Peripartum and neonatal factors associated with the persistence of neonatal brachial plexus palsy at 1 year: a review of 382 cases

Maternal Epidemiology of Brachial Plexus Birth Injuries in California: 1996 to 2012

OBJECTIVE

 This study aimed to evaluate the incidence of brachial plexus birth injury (BPBI) and its associations with maternal demographic factors. Additionally, we sought to determine whether longitudinal changes in BPBI incidence differed by maternal demographics.

STUDY DESIGN

 We conducted a retrospective cohort study of over 8 million maternal-infant pairs using California's Office of Statewide Health Planning and Development Linked Birth Files from 1991 to 2012. Descriptive statistics were used to determine BPBI incidence and the prevalence of maternal demographic factors (race, ethnicity, age). Multivariable logistic regression was used to determine associations of year, maternal race, ethnicity, and age with BPBI. Excess population-level risk associated with these characteristics was determined by calculating population attributable fractions.

RESULTS

 The incidence of BPBI between 1991 and 2012 was 1.28 per 1,000 live births, with peak incidence of 1.84 per 1,000 in 1998 and low of 0.9 per 1,000 in 2008. Incidence varied by demographic group, with infants of Black (1.78 per 1,000) and Hispanic (1.34 per 1,000) mothers having higher incidences compared with White (1.25 per 1,000), Asian (0.8 per 1,000), Native American (1.29 per 1,000), other race (1.35 per 1,000), and non-Hispanic (1.15 per 1,000) mothers. After controlling for delivery method, macrosomia, shoulder dystocia, and year, infants of Black (adjusted odds ratio [AOR] = 1.88, 95% confidence interval [CI] = 1.70, 2.08), Hispanic (AOR = 1.25, 95% CI = 1.18, 1.32), and advanced-age mothers (AOR = 1.16, 95% CI = 1.09, 1.25) were at increased risk. Disparities in risk experienced by Black, Hispanic, and advanced-age mothers contributed to a 5, 10, and 2% excess risk at the population level, respectively. Longitudinal trends in incidence did not vary among demographic groups. Population-level changes in maternal demographics did not explain changes in incidence over time.

CONCLUSION

 Although BPBI incidence has decreased in California, demographic disparities exist. Infants of Black, Hispanic, and advanced-age mothers are at increased BPBI risk compared with White, non-Hispanic, and younger mothers.

KEY POINTS

· The incidence of BPBI has decreased over time.. · Demographic disparities in BPBI incidence and risk exist.. · Infants of Black, Hispanic, and advanced age mothers are at greatest risk of BPBI..

Utilizing International Classification of Diseases Codes to Identify Shoulder Dystocia and Neonatal Brachial Plexus Injury

BACKGROUND

The utilization of International Classification of Diseases, Ninth or Tenth Revision, (ICD-9/10) coding to identify the incidence of disease is frequently performed in medical research. This study attempts to assess the validity of using ICD-9/10 codes to identify patients with shoulder dystocia (SD) with concurrent neonatal brachial plexus palsy (NBPP).

METHODS

This retrospective cohort study examined patients evaluated at the University of Michigan Brachial Plexus and Peripheral Nerve Program (UM-BP/PN) from 2004 to 2018. We reported the percentage of patients with reported NBPP ICD-9/10 and SD ICD-9/10 discharged at birth who were later diagnosed with NBPP by a specialty clinic by interdisciplinary faculty and staff utilizing physical evaluations and ancillary testing such as such as electrodiagnostics and imaging. The relationship of reported NBPP ICD-9/10, SD ICD-9/10, extent of NBPP nerve involvement, and NBPP persistence at age two years were examined via chi-square or Fischer exact test.

RESULTS

Of the 51 mother-infant dyads with complete birth discharge records evaluated at the UM-BP/PN, 26 (51%) were discharged without an ICD-9/10 code documenting NBPP; of these 26 patients, only four had ICD-9/10 documentation of SD at discharge, which left 22 patients with no ICD-9/10 code documentation of either SD or NBPP (43%). Patients with pan-plexopathy were more likely to be discharged with an NBBP ICD-9/10 code than those infants with upper nerve involvement (77% vs 39%, P < 0.02).

