Bell’s Palsy in Children: 29% Had Lyme Disease in a UK Study

A retrospective review examined 93 children with idiopathic facial nerve palsy, formerly called Bell’s palsy, who were evaluated at University Hospital Southampton NHS Foundation Trust between 2010 and 2017. Facial nerve palsy can be an early sign of Lyme disease in children.

Very few children in the study recalled a tick bite or rash. Only 14% reported a tick bite, and just 5% reported a rash. Lyme disease testing was performed in 76 of the 93 children, and 22 of those tested (29%) were positive for Lyme disease.

Neuroimaging was performed in approximately 20% of the children. The most common findings were consistent with facial nerve inflammation or infection.

Despite increased awareness of Lyme disease in the Hampshire region, nearly 1 in 5 children with facial nerve palsy were not tested for Lyme disease. As the authors noted, “even in the absence of other signs or symptoms of Lyme disease, an FNP could be the sole presenting sign.”

Treatment Variations in Children With Bell’s Palsy

“We found significant variation in medical management, with some children appearing to receive no treatment,” the authors write.

• Only 73.1% were treated with an antibiotic
• Treatment duration ranged from 1 to 28 days, with a median of 14 days
• 44% of the children received the oral steroid prednisolone
• More than 17% were prescribed an antiviral medication
• Nearly 20% underwent neuroimaging

The study was not designed to evaluate long-term outcomes. Still, it raises important questions. Could steroid use affect recovery in children with Lyme-related facial palsy? Could little or no treatment affect long-term outcome? Would some of these children go on to develop persistent facial nerve dysfunction?

Why Testing and Treatment Variability Matters

The lack of consistent testing and treatment protocols has important implications for children living in endemic areas. Nearly 1 in 5 children presenting with facial nerve palsy were not tested for Lyme disease at all, despite living in a region where Lyme disease is common.

The use of steroids in nearly half of the children is particularly concerning. Corticosteroids may be helpful for viral Bell’s palsy, but research suggests they may worsen outcomes when facial palsy is caused by Lyme disease.

Study Conclusions and Recommendations

The authors reached several important conclusions:

• “Lyme disease is a significant cause of FNP in this endemic area of the UK, and there was a large degree of variability in management prior to national guideline publication.”
• “In areas endemic with Lyme disease, Lyme disease should be considered as the likely cause of facial nerve palsy in children until proven otherwise.”
• “All children presenting with facial nerve palsy to health care providers in these areas should have Lyme serology tested and empirical treatment for Lyme initiated pending the results of tests.”
• “Areas with endemic Lyme disease should consider introducing local guidelines supporting routine investigation and management for facial nerve palsy, including empiric treatment for Lyme disease in accordance with NICE guidelines, to improve care and reduce variability.”

NICE refers to the UK National Institute for Health and Care Excellence, which developed guidelines for the diagnosis and management of Lyme disease.

Frequently Asked Questions

What percentage of children with Bell’s palsy had Lyme disease?

In this UK study, 29% of the children who were tested were positive for Lyme disease. Because nearly 1 in 5 children were never tested, the true percentage may have been even higher.

Should children with Bell’s palsy be tested for Lyme disease?

Yes, especially in endemic areas. The study authors recommended Lyme serology for all children presenting with facial nerve palsy and empiric treatment while awaiting results.

Why don’t most children with Lyme-related Bell’s palsy recall a tick bite?

Only 14% of children in this study recalled a tick bite. Ticks are often very small, especially in the nymph stage, and may attach in hidden areas such as the scalp or behind the ear. The absence of a known tick bite should not rule out Lyme disease.

Are steroids safe for children with Bell’s palsy caused by Lyme disease?

Steroids may be harmful when Bell’s palsy is caused by Lyme disease. Research has shown that corticosteroid use may be associated with worse long-term facial nerve outcomes in Lyme-related facial palsy.

What is the recommended treatment for Bell’s palsy caused by Lyme disease in children?

The authors recommended empiric antibiotic treatment for Lyme disease while awaiting test results. Treatment in the study ranged from 1 to 28 days, with a median of 14 days, although the optimal duration may vary by patient.

Clinical Takeaway

This UK study highlights important gaps in the recognition and treatment of Lyme disease in children presenting with Bell’s palsy. Despite living in an endemic area, nearly 20% of the children were never tested, and treatment varied widely—from no treatment at all to 28 days of antibiotics. The 29% positive rate among those tested underscores that Lyme disease is a significant cause of facial nerve palsy in endemic areas.

For clinicians, Bell’s palsy in a child from an endemic area should prompt immediate Lyme testing and empiric treatment while awaiting results. For parents, a child who develops facial weakness should be evaluated for Lyme disease even if no tick bite or rash was noticed.

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Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention