Original Article

Journal of Child Neurology

1-4
Efficacy of Low-Dose Corticosteroid ª The Author(s) 2016
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Therapy Versus High-Dose Corticosteroid DOI: 10.1177/0883073816668774
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Therapy in Bell’s Palsy in Children

Pinar Arican, MD1, Nihal Olgac Dundar, MD2, Pinar Gencpinar, MD1,
and Dilek Cavusoglu, MD2

Abstract
Bell’s palsy is the most common cause of acute peripheral facial nerve paralysis, but the optimal dose of corticosteroids in
pediatric patients is still unclear. This retrospective study aimed to evaluate the efficacy of low-dose corticosteroid therapy
compared with high-dose corticosteroid therapy in children with Bell’s palsy. Patients were divided into 2 groups based on the
dose of oral prednisolone regimen initiated. The severity of idiopathic facial nerve paralysis was graded according to the House-
Brackmann Grading Scale. The patients were re-assessed in terms of recovery rate at the first, third, and sixth months of
treatment. There was no significant difference in complete recovery between the 2 groups after 1, 3, and 6 months of treatment.
In our study, we concluded that even at a dose of 1 mg/kg/d, oral prednisolone was highly effective in the treatment of Bell’s palsy
in children.

Keywords
facial nerve paralysis, treatment, children, corticosteroids, Bell’s palsy

Received March 8, 2016. Received revised June 2, 2016. Accepted for publication June 29, 2016.

Bell’s palsy is an acute, unilateral, peripheral paralysis of the
facial nerve.1 The annual incidence of Bell’s palsy is approx-
imately 6.1 cases per 100 000 in children aged between 1 and
15 years.2,3 The etiology of paralysis remains unknown, but it
may arise due to inflammation and edema of the facial nerve.4,5
A number of treatment options has been tried with varying
results. Corticosteroids and antiviral drugs are widely used
either alone or in combination. The use of corticosteroids in
the course of Bell’s palsy is known to improve the chances of
recovery; corticosteroid treatment may prevent further nerve
damage and is beneficial in most cases.6 Although the optimal
dose of corticosteroids in pediatric patients is still unclear, the
use of oral corticosteroids is recommended preferably within 3
days from onset of symptoms.7
In this study, we retrospectively compared the efficacy of
low-dose corticosteroid therapy (1 mg/kg/d oral prednisolone)
with high-dose corticosteroid therapy (2 mg/kg/d oral predni-
solone) in the treatment of Bell’s palsy in children.
Materials and Methods
This retrospective study was conducted on children diagnosed with
Bell’s palsy from January 2014 to January 2016. The demographic
data, clinical presentation, management and clinical outcome of
patients were collected from the medical records and reviewed. The
study protocol was approved by local ethics committee. All children
were allowed to assent or decline, and informed consent was obtained
from all caregivers after they were informed about the aims and meth-
ods of the study.
Patients aged 0 to 18 years were included in the study if they were
diagnosed with Bell’s palsy. Exclusion criteria included patients with
paralysis of other cranial nerves, passing more than 3 days past of
symptom onset, patients older than 18 years, and presence of second-
ary causes of the seventh nerve palsy.
The optimal dose of corticosteroids is not clear in children with
Bell’s palsy. The recommended treatment regimen for corticosteroids
is 1 to 2 mg/kg/d. Some patients were treated with a dose of 1 mg/kg/d
and the others with a dose of 2 mg/kg/d.
Patients with Bell’s palsy were divided into 2 groups based on the
dose of oral prednisolone regimen initiated. Patients in group 1
received 1 mg/kg/d oral prednisolone whereas those in group 2 were
treated with 2 mg/kg/d oral prednisolone for 5 days followed by 10
days’ taper. Acyclovir therapy and home-based exercise program
1
Department of Pediatric Neurology, Izmir Tepecik Education and Research
Hospital, Izmir, Turkey
2
Department of Pediatric Neurology, Izmir Katip Celebi University, Izmir,
Turkey
Corresponding Author:
Nihal Olgac Dundar, MD, Department of Pediatric Neurology, Izmir Tepecik
Education and Research Hospital, Yenisehir 35120, Izmir, Turkey.
Email: nodundar@gmail.com

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2 Journal of Child Neurology

Table 1. Demographic Characteristics and Clinical Features in Table 2. Outcome Assessment at 1, 3, and 6 Months Between the 2
Patients With Bell’s Palsy. Groups.