CONCLUSION

Use of ICD-9/10 codes for the identification of NBPP appears to undercount the true incidence. This underestimation is more pronounced for milder forms of NBPP.

Prevalence of perinatal factors in infants with brachial plexus birth injuries and their association with injury severity

OBJECTIVES

To determine the prevalence of perinatal factors associated with brachial plexus birth injury (BPBI) in affected infants and their relationship with BPBI severity.

STUDY DESIGN

Retrospective study of BPBI infants prospectively enrolled in a multicenter registry. The prevalence of perinatal factors was calculated. Infants were stratified by injury severity and groups were compared to determine the association of severity and perinatal factors.

RESULTS

Seven-hundred-ninety-six BPBI infants had a mean 4.2 ± 1.6 perinatal factors. Nearly all (795/796) reported at least one factor, including shoulder dystocia(96%), no clavicle fracture (91%), difficult delivery(84%), parity >1(61%) and birthweight >4000 g(55%). Ten-percent (74/778) had Horner's syndrome and 28%(222/796) underwent nerve surgery. Birth asphyxia and NICU admission were significantly associated with injury severity.

CONCLUSIONS

NICU admission and asphyxia were associated with BPBI severity. An improved understanding of the relationship between perinatal factors and BPBI severity may be used to guide early referral to BPBI providers and support prevention efforts.

Shoulder Dystocia: Challenging Basic Assumptions

Most of our knowledge pertaining to this obstetric emergency has emanated from case reports and retrospective studies that have subsequently resulted in empirical management protocols. This article has identified the existence of large gaps in our clinical knowledge base regarding the prevention and resolution of shoulder dystocia, as well as its long-term sequelae. We have attempted to challenge current recommendations regarding whether prophylactic cesarean delivery should be performed based on estimated fetal weight alone or a prior history of shoulder dystocia, shoulder dystocia management techniques, what defines "excessive" traction, and the role of simulation training for all clinicians.

Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis

OBJECTIVE

This study aimed to evaluate the outcomes associated with the implementation of simulation exercises to reduce the sequela of shoulder dystocia.

DATA SOURCES

Electronic databases (Ovid MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature database, and Scopus) were initially queried in June 2020 and updated in November 2020. The following 3 concepts were introduced and refined using the controlled vocabulary of the database: vaginal birth, shoulder dystocia, and simulation training. There were no limitations to the year of publication as part of the search strategy.

STUDY ELIGIBILITY CRITERIA

We included all studies that reported on the frequency of shoulder dystocia and the associated complications before and after the implementation of interventional exercises to improve outcomes.

METHODS

Two authors independently assessed the abstracts and full-text articles of all studies for eligibility and evaluated the quality of the included studies using the Newcastle-Ottawa Scale. Any inconsistencies related to study evaluation or data extraction were resolved by a third author. The coprimary outcomes of this systematic review and meta-analysis were neonatal brachial plexus palsy diagnosed following deliveries complicated by shoulder dystocia and persistence of brachial palsy at 12 months or later. The secondary outcomes were the frequency of shoulder dystocia and cesarean delivery. Study effects were combined using a Bayesian meta-analysis and were reported as risk ratios and 95% credible intervals (Crs).

