Facial Nerve Palsy in Children With Lyme Disease

A child who suddenly develops facial drooping is often diagnosed with Bell’s palsy. In Lyme-endemic regions, however, Lyme disease is a common cause of facial nerve palsy in children. Recognizing Lyme-related facial palsy is important because treatment strategies differ from those used for idiopathic Bell’s palsy.

Facial nerve palsy represents one of the neurologic manifestations of Lyme disease in children. This article is part of the Pediatric Lyme Disease guide, which explores how Lyme disease can affect children differently from adults.

What Facial Nerve Palsy Looks Like in Children

Facial nerve palsy occurs when the seventh cranial nerve becomes inflamed or impaired, leading to weakness of the facial muscles. In children, symptoms may include:

• drooping of one side of the face
• difficulty closing one eye
• asymmetry when smiling
• drooling
• changes in speech articulation

In some cases the weakness appears suddenly, while in others it may develop more gradually. Parents sometimes notice subtle changes first, such as incomplete eye closure or a crooked smile.

Although most children develop weakness on one side of the face, bilateral facial palsy can occur in Lyme disease, although it is uncommon.

Bell’s Palsy vs Lyme-Related Facial Palsy

Facial nerve palsy in children is often referred to in the community as “Bell’s palsy.” Strictly speaking, Bell’s palsy describes facial paralysis without a clearly identified cause. However, in clinical practice the term is sometimes used more loosely to describe any sudden facial weakness.

In Lyme-endemic regions, facial palsy initially labeled as Bell’s palsy may actually represent Lyme disease affecting the facial nerve. Because Lyme disease is a recognized cause of facial nerve palsy in children, clinicians often consider Lyme testing when facial weakness occurs during tick season.

Facial nerve palsy is one of several neurologic findings associated with Lyme disease in children. Broader neurologic symptoms are discussed in Neurologic Lyme Disease in Children.

Findings From a Pediatric Study

A retrospective study published in Pediatrics evaluated children presenting with acute facial palsy in a Lyme-endemic region (Guez-Barber et al., 2022).

Among 306 children with facial palsy:

• 68% had Bell’s palsy
• 27% had Lyme-related facial palsy
• a small number had other causes

Several clinical patterns helped distinguish Lyme-related facial palsy from Bell’s palsy.

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

• present between June and November
• report a systemic prodrome such as fever, malaise, headache, muscle pain, or joint pain

Importantly, many children with Lyme-related facial palsy did not recall a tick bite and did not have a preceding erythema migrans rash.

Evaluation of Isolated Facial Palsy

When a child presents with facial nerve weakness, clinicians consider several possible causes.

In the study cohort, neuroimaging and lumbar puncture did not add diagnostic value in children with isolated facial palsy. These tests may be considered when additional neurologic symptoms or atypical findings are present but are not always necessary in straightforward cases.

Laboratory testing for Lyme disease may be appropriate in endemic regions, particularly during tick season.

Facial nerve palsy is one of the neurologic findings included in the broader Lyme Disease Symptoms Guide.

Recovery and Prognosis

Most children in the study recovered from facial palsy regardless of whether the diagnosis was Bell’s palsy or Lyme-related facial palsy. Nearly all patients with follow-up were reported to have regained normal facial strength.

The role of corticosteroids in children with facial palsy remains uncertain. In this retrospective study, early corticosteroid treatment was not associated with differences in recovery between children with Bell’s palsy and those with Lyme-related facial palsy.

Further research is needed to better understand the optimal management of facial palsy in children.

Clinical Perspective

In my clinical practice in a Lyme-endemic region, facial nerve palsy is one of the more recognizable neurologic presentations of Lyme disease in children. Awareness of this presentation may help clinicians consider Lyme disease when children develop sudden facial weakness.

Final Thoughts

Facial nerve palsy in children can have several causes, but Lyme disease remains an important consideration in endemic regions. Recognizing the clinical features that distinguish Lyme-related facial palsy from Bell’s palsy can help guide appropriate evaluation and treatment.

Early recognition also helps ensure that children with Lyme disease receive appropriate care while avoiding unnecessary testing in uncomplicated cases.

Reference

Guez-Barber, D., Swami, S. K., Harrison, J. B., & McGuire, J. L. (2022). Differentiating Bell’s palsy from Lyme-related facial palsy. Pediatrics, 149(6), e2021053992. https://doi.org/10.1542/peds.2021-053992