Group 1 Group 2 Total Group 1 Group 2

(n ¼ 35) (n ¼ 53) (n ¼ 88) Follow-up (n ¼ 35) (n ¼ 53) P Value

Gender, n (%) 1-month follow-up, n (%) .82

Female 18 (51%) 34 (64%) 52 (59%) Complete 15 (43%) 24 (45%)
Male 17 (49%) 19 (36%) 36 (41%) Partial 20 (57%) 29 (55%)
Age, y (median) 12 11 11 3-month follow-up, n (%) .21
Affected side, n (%) Complete 23 (66%) 42 (79%)
Right 15 (43%) 26 (49%) 41 (47%) Partial 12 (34%) 11 (21%)
Left 20 (57%) 27 (51%) 47 (53%) 6-month follow-up, n (%) .26
HB FGS, n (%) Complete 27 (77%) 46 (87%)
Grade II 0 (0%) 0 (0%) 0 (0%) Partial 8 (23%) 7 (13%)
Grade III 3 (9%) 3 (6%) 6 (7%)
Grade IV 13 (37%) 14 (26%) 27 (31%)
Grade V 19 (54%) 36 (68%) 55 (62%)
Grade VI 0 (0%) 0 (0%) 0 (0%)
Fifty-five (62%) patients had grade V, 27 (31%) patients grade
Time between onset of symptoms IV, and 6 (7%) patients grade III facial nerve paralysis at the
and start of treatment, n (%) time of first presentation in outpatient clinics.
Within 24 hours 23 (66%) 22 (41%) 45 (51%) As regards the treatment groups, group 1 consisted of 35
Within 48 hours 9 (26%) 22 (41%) 31 (35%) patients treated with 2 mg/kg/d oral prednisolone and group 2
Within 72 hours 3 (8%) 9 (18%) 12 (14%) consisted of 53 patients treated with 1 mg/kg/d oral
Abbreviation: HB FGS, House-Brackmann Facial Grading System. prednisolone.
There was no significant difference in the distribution of
facial grades between the 2 groups (P > .05). There were no
consisting of training the facial muscles following a standardized significant intergroup differences in age, sex, and the duration
protocol were initiated in all patients at the time of diagnosis. between onset and treatment (P > .05). Table 2 presents the
Cranial magnetic resonance imaging or computed tomography was
outcome data after 1 month, 3 months, and 6 months of treat-
performed in all patients to rule out other possible sources of pressure
ment between the 2 groups.
on the facial nerve, such as a tumor or skull fracture.
The severity of idiopathic facial nerve paralysis was graded based After 1 month of treatment, 15 (43%) patients from group 1
on the House-Brackmann Grading Scale.8 Based on the House- and 24 (45%) patients from group 2 were completely recov-
Brackmann criteria, the response to treatment are graded as complete ered. Twenty (57%) patients from group 1 and 29 (55%)
recovery (grade 1) and partial recovery (grade 2-4). The patients were patients from group 2 were partially recovered. No statistically
reassessed in terms of recovery rate at the first, third, and sixth months significant differences were observed between the 2 treatment
of treatment. groups (P > .05).
After 3 months of treatment, 23 (66%) patients from group 1
Statistical Analysis and 42 (79%) patients from group 2 had complete recovery,
whereas 12 (34%) and 11 (21%) patients, respectively, had
Statistical analysis was performed using Statistical Package for the
partial recovery. No statistically significant differences were
Social Sciences (SPSS) for Windows. Frequencies and percentages
observed between the 2 treatment groups (P > .05).
were calculated. Patient age was also described using medians and
interquartile ranges. The chi-square test and Fisher exact test were After 6 months of treatment, 27 (77%) patients from group 1
used for comparison between independent groups of categorical data. and 46 (87%) from group 2—a total of 73 (83%) patients—
For all statistical tests, values of P < .05 (2-tailed) were considered showed complete recovery. A total of 15 (17%) patients, with 8
statistically significant. (23%) patients from group 1 and 7 (13%) patients from group 2,
showed partial recovery. In both groups, patients showed
improvement in the symptoms and the results were statistically
Results nonsignificant between the 2 groups (P > .05).
A total number of 88 patients with Bell’s palsy were reviewed,
of whom 52 (59%) were female and 36 (41%) male with a
median age of 11 years (interquartile range ¼ 7-14). The demo-
Discussion
graphic and clinical data of the patients are presented in Table Bell’s palsy is the most common cause of acute peripheral
1. Bell’s palsy affected the left side in 47 (53%) and the right facial nerve paralysis and is a diagnosis of exclusion requiring
side in 41 (47%) patients. the other causes of acute peripheral facial nerve palsy to be
After the onset of symptoms, most patients (51%) initiated ruled out.9 In this study, we evaluated the efficacy of 1 mg/kg/d
treatment within 24 hours, 35% within 48 hours, and 14% oral prednisolone, compared with 2 mg/kg/d oral prednisolone.
within 72 hours. All the patients were graded according to the In a retrospective study by Chen et al, it was reported that
House-Brackmann Grading Scale during initial presentation. the mean age of Bell’s palsy in children was 6 years 7 months,