RESULTS

Of the 372 articles reviewed, 16 publications, which included 428,552 deliveries with 217,713 (50.8%) deliveries during the preintervention and 210,839 (49.2%) deliveries during the postinterventional period, were included in the meta-analysis. The incidence of neonatal brachial plexus palsy after shoulder dystocia decreased from 12.1% to 5.7% (risk ratio, 0.37; 95% Cr, 0.26-0.57; probability of reduction 100%). The overall proportion of neonatal brachial plexus palsy decreased, but with less precision, from 0.3% to 0.1% (risk ratio, 0.53; 95% Cr, 0.21-1.26; probability of reduction 94%). Two studies followed newborns with brachial plexus palsy for at least 12 months. One study that reported on persistent neonatal brachial plexus palsy at 12 months among 1148 shoulder dystocia cases noted a reduction in persistent neonatal brachial plexus palsy from 1.9% to 0.2% of shoulder dystocia cases (risk ratio, 0.13; 95% confidence interval, 0.04-0.49). In contrast, the study that reported on persistent neonatal brachial plexus palsy at 12 months for all deliveries noted that it did not change significantly, namely from 0.3 to 0.2 per 1000 births (risk ratio, 0.77; 95% confidence interval, 0.31-1.90). Following the implementation of shoulder dystocia interventional exercises, the diagnosis of shoulder dystocia increased significantly from 1.2% to 1.7% of vaginal deliveries (risk ratio, 1.39; 95% Cr, 1.19-1.65; probability of increase 100%). Compared with the preimplementation period, the cesarean delivery rate increased postimplementation from 21.2% to 25.9% (risk ratio, 1.22; 95% Cr, 0.93-1.59; probability of increase 93%). We created an online tool (https://ccrebm-bell.shinyapps.io/sdmeta/) that permits calculation of the absolute risk reduction and absolute risk increase attributable to the intervention vis-à-vis the incidence of shoulder dystocia, neonatal brachial plexus palsy, and cesarean deliveries.

CONCLUSION

Introduction of shoulder dystocia interventional exercises decreased the rate of neonatal brachial plexus palsy per shoulder dystocia case; the data on persistence of neonatal brachial plexus palsy beyond 12 months is limited and contradictory. Implementation of the interventions was associated with an increase in the diagnosis of shoulder dystocia and rate of cesarean deliveries.

Neonatal brachial plexus palsy: associated birth injury outcomes, hospital length of stay and costs

OBJECTIVE

To compare the birth injury outcomes and hospital length of stay and costs among newborns delivered at 34-42 weeks with neonatal brachial plexus palsy (NBPP) versus those without.

STUDY DESIGN

We conducted a retrospective, cross-sectional study using data from the National Inpatient Sample to identify all newborns hospitalizations that occurred in the U.S. between 2016 and 2017. We included non-anomalous single liveborn delivered in-hospital at 34-42 weeks. The newborns with NBPP were identified by International Classification of Diseases, 10th Revision, Clinical Modification codes. Birth injury outcomes, and hospital length of stay and hospital costs were examined. A multivariable Poisson regression model with robust error variance was used to examine the association between NBPP and birth injury outcomes. A multivariable generalized linear regression model was used to examine the association between NBPP and hospital length of stay and hospital costs.

RESULTS

Of 7,019,722 non-anomalous single liveborn delivered at 34-42 weeks in the U.S. from 2016 to 2017, the rate of NBPP (n = 6695) was 0.95 per 1000 newborn hospitalizations. After multivariable regression adjustment, compared to newborns without NBPP, the risk of the composite birth injury outcome was 2.91 (95% CI 2.61-3.25) times higher in those with NBPP. Similar results of an increased risk among newborns with NBPP were observed in all individual birth injury outcomes. Compared to newborns without NBPP, after adjustment, the hospital length of stay was 1.48 (95% IC 1.38-1.59) times higher and the hospital costs were 2.21 (95% CI 1.97-2.48) times higher in those with NBPP.

CONCLUSIONS

Among newborns delivered at 34-42 weeks, the risk of associated birth injuries, hospital length of stay and costs, were significantly higher in newborns with NBPP than those without.

Predictors of neonatal brachial plexus palsy subsequent to resolution of shoulder dystocia

OBJECTIVE

The objective was to ascertain factors among deliveries complicated by shoulder dystocia (SD) and neonatal brachial plexus palsy (NBPP).

METHODS

At 11 hospitals, deliveries complicated by SD were identified. The inclusion criteria were vaginal delivery of non-anomalous, singleton at 34-42 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for NBPP.

