Bell’s Palsy in Children: Could Lyme Disease or a Tick Bite Be the Cause?

Bell’s palsy in children may be caused by Lyme disease
Facial nerve palsy can appear even without rash or tick bite history
Early recognition and treatment decisions may affect recovery

Bell’s palsy in children is not always idiopathic. In Lyme-endemic areas, facial nerve palsy may be one of the earliest or only signs of infection. A retrospective review of children evaluated at University Hospital Southampton found substantial variation in testing and treatment approaches for Bell’s palsy associated with Lyme disease.

The retrospective review included 93 children with idiopathic Bell’s palsy evaluated at University Hospital Southampton NHS Foundation Trust from 2010 to 2017. Idiopathic facial nerve palsy, formerly called Bell’s palsy, is frequently seen in early Lyme disease. Testing limitations discussed in Lyme test accuracy may complicate diagnosis early in illness.

Can Lyme disease cause Bell’s palsy?

Very few children in the study with Bell’s palsy reported a tick bite or rash. Only 14% recalled a tick bite, while 5% reported a rash. Lyme disease testing was performed on 76 of the 93 children. Of those tested, 22 children (29%) were positive for Lyme disease.

These findings reinforce that pediatric Lyme disease may present without classic features. As the authors noted, facial nerve palsy may occasionally be the sole presenting symptom.

Can a tick bite cause Bell’s palsy?

Parents often ask whether Bell’s palsy after a tick bite should raise concern for Lyme disease. The challenge is that many children with Lyme-associated Bell’s palsy never recall a bite or notice a rash.

Children presenting with facial paralysis, facial weakness, or asymmetric smile changes after outdoor exposure may warrant evaluation, particularly in endemic areas. Delays may contribute to delayed Lyme disease diagnosis.

Neuroimaging and facial nerve findings

Neuroimaging was performed in approximately 20% of the children. The most common findings were consistent with inflammation or infection of the facial nerve. These neurologic presentations overlap with broader discussions around neurologic Lyme disease.

Despite increased awareness of Lyme disease in the Hampshire region, nearly one in five children were not tested for Lyme disease.

Bell’s palsy treatments varied considerably

The authors reported substantial variability in management patterns. Some children appeared to receive no treatment at all.

• 73.1% received antibiotics
• Treatment duration ranged from 1–28 days, with a median of 14 days
• 44% received prednisolone
• More than 17% received antiviral medication
• Nearly 20% underwent neuroimaging

The study was not designed to determine outcomes. However, important questions remain: Could steroid use affect outcomes? Could undertreatment influence long-term recovery? Would some children develop persistent complications?

Why Lyme disease Bell’s palsy may be missed in children

Facial palsy may appear before other Lyme symptoms emerge. Children may not complain of fatigue, pain, or cognitive symptoms until later, making diagnosis more difficult.

Parents and clinicians evaluating unexplained facial weakness may also find it useful to review broader symptom patterns in the Lyme disease symptoms guide.

The authors concluded that Lyme disease should be strongly considered in endemic areas because facial nerve palsy may be the only sign of infection.

Frequently Asked Questions

Can Lyme disease cause Bell’s palsy in children?

Yes. Lyme disease can cause facial nerve palsy, particularly in endemic regions where exposure risk is higher.

Can a tick bite cause Bell’s palsy?

Yes. Tick-borne Lyme disease is one recognized cause of facial nerve palsy, though many patients do not remember a bite.

Do children with Lyme Bell’s palsy always have a rash?

No. In this study, very few children reported rash or tick exposure despite positive Lyme testing.

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

Testing decisions depend on geography, exposure risk, and symptoms, but Lyme disease should be considered in endemic areas.

Is Bell’s palsy always idiopathic?

No. Infection, including Lyme disease, may account for a subset of pediatric facial nerve palsy cases.

Clinical Takeaway

Bell’s palsy in children may be one of the earliest signs of Lyme disease, even without rash or known tick exposure.

Facial nerve palsy in endemic regions deserves careful evaluation because delayed recognition may affect diagnosis, treatment decisions, and recovery.

Related Articles

Explore additional resources on neurologic Lyme disease and pediatric presentations:

Steroids harmful to patients with Bell’s palsy caused by Lyme disease
Case report: Bell’s palsy and Lyme disease
Clinical judgement leads to successful Lyme disease treatment in young child
Lyme disease misdiagnosis
Persistent Lyme disease symptoms

References

1. Munro APS, Dorey RB, Owens DR, Steed DJ, Petridou C, Herdman T, Jones CE, Patel SV, Pryde K, Faust SN. High frequency of paediatric facial nerve palsy due to Lyme disease in a geographically endemic region. Int J Pediatr Otorhinolaryngol. 2020;132:109905.

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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