What is the prognosis and management for a 1-day-old newborn with facial nerve paralysis following a prolonged labor and forceps delivery (Special Care Baby Unit, SCBU)?

Management of Neonatal Facial Nerve Paralysis Following Forceps Delivery

The most appropriate response is to reassure the mother that facial paralysis will likely resolve spontaneously with conservative management and close follow-up (Option A). Birth trauma-related facial nerve palsy has an excellent prognosis, with 89-91% of affected newborns achieving complete recovery without intervention 1, 2.

Immediate Assessment and Reassurance

This is almost certainly traumatic facial nerve palsy from forceps delivery, not Bell's palsy or a congenital syndrome. The clinical context—prolonged labor requiring forceps delivery in a 1-day-old newborn with isolated facial weakness and no other congenital features—strongly indicates birth trauma as the etiology 1, 3.

Key Prognostic Information to Share with Parents

• 91% of newborns with forceps-related facial palsy recover completely with conservative management alone, with a mean follow-up of 34 months 1
• Forceps delivery is associated with 74 of 81 cases (91%) of acquired neonatal facial palsy in large series, compared to only 19% forceps use in the general delivery population 1
• The condition is self-limited in the vast majority of cases, requiring only observation and supportive care 2, 3

Conservative Management Protocol

Initial Management (First 5 Weeks)

• Implement eye protection immediately to prevent corneal exposure and damage: lubricating ophthalmic drops every 1-2 hours while awake, ophthalmic ointment at bedtime, and gentle eye taping at night if needed 4, 5
• Initiate physiotherapy/gentle facial massage as supportive care 3
• Provide parental counseling about the expected natural history and excellent prognosis 3
• Schedule close follow-up to monitor for signs of recovery 2, 1

Timeline for Expected Recovery

• Most cases show gradual improvement beginning within the first few weeks 2, 3
• Complete recovery typically occurs within 3-4 months in the majority of cases 1
• Only 11% may have incomplete recovery, and even these cases often have minimal residual deficits 1

When to Consider Further Intervention

Electrodiagnostic Testing Indications

Facial electroneurography (ENoG) and electromyography (EMG) should only be considered if there is complete paralysis with no clinical improvement by 5 weeks of age 2, 6. Testing before this timeframe is premature given the excellent natural history.

• Testing is most reliable when performed 3-14 days after the injury in cases requiring evaluation 5, 6
• ENoG showing >90% amplitude reduction compared to the contralateral side would indicate severe nerve injury 5

Surgical Exploration Criteria

Surgical exploration should only be considered for infants with:

• Complete paralysis both clinically and electrophysiologically 2
• No improvement whatsoever by 5 weeks of age 2
• Evidence of facial nerve disruption on electrodiagnostic testing 6

This represents a very small minority of cases, as most recover spontaneously 2, 1.

Why Other Options Are Inappropriate

• IV steroids (Option B): Not indicated for neonatal traumatic facial palsy. Steroids are recommended for Bell's palsy in patients ≥16 years old, but this is birth trauma, not Bell's palsy 4. The evidence for steroid benefit in children is inconclusive, and neonates have excellent spontaneous recovery rates 4

• Facial reanimation (Option C): Premature and inappropriate at 1 day of age. Reconstructive procedures are only considered after 6-12 months if incomplete recovery persists, which occurs in <11% of cases 1, 4

• Facial ENoG now (Option D): Too early. Testing is unreliable in the first few days and should only be performed at 3-14 days post-injury, and only if complete paralysis persists 5, 6

• CT temporal bone (Option E): Not indicated. This newborn has no skull fracture or temporal bone trauma—the mechanism is peripheral nerve compression from forceps, not bony injury 1, 6

• Genetic counseling (Option F): Inappropriate. The history clearly indicates acquired traumatic injury from forceps delivery, not a congenital or genetic syndrome 1, 3

Critical Follow-Up Parameters

• Reassess at 5 weeks: If no improvement whatsoever, consider electrodiagnostic testing 2
• Reassess at 3 months: If incomplete recovery, refer to pediatric facial nerve specialist 4
• Monitor eye protection: Ensure parents are maintaining corneal protection measures and watch for signs of exposure keratitis 4, 5