 3 months - refer to facial nerve specialist if incomplete recovery persists 2, 3
• Immediate referral for new or worsening neurologic findings or development of ocular symptoms at any point 2, 3
• Most children begin showing recovery within 2-3 weeks, with complete recovery typically within 3-4 months 2