Facial nerve palsy in newborns is a condition where an infant loses normal muscle movement on one side of their face, typically becoming noticeable when the baby cries. While this condition can be alarming for new parents, the good news is that the majority of cases resolve spontaneously without intervention. In fact, research shows that more than 90% of traumatic facial nerve palsies recover completely. Understanding the causes, recognizing symptoms early, and knowing what to expect during recovery can help parents make informed decisions about their baby’s care.
What is Facial Nerve Palsy in Newborns?
Facial nerve palsy due to birth trauma is the temporary or permanent loss of controllable muscle movement in an infant’s face resulting from pressure on the facial nerve before, during, or immediately after birth. The facial nerve (cranial nerve VII) controls all the muscles that create facial expressions on one side of the face. When this nerve is compressed, stretched, or damaged during delivery, the muscles it controls cannot function properly.
The most distinctive sign parents notice is asymmetric crying facies—when the baby cries, the mouth doesn’t pull down evenly on both sides. The affected side appears to stay straighter while the unaffected side pulls down normally. This asymmetry is often most obvious during crying because that’s when these facial muscles work hardest.
How Common is Facial Nerve Palsy at Birth?
Key Fact: Facial nerve palsy occurs in approximately 0.8 to 2.1 per 1,000 live births. This makes it one of the more common facial nerve problems in newborns, though many cases are mild and parents may not initially notice the symptoms.
Understanding the prevalence helps parents know they’re not alone—thousands of babies experience this condition each year. The condition can occur with any type of delivery, though certain risk factors increase the likelihood.
What Causes Facial Nerve Injury During Birth?
Forceps Delivery (Most Common Cause)
The primary cause of facial nerve palsy in newborns is pressure from forceps during delivery. Research published in JAMA Otolaryngology reports that 91% of cases involving facial nerve palsy are associated with forceps delivery, and 88% of cases with difficult labor show forceps involvement.
The injury mechanism is specific: the posterior blade of the forceps compresses the bone overlying the vertical segment of the facial canal, where the facial nerve is particularly vulnerable. Middle forceps deliveries carry greater risk than low forceps because the nerve compression occurs in a more critical area.
Other Birth-Related Causes
While forceps are the leading cause, facial nerve palsy can also result from:
- Pelvic bone pressure: Direct compression against the mother’s pelvis during labor, especially in prolonged second-stage labor
- Soft tissue compression: Pressure as the nerve exits the skull at the stylomastoid foramen
- Difficult delivery factors: Large birth weight (over 3,500g), first-time mothers, use of labor-inducing medications, and epidural anesthesia (indicating more complex deliveries)
- Developmental abnormalities: Rarely, congenital syndromes like Möbius syndrome or hemifacial microsomia can cause facial paralysis
Recognizing Symptoms: What Parents Should Watch For
Symptoms of facial nerve palsy may be subtle at first or quite obvious, depending on the severity of the nerve compression or injury. Most parents first notice something is different during feeding or crying.
Obvious Symptoms
- Mouth doesn’t pull down evenly when crying (asymmetric crying facies)
- One corner of mouth sags
- Facial drooping on one side
- Uneven nose position
- Weakness when feeding on the affected side
Subtle Symptoms
- Eyelid doesn’t close fully on the affected side
- Eye doesn’t blink symmetrically
- Difficulty feeding on the weak side
- Drooling more on the affected side
- Reduced facial expression when smiling
The majority of facial nerve palsy cases affect only the lower portion of the face, controlling the muscles around the mouth and lips. This is why the asymmetric crying face is such a telltale sign. Upper facial involvement (affecting the eyes and forehead) is less common with traumatic birth injuries.
Understanding Severity: The House-Brackmann Scale
Medical professionals use a standardized grading system called the House-Brackmann Facial Nerve Grading Scale to assess how severe the facial paralysis is. Understanding this scale helps parents communicate with their medical team and understand prognosis.
| Grade | Severity Level | Clinical Presentation | Prognosis |
|---|---|---|---|
| I | Normal | Complete normal facial function in all areas | Baseline – no nerve injury |
| II | Mild | Slight facial weakness, normal symmetry at rest, slight weakness noted only on close inspection | Excellent – typically full recovery |
| III | Moderate | Obvious weakness but can still close eye, normal symmetry at rest, mouth slightly weak | Good – usually complete recovery within weeks |
| IV | Moderately Severe | Obvious weakness, incomplete eye closure, asymmetrical mouth with effort | Good – recovery typically occurs |
| V | Severe | Only barely perceptible motion, incomplete eye closure, asymmetrical facial features | Variable – longer recovery expected |
| VI | Total Paralysis | No facial movement on affected side, cannot close eye, complete asymmetry | Requires monitoring – may need intervention if no improvement |
Forceps-related facial nerve palsy is typically mild to moderate on the House-Brackmann scale, which is an excellent prognostic indicator. This is one reason why the prognosis for birth-related facial palsy is generally so favorable compared to other causes of facial nerve injury.
