Facial Palsy in Children: Could It Be Lyme Disease?
Facial palsy in children may be caused by Lyme disease, particularly in endemic regions during summer and fall. Although Bell’s palsy is common, Lyme-related facial palsy should be considered when a child develops sudden facial weakness after outdoor exposure or after a recent systemic illness.
Because children with Lyme-related facial palsy often do not recall a tick bite or rash, the diagnosis may be missed if clinicians rely too heavily on those features alone.
For a broader overview, see the Pediatric Lyme Disease guide.
What Parents May Notice First
Facial palsy in children often appears suddenly. Parents may notice:
- An uneven smile
- Drooping on one side of the face
- Difficulty closing one eye
- Drooling or difficulty holding liquids in the mouth
- Speech sounding slightly slurred
Although these symptoms can be alarming, facial palsy in children is usually not a stroke. However, it should prompt careful medical evaluation to determine the underlying cause.
Bell’s Palsy and Lyme Disease Are Common Causes
Acute unilateral facial weakness in children is usually described as peripheral facial palsy or seventh cranial nerve palsy. In everyday clinical practice, many patients and clinicians refer to this simply as Bell’s palsy.
Strictly speaking, Bell’s palsy refers to facial paralysis with no identifiable cause. Lyme disease is one of several infections that can produce the same clinical picture.
In a large pediatric study from a Lyme-endemic region, 27% of children presenting with acute unilateral facial palsy had Lyme-related facial palsy, while 68% were diagnosed with Bell’s palsy.
This overlap means Lyme disease should remain part of the differential diagnosis whenever a child presents with facial weakness in an endemic area.
When Lyme-Related Facial Palsy Is More Likely
Several clinical clues may help distinguish Lyme-related facial palsy from Bell’s palsy.
- Presentation between late spring and early fall
- Recent fever, malaise, headache, myalgias, or arthralgias
- Outdoor exposure in a tick-endemic region
- Absence of a recent upper respiratory infection
In the study, 93% of children with Lyme-related facial palsy presented between June and November. More than half had a preceding systemic prodrome, compared with only 6% of children with Bell’s palsy.
Tick Bite and Rash Are Often Absent
Many parents expect Lyme disease to begin with a known tick bite or the classic bull’s-eye rash. However, these features are often missing in children with Lyme-related facial palsy.
In the study, only 30% of children with Lyme-related facial palsy had a recent erythema migrans rash, and only a few recalled a tick bite.
This reinforces an important point: the absence of a rash or remembered tick bite does not rule out Lyme disease.
See also Only a Minority of Children With Lyme Disease Recall a Tick Bite.
Facial Palsy May Be the First Sign of Lyme Disease
In some children, facial palsy may be the first recognizable manifestation of Lyme disease. The infection can affect the facial nerve as part of early disseminated Lyme disease.
Children may also develop other neurologic symptoms such as headache, neck stiffness, sensitivity to light, or fatigue if meningitis is present.
In rare cases, Lyme disease can cause bilateral facial palsy, affecting both sides of the face. This pattern is uncommon in idiopathic Bell’s palsy and should prompt evaluation for infectious causes.
Bell’s Palsy, Seventh Nerve Palsy, and Lyme Disease
Because seventh cranial nerve palsy may be described as Bell’s palsy early in its course, distinguishing between idiopathic Bell’s palsy and Lyme-related facial palsy can be challenging at the initial visit.
Laboratory testing, exposure history, seasonality, and associated symptoms may help clarify the diagnosis over time.
The Question of Corticosteroids
Corticosteroids are commonly prescribed for Bell’s palsy because studies in adults suggest they may improve facial nerve recovery.
However, the role of corticosteroids in Lyme-related facial palsy remains uncertain. Some adult studies have suggested that corticosteroids given in Lyme-associated facial palsy may be associated with worse long-term facial outcomes.
Evidence in children remains limited, and treatment decisions are often individualized.
In clinical practice, some children present with features consistent with both Bell’s palsy and Lyme disease. When suspicion for Lyme disease is significant, clinicians may evaluate for Lyme disease and consider antibiotic therapy while awaiting test results.
Do Imaging or Lumbar Puncture Help?
In children with isolated peripheral facial palsy, neuroimaging and lumbar puncture usually do not add diagnostic value.
These tests are generally reserved for children with additional neurologic signs, atypical symptoms, or lack of improvement.
Most Children Recover
The overall prognosis for pediatric facial palsy is reassuring. In the study, nearly all children with Bell’s palsy or Lyme-related facial palsy ultimately recovered.
Although facial weakness can be distressing for families, most children improve with appropriate evaluation and care.
When to Suspect Lyme Disease in a Child With Facial Palsy
Lyme disease should be considered when facial palsy occurs in a child who:
- Lives in or recently visited a Lyme-endemic region
- Presents during late spring, summer, or fall
- Had recent fever, headache, or fatigue
- Has no clear alternative explanation
For a broader recognition guide, see When to Suspect Lyme Disease in Children.
Clinical Perspective
In my practice, Lyme disease should remain on the differential diagnosis whenever a child presents with facial palsy in an endemic region, even when there is no remembered tick bite or rash.
The combination of season, exposure history, and systemic symptoms can provide important clues that the facial weakness may be part of a broader infectious illness.
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
