Objective: In this retrospective study, we aimed to obtain information about the demographic characteristics, risk factors, clinical classification, treatment of patients who were followed up with the diagnosis of neonatal brachial plexus palsy (NBPP). 

Method: 79 patients were included in the study. Data were collected from patient files for age, gender, type of birth, birth weight, place of birth, palsy side, age at admission to hospital for treatment, accompanying problems, type of palsy (according to Narakas classification), and treatment methods. 

Results: Of the 79 patients in our study, 57% were girls. 91.1% of the patients were born with vaginal delivery, and 81% of them were admitted to the hospital in the first three months of life. Mean birth weights were 3987.57 ±528.424 grams, and 58.2% were born macrosomic. Among the risk factors related to baby, mother and delivery, the presence of gestational diabetes in the mother and prolonged labour were found to be significantly related to Narakas clinical classification. The risk factors present in our patients were determined as high birth weight, breech presentation, advanced maternal age, maternal excessive weight gain, maternal uterine anomaly, shoulder dystocia, and assisted device birth. 98.7% of the patients received physiotherapy, 73% received physiotherapy in the first 3 months. The mean duration of physiotherapy was 36.71±36.34 months. It was found that 16% of the patients underwent surgical treatment and the mean age of surgical treatment was 6.07±3.54 years. There was complete recovery in 32% of the patients, partial recovery in 52%, and no improvement in 16% of the patients. 

Conclusion: In our study, a higher rate of total brachial plexus paralysis was presented in the patients who were infants of gestational diabetes mellitus and prolonged birth history was found to have a borderline significant relationship with the Narakas clinical classification. It is important to know and recognize the risk factors in the literature and to be more careful in cases where more than one risk factor is associated. There is a need for additional studies such as the incidence in recent years in our country, determining its one-to-one relationship with risk factors, and finding ideal and highly specific imaging methods.

Neonatal brachial plexus palsy (NBPP) is a unilateral or bilateral clinical condition and occurs secondarily to problems that develop due to injury at birth on the C5, C6, C7, C8 roots and T1 trunks, divisions, cords, and branches, and varying degrees of paralysis at various levels of the upper limb. The incidence of NBPP ranges between 0.38 and 3 per 1000 live births in different countries [1]. 

Structural problems such as muscle imbalance, contracture, and joint deformities are seen in the upper limbs with NBPP, which limit performance of activities of daily living. The aim of either conservative (physiotherapy, occupational therapy, orthotics, and botulinum toxin A injections) or surgical treatments (primary microsurgical reconstruction and secondary tendon transfers) is to develop optimal function in the children [2]. The assessment and planning of treatment are very important in children with NBPP. Muscle strength, range of motion, and upper limb functionality are the main components of assessment. The activities are assessed in eligible age within the evaluation of upper limb strength, active upper limb movement, and the ability to perform age-appropriate activities [3]. Different methods of evaluation have been used in studies of children with NBPP. The most useful classification scheme for the management and the prognosis of NBPP was proposed by Gilbert and Tassin, refined by Narakas, and supported by Birch et al., [4] The aim of this study was to obtain information about the patients' demographic data, accompanying problems, risk factors, clinical classification, treatment requirements and post-treatment recovery results.

Seventy-nine patients diagnosed with NBPP and regularly followed up were included in the study. Age, gender, delivery type, birth weight, place of birth, side of involvement, age at hospital admission, accompanying complications, type of involvement (according to Narakas classification), patients who underwent surgery and their characteristics were recorded from the patient files.

The patients' application ages were classified as "those who applied in the first 3 months" and "those who applied after the 3rd month". The type of delivery was divided into normal vaginal delivery (NVY) and cesarean delivery (C/S); the place of delivery was divided into home delivery and hospital delivery. Birth weight was recorded in grams and patients were determined in 3 groups according to their birth weight as over 4000 grams, between 2500-4000 grams and under 2500 grams. Patients were classified according to their gestational week as under 37 gestational weeks (GH), between 37-42 GH and over 42 GH.