RESULTS

Of the 62,939 individuals who delivered vaginally, 1,134 (1.8%) had SD and met other inclusion criteria. Among the analytic cohort, 74 (6.5%) had NBPP. The factor known before delivery which was associated with NBPP was diabetes (aOR = 3.87; 95% CI = 2.13-7.01). After delivery, the three factors associated with NBPP were: (1) birthweight of at least 4000 g (aOR = 1.83; 95% CI = 1.05-3.20); (2) calling for help during the SD (aOR = 4.09, 95% CI = 2.29-7.30), and (3) the duration of SD ≥120 sec (aOR = 2.47, 95% CI = 1.30-4.69). The AUC under the ROC curve for these independent factors was 0.79 (95% CI = 0.77 - 0.82).

CONCLUSIONS

Few factors were identified that were associated with NBPP after SD, but they could not reliably predict which neonates will experience the complication.

A retrospective analysis of risk factors for clavicle fractures in newborns with shoulder dystocia and brachial plexus injury: A single-center experience

OBJECTIVE

We aimed to analyze the risk factors for clavicle fractures in newborns with shoulder dystocia and brachial plexus injury and to determine whether their incidence is associated with local characteristics.

METHODS

This study was conducted as a retrospective trial between January 2017 and December 2018. Patients with clavicular fracture who were hospitalized in the neonatal intensive care unit of a community hospital were retrospectively analyzed. The clavicular fracture cohort was first divided into two groups and then two subgroups: patients with/without shoulder dystocia and patients with/without a brachial plexus injury. Peripartum and neonatal risk factors of these patients were reviewed using the patient information system. Any additional neurological or musculoskeletal trauma was noted. A multivariate logistic regression analysis was performed to determine independent predictors of shoulder dystocia and brachial plexus injury.

RESULTS

A total of 46 patients with shoulder dystocia in 25 (54%) and brachial plexus injury in 12 (26%) were included in the study. The birth weight of patients with shoulder dystocia was 4,164.2±412.7 g, and that of patients without was 3,535.8±865.2 g (p=0.003). In 11 of 14 patients (44%) in whom labor was induced and whose infant had a fractured clavicle, the infant also had shoulder dystocia (p=0.029). Brachial plexus injury was found in 8 (66.7%) of 14 infants who were born by induced labor and who had a clavicular fracture (p=0.002). The regression analysis revealed that age and induction of labor were independent risk factors for brachial plexus injury (odds ratio=1.599 and 81.862, respectively). Gestational weight gain (p=0.003) and neonatal birth weight (p=0.047) were also found as independent risk factors for shoulder dystocia.

CONCLUSION

Evidence from this study has shown that not only birth age or birth weight but also excessive weight gain by mother and induction of labor may increase the risk of clavicula fracture with brachial plexus palsy. Advanced maternal age, multiparity, and deliveries after 39 weeks seem to be risk factors for a clavicular fracture with a brachial plexus injury.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Causation of permanent brachial plexus injuries to the anterior arm after shoulder dystocia – Literature review

Not all neonatal brachial plexus injuries should be deemed the fault of the accoucheur. However, there is a small (<10%) subset of neonatal brachial plexus injuries that are related to excessive traction by the accoucheur: permanent injuries to the anterior arm after SD. The position regarding posterior injuries remains predominantly the same; if the injury is to the posterior shoulder, the injury is likely to have been caused by maternal propulsion against the sacral promontory before the foetal head is delivered, rather than excessive and inappropriate traction. However, there is no reliable evidence that a combination of maternal propulsion and diagnostic traction alone causes significant and permanent injury to the anterior shoulder after shoulder dystocia. This was recognised in Deith vs. Lanarkshire where the judge found: that where there is a severe injury to an anterior arm after SD, excessive traction is overwhelmingly likely to be the cause.

The Epidemiology of Brachial Plexus Birth Palsy in the United States: Declining Incidence and Evolving Risk Factors

BACKGROUND

The epidemiology of brachial plexus birth palsy (BPBP) in the United States may be changing over time due to population-level changes in obstetric care.

