PC1075: Neonatal Brachial Plexus Palsy: Importance of Early Referral to Multidisciplinary Specialty Centers

Background: Neonatal brachial plexus palsy (NBPP) results in lifelong disability for >30% of affected children, with an estimated overall societal cost of persistent palsy of $1-3 billion annually. A systematic description of the long-term recovery of upper extremity movement remains elusive, and an understanding of the optimal timing of referral to multidisciplinary referral centers remains unexplored. In this 15-year longitudinal cohort study, we aim to describe the recovery of patients with conservatively-managed NBPP and determine if early referral to a multidisciplinary brachial plexus center alters the trajectory and extent of maximal recovery.

Methods: All children evaluated for NBPP at a single multidisciplinary specialty center comprising neurosurgeons, pediatric neurologists, pediatric physical medicine and rehabilitation physicians, and occupational therapists between 2005 and 2020 were considered for inclusion in this study. Those who were seen at a single visit, initially seen >2 years old, and those deemed to be surgical candidates were excluded. Active range of motion (AROM) for shoulder and elbow movements captured at each appointment was measured against patient age and logistic regression analysis used to demonstrate the overall trajectory and percentage of recovery for each movement. This analysis was then applied to patients in whom formal evaluation or treatment was initiated at ≤30 and >30 days old.

Results: 703 children were considered for inclusion in this study; 378 children were excluded, including 99 surgical candidates (14% of all referrals), leaving 325 children representing over 12,000 prospectively collected data points for analysis. Approximately half of children included in the study were referred by pediatricians. 112 children underwent initial formal interdisciplinary evaluation or treatment at ≤30 days old and 215 were delayed to >30 days old. No significant difference in follow-up existed between the early and late referrals (31.32 ± 38 months vs. 38.29 ± 40.61 months). AROM improved to at least ~70% function for shoulder abduction and forward flexion, elbow flexion, and elbow supination, but improvement was more rapid and with greater maximal function for the ≤30-day group. AROM for external rotation and elbow extension improved or remained stable for the ≤30-day group but decreased over time for the >30-day group. Lastly, AROM for elbow pronation decreased over time for both referral groups.

Conclusion: This study represents the first description of long-term functional recovery for children with NBPP treated non-surgically. Importantly, we found that patients evaluated at a multispecialty program within 30 days of birth tend to have better long-term outcomes than those who are seen later. Our data thus underscore the critical significance of early referral to a clinic specialized in the care of NBPP to optimize long-term functional recovery. As pediatricians are the most common referrers for NBPP, their referral patterns can strongly influence outcomes for these children.