Brachial Plexus Injury Management in Neonates: Distinct Considerations
No, the guidelines for managing brachial plexus injuries are NOT the same for neonates—neonatal brachial plexus palsy (NBPP) requires specialized assessment protocols, earlier intervention timelines, and age-specific surgical decision-making that differ fundamentally from adult perioperative positioning guidelines.
Key Differences Between Neonatal and Adult Brachial Plexus Management
Etiology and Context
- Neonatal injuries occur during the birthing process, affecting 0.38-5.1 per 1000 births, with injury patterns specific to delivery trauma involving spinal roots C5-C8 and T1 1, 2.
- Adult perioperative injuries result from positioning during anesthesia, primarily related to arm abduction angles and pressure points during surgical procedures 3.
Assessment Timeline and Approach
- Neonates require immediate referral ideally before 3 months of age, with initial assessment by a physiotherapist and specialized brachial plexus clinic evaluation 2.
- The average age at first appointment should be approximately 16.9 weeks, though earlier is preferable 2.
- Adults receive preoperative risk assessment focusing on body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, and arthritis 3.
Diagnostic Protocols
- For neonates, electromyography testing is indicated when conditions fail to improve within several months after birth to guide surgical decision-making 4.
- MRI of the brachial plexus should be delayed until approximately 1 month after trauma in both populations to allow hemorrhage and edema resolution 5, 6.
- Neonatal imaging must account for smaller anatomical structures and different injury patterns (preganglionic vs postganglionic) 5.
Treatment Approach and Prognosis
- Neonates demonstrate high spontaneous recovery rates of 66-92%, with initial management consisting of passive range of motion and observation for all lesions 1.
- Prevention and correction of contractures through occupational therapy and serial splinting/casting are primary goals in the first 4-6 months 1, 7.
- Surgical intervention timing is critical: if spontaneous recovery does not occur within 4-6 months of life, prognosis for movement and function is significantly impaired, potentially resulting in lifelong disfiguring and functional handicap 7.
- Adult perioperative injuries focus on positioning strategies (limiting arm abduction to 90° in supine position) and periodic assessment during procedures 3.
Special Neonatal Considerations
- Comorbidities such as plagiocephaly commonly accompany NBPP and require concurrent management 2.
- Nontraumatic etiologies must be considered in neonatal cases, not just delivery trauma 4.
- A multidisciplinary approach with specialized microsurgical techniques is essential for neonates requiring surgical exploration 7.
Critical Pitfall to Avoid
The most significant error is applying adult perioperative positioning guidelines to neonatal birth-related brachial plexus injuries—these are fundamentally different conditions requiring distinct diagnostic frameworks, intervention timelines, and treatment algorithms 1, 7, 2.