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Arican et al
52.6% of patients were male and also 44.4% of patients had
right-sided Bell’s palsy.10 In another study, Cubukcu et al
showed that the mean age of Bell’s palsy was 9 years 5 months,
57.5% of patients with Bell’s palsy were female, and 52.2% of
patients had right-sided Bell’s palsy.11 Our findings with
respect to gender, age, and the affected side of the face are
consistent with these studies.
In Bell’s palsy, the main limitations regarding drug therapy
in children concern the lack of controlled clinical trials on
children.12 The use of oral corticosteroids is recommended,7
although several studies did not find significant differences
between the outcomes of children treated with corticosteroids
and not.13,14 Treatment with oral corticosteroids for children
with Bell’s palsy is consistent with guidelines from the Amer-
ican Academy of Neurology.15
There is still lack of strong evidence for an optimal dose for
clinical practice in children. There are some reports in the
literature supporting the use of 1 mg/kg/d oral predniso-
lone,16,17 whereas the others support the use of 2 mg/kg/d in
the treatment of Bell’s palsy in children.18 We found that 1 mg/
kg/d oral prednisolone administration is as effective as 2 mg/
kg/d treatment with oral prednisolone in patients with Bell’s
palsy after 1, 3, and 6 months of treatment.
Corticosteroid treatment in patients with Bell’s palsy
showed better results if started within 72 hours of symptom
onset.19,20 An antiviral combined with a corticosteroid is pos-
sibly effective in improving facial functional outcomes in
patients with Bell’s palsy.15 Physical therapy may offer shorter
recovery time and greater proportion of patients with normal
nerve function.21 Because all patients had received acyclovir
treatment with prednisolone and physical therapy within 72
hours of symptom onset, we could not make any conclusions
on their effect on the outcome of the disease.
The main limitation of this study is its retrospective design.
Further prospective, randomized controlled trials are needed to
evaluate the optimal dose of corticosteroids in children with
Bell’s palsy.
The treatment of Bell’s palsy focuses on improving facial
nerve function and reducing neuronal damage. In our study, we
concluded that even at a dose of 1 mg/kg/d oral prednisolone
was highly effective in the treatment of Bell’s palsy in children.
Authors’ Note
This work was performed at the Izmir Tepecik Education and
Research Hospital. There was no assistance or efforts beyond those
of the primary authors.
Author Contributions
PA prepared the original manuscript and performed the data collection.
NOD and PG contributed to the statistical analysis, writing, and revision
of the final manuscript. DC assisted in the preparation of the manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
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3
Ethical Approval
The local ethics committee approved this study (approval number:
70-11.03.2016).
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
References
1. Gilden DH. Bell’s palsy. N Engl J Med. 2004;351:1323-1331.
_ Saygı S, Yılmaz I.
2. Özkale Y, Erol I, _ Overview of pediatric per-
ipheral facial nerve paralysis: analysis of 40 patients. J Child
Neurol. 2015;30:193-199.
3. Barr JS, Katz KA, Hazen A. Surgical management of facial nerve
paralysis in the pediatric population. J Pediatr Surg. 2011;46:
2168-2176.
4. Jackson CG, von Doersten PG. The facial nerve: current trends in
diagnosis, treatment, and rehabilitation. Med Clin North Am.
1999;83:179-195.
5. Kim IS, Shin SH, Kim J, Lee WS, Lee HK. Correlation between
MRI and operative findings in Bell’s palsy and Ramsay Hunt
syndrome. Yonsei Med J. 2007;48:963-968.
6. Linder TE, Abdelkafy W, Cavero-Vanek S. The management
of peripheral facial nerve palsy: ‘‘paresis’’ versus ‘‘paralysis’’ and
sources of ambiguity in study designs. Otol Neurotol. 2010;31:
319-327.
7. Pitaro J, Waissbluth S, Daniel SJ. Do children with Bell’s palsy
benefit from steroid treatment? A systematic review. Int J Pediatr
Otorhinolaryngol. 2012;76:921-926.
8. House JW, Brackmann DE. Facial nerve grading system. Otolar-
yngol Head Neck Surg. 1985;93:146-147.
9. Peitersen E. Bell’s palsy: the spontaneous course of 2,500 periph-
eral facial nerve palsies of different etiologies. Acta Otolaryngol
Suppl. 2002;549:4-30.
10. Chen WX, Wong V. Prognosis of Bell’s palsy in children—
analysis of 29 cases. Brain Devel. 2005;27:504-508.
11. Cubukcu D, Yilmaz U, Alkan H, Metinkisi F, Ozcan M. Clinical
features of Bell’s palsy in children and outcomes of physical
therapy: a retrospective study. ISRN Rehabil. 2013:501034.
http://dx.doi.org/10.1155/2013/501034
12. Pavlou E, Gkampeta A, Arampatzi M. Facial nerve palsy in child-
hood. Brain Dev. 2011;33:644-650.
13. Tsai HS, Chang LY, Lu CY, et al. Epidemiology and treatment of
Bell’s palsy in children in northern Taiwan. J Microbiol Immunol
Infect. 2009;42:351-356.
14. Wang CH, Chang YC, Shih HM, Chen CY, Chen JC. Facial palsy
in children: emergency department management and outcome.
Pediatr Emerg Care. 2010;26:121-125.
15. Gronseth GS, Paduga R. American Academy of Neurology.
Evidence-based guideline update: steroids and antivirals for Bell
palsy: report of the Guideline Development Subcommittee of the
American Academy of Neurology. Neurology. 2012;79:
2209-2213.
4 Journal of Child Neurology

