What is the management of Bell's (Bell's) palsy in the pediatric age group?

Management of Bell's Palsy in Pediatric Patients

Primary Treatment Recommendation

Children with Bell's palsy may be offered oral corticosteroids within 72 hours of symptom onset on an individualized basis with substantial caregiver involvement in shared decision-making, though the evidence for benefit in pediatrics is inconclusive and most children (80-90%) recover spontaneously without treatment. 1, 2

Key Differences Between Pediatric and Adult Management

• Children have significantly better prognosis than adults, with spontaneous recovery rates of 80-90% compared to approximately 70% in adults with complete paralysis 1, 3, 4
• The strong evidence supporting corticosteroids in adults (16 years and older) does not extend to children, as most Bell's palsy treatment trials excluded pediatric patients entirely or did not analyze them separately 1
• A recent high-quality randomized controlled trial (2022) found no significant benefit from prednisolone in children, with 57% recovery at 1 month in the placebo group versus 49% in the prednisolone group, though the study was underpowered 5

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) orally for 5-10 days, followed by a 5-day taper 1, 3
• Engage caregivers in shared decision-making, clearly explaining that benefit remains unproven in children and most recover without treatment 1, 2

For incomplete paralysis:

• Observation is reasonable given the excellent prognosis (up to 94% recovery) 1
• Focus on supportive care and eye protection 1, 2

Never prescribe:

• Antiviral monotherapy alone (completely ineffective) 1, 2

Beyond 72 Hours of Symptom Onset

• Do not initiate corticosteroids, as there is no evidence supporting benefit after the 72-hour window 6
• Focus entirely on eye protection and monitoring for recovery 6

Mandatory Eye Protection Protocol

All pediatric patients with impaired eye closure require aggressive eye protection immediately to prevent corneal damage: 1, 2

• Daytime: Lubricating ophthalmic drops every 1-2 hours while awake 1, 2
• Nighttime: Ophthalmic ointment at bedtime for sustained moisture retention 1, 2
• Mechanical protection: Eye patching or taping at night (with careful instruction on proper technique to avoid corneal abrasion) 1, 2
• Outdoor protection: Sunglasses to protect against wind and foreign particles 1, 2
• Severe cases: Consider moisture chambers using polyethylene covers 1, 2

Urgent ophthalmology referral required for:

• Complete inability to close the eye 1
• Signs of corneal exposure or damage (eye pain, vision changes, redness, discharge) 1

Follow-Up and Reassessment Timeline

Mandatory reassessment or specialist referral at: 1, 2

• 3 months if incomplete facial recovery persists
• Any point if new or worsening neurologic findings develop
• Any point if ocular symptoms develop

Expected recovery timeline: 1, 2

• Most children begin showing recovery within 2-3 weeks
• Complete recovery typically occurs within 3-4 months
• Up to 90% of children achieve complete recovery 4

Diagnostic Considerations

Bell's palsy diagnosis requires: 7, 1

• Acute onset (less than 72 hours) of unilateral facial weakness involving the forehead
• Exclusion of identifiable causes through history and physical examination
• No other neurologic abnormalities

Do NOT routinely order: 1

• Laboratory testing
• Diagnostic imaging

Consider MRI with and without contrast if: 1

• Bilateral facial weakness (rare in Bell's palsy)
• Isolated branch paralysis
• Other cranial nerve involvement
• No recovery after 3 months
• Recurrent paralysis on the same side

Common Pitfalls to Avoid

• Overestimating steroid benefit in children based on adult data—pediatric evidence does not support the same advantage 1
• Prescribing antiviral monotherapy, which is completely ineffective 1, 2
• Inadequate eye protection, which can lead to permanent corneal damage 1, 2
• Failing to refer at 3 months for incomplete recovery, delaying access to reconstructive options 1, 2
• Improper eye taping technique, which can cause corneal abrasion—caregivers must receive careful instruction 1, 2
• Starting corticosteroids beyond 72 hours, which provides no proven benefit and exposes children to medication risks 6

Therapies NOT Recommended

The following have no evidence of benefit in Bell's palsy: 1, 2

• Surgical decompression (rarely indicated)
• Acupuncture (poor-quality trials)
• Physical therapy (limited evidence, though one study suggests potential benefit in severe cases) 4

Special Considerations

Vitamin supplementation (B1, B6, B12) has been used in some protocols but shows no significant impact on recovery 3, 8

Recent evidence suggests that higher doses of corticosteroids may correlate with poorer outcomes in children, though this requires further validation 8