Phrenic nerve injury is a serious but manageable birth injury that affects the newborn’s ability to breathe properly. This condition occurs when the phrenic nerve—which controls the diaphragm muscle responsible for breathing—becomes damaged during delivery. Understanding the causes, symptoms, and treatment options is essential for families facing this diagnosis.
As an educational resource for families affected by birth injuries in New York, we provide evidence-based information to help you understand what happened to your baby and what treatment options are available. This article covers everything you need to know about phrenic nerve injury and diaphragmatic paralysis in newborns.
What Is Phrenic Nerve Injury?
The phrenic nerve is a critical nerve that controls the diaphragm, the large muscle beneath the lungs responsible for breathing. When this nerve is injured during birth, the diaphragm becomes partially or completely paralyzed, preventing normal breathing on one or both sides.
According to the MSD Manual’s Professional Edition, phrenic nerve injuries account for a significant portion of birth-related nerve injuries, and most cases (about 75%) occur in conjunction with brachial plexus injuries.
Key Fact: Phrenic nerve injury results from a stretch injury to the nerve roots (C3-C5) in the neck during delivery, most commonly occurring with difficult or traumatic births.
How Does Phrenic Nerve Injury Occur?
Mechanism of Injury
Phrenic nerve injury typically occurs when the baby’s head and neck are stretched excessively during delivery. This excessive stretching happens at the point where the nerve roots emerge from the spinal cord in the neck (C3-C5 levels). The stretching causes damage to the nerve fibers, preventing proper nerve signal transmission to the diaphragm.
Risk Factors for Phrenic Nerve Injury
Certain delivery complications significantly increase the risk of phrenic nerve injury:
- Breech presentation: When the baby is positioned feet-first rather than head-first
- Shoulder dystocia: When the baby’s shoulder becomes stuck behind the mother’s pubic bone
- Forceps or vacuum extraction: Instrumental assistance during difficult deliveries
- Macrosomia: Babies that are significantly larger than average
- Prolonged or difficult labor: Extended labor increasing mechanical stress on the baby
Association with Brachial Plexus Injury
Research published in peer-reviewed medical journals shows that approximately 75% of infants with phrenic nerve injury also suffer from brachial plexus injuries. Both conditions result from similar mechanisms of nerve stretching during traumatic delivery. The brachial plexus injury typically affects the baby’s arm and hand function, while the phrenic nerve injury affects breathing.
Symptoms of Phrenic Nerve Injury and Diaphragm Paralysis
Newborns with phrenic nerve injury typically present with symptoms within the first hours or days after birth:
Respiratory Symptoms
Breathing difficulties distinguishing phrenic nerve injury
- Rapid or labored breathing (tachypnea)
- Grunting sounds while breathing
- Retractions (chest wall pulling inward with breaths)
- Cyanosis (bluish discoloration of skin)
- Difficulty with oral feeding due to respiratory distress
Associated Symptoms
Other clinical findings in affected newborns
- Weak or high-pitched cry
- Vomiting or feeding intolerance
- Asymmetric Moro reflex
- Diminished breath sounds on affected side
- Gastrointestinal distress from respiratory struggle
Diagnosis of Phrenic Nerve Injury
Diagnosis begins with clinical observation and physical examination by the pediatric team. Several diagnostic tools help confirm phrenic nerve injury:
Physical Examination
The pediatrician will observe:
- Asymmetric breathing patterns
- Unequal breath sounds between left and right sides
- The baby’s breathing difficulty position and posture
Imaging Tests
Doctors use specific imaging to visualize the diaphragm and confirm paralysis:
| Imaging Method | What It Shows | Key Information |
|---|---|---|
| Chest X-Ray | Elevated hemidiaphragm (high position on one side) | Initial screening tool; shows abnormal diaphragm position |
| Ultrasound | Diaphragm movement during breathing | Non-invasive; can assess if diaphragm moves |
| Fluoroscopy | Real-time diaphragm movement | Confirms paralysis by showing no movement during breathing |
| CT Scan | Detailed anatomy of chest and diaphragm | Used if surgical intervention being considered |
Treatment Options for Phrenic Nerve Injury
Treatment depends on the severity of the infant’s respiratory distress and ranges from conservative supportive care to surgical intervention. Most cases require a stepwise approach, starting with non-invasive support and escalating only if necessary.