METHODS

The Kids' Inpatient Database from 1997 to 2012 was analyzed. Annual estimates of BPBP incidence and disease determinant distribution were calculated for the general population and the study population with BPBP. Long-term trends were analyzed. A multivariate logistic regression model was used to quantify the risk associated with each determinant.

RESULTS

The database yielded a combined total of 5,564,628 sample births extrapolated to 23,385,597 population births. The population incidence of BPBP dropped 47.1% over the 16-year study period, from 1.7 to 0.9 cases per 1000 live births (P<0.001). Female, black, and Hispanic subgroups had moderately increased risks of BPBP. Among children with BPBP, 55.0% had no identifiable risk factor. Shoulder dystocia was the strongest risk factor for BPBP in the regression model [odds ratio (OR), 113.2; P<0.001], although the risk of sustaining a BPBP in the setting of shoulder dystocia decreased from 10.7% in 1997 to 8.3% in 2012 (P=0.006). Birth hypoxia was independently associated with BPBP (OR, 3.1; P<0.001). Cesarean delivery (OR, 0.16; P<0.001) and multiple gestation birth (OR, 0.45; P<0.001) were associated with lower incidence of BPBP. Notably, the rate of cesarean delivery increased by 62.8% during the study period, from 20.9% in 1997 to 34.0% in 2012 (P<0.001).

CONCLUSIONS

Over a 16-year period, the incidence of BPBP fell dramatically, paralleled by a significant increase in the rate of cesarean delivery. Systemic changes in obstetric practice may have contributed to these trends. As more than half of BPBP cases have no identifiable risk factor, prospective investigation of established risk factors and characterization of new disease determinants are needed to more reliably identify infants at greatest risk. Racial and geographic inequalities in disease burden should be investigated to identify interventional targets.

LEVEL OF EVIDENCE

Level III-case series.

Obstetric brachial plexus injuries (OBPIs): health-related quality of life in affected adults and parents

Background

Obstetric brachial plexus injuries (OBPIs) are rare but can have significant implications for those affected, their caregivers and the health system. Symptoms can range from restricted movement to complete paralysis of the arm. We investigated health-related quality of life in adults with OBPIs and parents of children with permanent OBPIs, compared these with population norms, and investigated whether certain socio-demographic or clinical factors were associated with the quality of life in these cohorts.

Methods

A cross-sectional study examined 50 affected adults and 78 parents. Participants completed EQ-5D-5 L and characteristics questionnaires. EQ-5D-5 L responses were mapped onto an EQ-5D-3 L value set to generate utility scores. Mean utility scores were compared with English population norms. Univariable and multivariable linear regression models were conducted to assess for associations between participant characteristics and the utility scores.

Results

The overall mean utility scores for affected adults and parents were 0.56 (SD 0.28) and 0.80 (SD 0.19) respectively. Affected adults (95% CI (− 0.38, − 0.22), p < 0.001) and parents of children with permanent OBPIs (95% CI (− 0.10, − 0.02), p = 0.007) had lower mean utility scores, and therefore quality of life, compared to English population norms. For affected adults, previous OBPI surgery (95% CI (0.01, 0.25), p = 0.040), employment in non-manual work (95% CI (0.06, 0.30), p = 0.005) and having a partner (95% CI (0.04, 0.25), p = 0.009) appeared to be positively associated with the utility score. Affected adults receiving disability benefits related to OBPIs appeared to have worse utility scores than those not receiving any disability benefits (95% CI (− 0.31, − 0.06), p = 0.005). For parents, employment was associated with better utility scores (95% CI (0.02, 0.20), p = 0.024) but the presence of one or more medical condition appeared to be associated with worse utility scores (95% CI (− 0.16, − 0.04), p = 0.001).

Conclusions

Adults with OBPIs and parents of children with permanent OBPIs reported worse utility scores, and therefore quality of life, compared to the English general population. We also identified certain characteristics as possible factors to consider when dealing with utility scores in these cohorts. The utility scores in this study can be used in future economic evaluations related to OBPIs.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-1039-z) contains supplementary material, which is available to authorized users.

