Facial Palsy in Children: When It’s Lyme Disease—Not Bell’s Palsy

Facial palsy Lyme disease children is a common but often underrecognized presentation in endemic areas.

A child who suddenly develops facial drooping is frequently diagnosed with Bell’s palsy. However, in Lyme-endemic regions, Lyme disease is a well-recognized cause of facial nerve palsy in children. :contentReference[oaicite:0]{index=0}

Clinical risk: mislabeling Lyme-related facial palsy as Bell’s palsy can delay appropriate treatment.

This article is part of the Pediatric Lyme Disease guide, which explores how Lyme disease presents differently in children.

What Facial Nerve Palsy Looks Like in Children

Facial nerve palsy occurs when the seventh cranial nerve is affected, leading to weakness of the facial muscles.

In children, symptoms may include:

• Drooping on one side of the face
• Difficulty closing one eye
• Asymmetry when smiling
• Drooling
• Changes in speech articulation

Clinical pattern: symptoms often appear suddenly but may be subtle at first.

Parents may initially notice incomplete eye closure or a slight asymmetry in the smile.

Although most cases are unilateral, bilateral facial palsy—while uncommon—can occur in Lyme disease.

Bell’s Palsy vs Lyme-Related Facial Palsy

Bell’s palsy refers to facial paralysis without a clearly identified cause.

In practice, however, the term is often used broadly for any sudden facial weakness.

In Lyme-endemic regions, this can be misleading.

Facial palsy labeled as Bell’s palsy may actually represent Lyme disease affecting the facial nerve.

Clinical takeaway: Lyme disease should be considered before labeling a case as idiopathic.

For broader neurologic involvement, see Neurologic Lyme Disease in Children.

What the Research Shows

A retrospective study published in Pediatrics evaluated 306 children presenting with acute facial palsy in a Lyme-endemic region.

• 68% were diagnosed with Bell’s palsy
• 27% had Lyme-related facial palsy
• A small number had other causes

Key insight: more than 1 in 4 cases were Lyme-related.

Children with Lyme-related facial palsy were more likely to:

• Present between June and November
• Have preceding symptoms such as fever, malaise, headache, muscle pain, or joint pain

Important: many did not recall a tick bite and did not have a rash.

Evaluation of Facial Palsy

When a child presents with facial weakness, clinicians consider multiple causes.

In children with isolated facial palsy:

• Neuroimaging often does not add diagnostic value
• Lumbar puncture is not routinely necessary

These tests may be reserved for cases with additional neurologic findings.

In endemic regions, Lyme testing is often appropriate—especially during tick season.

See the Lyme Disease Symptoms Guide for a broader symptom overview.

Recovery and Prognosis

Most children recover from facial palsy—whether due to Bell’s palsy or Lyme disease.

In the study, nearly all patients with follow-up regained normal facial strength.

Clinical reassurance: prognosis is generally favorable.

The role of corticosteroids remains uncertain. In this study, early steroid use did not significantly affect recovery outcomes.

Clinical Perspective

In my practice in a Lyme-endemic region, facial nerve palsy is one of the more recognizable neurologic presentations of Lyme disease in children.

Early recognition can change management—and outcomes.

Final Thoughts

Facial palsy in children should not automatically be labeled as Bell’s palsy—especially in Lyme-endemic areas.

Recognizing Lyme-related facial palsy allows for appropriate evaluation and treatment while avoiding unnecessary testing.

Key question: Could sudden facial weakness in a child be Lyme disease—even without a tick bite or rash?

Reference

Guez-Barber D, et al. Differentiating Bell’s palsy from Lyme-related facial palsy. Pediatrics. 2022.

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