Babies born with cerebral palsy, Erb's palsy or brachial plexus palsy suffer injuries to the brain or stretching, scarring, tearing or rupturing of nerves that run from the back of the neck down to the fingers. Injuries may stem from a difficult delivery.
According to the U.S. Centers for Disease Control and Prevention (CDC), from 2000-09 the number of emergencies during child birth increased 75 percent. Birth injuries can range from bone fractures and spinal cord injuries to facial paralysis.
The most common motor disability stemming from birth injuries is cerebral palsy (CP) – a group of disorders characterized by muscle weakness or problems using muscles, according to the CDC. Injuries stem from brain damage before, during or after birth. The CDC estimates that 1 in 323 children are living with CP and 4 in 1,000 babies are diagnosed with the condition after birth. Parents recognize symptoms in their child’s first year.
Erb’s palsy is a form of brachial plexus palsy, a nerve disorder that affects the network of spinal nerves that run from the back of the neck to the shoulder and upper arm. The condition occurs in approximately 2 out of every 1,000 births.
CP has no cure, and children who have the condition face life-long difficulties. Treatment can take an emotional toll on the child and on the family, and medical costs associated with treatment can grow quickly. CP is caused by brain abnormality and not by a disease, so it does not grow worse over time.
Through physical therapy, a child with mild forms of Erb’s Palsy often can gain use of an affected arm and manage pain associated with the condition. In some cases, nerves torn at birth cause permanent damage.
Strokes, brain infections, genetic disorders and premature births all can cause CP and Erb's Palsy. But sometimes physicians make mistakes during delivery that may damage a baby's brain, muscles or nerves. A number of parents filed lawsuits against hospitals and doctors after their babies were diagnosed with CP or Erb's Palsy, disorders that can affect a child for the rest of their lives.
Causes and Risks of Cerebral Palsy
Cerebral palsy is caused by damage to the part of the brain called the cerebrum. This part controls memory, ability to learn, communication and muscle control. The damage can occur while the baby is still in the womb, during birth or after birth.
A mother may have an infection that damages the baby's brain while still in the womb. Or the brain may form incorrectly because of genetics. In other cases, an infant may experience lack of oxygen to his or her brain during childbirth if doctors do not deliver the baby in time or fail to recognize signs of fetal distress and perform a timely Caesarian section (C-section).
Congenital and Acquired CP
Doctors classify Cerebral Palsy into two categories--congenital and acquired--depending on when the brain injury occurs.
Congenital brain damage occurs before or during birth, and 85 to 90 percent of CP cases fall in this category. Sometimes, the exact cause of the damage cannot be pinpointed, but there are risk factors that increase the chance that a child will suffer from congenital CP.
Risk factors and causes include:
- Low birth weight (less than 5.5 pounds)
- Premature birth
- Multiple births, such as twins or triplets
- Children conceived with fertility treatments
- Infections during pregnancy
- Mothers who suffer from disabilities, seizures or thyroid issues
- Detachment of the placenta
- Uterine rupture
- Umbilical cord problems
- Oxygen disruption to the baby's brain
- Complications during delivery
- Drug use by the mother
CP that results from medical negligence is also considered congenital since it occurs at the time of birth. Doctors may fail to note the signs of fetal distress, such as irregular fetal heartbeat during contractions. Sometimes, a hospital is understaffed and unable to perform all the steps necessary to ensure the baby is delivered in a timely manner.
If the baby is not delivered in time, the brain may be deprived of oxygen and brain damage can occur, which can lead to CP.
Acquired CP is rarer and occurs more than 28 days after birth. Usually it is caused by an infection or head injury. Some of the causes of acquired CP include:
- Infections such as meningitis
- Head injuries
- Bleeding in the brain
- Undiagnosed heart defects
- Sickle cell disease
Types of CP
There are several types of CP, classified by the symptoms and motor dysfunction. While there are several subtypes, doctors recognize four main classifications. A person may also have a more than one type of palsy.
