How should a 4‑year‑old with acute idiopathic facial nerve palsy (Bell’s palsy) be treated?

Treatment of Bell's Palsy in a 4-Year-Old

Offer oral prednisolone 1 mg/kg/day (maximum 50–60 mg) for 5–10 days within 72 hours of symptom onset, but only after shared decision-making with caregivers who understand that most children (80–90%) recover spontaneously without treatment and that steroid benefit remains unproven in pediatrics. 1, 2

Key Differences from Adult Management

Children have a fundamentally better prognosis than adults, with spontaneous recovery rates of 80–90% compared to approximately 70% in adults with complete paralysis. 2 The strong evidence supporting corticosteroids in patients ≥16 years does not extend to children, as most Bell's palsy treatment trials excluded pediatric patients entirely or did not analyze them separately. 1, 2

Treatment Decision Algorithm

Step 1: Confirm Diagnosis Within 72 Hours

• Verify acute onset (≤72 hours) of unilateral facial weakness involving the forehead. 2
• Exclude identifiable causes through history (trauma, infection, tumor) and complete cranial nerve examination—any additional cranial nerve deficit excludes Bell's palsy. 1, 2
• Do NOT order routine laboratory tests or imaging for typical presentations. 1, 2

Step 2: Assess Severity and Engage Caregivers

• For severe or complete paralysis: Consider prednisolone 1 mg/kg/day (maximum 50–60 mg) orally for 5–10 days, followed by a 5-day taper. 2 Even low-dose prednisolone (1 mg/kg/day) is highly effective in children when treatment is chosen. 3
• For incomplete paralysis: Observation is reasonable given the excellent prognosis (up to 94% recovery); focus on supportive care and eye protection. 2
• Critical counseling point: Clearly explain to caregivers that benefit remains unproven in children and most recover without treatment. 1, 2

Step 3: Initiate Mandatory Eye Protection Immediately

All pediatric patients with impaired eye closure require aggressive eye protection to prevent corneal damage, regardless of whether steroids are prescribed: 2

• Lubricating ophthalmic drops every 1–2 hours while awake. 1, 2
• Ophthalmic ointment at bedtime for sustained moisture. 1, 2
• Eye patching or taping at night with proper technique instruction to avoid corneal abrasion. 1, 2
• Sunglasses outdoors for protection against wind and debris. 1, 2

Timing Considerations

Do NOT initiate corticosteroids beyond 72 hours of symptom onset—there is no proven benefit after this window and it exposes children to medication risks without evidence of efficacy. 1, 2 The critical 72-hour window applies equally to pediatric and adult patients. 1

Therapies to Avoid

• Never prescribe antiviral monotherapy (acyclovir or valacyclovir alone)—it is completely ineffective. 1, 2, 4
• Do not offer combination antiviral + steroid therapy in children—the modest benefit seen in some adult studies (absolute benefit +6.8%) is not established in pediatrics. 1
• Surgical decompression, acupuncture, and physical therapy have no evidence of benefit in Bell's palsy. 1, 2

Follow-Up Protocol

Mandatory Reassessment Triggers

• At 3 months: Refer to a facial nerve specialist if recovery is incomplete. 1, 2
• At any time: Refer immediately for new or worsening neurologic findings or development of ocular symptoms. 1, 2
• Early follow-up at 1–2 weeks is valuable for monitoring recovery progress, ensuring adequate eye protection, and identifying complications. 1

Red Flags Requiring Urgent Imaging and Referral

• Progressive weakness beyond 3 weeks. 1
• Bilateral facial weakness. 1
• Isolated branch paralysis. 1
• Other cranial nerve involvement. 1
• Recurrent paralysis on the same side. 1

Expected Recovery Timeline

Most children begin showing signs of recovery within 2–3 weeks, with complete recovery typically occurring within 3–4 months. 1 With early corticosteroid treatment in adults, 83% recover at 3 months and 94.4% at 9 months, but these figures cannot be extrapolated to children given the lack of pediatric-specific evidence. 1, 4

Common Pitfalls

• Overestimating steroid benefit based on adult data—pediatric evidence does not support the same advantage. 2
• Inadequate eye protection monitoring—can lead to permanent corneal damage, particularly in severe lagophthalmos. 1, 2
• Improper eye taping technique—caregivers must receive careful instruction to avoid corneal abrasion. 1, 2
• Failing to refer at 3 months for incomplete recovery—delays access to reconstructive options and psychological support. 1, 2
• Delaying treatment to await test results—compromises the 72-hour window and offers no clinical benefit. 1