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

A 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 seen in early Lyme disease.

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

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

Surprisingly, despite increased awareness of Lyme disease in the Hampshire region, nearly 1 in 5 children in the study were not tested for the tick-borne disease. Additionally, the authors point out, “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
• The number of treatment days varied from 1 to 28, with a median of 14 days
• 44% of the children were treated with the oral steroid, prednisolone
• Over 17% were prescribed an antiviral medication
• Nearly 20% received neuroimaging

The study was not designed to determine the outcome for these children. The study raises several unanswered questions: Could steroid use in these children affect the outcome? Could little or no treatment affect their outcome? Would any of these children develop long-term complications?

Why Testing and Treatment Variability Matters

The lack of consistent testing and treatment protocols has significant implications for children in endemic areas. Nearly 1 in 5 children presenting with facial nerve palsy were not tested for Lyme disease at all, despite living in an area with known tick-borne disease risk.

The use of steroids in nearly half the children is particularly concerning. Research suggests that corticosteroids, while helpful for viral Bell’s palsy, may worsen outcomes when the cause is 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] FNP 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 FNP, 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 clinicians on the investigation and management of Lyme disease.

Frequently Asked Questions

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

In this UK study, 29% of children tested positive for Lyme disease. However, nearly 1 in 5 children were never tested at all, meaning the true percentage could be higher. This underscores why testing is essential in endemic areas.

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

Yes, particularly in areas where Lyme disease is endemic. The study authors recommend that all children presenting with facial nerve palsy should have Lyme serology tested and empirical treatment initiated 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 (nymph stage), attach in hidden locations like the scalp or behind the ear, and cause no pain when biting. Absence of a tick bite should never 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 shows that patients treated with corticosteroids often experience long-term facial nerve dysfunction. However, 44% of children in this study received steroids, highlighting the need for Lyme testing before treatment decisions.

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

The study authors recommend empirical antibiotic treatment for Lyme disease while awaiting test results. Treatment duration in the study ranged from 1 to 28 days (median 14 days), though optimal duration remains unclear and should be individualized based on response.

Clinical Takeaway

This UK study reveals concerning gaps in Lyme disease recognition and treatment for children presenting with Bell’s palsy. Despite living in an endemic region, nearly 20% were never tested, and treatment varied wildly—from no treatment at all to 28 days of antibiotics. The 29% positive rate among tested children 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 empirical treatment while awaiting results. For parents: if your child develops facial weakness, advocate for Lyme testing regardless of whether you recall a tick bite—86% of these children didn’t either.