Facial nerve palsy in newborns

How does this happen?

The facial nerve leaves the skull through a small opening just in front of and below the ear, then fans out across the face. At that point it lies close to the surface with little padding over it.

Anything that presses on that spot during birth can bruise or compress the nerve. The usual candidates are the maternal sacrum, a prolonged period with the head in one position, and forceps blades placed over that area. ²

A compressed nerve is usually a neurapraxia, meaning it is stunned rather than torn. The insulation is disrupted, signals stop passing, and once the swelling settles the nerve works again. That is why most newborn facial palsy resolves in days to weeks. ¹

There is a second, quite different group. Some babies have facial asymmetry because the nerve or the muscle did not develop normally, or as part of a syndrome. That does not recover, and the distinction matters for what families are told.

A useful clue on examination is the forehead. The facial nerve supplies the forehead on its own side, so a pressure injury to the nerve affects the forehead too. If the forehead still wrinkles on the affected side, the problem is more likely to be in the brain than in the nerve. ¹

One more distinction is worth knowing. A common cause of facial asymmetry that is often confused with facial palsy is an underdeveloped muscle that pulls the lower lip down. In that case only the lower lip is asymmetric when the baby cries, the eye closes normally, and the rest of the face is fine. It is usually mild and it is sometimes associated with heart differences, so it is worth mentioning to a doctor rather than ignoring.

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• Pressure from the maternal pelvis during labor, without any instrument involved. ¹
• A long labor with the head in one position.
• Forceps-assisted birth that was genuinely necessary, where the alternative for the baby was worse. ²
• A large baby in a tight pelvis. ³
• Developmental causes, where the nerve or muscle did not form normally.
• Genetic syndromes involving facial nerve development. ⁴

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• Forceps applied incorrectly, including blades placed over the path of the nerve, or forceps used outside recommended limits for duration and number of attempts. ²
• Vacuum followed by forceps, or the reverse. ²
• The eye not protected while the nerve recovers, so the cornea dried out. This is the complication that causes lasting harm in an otherwise recoverable condition. ¹
• Not recognized before discharge, where newborn examination is standard. ⁵
• A non-recovering palsy never re-evaluated, so a developmental cause was not identified and the family was told to keep waiting.
• Feeding difficulty not addressed, since a weak seal on one side makes feeding hard.

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record. Facial palsy occurs after births with no instrument used at all.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• One side of the face does not move when the baby cries. The mouth pulls toward the unaffected side.
• The eye on the affected side does not close fully.
• The nasolabial fold, the line from the nose to the corner of the mouth, is flattened on that side.
• The forehead does not wrinkle on that side in a nerve injury.
• The face may look symmetric at rest and asymmetric only when crying, which is why it is often noticed during a cry.
• Sometimes bruising or a mark in front of the ear.

The first week

• Difficulty feeding, with milk leaking from the affected corner because the seal is weak.
• Eye redness or dryness if the eye is not being protected.
• The beginning of recovery in many babies.

Around 3 months

• Most pressure-related palsies have recovered by now. ¹
• Persistent complete palsy at this point should prompt re-evaluation for a developmental cause.
• Continued feeding difficulty.

Around 6 months

• Residual weakness in a minority.
• Eye protection may still be needed if the eye does not close.
• Asymmetry most noticeable during smiling and crying.

Around 12 months

• Where recovery was complete, no findings.
• Where it was not, asymmetry that is now clearly established.

Toddler years

• Asymmetric smile.
• Difficulty with sounds that need lip closure, such as p, b and m.
• Drooling on the affected side.

School age

• Social awareness of facial asymmetry, which matters and should be taken seriously.
• Speech that may need therapy.
• Reconstructive options are discussed in later childhood in persistent cases.

How is it diagnosed?

Diagnosis is clinical, made by watching the face during a cry.

The key questions on examination

• Does the forehead move on the affected side? If yes, think brain rather than nerve. ¹
• Does the eye close?
• Is the whole side affected, or only the lower lip? Lower lip only points toward the underdeveloped muscle rather than a nerve injury.
• Are there other findings suggesting a syndrome? ⁴

Imaging is not routinely needed for a straightforward pressure palsy. MRI or CT scan is used where there is no clear birth-related explanation, where there are other neurological findings, or where the palsy is not recovering. ¹

Electrical studies are used in some centers where recovery is not happening, to assess how much nerve function remains.

Eye assessment if the eye has been exposed, to check the surface of the cornea.

Hearing assessment where a developmental cause is suspected, because the nerves are close together in the skull. ⁶

The single most useful piece of information is time. A palsy that is improving week by week is behaving like a pressure injury. One that is unchanged at 3 months is not, and needs re-evaluation.

What is the treatment?

Protect the eye. This is the priority. ¹

• Lubricating drops during the day and ointment at night, as prescribed.
• Taping the eye closed for sleep, if your team advises it and shows you how.
• Watch for redness, discharge or cloudiness of the eye surface and report it the same day.

Feeding support. A weak seal on one side makes feeding slow and messy. A feeding specialist can help with positioning, bottle choice or breastfeeding holds.

Time. Most pressure palsies resolve without any active treatment of the nerve itself. ¹

Re-evaluation if there is no improvement by around 3 months, to consider a developmental cause and to discuss what happens next.

Therapy in persistent cases, including facial exercises and speech therapy for sounds that need lip closure.

Surgery is considered in later childhood in persistent complete palsy, and options include nerve or muscle transfer to restore a smile. That is a specialist discussion, not an early one.

Referral to early intervention where feeding or speech is affected, which is free to evaluate for a child under 3. ⁷

What is the long-term outlook?

Most newborn facial palsy caused by pressure recovers completely, usually within days to a few weeks. ¹

Recovery that has not started by around 3 months makes a developmental cause more likely, and that does not recover on its own.

Where the palsy persists, the practical effects are on the smile, on speech sounds that require lip closure, and on eye protection. All three have management.

The complication that causes avoidable harm is corneal damage from an unprotected eye. That is the reason the eye instructions matter more than they sound.

What does daily life look like?

Eye drops and ointment several times a day, and taping at night if advised. Families describe this as fiddly and important.

Feeding takes longer and is messier, and a different bottle or a different hold often helps more than persistence.

For older children with persistent palsy, the social side of an asymmetric smile is real. It is worth naming rather than minimizing, and it is one of the things a child may want addressed as they get older.

What does care cost over a lifetime?

A recovering facial palsy generates the cost of eye lubricants and follow-up visits.

No agency publishes a lifetime cost estimate for newborn facial palsy and this site does not invent one.

Where reconstructive surgery is undertaken in later childhood, the cost is substantially higher. See paying for care.

What can you do this week?

1. Ask exactly how to protect the eye, and get the drops and ointment before discharge.
2. Ask whether the forehead moves on the affected side. It changes what this is.
3. Ask whether feeding is being assessed.
4. Ask what recovery should look like and by when, so you know if it is off track.
5. If forceps were used, ask where they were placed and how many attempts. Request the operative note.
6. Report eye redness, discharge or cloudiness the same day.
7. Book a re-evaluation at around 3 months if recovery has not started.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the pediatrician or neonatologist

• Does the forehead move on that side?
• Is the whole side affected, or only the lower lip?
• How do I protect the eye, and what should I watch for?
• What recovery should I expect, and by when?
• What happens if it has not improved by 3 months?

For the obstetric team

• Were forceps used, and where were the blades placed?
• How many attempts?
• What was the indication for the assisted delivery?

For the feeding team

• How do we get a better seal for feeding?
• Would a different bottle or position help?
• Is my baby getting enough, and how will we know?

You can also build a printable list with the question generator.