Corticosteroids vs Supportive Care for Paediatric Bell’s Palsy

Date First Published:
January 5, 2026
Last Updated:
January 5, 2026
Report by:
Qais Mousa, Senior Clinical Fellow in Emergency Department (North Manchester General hospital, MFT)
Search checked by:
Mohsin bin majid, Specialty Doctor in Emergency Department (North Manchester General Hospital. MFT)
Three-Part Question:
In [children with idiopathic Bell’s palsy (presenting within 72 hours)] )], is [oral corticosteroids superior to supportive care/no steroids] ] for [faster recovery and higher rates of complete facial nerve recovery]?
Clinical Scenario:
A 7-year-old presents to the Emergency Department with 48 hours of sudden left-sided lower motor neuron facial weakness. The features are consistent with Bell’s palsy. You must decide whether to start oral prednisolone or only provide supportive care alone.
Search Strategy:
A previous BestBET (Ashtekar et al., 2005) concluded: “Currently there is no evidence to recommend the use of corticosteroids for the treatment of Bell’s palsy in children.” Given the time elapsed, We conducted a focused literature search in PubMed (including MEDLINE-indexed and publisher-supplied records) for studies published 2004–2025, aiming to identify evidence on the use of systemic corticosteroids for paediatric Bell’s palsy.
Search Details:
Search terms:
"Bell Palsy"[Mesh] OR "Bell* palsy"[tiab])
AND (Child[Mesh] OR child*[tiab] OR pediatric*[tiab] OR paediatric*[tiab])
AND (prednisolone[tiab] OR prednisone[tiab] OR steroid*[tiab])
Outcome:
76 publications were identified. After screening, 10 were relevant: 9 on corticosteroid/prednisolone treatment in paediatric Bell’s palsy, and 1 on risk of new-onset malignancy after an ED diagnosis (which can inform the clinical decision to treat or not to treat)
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Pediatric Bell's Palsy: Prognostic Factors, Management Strategy, and Treatment Outcomes Lorenzo Di Sarno 1, Anya Caroselli 2, Benedetta Graglia 2, Francesco Andrea Causio 3, Antonio Gatto 1, Valeria Pansini 1, Natalia Camilla Di Vizio 2, Antonio Chiaretti 2 27/12/2024 Italy 88 children (<18 y) with Bell’s palsy at a single tertiary care center Retrospective cohort, observational Primary: complete recovery at 2 months (HB grade 1). Secondary: association of prednisone use and dose with recovery 2 months; prednisone use associated with higher incomplete recovery at 2 months. Higher prednisone dose correlated with poorer outcomes . Vitamin supplementation no significant impact. Single-center; retrospective; treatment non randomized (confounding by indication and by severity); short follow up (2 months); limited adjustment for timing of treatment/onset and co interventions
Facial Function in Bell Palsy in a Cohort of Children Randomized to Prednisolone or Placebo 12 Months After Diagnosis Franz E Babl 1, David Herd 2, Meredith L Borland 3, Amit Kochar 4, Ben Lawton 5, Jason Hort 6, Adam West 7, Shane George 8, Ed Oakley 9, Catherine L Wilson 10, Sandy M Hopper 11, John A Cheek 12, Stephen Hearps 10, Mark T Mackay 13, Stuart R Dalziel 14, Katherine J Lee 15 11/01/2024 Australia Children aged 6 months to <18 y with Bell’s palsy enrolled in a multicenter RCT of prednisolone vs placebo (n randomized = 187: 93 steroid, 94 placebo). Randomized controlled trial follow up at 12 months Proportion with complete recovery at 6 and 12 months by clinician administered House–Brackmann (HB) and modified parent administered HB scales. No statistically significant differences; vast majority recovered by 6–12 months regardless of treatment. limited power
for small
differences;
some outcomes relied on parent-reported history, introducing potential reporting bias
Efficacy of High-Dose Corticosteroid Therapy in Acute Stage Severe Facial Palsy in Children Shintaro Baba, Kenji Kondo 1, Ai Yoshitomi 2, Kenshiro Taniguchi 2, Muneo Nakaya 3, Tatsuya Yamasoba 1 29/11/2022 Japan 18 Children with severe Bell’s palsy (HB VI): high-dose prednisolone 3–4 mg/kg/day for 2–3 days + 10-day taper (n=10) vs low-dose 0.5–1 mg/kg/day + taper (n=8). Observational comparative cohort (non-randomized) Facial nerve recovery (House–Brackmann grade) and development of synkinesis (synkinesis index) at follow-up. Pediatric high-dose group had better HB scores than low-dose (p<0.01); lower synkinesis index than pediatric low-dose and adult high-dose (p<0.05). Very small sample, non-randomized dosing (confounding), no no-steroid control, limited/unclear follow-up details, possible case-mix issues (idiopathic vs other)
Efficacy of Low-Dose Corticosteroid Therapy Versus High-Dose Corticosteroid Therapy in Bell's Palsy in Children Pinar Arican 1, Nihal Olgac Dundar 2, Pinar Gencpinar 1, Dilek Cavusoglu 2 30/09/2016 Japan Children with idiopathic (Bell’s) facial nerve palsy treated with oral prednisolone, divided into low-dose vs high-dose groups; severity graded by House–Brackmann; reassessed at 1, 3, and 6 months. Retrospective comparative cohort (non-randomized) Complete recovery at 1, 3, 6 months (House–Brackmann–based) No significant difference in complete recovery between low-dose vs high-dose at 1, 3, or 6 months; authors conclude prednisolone 1 mg/kg/day was highly effective overall. non-randomized dosing (confounding by indication/severity), no no-steroid control,