The part affected by congenital brachial plexus paralysis was recorded as right, left and bilateral. Additional problems accompanying the patients were determined as clavicle fracture, shoulder dislocation, humerus fracture, facial paralysis, cephalohematoma, torticollis, ecchymosis, conjunctival hemorrhage, hypoxic ischemic encephalopathy (HIE) and Horner syndrome and the existing problems were recorded. Risk factors were examined in 3 categories as factors related to the baby, mother and birth. Risk factors related to the baby were recorded as high birth weight (≥4000 grams) and breech presentation. Among the risk factors related to the mother, the presence of gestational diabetes, excessive weight gain during pregnancy (>20 kg), mother's age being 35 years and above, first birth, maternal pelvic anatomy disorder and uterine anomaly were recorded. Risk factors related to birth were recorded as the presence of a history of shoulder dystocia, the presence of prolonged second stage of labor, and assisted birth using vacuum/forceps.

Data on physical therapy and/or surgical treatment received by patients in our hospital and external centers were collected. The age at which physical therapy began in any hospital and the duration of treatment received were recorded in months. The age at which surgery was performed was recorded as 32 years for patients who underwent surgery. Treatment results were recorded as complete recovery, partial recovery, or no recovery based on the patients' latest physical examination findings.

The approval of the Ethics Committee of Cukurova University, Faculty of Medicine was obtained prior to the study. Written consents were obtained from patients’ parents who participated in this study. 

Measured values were evaluated and reported as means standard deviation (SD) using the SPSS 25.0 statistical program. The normality of the distribution of the groups was juxtaposed with the Kolmogorov-Smirnov test. The Independent T test was used in the analysis of normally distributed numerical variables. The chi-Square test was used in the evaluation of the gender distribution of the groups. A p-value less than 0.05 was considered as significant.

Of the patients included in the study, 57% were female and 43% were male. The age of admission to our hospital varied between the first day of life and 14 years of age. The mean age of presentation of 79 patients was found to be 14.7±3.7 months. While 80% of the patients were noticed by their families within the first month, 97% were noticed within the first 3 months. Of the patients, 91.1% had a normal vaginal delivery and 8.9% had a cesarean delivery. It was determined that 98.7% of the patients were born in the hospital and only one patient (1.3%) was born at home. 58.2% of the patients were over 4000 grams, 41.8% were between 2500-4000 grams. There were no patients born under 2500 grams. The mean birth weight of our patients was 3987.57±528.424 (2750-6000) grams. Demographic information of the patients is shown in Table 1.

                                                                                                          Table 1: Demographic findings of the patients.

Patient classification was made according to the Narakas classification, which is a clinical classification method, and the distribution percentage of our patients was; Group 1 39%, Group 2 30%, Group 3 27% and Group 4 4%. Due to the small number of patients in Group 4, Groups 3 and 4 were combined. The largest proportional majority was in Group 1. While DBPP was on the right side in 74.7% of the patients, it was on the left side in 25.3%. We did not have a patient who was affected bilaterally.

While 24.1% of patients with congenital brachial plexus palsy had accompanying additional problems, 75.9% did not have any accompanying additional problems. The most common accompanying additional problems was clavicle fracture (10.1%), while the second most common problem was ecchymosis in the trunk and arm (6.3%). None of our patients had facial paralysis or humerus fracture as additional findings. 47% of patients with accompanying additional problems had more than one accompanying additional problem. One of our patients had three problems at the same time, including cephalohematoma, eye hemorrhage, and ecchymosis.

NBPP is a unilateral or bilateral clinical picture characterized by varying degrees of paralysis at various levels of the upper extremity and related secondary problems. High birth weight and related difficult birth are the most important risk factors. The incidence is higher in those with a birth weight over 4000 grams, those born with shoulder dystocia or those with a history of difficult birth in general. In babies with an average birth weight of 4272 grams, the rate of obstetric brachial plexus injury has been reported as 2.4% and the rate of clavicle fracture as 2.3% [5]. The incidence of obstetric brachial plexus is between 0.3-4 per thousand. In Turkey, the incidence was found to be 0.9/1000 in a screening of 47,000 children [6].

In studies conducted on congenital brachial plexus paralysis, it was found that gender was not a risk factor and the incidence was not affected by sex. In the study conducted by Acar et al. [7], it was stated that 393 (50.5%) of 777 DBPP patients were female and 384 (49.5%) were male. In another study conducted by Akel et al. [8] examining 70 DBPP patients, it was stated that 36 (51.4%) patients were female and 34 (48.6%) patients were male. They did not find a significant relationship between gender and DBPP classification. Of the 79 patients included in our study, 45 (57%) were female and 34 (43%) were male. When we looked at sex and DBPP classification, no significant relationship was found, consistent with the literature.

