Peripheral nerve injuries in neonates are commonly associated with traumatic delivery or prolonged labor, particularly in macrosomic infants or those requiring instrumental assistance. The most common injuries include brachial plexus injury, phrenic nerve injury, and facial nerve injury.
1. Brachial Plexus Injury
Clinical Characteristics:
- Erb’s Palsy (C5-C6):
- “Waiter’s tip” position: Shoulder adduction, internal rotation, extended elbow, pronated forearm, and flexed wrist.
- Grasp reflex preserved, but Moro and biceps reflexes are absent on the affected side.
- Klumpke’s Palsy (C8-T1):
- Weakness in the intrinsic muscles of the hand, resulting in a “claw hand.”
- Often associated with Horner syndrome (ptosis, miosis, anhidrosis) if T1 is involved.
- Total Plexus Palsy (C5-T1):
- Complete flaccid paralysis of the arm with absent reflexes and sensory loss.
Risk Factors:
- Macrosomia, shoulder dystocia, breech delivery, instrumental delivery.
Management:
- Conservative:
- Physical therapy (gentle range-of-motion exercises starting within the first week).
- Splinting for proper limb positioning.
- Surgical Intervention:
- Considered for persistent deficits by 3–6 months of age.
2. Facial Nerve Palsy
Clinical Characteristics:
- Asymmetry of the face during crying (affected side appears smooth).
- Inability to close the eye or move the mouth on the affected side.
- Often unilateral and associated with forceps delivery.
Risk Factors:
- Birth trauma, particularly with forceps or prolonged labor.
Management:
- Observation:
- Most cases resolve spontaneously within weeks to months.
- Eye care:
- Use artificial tears or tape the eye shut to prevent corneal drying if eyelid closure is impaired.
- Surgical Intervention:
- Rarely required; indicated if no recovery within 6–12 months.
3. Phrenic Nerve Injury
Clinical Characteristics:
- Associated with diaphragmatic paralysis.
- Respiratory distress, paradoxical chest movements, and a raised hemidiaphragm on chest X-ray.
Risk Factors:
- Birth trauma, often with brachial plexus injury.
Management:
- Supportive:
- Oxygen supplementation or mechanical ventilation in cases of significant respiratory distress.
- Surgical Intervention:
- Plication of the diaphragm if respiratory compromise persists.
4. Lumbosacral Plexus Injury
Clinical Characteristics:
- Rare but presents as flaccid paralysis of the lower limb.
- May involve urinary or bowel incontinence if sacral nerves are affected.
Risk Factors:
- Breech delivery or sacral trauma during delivery.
Management:
- Multidisciplinary approach with physical therapy and orthopedic support.
Summary Table:
References:
- Cloherty, J.P., et al. Manual of Neonatal Care.
- Kliegman, R., et al. Nelson Textbook of Pediatrics