Comparison of the Efficacy of Combination Therapy of Prednisolone - Acyclovir with Prednisolone Alone in Bell's Palsy Ali Khajeh 1, Afshin Fayyazi 2, Gholamreza Soleimani 1, Ghasem Miri-Aliabad 1, Sara Shaykh Veisi 3, Behrouz Khajeh 4 2015 Iran 43 children (age 2–18 y) with Bell’s palsy, randomized to prednisolone alone (n=23) vs prednisolone + acyclovir (n≈20). Assessed with the House–Brackmann (HB) scale Randomized controlled trial Complete recovery (HB grade I) at follow-up; baseline comparability (age/sex) 65.2% (prednisolone) vs 90% (prednisolone + acyclovir), p=0.04. Age/sex not associated with recovery; no other between-group baseline differences. Small sample, unclear randomization/blinding, no no-steroid control (both groups received steroids)
Management of Bell's palsy in children: an audit of current practice, review of the literature and a proposed management algorithm Amir Saam Youshani 1, Bimal Mehta 2, Katharine Davies 3, Helen Beer 3, Sujata De 3 6/12/2023 UK Paediatric Bell’s palsy cases presenting within 72 h; audit cycle 1: n=17; re-audit: n=8 Clinical audit (two-cycle) + narrative literature review Audit metrics — HB grade documented, initial treatment given (steroids/antivirals/both/none), ENT follow-up, and recovery documentation The initial audit demonstrated wide variation in management, with incomplete documentation of House–Brackmann grade, steroids given in a minority of cases, and inconsistent ENT follow-up. Following introduction of a local management protocol, re-audit showed improved documentation, 100% of children receiving steroid treatment, and 100% having ENT follow-up arranged, indicating improved adherence to evidence-based care Small numbers, single-region audit, not randomized; no direct comparison of steroid vs supportive care on outcomes
Do oral steroids aid recovery in children with Bell's palsy? Abdul Qader Ismail 1, Oluwaseyi Alake 2, Chetana Kallappa 2 29/10/2024 UK Notes review of 100 children coded for facial nerve palsy over 12 years; 79 had Bell’s palsy Retrospective longitudinal cohort (observational Time to resolution of symptoms (weeks); overall recovery Time to resolution of symptoms (weeks); overall recovery All 79 children with Bell’s palsy recovered. Median time to resolution 5 weeks (treated) vs 6 weeks (untreated), P=0.86 — no significant difference non-randomized (confounding by indication); no standardized severity measure reported; dosing/timing of steroids unclear
Medium term outcome in Bell's palsy in children Roisin McNamara 1, Jennifer Doyle, Mary Mc Kay, Peter Keenan, Franz E Babl 30/6/2013 Irland 48 presentations (45 children) with Bell’s palsy at an Irish paediatric ED; Retrospective cohort (single-centre) Primary: resolution at 6–18 months (telephone follow-up). Secondary: ED treatment given, imaging, and time to resolution Follow-up reached 35/48 at 6–18 months: 28/35 (80%) complete recovery, 6/35 (17%) residual weakness, 1/35 (3%) no improvement. Among those with treatment data, complete recovery was 9/13 (69%) with prednisolone vs 19/22 (86%) without; p=0.22 — no significant difference (cannot show steroids help) Retrospective, incomplete follow-up (35/48), non-randomised treatment (confounding by indication), dose/timing not reported, single centre; lacks standardised severity scoring
Outcomes of facial palsy in children Wei-Hsun Shih 1, Fen-Yu Tseng, Te-Huei Yeh, Chuan-Jen Hsu, Yuh-Shyang Chen 12/8/2009 Taiwan 56 children <15 y with facial palsy Retrospective chart review (single-centre) Etiology distribution; recovery/outcome of Bell’s palsy; effect of prednisolone use and timing (≤1 week vs >1 week). In pediatric Bell’s palsy, prednisolone made no significant difference in recovery, and starting within 1 week vs later also showed no difference. Overall prognosis for Bell’s palsy was good, with recovery usually within ~3 months Retrospective; small sample; mixed etiologies (not Bell’s-only); likely non-standardised severity measures/dosing; single centre; follow-up details limited
Risk of malignancy following emergency department Bell's palsy diagnosis in children Patrick S Walsh 1, James M Gray 2, Sriram Ramgopal 3, Matthew J Lipshaw 4 March 2022 USA Children 6 months–17 years with an ED diagnosis of Bell’s palsy in the Pediatric Health Information System, 2011–2020; n = 12,272 encounters after excluding prior neurologic conditions or known malignancy Retrospective cohort using a large administrative database — observational Primary: new oncologic diagnosis within 60 days of the ED visit. 41/12,272 = 0.33% (95% CI 0.25–0.45%) had a new malignancy within 60 days; median 22 days to diagnosis. Most were primary CNS tumors (59%) and leukemia (17.1%). Higher incidence in younger children: <2 y 0.68%, 2–5 y 0.70%, 6–11 y 0.26%, 12–17 y 0.21%. database review; possible coding/selection bias; no standardized severity data or outcomes
Secondary: time to diagnosis, malignancy type, and age-stratified incidence.