This is the most common type of palsy and affects about 80 percent of children who are diagnosed with CP. This type of palsy has three subtypes:
Spastic diplegia affects the legs and causes difficulty walking. Legs have a tendency to pull together and inward.
Spastic hemiplegia affects only one side of the body, and typically it is an arm.
Spastic quadriplegia affects the whole body – all four limbs, the torso and face. This is the most severe form of palsy, and people with this type of CP typically have difficulty walking or cannot walk at all. They may also suffer from mental disability and have trouble hearing, seeing or speaking.
People with this type of palsy have muscle tone that changes throughout the day, sometimes too loose or too tight. This makes them prone to sudden, uncontrollable movements of the hands, feet, arms and legs.
Ataxic CP affects balance and coordination. This makes activities like walking, writing and controlling limbs difficult.
Early Symptoms and Signs of Cerebral Palsy
Cerebral palsy symptoms can develop slowly as the baby grows. Parents may notice their baby has trouble turning over or learning how to crawl. Parents may also notice floppiness in their child’s limbs. The CDC lists some signs that parents can watch for:
Babies Younger than 6 months
- Floppy or stiff muscles
- Inability to hold up their head
- Legs cross or scissor when baby is picked up
Babies Older than 6 Months
- Unable to roll over
- Cannot bring hands together or toward mouth
- Reaches out with one hand and keep one fisted
Babies Older than 10 Months
- Lopsided crawling, dragging limbs
- Scoots on buttocks or hops on knees instead of crawling
- Inability to stand
Parents who are concerned should contact their doctor. There are developmental tests that pediatricians can use to diagnose CP.
Patients who suffer from CP will face a number of health issues as they age. Premature aging occurs because of the strain on the body and improperly functioning organs. Chronic pain is a concern because of tight muscles and degenerative arthritis. Functioning in the workplace is also difficult. Depression can also be a problem. Someone with CP is three to four times more to develop depression than someone without CP.
Treatment for Cerebral Palsy
There is no cure for cerebral palsy, but there are ways parents can help. Beginning treatment early will yield a better outcome. Each treatment plan will be different, depending on the type of CP and needs of the child.
Some forms of treatment include:
- Physical Therapy. This is considered the foundation of CP treatment. Starting therapy soon after diagnosis or in the early years of life can help improve muscle strength, coordination, balance and motor skills.
- Recreation Therapy. Art, sports and other activities can help develop self-esteem, speech and emotional well-being. It can often be difficult for children with CP to make friends and be socially adjusted.
- Occupational Therapy. This type of therapy teaches children with daily activities like dressing and going to school.
- Help with Eating and Drooling. Some children with Cerebral Palsy experience difficulty eating and drinking because they can’t move their mouths and tongue or swallow correctly. This can lead to malnutrition and lung infections from food and fluid getting into the lungs. Oral motor training by an occupational and physical therapist can help train muscles in the jaw but is time consuming. Some medications can be used to reduce the rate of drooling, but it does not stop it completely. As a last resort, doctors may try surgical intervention.
- Speech and Language Therapy. This helps a child learn how to speak clearly and manage swallowing disorders. Therapists can also teach children how to use technologies like computers or voice synthesizers to communicate.
- Oral Medications. Some drugs can help relax overactive muscles, but may also have side effects.
- Surgery. Doctors can perform surgery to lengthen muscles and tendons to ease the tightness, improve mobility and lessen pain. But, operating on children can cause additional problems and the surgeries may have to be spread out over time. Some children are not candidates for surgery. A doctor may also cut nerves when conservative treatment fails to lessen pain or spasticity.