Macrosomia, confirmed only after delivery of the neonate, is the second risk factor. The 70% heterogeneity was mostly caused by two studies [9,10]. As both were prospectively performed in Asia, their remarkably higher incidence of macrosomia might be explained by population bias. Sixty per cent of infants with macrosomia in the study by Najafian and Cheraghi were of Arab ethnicity [10]. Dawodu et al. revealed a higher frequency of maternal diabetes, shoulder dystocia, and macrosomia in Arab versus Western populations [9]. Both studies had a strong association of NBPP and macrosomia. In our study, the mean birth weight was 3987.57 grams (±528 grams) and 58.2% of our cases were 4000 grams and above. In our study, the highest birth weight was 6000 grams, while the lowest birth weight was 2750 grams. Similar to the literature, we found that the probability of NBPP increased as birth weight increased.

In accordance with previous reports, maternal diabetes is the third significant risk factor [11-13]. Two studies [14,15], showing higher odds for NBPP in the diabetic group, were responsible for the 59% heterogeneity. As the incidence of NBPP, respectively diabetes, in these studies was comparable with the included studies, other factors should be accountable. Al-Qattan and El-Sayed [16], compared the babies of gestational diabetic mothers with NBPP and the babies of non-diabetic mothers and observed that total NBPP developed more in babies of diabetic mothers. In our study, gestational diabetes was detected in the mothers of 13 of our patients (16.5%). When the relationship between the presence of gestational diabetes and the classification was examined, a significant relationship was found. It was thought that this significant difference was due to the fact that 61.5% of the babies of diabetic mothers were in the total NBPP group. This situation was consistent with the idea in the literature that total NBPP was higher in babies of gestational diabetic mothers.

NBPP is more common in those born vaginally than in those born by cesarean section (C/S) [17]. In a meta-analysis study examining 22 articles on NBPP P by Ruth van der Looven et al. [18], they determined that cesarean section is a protective factor. Studies by Lurie et al. [19] suggested that there is a decrease in fetal injury with increasing cesarean incidence. Seventy-two of our patients (91.1%) were born by normal delivery, and 7 of our patients (8.9%) were born by cesarean section. When the relationship between the type of delivery and the classification was examined, no significant relationship was found. This supports the hypothesis that cesarean delivery may be a protective factor, but it does not completely eliminate the possibility of NBPP.

Acar et al. [7] found that 332 (43%) of the patients were born as a result of the mother's first pregnancy, 260 (33%) as a result of the mother's second pregnancy, 129 (17%) as a result of the mother's third pregnancy, and 56 (7%) as a result of the mother's fourth and/or subsequent pregnancy. In our study, 30 (38%) of our patients were born as a result of the mother's first pregnancy, 21 (26.6%) as a result of the mother's second pregnancy, and 28 (35.4%) as a result of the mother's third and/or subsequent pregnancy. When the relationship between the number of pregnancies and NBPP classification was examined, no significant result was obtained. (p>0.05) When we look at the literature, there are not many studies examining the number of pregnancies of the mother of a NBPP patient. More studies are needed on this subject.

As a result, in our study, the current risk factors were determined as high birth weight, breech presentation, advanced maternal age, excessive maternal weight gain, maternal uterine anomaly, shoulder dystocia and delivery with an assistive device. 98.7% of the patients received physiotherapy, 73% received physiotherapy in the first 3 months. The average physiotherapy duration was found to be 36.71±36.34 months. Surgical treatment was applied to 16% of the patients and the average age at surgical treatment was 6.07±3.54 years. 32% of the patients had complete recovery, 52% had partial recovery and 16% had no recovery.

In conclusion, the decreasing incidence might be the result of augmented awareness of the problem and improved obstetric techniques and strategies. This encourages further research to determine predictable and modifiable risk factors. A future worldwide meta-analysis of incidence could be important to evaluate geographical differences and their influence on the risk of NBPP.

Data are available on reasonable request

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