Author Commentary:
Currently, there is no clear paediatric evidence that oral corticosteroids improve recovery in Bell’s palsy compared with supportive care. The only multicentre paediatric RCT showed no meaningful difference between prednisolone and placebo at 6-12 months and multiple cohorts steroid studies show no advantage of steroids, as most children recover spontaneously by 3-6 months. A small, non-randomised study in severe cases suggested benefit with higher dose regimens, but its size and design severely limits confidence and generalisability. From a practical point of view, short steroid courses are well tolerated, but the routine use of prednisolone is difficult to justify given the high natural recovery rate coupled with the uncertain benefit. Clinical vigilance remains essential. A recent large database study reports a small but clinically relevant risk of new malignancy within 60 days, after the ED diagnosis of Bell’s Palsy, particularly in younger children. Clinicians should try and obtain a detailed history and do a neurological examination, check for red flags, and arrange follow-up, before deciding on a treatment regimen. Evidence gaps include adequately powered paediatric RCTs and research on whether steroid use could delay recognition of serious alternative diagnoses.
Bottom Line:
The majority of children recover without oral corticosteroids in 3–6 months, and pediatric studies to date have not demonstrated a significant benefit over supportive care. Therefore, we do not recommend routine prednisolone use, especially in light of the need to avoid any delay in identifying rare but serious alternative diagnoses (particularly primary CNS tumors and leukemia). Use shared decision-making with families, provide clear safety-netting with appropriate follow-up, and make decisions case-by-case after ruling out red flags, pending more solid evidence and clear pediatric guidelines.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
  1. Lorenzo Di Sarno 1, Anya Caroselli 2, Benedetta Graglia 2, Francesco Andrea Causio 3, Antonio Gatto 1, Valeria Pansini 1, Natalia Camilla Di Vizio 2, Antonio Chiaretti 2. Pediatric Bell's Palsy: Prognostic Factors, Management Strategy, and Treatment Outcomes
  2. Franz E Babl 1, David Herd 2, Meredith L Borland 3, Amit Kochar 4, Ben Lawton 5, Jason Hort 6, Adam West 7, Shane George 8, Ed Oakley 9, Catherine L Wilson 10, Sandy M Hopper 11, John A Cheek 12, Stephen Hearps 10, Mark T Mackay 13, Stuart R Dalziel 14, Katherine J Lee 15. Facial Function in Bell Palsy in a Cohort of Children Randomized to Prednisolone or Placebo 12 Months After Diagnosis
  3. Shintaro Baba, Kenji Kondo 1, Ai Yoshitomi 2, Kenshiro Taniguchi 2, Muneo Nakaya 3, Tatsuya Yamasoba 1. Efficacy of High-Dose Corticosteroid Therapy in Acute Stage Severe Facial Palsy in Children
  4. Pinar Arican 1, Nihal Olgac Dundar 2, Pinar Gencpinar 1, Dilek Cavusoglu 2. Efficacy of Low-Dose Corticosteroid Therapy Versus High-Dose Corticosteroid Therapy in Bell's Palsy in Children
  5. Ali Khajeh 1, Afshin Fayyazi 2, Gholamreza Soleimani 1, Ghasem Miri-Aliabad 1, Sara Shaykh Veisi 3, Behrouz Khajeh 4. Comparison of the Efficacy of Combination Therapy of Prednisolone - Acyclovir with Prednisolone Alone in Bell's Palsy
  6. Amir Saam Youshani 1, Bimal Mehta 2, Katharine Davies 3, Helen Beer 3, Sujata De 3. Management of Bell's palsy in children: an audit of current practice, review of the literature and a proposed management algorithm
  7. Abdul Qader Ismail 1, Oluwaseyi Alake 2, Chetana Kallappa 2. Do oral steroids aid recovery in children with Bell's palsy?
  8. Roisin McNamara 1, Jennifer Doyle, Mary Mc Kay, Peter Keenan, Franz E Babl. Medium term outcome in Bell's palsy in children
  9. Wei-Hsun Shih 1, Fen-Yu Tseng, Te-Huei Yeh, Chuan-Jen Hsu, Yuh-Shyang Chen. Outcomes of facial palsy in children
  10. Patrick S Walsh 1, James M Gray 2, Sriram Ramgopal 3, Matthew J Lipshaw 4. Risk of malignancy following emergency department Bell's palsy diagnosis in children