Information For Parents Of A Newborn With A Weak Or Paralyzed Arm
If your newborn's arm is notably weak or completely paralyzed, your child may have Brachial Plexus Palsy (BPP), also known as Erb's Palsy or Brachial Plexus Injury (BPI). The cause of this injury is usually the stretching of one (or both) sides of the neck during a difficult delivery.
The Brachial Plexus is a network of nerves that go from the spinal column in the neck down to the fingers. The mildest form of this injury is when the nerves have been stretched. When the nerves are torn (ruptured) or pulled out of their spinal "socket" (avulsed), surgical intervention may be the only hope to regain function of the arm.
The 1st Weeks of Life
During the first few weeks of life, handle your baby’s neck and arm carefully. Be aware of the positioning of your baby's arm especially when you lift or carry him/her. Family, friends and caretakers will need to be taught that pulling or lifting by the arm can cause further injury and pain.
Doctors & Therapists
One of the first steps you may wish to consider is to make an appointment with a Pediatric Neurologist experienced in brachial plexus injuries to define the nature of your child's injuries and whether or not there are any other complications.
See a Physical (PT) or Occupational (OT) therapist to learn how to do “Range of Motion” (ROM) exercises that you will do with each diaper change to keep your child's joints from becoming stiff. A regular schedule of therapy will also begin at this time. Choose a therapist that understands brachial plexus injuries and has experience at making splints.
Research the resources for a Pediatric Brachial Plexus Specialist. These are doctors who specialize in the treatment and repair of these types of injuries in babies. Their expert assessment of your child's recovered movements will define whether or not the injury is temporary or permanent and severe.
Timeframe For Recovery
The brachial plexus nerves originate in the neck - in the cervical spine. They branch down the arm all the way to the fingertips. When the nerve is severely injured, it has to regrow from the neck, down the arm. Regeneration of nerves happen at a slow rate of one inch or three centimeters per month. As they regenerate, movements of the muscles associated with that nerve will begin to appear. At first they will be very weak and the child will use gravity as a helper. As the muscles get fully innervated (connection from nerve to muscle established), they will gain strength and move without the assistance of gravity.
A real turning point in your child's prognosis will be the presence or absence of biceps function at three months of age. The brachial plexus specialists worldwide agree that if the child does not have biceps function by that time, surgical repair is discussed.
Time Is Of The Essence
The timeframe for surgical repair is a very important factor for recovery.
Within 12 to 18 months of the injury, the muscles that have not already been innervated (connected to nerves) will have atrophied to the point where innervation is no longer possible.
It is most important to contact the Pediatric Brachial Plexus Specialist as early as possible so that appointments can be scheduled. Wait lists are common in the larger clinics.
The neurosurgical techniques most often used to repair a severe injury are: exploration of the brachial plexus nerves, testing the nerves to see if the brain is receiving messages from them (EMG), removal of the scar tissue that has formed around the nerve (neuroma), and if necessary, nerve grafting. This first surgery - called "primary surgery" is done between the ages of 8 weeks and 12 months of age depending on the protocol of the clinic you choose and the severity of the injury.
Handling Medical Costs
Contact your health insurance company to see if they have a program for children with special needs. Your state has programs that will give your child access to free or low cost in-home therapies. In some states it is called Early Intervention (EI) (ages 0-3). Medicaid programs may give you an option for free or low cost secondary insurance.
Your health insurance may cover travel to out-of-state clinics. If not, free or discounted medical airfare is available from many airlines. (see http://www.injurednewborn.com/maia/travel.html)
Emotions will be strong during the first few years of your child's life. The best support can come from a counselor who is experienced at the issues of having a special needs child and from other families experiencing the same thing. A local support group can be very helpful for the entire family. Also, there are some very good Internet sites to visit and gain support and information from, too. Anger, sadness and grief are normal and important processes.
Glossary of Terms
Abduction: Movement of the limbs away from the body, such as lifting the arm out to the side
Adduction: Movement of the limbs toward the body, such as bringing the arm close to the body from the side
Apraxia: A child with apraxia is often unaware that they are carrying or using their affected limb for a particular task
Avulsion: Tearing away; the nerve root being torn out of the spinal cord is the most severe type of nerve injury
Atrophy: A wasting away, in the size of a cell, tissue, organ or part
Axilla: under the arm; the armpit
Bilateral: Both sides
Brachial Plexus: A network of 5 nerves that extend from the spinal column in the neck down to the fingers
Cervical: The neck area
Contracture: A permanent shortening (as of muscle tendons or scar tissue that produces deformity or distortion)
Electromyography (EMG): A test in which a small needle is inserted, to record electrical activity of the muscles
Extension: The movement of two elements of any jointed body part are directed away from each other (straightened)
Extensor: A muscle that extends or straightens a body part, such as a finger or an arm
Flaccid: Weak, lacking firmness, muscle tone and resilience
Flexion: Moving a joint inward to bring it closer to the body (bend)
Flexor: A muscle that bends or flexes any body part, such as the arm or hand
Horner's Syndrome: A nerve condition which involves a drooping eyelid (ptosis), constricted pupil, enophthalmos (sunken eyeball) and lack of sweating on one side of the face
Hypotonia: low muscle tone, often involving reduced muscle strength
Multidisciplinary Team: a team of medical professionals that work together to support the patient; a multidisciplinary team for brachial plexus specialization would include a pediatric neurologist, rehabilitation physician, specialized and experienced surgeons, OT/PT
Neurologist: A physician who diagnoses and treats disorders of the nervous system
Neurolysis: Surgical removal or part of a neuroma
Neuroma: A benign tumor composed of nerve cells, or scar tissue that forms when there is nerve damage
Nerve grafting: When the gap between nerve ends is so large that it is not possible to have a tension-free repair using the end-to-end techniques or with nerve grafts
Neurotization: This is used generally in those cases where there is an avulsion; donor nerves are used for the repair
Neurapraxia: The nerve has been stretched and damaged but not torn
Occupational Therapist (OT): A health care professional who provides services designed to restore self-care, work, and leisure skills to patients who have specific performance incapacities or deficits that reduce their abilities to cope with the tasks of everyday living
Physiatrist: A physician specializing in physical medicine and rehabilitation; help restore optimal function to people with injuries to the muscles, bones, tissues and nervous system
Physical Therapist (PT): A rehabilitation professional who promotes optimal health and functional independence through the application of scientific principles to prevent, identify, assess, correct, or alleviate acute or chronic movement dysfunction, physical disability, or pain
Range of motion (ROM): The range through which a joint can be moved, usually its range of flexion and extension; Active range of motion (AROM) is the active movement of the muscle and Passive range of motion (PROM) is the motion range of a joint through manual assistance
Rupture: Torn nerve or tissue
Supine: Lying on the back
Torticollis: A contracted state of the cervical muscles, producing twisting of the neck and an unnatural position of the head