Looking Beyond Brachial Plexus Palsy
A
term male newborn weighing 2.3 kg born by forceps delivery had respiratory distress and decreased right upper limb movements since birth. On examination, he had right sided Erb palsy and chest movements and air entry on the right were decreased (Video 1; available at www. jpeds.com). Subsequently, he required mechanical ventilation for increased effort in breathing and respiratory
acidosis. Elevation of right dome of diaphragm in the chest radiograph (Figure) and absent diaphragmatic movements in fluoroscopy (Video 2; available at www.jpeds.com) confirmed right phrenic nerve injury. He was gradually weaned from the ventilator and diaphragmatic movements were normalized by the third week without any surgical intervention. His Erb’s palsy also resolved partially with physiotherapy. A retrospective review by Bowerson et al showed that the incidence of clinically significant phrenic nerve palsy in patients with brachial plexus palsy was 2.4%.1 Though the incidence is small, one should carefully examine diaphragmatic movements in every neonate with brachial plexus injury. Diaphragmatic paralysis due to phrenic nerve paralysis may result in significant respiratory compromise, pulmonary infection, growth failure, and even death. This rare cause of respiratory distress in the newborn may be missed easily among multiple common etiologies of respiratory distress in the newborn if this entity is not kept in mind, and if a thorough examination is not done especially in the context of brachial plexus palsy. These newborn babies may require continuous positive airway pressure or mechanical ventilation and, if unresponsive, surgical plication of diaphragm should be performed.2 Bottom line, one should always do a complete exam on every child with brachial plexopathy and beware of phrenic nerve paresis and Horner syndrome. n
Barathi Balachander, MD Febi Francis, MD Shruthi K. Bharadwaj, MD Prasad Kumar, MD Adhisivam Bethou, DCH, DNB(Ped) Vishnu Bhat, MD Division of Neonatology Department of Pediatrics Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Pondicherry, India
References
Figure. Chest radiograph showing elevation of right dome of diaphragm.
1. Bowerson M, Nelson VS, Yang LJ. Diaphragmatic paralysis associated with neonatal brachial plexus palsy. Pediatr Neurol 2010;42: 234-6. 2. Murty VS, Ram KD. Phrenic nerve palsy: a rare cause of respiratory distress in newborn. J Pediatr Neurosci 2012;7:225-7.
J Pediatr 2014;165:635. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.04.057
635
A
term male newborn weighing 2.3 kg born by forceps delivery had respiratory distress and decreased right upper limb movements since birth. On examination, he had right sided Erb palsy and chest movements and air entry on the right were decreased (Video 1; available at www. jpeds.com). Subsequently, he required mechanical ventilation for increased effort in breathing and respiratory
acidosis. Elevation of right dome of diaphragm in the chest radiograph (Figure) and absent diaphragmatic movements in fluoroscopy (Video 2; available at www.jpeds.com) confirmed right phrenic nerve injury. He was gradually weaned from the ventilator and diaphragmatic movements were normalized by the third week without any surgical intervention. His Erb’s palsy also resolved partially with physiotherapy. A retrospective review by Bowerson et al showed that the incidence of clinically significant phrenic nerve palsy in patients with brachial plexus palsy was 2.4%.1 Though the incidence is small, one should carefully examine diaphragmatic movements in every neonate with brachial plexus injury. Diaphragmatic paralysis due to phrenic nerve paralysis may result in significant respiratory compromise, pulmonary infection, growth failure, and even death. This rare cause of respiratory distress in the newborn may be missed easily among multiple common etiologies of respiratory distress in the newborn if this entity is not kept in mind, and if a thorough examination is not done especially in the context of brachial plexus palsy. These newborn babies may require continuous positive airway pressure or mechanical ventilation and, if unresponsive, surgical plication of diaphragm should be performed.2 Bottom line, one should always do a complete exam on every child with brachial plexopathy and beware of phrenic nerve paresis and Horner syndrome. n
Barathi Balachander, MD Febi Francis, MD Shruthi K. Bharadwaj, MD Prasad Kumar, MD Adhisivam Bethou, DCH, DNB(Ped) Vishnu Bhat, MD Division of Neonatology Department of Pediatrics Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Pondicherry, India
References
Figure. Chest radiograph showing elevation of right dome of diaphragm.
1. Bowerson M, Nelson VS, Yang LJ. Diaphragmatic paralysis associated with neonatal brachial plexus palsy. Pediatr Neurol 2010;42: 234-6. 2. Murty VS, Ram KD. Phrenic nerve palsy: a rare cause of respiratory distress in newborn. J Pediatr Neurosci 2012;7:225-7.
J Pediatr 2014;165:635. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.04.057
635