Recovery Timeline: What to Expect
One of the most important questions parents ask is: “How long will this take to improve?” The good news is that recovery from birth-related facial nerve palsy is typically fast and complete.
Recovery Statistics: All 21 neonates with adequate follow-up recovered fully after an average of 24 days. Additionally, 89% of babies with congenital facial nerve palsy achieved complete resolution by 7 months of age.
Typical Recovery Timeline
Week 1-3: Initial period where parents monitor symptoms closely. Clinical improvement within three weeks is a favorable prognostic indicator—if your baby shows even slight improvement in this window, full recovery is very likely.
Week 3-8: Most babies show significant improvement. Facial symmetry during crying becomes more noticeable, eye closure improves, and feeding becomes easier as mouth weakness decreases.
Month 2-7: Continued gradual improvement. By this time, most cases show near-complete or complete recovery. Even cases that appeared more severe typically resolve by this point.
After 7 months: By seven months, the vast majority of babies have achieved complete or near-complete recovery. Only rarely do cases persist beyond this timeframe, and those typically involve either incomplete recovery or associated developmental causes rather than birth trauma.
How is Facial Nerve Palsy Diagnosed?
Diagnosis of facial nerve palsy in newborns is usually straightforward and requires minimal testing. Physical examination is typically all that’s needed to diagnose the condition based on visible facial asymmetry and weakness.
Clinical Examination
Your pediatrician will:
- Observe the baby’s face at rest and during crying
- Note the degree of facial droop or asymmetry
- Check for eye closure ability
- Assess feeding and sucking strength
- Grade severity using the House-Brackmann scale
When Additional Testing is Needed
In rare cases, nerve conduction testing (EMG/NCS) may be performed to pinpoint the exact location of nerve injury. This is more commonly done if:
- Diagnosis is unclear
- The paralysis is complete rather than partial
- There’s concern about severity or prognosis
- The condition doesn’t improve as expected
Imaging (CT or MRI) is rarely needed for birth-related facial palsy unless there’s suspicion of temporal bone fracture or other structural injury.
Treatment Approaches: What Works Best
Conservative “Watch and Wait” Approach
The standard treatment for most cases of facial nerve palsy due to birth trauma is observation and supportive care. Because facial palsy due to birth trauma frequently improves on its own within a few months, there is often a “wait and see” approach, with infants closely monitored to see if the paralysis goes away without further treatment.
Because facial nerve palsy caused by forceps use is generally mild and associated with a favorable outcome, treatment with corticosteroids or surgery is generally not required. This conservative approach avoids unnecessary medication exposure and recognizes that most cases resolve naturally.
Eye Care During Recovery
The most important supportive care focuses on protecting the baby’s eye on the affected side, since incomplete eye closure is one of the main risks during recovery:
- Keep the eye clean and moist: Use artificial tears or lubricating eye ointment several times daily
- Protect from dust and irritants: Avoid smoke, wind, and dry environments when possible
- Monitor for eye complications: Watch for excessive tearing, redness, or swelling
- Ophthalmology referral: If significant eye closure problems persist beyond a few weeks, ask your pediatrician about evaluation by an eye specialist
- Avoid contact during healing: Be gentle when cleaning the face, especially around the affected eye
When Surgery Might Be Considered
Surgery may be considered in infants with poor prognostic factors, including complete paralysis at birth, specific EMG findings showing no muscle response, and absence of improvement after 5 weeks. However, these cases are rare. Surgery to relieve pressure on the nerve is only considered when:
- The nerve injury is complete and severe
- No improvement is seen after 5+ weeks
- Specific nerve conduction findings indicate nerve severance
- There’s evidence of bone fragments pressing on the nerve
Key Takeaways
- Common condition: Affects 0.8-2.1 per 1,000 births, usually from forceps during difficult deliveries
- Excellent prognosis: Over 90% recover spontaneously without treatment
- Rapid recovery: Average recovery is just 24 days, with 89% fully resolved by 7 months
- Mild to moderate usually: Forceps injuries typically grade II-IV on House-Brackmann scale, predicting good outcomes
- Conservative treatment works: Most cases need only observation and eye care, not medication or surgery
- Monitor for improvement: Clinical improvement within first 3 weeks strongly predicts complete recovery
Frequently Asked Questions
What’s the difference between facial nerve palsy and asymmetric crying facies?
