Childbirth is difficult for moms—and sometimes for babies, too. As the woman labors and pushes, the baby might be stuck in a tricky position that puts extra strain on their body. Sometimes, the result is a brachial plexus injury, which affects as many as 3 in 1,000 babies.
The brachial plexus is a group of nerves on each side of your body, between your neck and shoulder; the nerves start at the spinal cord, crisscross each other and then make their way down the arm to the muscle they control. Everything you do when moving your arm passes from the brain to the spine and through the brachial plexus.
In teens and adults with brachial plexus injuries, the cause can be any force that causes their necks and shoulders to be yanked; contact sports and bike or car accidents are common culprits.
When a baby has a brachial plexus injury, quick diagnosis and treatment are essential to maintain nerve function and communication with the rest of the arm.
UNC Health pediatric neurosurgeon Kimberly Hamilton, MD, leads UNC Health’s brachial plexus clinic, which provides multidisciplinary support to children with these injuries and their families. She explains what to expect when your baby has a brachial plexus injury.
Brachial Plexus Injury Symptoms in Babies
If you know your baby was stuck at any point during childbirth, you and your doctor should keep an eye out for signs of a brachial plexus injury. These injuries most commonly happen in cases of shoulder dystocia, when a baby’s shoulders get stuck behind their mother’s pelvic bone. They also can happen when there’s a breech birth, prolonged pushing, a larger baby and in some cesarean sections, depending on the baby’s position.
“Think about putting your right ear to your right shoulder—you feel a stretch in your left neck,” Dr. Hamilton says. “When this happens in a forceful way, the brachial plexus is stretched.”
The stretch won’t necessarily cause your baby pain, but it can affect their ability to move their arm, which might eventually cause stiffness of the joint and affect how their bones develop.
“In their first couple of weeks, you might notice differences in how the baby is using one of their arms,” Dr. Hamilton says. “Maybe they’re not moving one arm as much as the other and one arm is held in an unchanged position. One arm might be floppier and looser.”
There’s a signature posture that’s a sign of the injury, called the waiter’s tip. Imagine how you put your arm down the side of your body. Now imagine that you rotate your shoulder inward, there’s mild flexion at the elbow, and your wrist is turned so that your palm faces out—like someone might put a cash tip in your hand. A baby with a brachial plexus injury may hold that position, depending on their injury.
If you see any sign that one of your baby’s arms is moving differently, alert your pediatrician as soon as possible. There isn’t a scan or test to confirm brachial plexus injuries (though your baby may have imaging to confirm there aren’t broken bones), but a doctor familiar with the condition will be able to tell if there are differences in how your baby moves their arms.
Nonsurgical Treatment for Pediatric Brachial Plexus Injuries
Early diagnosis of a brachial plexus injury is important because the sooner you can start therapy, the better outcome your child will have, and if surgery will be helpful, the surgical window is very small. At UNC Health’s brachial plexus clinic, families are seen by a neurologist, neurosurgeon and occupational therapist all at once so that all options can be considered.
“The vast majority of babies recover on their own,” Dr. Hamilton says. “But while the nerve is recovering, parents need to do stretches with their baby to protect the joints in the arm, because those joints are not getting a normal signal from the brain via the nerves.”
Your doctor or occupational therapist will show you stretches to do every diaper change to help preserve your baby’s range of motion. Dr. Hamilton likens one stretch to how a child makes a snow angel with their arms, except the arms are held in goalpost position, with the elbows bent, and each elbow and back of the hand are flat against the changing table or floor.
Stretching might be uncomfortable for your baby if they have very limited range of motion, so don’t force it, but not having this range of motion can cause pain later because the joints will get stiff.
Within a few months, your providers will be able to tell whether your baby will make a recovery on their own, if they’ll need additional therapy or if they’ll need surgery.
“Those that mostly recover, but not fully, will have what we call a ‘helper arm,’” Dr. Hamilton says. “It won’t be totally normal, but we can make sure it’s healthy in the joints and as functional as possible, so that they can get their hand to their mouth and their arm overhead. They’re still going to be able to participate in activities they enjoy.”
These children will need additional monitoring to make sure their joints develop properly as they grow and occupational therapy to maintain as much arm function as possible. The affected hand and arm will always be weaker, but regular occupational therapy throughout life will help them do the tasks they need to do or find ways to adapt.
If your baby is approaching 6 months old and not showing much improvement after stretching, your doctor may recommend surgery.
Surgery for Pediatric Brachial Plexus Injuries
If surgery is necessary for a baby’s brachial plexus injury, it’s typically done around 6 months old, before their nerves, joints and muscles suffer irreversible damage.
With a baby, that six months goes by quickly, which is why your provider might start talking about surgical options very early.
“Because that window is so small, we start planning for a surgery early in the process, and then we gladly cancel it if the baby is improving and doesn’t need it,” Dr. Hamilton says. “That’s a lot easier than deciding on surgery at the last moment and scrambling to make it work.”
There are several surgical options, and the best one for your baby will depend on what type of function they have in their arm and what they will need going forward. Dr. Hamilton focuses on elbow function, which will help your child bring their hand to their mouth, and deltoid function, which helps them put their hand over their head.
“If they can do those things, they’re more likely to independently eat, get dressed or wash their own hair,” she says, noting that the child might not be able to achieve fine motor skills in the hand; its distance from the brachial plexus makes surgery to address this function extremely complex. A child may always need special utensils or keyboards.
One technique is to use a healthy nerve, either from a donor or from the baby’s leg, and graft it from the brachial plexus to the muscle that needs it. Another approach is to free the existing nerves from the scar tissue that formed because of the original injury; scar tissue can block the messages that healthy nerves are sending to the arm. Surgery might be a combination of both.
It will take time to know if surgery was successful, because nerves recover and grow slowly. During that time, your baby will wear a cast or splint that provides a static stretch to preserve their range of motion. They will require regular occupational therapy to strengthen their arm.
If you don’t recognize a brachial plexus injury right away and miss the surgical window, there are still options to help your child.
“There may not be anything we can do with the nerves that will make an impact, but we can look at what can be done to address the joints specifically and improve their range of motion and function,” Dr. Hamilton says, noting that an orthopedic surgery that transfers a tendon might help the muscle function. Botox injections can help relax the arm muscles if they’ve become tight from lack of use.
Dr. Hamilton knows this information can be overwhelming to new parents.
“It’s important to reiterate that so many of these injuries get better on their own, but if they don’t, we have options to increase the arm’s functionality,” she says.
Concerned about your baby’s health? Talk to their doctor or find one near you.