What is the recommended diagnosis and treatment for Bell's palsy in pediatric patients?

Bell's Palsy in Children: Diagnosis and Treatment

Primary Treatment Recommendation

Children with Bell's palsy do not require corticosteroid treatment, as 80-90% recover spontaneously without intervention, and the highest quality pediatric trial found no benefit from prednisolone at 1,3, or 6 months. 1, 2

Diagnosis

Clinical Criteria

• Acute onset (less than 72 hours) of unilateral facial weakness involving the forehead distinguishes Bell's palsy from central causes 1, 3
• No other neurologic abnormalities should be present—any additional cranial nerve involvement, bilateral weakness, or isolated branch paralysis suggests an alternative diagnosis 1, 4
• Thorough history and physical examination must exclude identifiable causes including trauma (temporal bone fracture), infection, tumor, or stroke 3, 4

Diagnostic Testing

• Do NOT order routine laboratory tests or imaging for typical presentations 1, 3
• MRI with and without contrast is reserved for atypical features: recurrent paralysis on the same side, progressive weakness beyond 3 weeks, no recovery after 3 months, or other cranial nerve involvement 3, 4

Treatment Algorithm

For Severe or Complete Paralysis

• Corticosteroids may be offered on an individualized basis with substantial caregiver involvement in shared decision-making, though benefit remains unproven 1, 3
• If caregivers prefer intervention: prednisolone 1 mg/kg/day (maximum 50-60 mg) orally for 5-10 days, followed by a 5-day taper 1
• Critical timing: Must initiate within 72 hours of symptom onset—no benefit exists beyond this window 1, 4
• Clearly explain to families that most children (80-90%) recover completely without treatment and steroid benefit is unproven in pediatrics 1, 2

For Incomplete Paralysis

• Observation is the preferred approach given the excellent prognosis (up to 94% recovery) 1, 3
• Focus on supportive care and mandatory eye protection 1

Evidence Quality Discussion

The 2022 randomized controlled trial in Neurology (the highest quality pediatric-specific evidence) enrolled 187 children and found no significant difference in recovery rates: 49% recovered at 1 month with prednisolone versus 57% with placebo (adjusted OR 0.7,95% CI 0.4-1.3) 2. By 6 months, 99% of the prednisolone group and 93% of the placebo group had recovered 2. This contrasts sharply with adult data showing clear benefit (83% recovery with prednisolone versus 63.6% with placebo at 3 months) 5, 6. The pediatric trial was underpowered but provides Class I evidence against routine steroid use in children 2.

Mandatory Eye Protection (All Patients with Impaired Eye Closure)

Immediate Implementation Required

• Lubricating ophthalmic drops every 1-2 hours while awake 1, 3
• Ophthalmic ointment at bedtime for sustained moisture retention 1, 3
• Eye patching or taping at night with careful instruction on proper technique to avoid corneal abrasion 1, 3
• Sunglasses for outdoor protection against wind and foreign particles 1, 3
• Moisture chambers using polyethylene covers for severe cases 3

Critical Pitfall

Improper eye taping technique can cause corneal abrasion—caregivers must receive detailed instruction on gentle application without pressure on the globe 1, 3

Urgent Ophthalmology Referral Triggers

• Severe impairment with complete inability to close the eye 3
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1
• Signs of corneal exposure or damage 3

Therapies NOT Recommended

• Antiviral monotherapy is completely ineffective and should never be prescribed 1, 4
• Surgical decompression has no evidence of benefit 1
• Acupuncture has no evidence of benefit 1, 3
• Physical therapy has no evidence of benefit over spontaneous recovery 1, 3

Follow-Up Schedule

Initial Visit

• Within 72 hours of symptom onset for treatment decision-making and eye care education 1

Early Follow-Up

• 1-2 weeks after onset to assess recovery trajectory, reinforce eye protection, and identify early complications 1

Mandatory Reassessment

• At 3 months for all patients with incomplete recovery—refer to facial nerve specialist for evaluation of reconstructive options 1, 3

Urgent Reassessment Triggers (Any Time Point)

• New or worsening neurologic findings suggest alternative diagnoses (stroke, tumor, CNS pathology) 1, 3
• Development of ocular symptoms requires immediate ophthalmology referral 1, 3
• Progressive weakness beyond 3 weeks is a red flag requiring immediate reassessment 3

Prognosis

Excellent Natural History in Children

• 80-90% spontaneous recovery without treatment, significantly better than adults (70% with complete paralysis) 1, 7
• Most begin showing recovery within 2-3 weeks 3
• Complete recovery typically occurs within 3-4 months 3
• Incomplete paralysis at presentation predicts up to 94% complete recovery 1, 3

Long-Term Complications (Rare in Children)

• Approximately 30% may experience permanent facial weakness with muscle contractures if recovery is incomplete 3
• Persistent lagophthalmos requires ongoing ophthalmology management 1
• Psychosocial impact from facial asymmetry may require psychological support 1

Common Pitfalls to Avoid

• Overestimating steroid benefit based on adult data—pediatric evidence does not support the same advantage 1, 2
• Prescribing antiviral monotherapy—completely ineffective and delays appropriate care 1, 4
• Inadequate eye protection—can lead to permanent corneal damage 1, 3
• Failing to refer at 3 months for incomplete recovery—delays access to reconstructive options 1, 3
• Starting corticosteroids beyond 72 hours—provides no proven benefit and exposes children to medication risks 1, 4
• Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) that suggest alternative diagnoses 3, 4
• Ordering routine labs or imaging for typical presentations—increases costs without benefit 3, 4