During delivery, April’s shoulder got caught on her mother, Andrea's, pelvic bone and the umbilical cord was wrapped twice around her neck. April was treated in the NICU for the lack of oxygen, but her parents soon noticed another problem — April never lifted her right arm. They soon learned that April likely had an injury to the brachial plexus nerves of her right arm, which can result in varying degrees of upper extremity weakness or paralysis and numbness.
Andrea left the New Jersey hospital where her baby was born with a packet of handouts and a knot in her stomach.
“I was so overwhelmed, wondering what the future would hold and how this would change her life,” says Andrea.
An early intervention therapist who evaluated April after her release from the hospital recommended Apurva S. Shah, MD, MBA, a pediatric orthopaedic surgeon and Co-director of the Brachial Plexus Injury Program at Children’s Hospital of Philadelphia (CHOP).
Dr. Shah evaluated April at CHOP’s Specialty Care Center at Virtua in Voorhees, NJ. Finally, Andrea had some answers — and a plan of action. April would need time to determine how much her arm would recover naturally as well as intensive occupational therapy to support her recovery.
A plan of action and a timeline
Dr. Shah confirmed that the baby had suffered an injury to her brachial plexus, a network of nerves that run from the cervical spinal cord in the neck to the shoulder, arm and hand. In April’s case the nerves that moved April’s shoulder, bend and straighten her elbow, and turn her palm and wrist up were impacted. He explained that nerves could take up to two years to recover. If April’s bicep muscle didn’t start functioning by the time she reached 6 months of age, she would likely need reconstructive nerve surgery.
Meagan Pehnke, MS, OTR/L, CLT, started April on occupational therapy at CHOP’s Voorhees location and taught her parents exercises to allow April to move the muscles in her arm more normally as the nerves healed. Andrea says she turned each exercise into a game: At diaper changes, she playfully worked on stretches to keep the muscles and joints loose. Throughout the day, she tickled and ran toys up and down April’s arm to stimulate feeling. She clapped her baby’s hands together and they made “snow angels” on the carpet.
Throughout those first couple of months, Andrea would test April’s arm strength by feeling for any sign of a muscle contraction in the infant’s bicep and testing if April could use her muscles to hold the arm when placed in the air. April’s arm would flop back to her side, until one day when April was just over 3 months old, Andrea lifted the arm, let go, and April held her arm steady in the air.
“When she held it up, I cried. I could feel the tension on her bicep,” says Andrea. “Once I knew she didn’t need the nerve surgery, it was like this weight was lifted off and I felt, now she can just be a baby — it’s not this constant worry all the time.”
A bright future
April is 18 months old now and is using her right arm more and more. April’s nerves recovered on their own, without surgery, to give enough strength to the muscles in her arm. Her family’s participation in regular occupational therapy combined with ongoing exercise at home allowed April to learn to move and use her arm without tight muscles limiting her motion.
She now checks in with her occupational therapist every few months and her parents continue to work with April on her range of motion and strengthening exercises every day. They make sure to offer toys and food to her right hand to encourage her to use it, and use light hand weights that April is now able to pick up by herself. Andrea enrolled April in a mommy-and-me swim class and takes her to the playground and a tumble gym regularly. And she recommends that any family facing a similar situation find ways to connect with other families, something that has been hugely helpful to her.
Dr. Shah, pediatric neurologist Sabrina Yum, MD, and an occupational therapist will monitor April’s progress at CHOP’s Brachial Plexus Clinic throughout her childhood and adolescence. But for now, Andrea is focusing on the next few months. She has until April’s second birthday before the window for further nerve recovery closes.
The CHOP Brachial Plexus team has been delighted to watch this magnetic little girl make a remarkable natural recovery. Dr. Shah credits April’s parents for their dedication. “We knew from the very first consultation just how committed April’s parents were to their daughter’s recovery. They have taken advantage of all the resources available to April at CHOP and beyond, and that has made a tremendous difference in April’s recovery.”
"I've heard that parents with little ones who have a good prognosis and are healing well have a tendency to ease up on stretching and home therapy activities,” says Andrea. “I'm always aware of that possibility. It's my job to give her the best possible outcome there is."