Facial nerve palsy affects one side of the face including the forehead, eye, and mouth due to facial nerve damage. Asymmetric crying facies is usually just one muscle (depressor anguli oris) underdeveloped, so only the mouth corner is affected. Both involve asymmetric crying, but the anatomy and prognosis differ. Physical exam and occasionally EMG testing can distinguish between them.
Will my baby have permanent facial scarring or disfigurement from facial nerve palsy?
No. Facial nerve palsy from birth trauma is a nerve injury, not a physical injury to the skin. There are no wounds, lacerations, or tissue damage. As the nerve heals and muscle function returns (which happens in the vast majority of cases), facial appearance normalizes. Even if some residual weakness persists in rare cases, it typically becomes increasingly less noticeable as the baby grows.
Can facial nerve palsy affect my baby’s speech or feeding ability?
Most babies feed normally even with facial nerve palsy because the muscles involved are secondary for feeding. The main challenges are weakness on the affected side during sucking and occasionally difficulty achieving a good latch on the affected side. These typically improve within weeks as the nerve heals. Speech development is rarely affected since speech depends on multiple muscles and neurological pathways. If feeding difficulties persist beyond a few weeks, talk to your pediatrician about whether feeding therapy might help.
Is facial nerve palsy at birth the same as Bell’s Palsy?
No, they’re different conditions. Facial nerve palsy at birth is caused by trauma during delivery (usually forceps pressure). Bell’s Palsy is idiopathic (unknown cause) facial nerve paralysis that can occur at any age. Bell’s Palsy has a different prognosis and treatment approach. While both involve the facial nerve, their causes, risk factors, and management differ significantly. True Bell’s Palsy in newborns is very rare.
Should my baby receive steroids or other medications for facial nerve palsy?
For birth-trauma related facial nerve palsy, medications are typically not recommended. Since the prognosis is so favorable without treatment and most cases resolve spontaneously, the risks of medication exposure usually outweigh the benefits. Steroids may be considered in some cases, but this decision should be made with your pediatrician or pediatric neurologist based on your baby’s specific situation, severity, and any complications.
How will I know if my baby’s facial nerve palsy is getting better?
Look for increasing symmetry during crying—the mouth will start to pull down more evenly on both sides. You’ll notice the affected side becoming more active when the baby smiles or cries. Eye closure on the affected side will improve. Feeding will become easier as mouth strength increases. Even small improvements are positive signs. Ask your pediatrician to document the House-Brackmann grade at each visit so you can objectively track improvement over time.
What’s the significance of improvement within the first three weeks?
Clinical improvement within the first three weeks is a very favorable prognostic sign. Babies who show even slight improvement in this timeframe almost always go on to complete or near-complete recovery. If there’s no improvement by 5 weeks, prognosis becomes less certain and more aggressive evaluation (EMG testing) might be recommended. But the majority of babies do show improvement early and proceed to full recovery.
Can I do anything at home to help my baby’s recovery?
Your primary role is observation, eye care, and reassurance. Keep the affected eye clean and moist with eye drops or ointment several times daily. Watch for signs of improvement. Attend all follow-up appointments. Most importantly, understand that recovery will likely happen naturally over time—this is not something that requires special exercises or intensive therapy for birth-trauma related cases. Just provide normal love and care while the nerve heals.
When should I contact my doctor about my baby’s facial weakness?
Contact your pediatrician if: you notice asymmetric crying or facial weakness, there’s persistent inability to close one eye (especially if redness or discharge develops), feeding difficulties that worsen or don’t improve, any discharge from the eye, or excessive tearing. Also reach out if you’re not seeing the expected improvement by 5 weeks. While most cases follow a favorable course, your pediatrician should monitor your baby’s progress regularly.
Conclusion
Facial nerve palsy in newborns can be worrying for parents, but understanding that over 90% of cases resolve completely with excellent prognosis can provide reassurance. Most babies recover fully within weeks, without needing surgery or medication. The typical course involves observation, supportive eye care, and monitoring for improvement—the vast majority of babies show positive signs within the first few weeks, leading to complete or near-complete recovery by 7 months of age.
If you’re concerned about your baby’s facial symmetry or movement, discuss it with your pediatrician. Early recognition and appropriate follow-up ensure your baby receives the monitoring they need and that complications like eye problems are prevented. With time and proper care, your baby’s smile will return to normal.
At Birth Injury Law NY, we understand that birth complications can be stressful for families. If you believe your baby’s facial nerve injury resulted from medical negligence or improper delivery techniques, we’re here to help. Our team can evaluate your case and explain your legal options. Contact us today for a free consultation.
