Brachial palsy in newborns

Definition

Brachial palsy is a paralysis or weakness of the arm caused by damage to the brachial plexus (the collection of nerves around the shoulder).

Causes, incidence, and risk factors

Brachial nerve injuries can occur during a difficult delivery. For example, it can occur if the infant's head and neck are pulled toward the side as the shoulders pass through the birth canal.

The condition can also be caused by excessive pulling on the shoulders during a vertex delivery (head first) or by pressure on the raised arms during a breech delivery (feet first).

The infant may have varying degrees of arm paralysis:

• Brachial plexus injuries typically affect only the upper arm
• Erb's paralysis affects the upper arm and rotation of the lower arm
• Klumpke paralysis affects the hand (the infant may also have an eyelid droop on the opposite side)

Brachial palsy is less common now that delivery techniques have improved and there is more use of C-sections when needed (where the baby is removed surgically through the abdomen).

Risk factors include a larger than average newborn, shoulder dystocia, and breech delivery.

Arm and shoulder fractures can also affect newborns who have had a difficult delivery. Fractures can cause pseudoparalysis. The symptoms may be very similar, although the long-term outlook is very different.

Symptoms

• Noticed immediately or soon after birth
• Lack of spontaneous movement in the upper or lower arm or hand
• Grip may be decreased on the affected side
• Moro reflex is absent on the affected side
• Normal arm position (arm flexed at elbow and held against body) may be absent or weak on affected side

Signs and tests

A physical exam of the infant may show that the Moro reflex is absent on the affected side. This reflex WILL be present in an infant with pseudoparalysis. (In pseudoparalysis, the infant has a fracture and is not moving the arm because of pain.)

The affected arm may flop when the infant is rolled side to side.

Treatment

A full recovery is expected in most cases. Rarely, the palsy may persist. If some strength has not returned to the affected muscles by 3-6 months of age, surgery on the nerves may restore it. Tendon transfers may also help to compensate for nerves that are not functioning properly.

Gentle massage of the arm and range of motion exercises are recommended for mild cases. In more severe cases, a pediatric neurologist and an orthopedic hand surgeon may need to be consulted.

In cases of pseudoparalysis, the child will begin to use the affected arm as the fracture heals.

Expectations (prognosis)

Most infants recover within 6 months, but those that do not have a very poor outlook and will need further surgery to try to compensate for the nerve deficits.

Complications

Complications include permanent, partial, or total loss of function of the affected nerves, causing paralysis of the arm or arm weakness.

Calling your health care provider

Call your health care provider if your newborn shows a lack of movement of either arm.

Prevention

Taking measures to avoid a difficult delivery, whenever possible, reduces the risk of brachial palsy in newborn babies.

Illustrations

Central nervous system

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