Bell's Palsy in Children (<16yrs) the Paediatric Emergency Department - Guideline for the management of

Publication: 12/05/2021  
Next review: 01/05/2024  
Clinical Guideline
ID: 6989 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the Management of Bell’s Palsy in Children (<16yrs) the Paediatric Emergency Department



Bell’s Palsy is an idiopathic isolated lower motor neuron lesion of the facial nerve.

It is a diagnosis of exclusion, and it is therefore important to consider the differentials.

Idiopathic: Bell’s Palsy

Infective: Herpes virus type 1, Herpes zoster (Ramsay-Hunt), Lyme disease, CMV, adenovirus, rubella, mumps, EBV, HIV, H influenza, TB, Mycoplasma pneumoniae, otitis media/cholesteatoma

Trauma: base of skull fracture

Neurological: Guillain Barre syndrome, multiple sclerosis, mononeuropathy (e.g. sarcoidosis)

Neoplastic: posterior fossa tumours, parotid gland tumours, leukaemia

Inflammatory: Henoch-Schonlein purpura

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The assessment of Bell’s Palsy is aimed at confirming the diagnosis and excluding other important causes of facial weakness.

Bell’s palsy is usually acute in onset, unilateral and in the absence of other systemic symptoms or neurological features.  The child may (less commonly) have mild pain behind the ear, hyperacusis (or intolerance to loud noises due to the disruption of the stapedius reflex), disturbed taste and dry eyes.  Ask about any recent infections, tick exposure or bites, history of trauma, pain and systemic symptoms such as fever and weight loss.

Confirm that all facial nerve branches are involved. THE FOREHEAD SHOULD NOT BE SPARED as this indicates an upper motor neuron lesion. Perform a thorough examination including the cranial nerves, peripheral nervous system, joints and skin. Examine the ears and tympanic membrane for signs of otitis media, mastoiditis, or lesions in the ear canal.  Examine the eye looking for degree of eyelid closure, redness of the conjunctiva, frequency of blinking and excessive watering or dryness of the involved eye.  Check observations including blood pressure and temperature.

Red flags suggestive of other causes of facial nerve palsy

  • Gradual onset over more than a few days
  • Young age - idiopathic or post-viral palsy is very uncommon in children <2yrs of age and all children <2yrs should be discussed with a paediatrician for consideration of admission and further investigations
  • Forehead sparing – suggests UMN/central nervous system cause
  • Bilateral involvement – suggests polyneuropathy e.g. GBS, MS
  • Fever – consider infection including otitis media
  • Rash – consider herpes zoster (vesicular), Lyme disease (erythema migrans)
  • ENT symptoms : Ear pain – consider Herpes zoster/Ramsay Hunt. Hearing loss, vertigo, ear discharge – consider ENT pathology e.g. otitis media/cholesteatoma. Refer to ENT acutely.
  • Hypertension - may cause facial palsy and has been presenting feature of coarctation of the aorta in case reports
  • Bruising/organomegaly – consider oncological diagnoses

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Consider doing a FBC and film to exclude leukaemia (although facial nerve palsy as a presenting feature of leukaemia is extremely rare it should be suspected in cases based on clinical examination)

Serologic tests for Lyme disease should be carried out when the history from the patient suggests exposure to ticks/tick bite, particularly with the classic erythema migrans rash.  Ticks that cause Lyme disease are found all over the UK but are especially prevalent in wooded areas of Southern England and the Scottish Highlands. Further advice regarding Lyme disease can be given by the Microbiologist on call or Dr O’Riordan (Paediatric Consultant) in hours.
Consider CT or MRI if there are any red flag or atypical features.

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Eye care:
Frequent use of artificial tears during the day (e.g. Hypromellose 0.3% eye drops) 6 times a day during the day time (1,2,3)

Eye ointment (liquid paraffin eye ointment such as Xailin Night) to lubricate the eye overnight (1,2,3)

Pad/tape the eye shut overnight/for all periods of sleep after inserting lubricating ointment (4)

Refer to eye clinic for examination and advice if there is no eye closure or a red/painful eye.

Steroids may be considered in older children if onset has been within the last 7 days. There are few studies demonstrating a clear benefit for corticosteroids in children as the best studies pertain to adults, and most children have a better prognosis than adults.  There are also patients in whom the risk of oral steroids would be too great to justify their use, for example a poorly-controlled diabetic patient.  Systematic reviews have not demonstrated a clear benefit for corticosteroids in Bell’s palsy in children (4, 5). If prescribed, a dose of prednisolone 1mg/kg for 10 days is preferred, ideally started within 72 hours.

(NB there is little evidence for the use of antivirals in Bell’s Palsy in the absence of any vesicles in children.  However, the Ramsay Hunt syndrome should be treated as soon as possible with steroid and antivirals and referred to ENT)

Referral for neurological physiotherapy may be beneficial for those children who have not improved by the time of review by the GP or Paediatric Rapid Access Clinic.

Follow up and patient information leaflet :

  • Arrange follow-up with the paediatricians in the Rapid Access Clinic for children with idiopathic/Bell’s Palsy. 
  • Children discharged from the ED may be given open access to CAT (Children’s Assessment and Treatment unit) in case of neurological deterioration until they are seen in the Rapid Access Clinic.  They should telephone the CAT nurse coordinator on (0113) 392 0920 to arrange review.
  • To ensure there has been no deterioration/progression, children should be reviewed by their GP within 7-14 days whilst awaiting Rapid Access Clinic. Please provide a thorough discharge letter.  If symptoms have fully resolved when they see the GP, they may be able to cancel the Rapid Access Clinic appointment
  • Provide the information leaflet “Information for parents, carers and children with Bell’s palsy”.

The symptoms should be stable within a few days.  If not, consider the possibility of an enlarging lesion, infection or other diagnosis and refer urgently to paediatrics and commence appropriate investigations.

Refer to a paediatrician for admission/investigation if the child is < 2 years of age, or with atypical/red flag features, or in the absence of any recovery by 4 weeks.

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Record: 6989

This guideline concerns the immediate issues around diagnosis and management of Bell’s Palsy in children (<16yrs) in the Emergency Department. This is an uncommon presentation and this guideline will assist in the correct investigation, treatment and follow-up of this condition.

Clinical condition:

Bell's Palsy

Target patient group: Children (<16yrs) with Bell’s Palsy
Target professional group(s): Secondary Care Doctors
Adapted from:

Evidence base

  1. Masterson, L., Vallis, M. and Quinlivan, R. et al (2015) Assessment and management of facial nerve palsy. BMJ 351, h3725.
  2. Phan, N.T., Panizza, B. and Wallwork, B. (2016) A general practice approach to Bell's palsy. Australian Family Physician 45(11), 794-797
  3. de Almeida, J.R., Guyatt, G.H. and Sud, S. et al (2014) Management of Bell palsy: clinical practice guideline. Canadian Medical Association journal 186(12), 917-922
  4. Baugh, R.F., Basura, G.J. and Ishii, L.E. et al (2013) Clinical practice guideline: Bell's palsy. Otolaryngology - Head and Neck Surgery 149(3 Suppl), S1-S27
  5. Salinas RA, Alvarez G, Alvarez MI, et al. Corticosteroids for Bell’s palsy (idiopathic facial paralysis). Most recent amendment 2001. Cochrane Database Syst Rev 2004; Issue 3. Art. No.: CD001942.pub2. DOI: 10.1002/14651858.CD001942.pub2.
  6. Pitaro et al, Do children with Bell’s palsy benefit from steroid treatment? A systematic review, Int J Pediatr Otorhinolaryngol. 2012 Jul; 76(7): 921-926

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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