Effect of fascicle composition on ulnar to musculocutaneous nerve transfer (Oberlin transfer) in neonatal brachial plexus palsy

OBJECTIVE Neonatal brachial plexus palsy (NBPP) continues to be a problematic occurrence impacting approximately 1.5 per 1000 live births in the United States, with 10%-40% of these infants experiencing permanent disability. These children lose elbow flexion, and one surgical option for recovering it is the Oberlin transfer. Published data support the use of the ulnar nerve fascicle that innervates the flexor carpi ulnaris as the donor nerve in adults, but no analogous published data exist for infants. This study investigated the association of ulnar nerve fascicle choice with functional elbow flexion outcome in NBPP. METHODS The authors conducted a retrospective study of 13 cases in which infants underwent ulnar to musculocutaneous nerve transfer for NBPP at a single institution. They collected data on patient demographics, clinical characteristics, active range of motion (AROM), and intraoperative neuromonitoring (IONM) (using 4 ulnar nerve index muscles). Standard statistical analysis compared pre- and postoperative motor function improvement between specific fascicle transfer (1-2 muscles for either wrist flexion or hand intrinsics) and nonspecific fascicle transfer (> 2 muscles for wrist flexion and hand intrinsics) groups. RESULTS The patients' average age at initial clinic visit was 2.9 months, and their average age at surgical intervention was 7.4 months. All NBPPs were unilateral; the majority of patients were female (61%), were Caucasian (69%), had right-sided NBPP (61%), and had Narakas grade I or II injuries (54%). IONM recordings for the fascicular dissection revealed a donor fascicle with nonspecific innervation in 6 (46%) infants and specific innervation in the remaining 7 (54%) patients. At 6-month follow-up, the AROM improvement in elbow flexion in adduction was 38° in the specific fascicle transfer group versus 36° in the nonspecific fascicle transfer group, with no statistically significant difference (p = 0.93). CONCLUSIONS Both specific and nonspecific fascicle transfers led to functional recovery, but that the composition of the donor fascicle had no impact on early outcomes. In young infants, ulnar nerve fascicular dissection places the ulnar nerve at risk for iatrogenic damage. The data from this study suggest that the use of any motor fascicle, specific or nonspecific, produces similar results and that the Oberlin transfer can be performed with less intrafascicular dissection, less time of surgical exposure, and less potential for donor site morbidity.

The prognostic value of concurrent Horner syndrome in surgical decision making at 3 months in total-type neonatal brachial plexus palsy

We investigated the prognostic value of concurrent Horner syndrome for predicting spontaneous motor recovery in surgical decision making at 3 months with neonatal brachial plexus palsy. Medical records of 129 neonates with total-type brachial plexus palsy were reviewed, and clinical and follow-up data of patients with or without Horner syndrome were compared. Twenty-seven of 129 newborn babies with total-type palsy (21%) had concurrent Horner syndrome. Poor spontaneous motor recovery was observed in 21 (78%) neonates with concurrent Horner syndrome and in 84 (82%) without concurrent Horner syndrome. Concurrent Horner syndrome in neonates with brachial plexus palsy has no prognostic value in predicting poor spontaneous motor recovery of the brachial plexus in patients with total-type palsy.

LEVEL OF EVIDENCE

III.

An Update on the Management of Neonatal Brachial Plexus Palsy-Replacing Old Paradigms: A Review

IMPORTANCE

Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, "all neonatal brachial plexus palsy recovers," "wait a year to see if recovery occurs," and "don't move the arm." Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms.

OBSERVATIONS

Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function.

CONCLUSIONS AND RELEVANCE

Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.

Oberlin transfer compared with nerve grafting for improving early supination in neonatal brachial plexus palsy

OBJECTIVE The use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting. METHODS This retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year. RESULTS No significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups. CONCLUSIONS The preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.