A Mother's Effort

By Sheila Dwyer, Body1 Staff

Katy and Peter Gentile anticipated the arrival of their third child like typical third-time parents. They debated baby names and set up a crib, but were not anxious the way they were before the birth of their first child. However, the birth of their son Brendan in February of 2000 confronted them with an unanticipated medical problem—Erb’s Palsy.

Erb’s Palsy is a birth-related injury of the brachial plexus nerve. The network of brachial plexus nerves controls the muscles of the shoulder, arm, elbow, wrist, hand, and fingers. If this nerve is stretched or torn during a newborn’s delivery, any or all of the associated muscles may be paralyzed. Erb’s Palsy affects two to three in 1,000 newborns, more than the number of children affected by Down’s Syndrome or Muscular Dystrophy.

In February, Katy Gentile’s obstetrician induced her labor. Brendan was good-sized, heavier than her two other children. Katy only had to push three times before he began to emerge and got stuck. She says, “when I delivered him, his head came out but his left shoulder stayed almost behind my pelvic bone. So when he came out … all the nerves in his neck were completely stretched out. He came out and his arm just flopped.” Adding to the parents’ anxiety was the fact that Brendan was bruised and had a cut across his shoulder.

In most cases, Erb’s Palsy results from excessive traction or force applied to the infant’s head during delivery. However, Katy’s obstetrician never used forceps or excessive force to deliver Brendan. When she realized that the baby was stuck, the doctor performed a full episiotomy and Brendan came out immediately, merely five minutes after Katy had begun pushing. Katy can only explain the bruising as the result of how Brendan had been positioned inside her womb.

“They did consider when they first saw him that he may have had a stroke because his whole left side drooped,” Katy says. “They thought it because he wasn’t meeting any of the benchmarks and he was definitely slouched.” Katy and Peter were relieved to know that Brendan did not suffer a stroke after the doctors ruled out any neurological damage. They took the baby home with them and followed the doctor’s advice: don’t worry, these injuries are fairly common and they usually fix themselves.

After eight weeks of seeing her son’s left arm hanging by his side, his left wrist twisted out, and his thumb tucked into his hand, she wanted an explanation from the doctors. She had been to several specialists already regarding the baby’s mild stomach problems, but now she was referred to a neurologist who diagnosed Brendan’s arm problem almost immediately as Erb’s Palsy. The neurologist, in turn, referred her to an orthopedic specialist.

“They said automatically that he needs physical therapy because the nerves are so damaged, the brain wasn’t sending messages to move his arm. So as his nerves were healing, he didn’t know how to move his muscles because he’d never done it before.” Katy and Brendan were sent to a physical therapist to work on developing his muscles.

The Gentiles soon learned that the bulk of the responsibility for exercising the baby’s arm fell on them. Their health insurance does not cover physical therapy for children under age three, so they were referred to a state-run program in Massachusetts that provides medical intervention for babies. However, the program offers more occupational therapy than physical therapy. An occupational therapist sees Brendan every two weeks, but Katy would like to see more physical therapy. “When I went last time to the physical therapist at the hospital, he said ‘why aren’t you updating his exercises?’ I then said, ‘because insurance wouldn’t cover physical therapy, so I didn’t know to change it.’ We were doing the same exercises repeatedly, but we should have been doing different ones.”

Through an area hospital, Brendan was fitted for two splints, one for his elbow and one for his hand. The elbow splint straightens his arm, which normally rests at an 80-degree angle. The hand splint opens up his hand and thumb so he does not hold it in its natural fisted position. He sleeps with the splints on, though as he gets older he becomes more adept at ripping them off.

Katy and Peter exercise Brendan’s arm at every diaper change for as long as five or ten minutes. Katy notices a difference in the arm’s motion on the days that she is home with Brendan. “If you don’t stretch him all day you can see him … playing while his left arm is in a held position, as if he has a sling on. He plays using the other arm. But if I’m home with him all day, you can tell the difference. His arm is loose.” Brendan uses his left arm only when forced. He crawls using both arms but he does not opt to use the left arm when playing.

Despite months of therapy, his left arm still has a limited range of motion. He cannot lift it over his head, he cannot fully lift it out to the side, and he cannot do a jumping jack motion at all. He also does not seem to have use of his left thumb. His scapula wings out, which indicates that the muscle is not fully attached to the bone. So when he goes to lift his left arm over his head, his shoulder blade stays under his armpit.

His arm is bent at an L-shaped angle because, though his bicep is strong, his tricep has no use. The use of the bicep muscle alone makes it easier for him to keep his arm bent up than to straighten it.

Despite Brendan’s limitations, Katy remains optimistic. “He’s crawling on it (the left arm), he pulls himself up, he can feed himself. And if it’s just going to be a limitation thing, for me, there are worse things that can happen than to have slightly limited use of his left arm.” The doctors have been pleased with Brendan’s progress so far and Katy takes comfort from a parent she met recently. The woman’s five-year-old son, who also has Erb’s Palsy, plays baseball and hockey despite his weaker left arm. In baseball, he adjusts to what he is able to do—he catches with his left hand and throws with his right.

Katy still feels some guilt about the delay in getting treatment for Brendan. “I waited too long … I didn’t push it. I really thought it would come back on its own. I mean, he didn’t move it for eight weeks. The doctor thought it would come back a lot more than it did … As a parent now, knowing, I would recommend starting physical therapy and getting a splint right away, even though they seem so little.”

By the time he is two years old, Brendan’s abilities and limitations will become clearer. He compensates for his left arm now, but he is only 10 months old. He doesn’t realize yet that he should not switch his toys from his left to his right hand or lift his left arm over his head by picking it up with his right hand.

His parents continue to remain positive about Brendan’s progress. They are going to buy him a basketball net for Christmas to encourage overhead stretching of his left arm. Nerve surgery in a few years is always a possibility, but, Katy says, “for Brendan, because of how far he’s come, I don’t think they’ll really choose to do surgery … He was doing so well and he’s still doing excellent.”

For more information on Erb's Palsy, visit The United Brachial Plexus Network.

Last updated: 12-Dec-00