16. Yeo SG, Lee YC, Park DC, Cha CI. Acyclovir plus steroid vs
steroid alone in the treatment of Bell’s palsy. Am J Otolaryngol.
2008;29:163-166.
17. Minnerop M, Herbst M, Fimmers R, et al. Bell’s palsy: combined
treatment of famciclovir and prednisone is superior to prednisone
alone. J Neurol. 2008;255:1726-1730.
18. Khajeh A, Fayyazi A, Soleimani G, Miri-Aliabad G, Shaykh Veisi
S, Khajeh B. Comparison of the efficacy of combination therapy
of prednisolone—acyclovir with prednisolone alone in Bell’s
palsy. Iran J Child Neurol. 2015;9:17-20.
19. Sullivan FM, Swan IR, Donnan PT, et al. Early treatment with
prednisolone or acyclovir in Bell’s palsy. N Engl J Med. 2007;
357:1598-1607.
20. Engström M, Berg T, Stjernquist-Desatnik A, et al. Prednisolone
and valaciclovir in Bell’s palsy: a randomised, double-blind,
placebo-controlled, multicentre trial. Lancet Neurol. 2008;7:
993-1000.
21. Teixeira LJ, Valbuza JS, Prado GF. Physical therapy for Bell’s
palsy (idiopathic facial paralysis). Cochrane Database Syst Rev.
2011;12:CD006283.

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