How Erb’s Palsy Develops
If a doctor has a difficult time pulling an infant from the birth canal, more pressure is placed on the infant’s shoulder, head and neck. This can cause Erb’s palsy, a nerve disorder that affects the shoulder and upper part of the arm. The condition affects the brachial plexus, a network of nerves that run from the back of the neck into the shoulder, arm, hand and fingers. Erb’s Palsy develops when, during a complicated delivery, the brachial plexus is stretched until the nerves bruise, tear or rupture. If the baby's head is pulled too much to one side during delivery the network of nerves is stretched or torn. This leads to difficulty moving the arm, pain or paralysis in the arm.
Causes of Erb’s Palsy
Unlike CP, which is a neurological condition caused by damage to the brain, Erb's – as well as its more serious form, brachial plexus palsy – is caused by physical damage to nerves.
It typically develops in larger infants after physicians apply too much pressure while using vacuum devices or forceps. The chance of Erb’s palsy increases if a physician fails to recognize conditions that are more optimal for a Caesarean section than for a vaginal delivery.
Doctor use Erb’s Palsy to describe several types of nerve injuries that can occur during birth:
Neurapraxia. This is a stretch injury where a nerve is shocked but not torn. In a few months, these injuries will usually heal. This is the most common type of nerve birth injury.
Neuroma. When nerve fibers are stretched, scar tissue may develop and press on the healthy nerves. This is a neuroma. The nerve may never fully heal.
Rupture. This injury occurs when a nerve is overstretched and torn. The damage does not heal on its own. In some cases a doctor may be able to repair the nerve by using a graft.
Avulsion. Avulsions are the most serious type of nerve injury. These occur when the nerve is severed from the spinal cord. In these cases, children lose use of the affected arm. Sometimes, a doctor may be able to restore function to the arm by using a nerve from another muscle.
Symptoms of Erb’s Palsy
An infant will experience different symptoms depending on whether there is a bruise, tear or rupture of the nerves in the brachial plexus. In extreme cases, Erb’s Palsy may paralyze the infant’s arm. Or he or she may experience limpness or no movement in one hand.
The baby may not show any pronounced symptoms as he or she grows. Instead, parents will notice their baby holding an affected arm extremely close to the body, indicating an inability to move the arm, hand or fingers. In other instances the baby may not have full range of arm motion.
If a nerve is torn, the infant may have permanent nerve damage. Less severe bruising and swelling around the nerves generally subsides in a few months, after which the child will have the ability to move the arm without any pronounced symptoms.
Serious cases may require surgery to treat.
Treatment for Erb’s Palsy
Many newborns with Erb’s Palsy or other forms of brachial plexus palsies recover in three to six months. Because nerves grow and recover slowly, complete recovery can take up to two years, although each child’s case is unique. A physician will take images of the shoulder to determine whether there is minor or severe damage to the nerves.
There are two types of primary treatment: non-surgical and surgical.
Doctors address most cases of Erb’s Palsy with physical therapy. Parents usually take an active role in the baby’s therapy by assisting with daily range-of-motion exercises. Infants as young as three weeks old can benefit from range-of-motion exercises to help hand, wrist, elbow and shoulder issues.
After three to six months of therapy with little to no improvement or if a nerve is separated from the spinal cord, a doctor may recommend surgery. In the case of a rupture, a nerve graft surgery repairs the ruptured nerve using a donor nerve graft. For nerves severed from the spinal cord, nerve transfer surgery with a donor muscle may restore some function in the arm.
In some children, the affected arm will be noticeably smaller and weaker because nerves play a role in growth, and damaged nerves cause the arm to grow at a slower pace. When children are older, the size difference will be more noticeable. There likely will always be weakness in the affected arm, hand or shoulder.
Klumpke’s Palsy is another form of brachial plexus palsy, and it also occurs during a difficult childbirth when brachial plexus nerves stretch, scar, tear or rupture.
The signs and symptoms of Klumpke’s Palsy are similar to Erb’s Palsy and brachial plexus palsy with the loss of movement and weakness in one arm. In addition, some infants experience a drooping of the eyelid on the opposite side of his or her face. The symptom is called Horner syndrome.