Conservative (Non-Surgical) Treatment
The majority of infants with phrenic nerve injury initially respond to supportive care measures:
Supplemental Oxygen and Respiratory Support
Mildly affected infants may improve with:
- Supplemental oxygen: Provided via oxygen hood or nasal cannula to maintain adequate oxygen saturation
- CPAP therapy: Continuous positive airway pressure provides gentle air pressure to keep the airway open without intubation
- Positioning: Specific body positioning to optimize breathing mechanics
Nutritional Support
If the baby cannot tolerate oral feedings due to respiratory distress, doctors may use:
- Nasogastric (feeding tube through nose) feeding to provide essential nutrition
- Intravenous fluids to maintain hydration during acute phase
- Gradual progression to oral feedings as breathing improves
Mechanical Ventilation
More severely affected infants, particularly those with bilateral (both sides) diaphragm paralysis, require:
- Mechanical ventilator support to manage breathing
- Careful monitoring to minimize ventilator dependency
- Gradual weaning as natural recovery occurs
Prognosis with Conservative Treatment
The good news is that many infants show remarkable improvement with supportive care alone:
Recovery Timeline: Approximately one-third to one-half of infants with phrenic nerve injury recover spontaneously within the first month of life. Most show significant improvement within 2-3 weeks, with continued recovery possible over 2 months as nerve healing occurs.
Surgical Treatment: Diaphragmatic Plication
If an infant does not show improvement after one month of conservative treatment, or if the baby deteriorates and cannot be weaned from mechanical ventilation, surgical intervention becomes necessary.
What Is Diaphragmatic Plication?
Diaphragmatic plication is a surgical procedure that:
- Involves folding: The surgeons fold the paralyzed diaphragm tissue to create a mechanical advantage
- Restores function: By shortening and tightening the diaphragm, it can move more effectively even if not controlled by the nerve
- Reduces work of breathing: The baby’s muscles don’t have to work as hard to breathe
Surgical Approach
Modern surgical techniques include:
- Thoracoscopic plication: Minimally invasive approach using small incisions and a camera
- Thoracotomy plication: Traditional open surgery approach (less commonly used now)
Outcomes After Surgical Plication
Research indicates excellent results with diaphragmatic plication:
- Most infants can be extubated (removed from ventilator) within 24-72 hours after surgery
- Significant improvement in respiratory function occurs quickly
- Long-term outcomes show normal or near-normal breathing function
- Infants can progress with normal feeding and development after recovery
Long-Term Outlook and Recovery
The long-term prognosis for infants with phrenic nerve injury is generally positive. Recovery depends on several factors:
Unilateral (One Side)
Injury affecting only one diaphragm side
- Better overall prognosis
- Other side compensates
- Higher spontaneous recovery rate
- Fewer require surgery
Bilateral (Both Sides)
Injury affecting both diaphragm sides
- More severe condition
- Requires prolonged support
- Higher likelihood of surgery
- Good outcomes with plication
Associated Injuries
Combined nerve injuries impact recovery
- Brachial plexus coinjury common
- May require additional treatment
- Multidisciplinary team approach
- Separate recovery timelines
Key Takeaways
- Phrenic nerve injury occurs: When the phrenic nerve is stretched during traumatic delivery, paralyzing the diaphragm muscle responsible for breathing
- Common association: About 75% of cases involve concurrent brachial plexus injury affecting arm and hand function
- Diagnosis is straightforward: Physical examination combined with chest imaging (X-ray, ultrasound, or fluoroscopy) confirms the diagnosis
- Most cases improve naturally: One-third to one-half of infants recover within the first month with supportive care alone
- Proven surgical option: Diaphragmatic plication provides excellent outcomes for infants who don’t recover spontaneously, typically allowing extubation within days
- Long-term outcomes are positive: With appropriate treatment, most infants develop normal or near-normal breathing function and continue with typical growth and development
Frequently Asked Questions
Can phrenic nerve injury be prevented?
While not all birth injuries can be prevented, careful obstetric management during difficult deliveries, appropriate use of delivery assistance, and immediate medical attention to signs of fetal distress can help minimize injury risk. Proper techniques for managing breech presentations and shoulder dystocia are particularly important for prevention.
How long does recovery from phrenic nerve injury take?
Most infants show improvement within 2-3 weeks of birth, with continued recovery possible over approximately 2 months. Approximately one-third to one-half recover spontaneously within the first month. Those requiring surgical plication typically show rapid improvement within days of surgery and can be discharged within 1-2 weeks post-operatively.
What is the difference between phrenic nerve injury and brachial plexus injury?
Phrenic nerve injury affects the nerve controlling the diaphragm (breathing muscle), while brachial plexus injury affects the nerves controlling arm and hand function. Both result from similar birth trauma mechanisms, and about 75% of phrenic nerve injuries occur alongside brachial plexus injury. Treatment and recovery are separate for each condition.
Will my baby need surgery?
Many infants recover with supportive care alone. Surgery (diaphragmatic plication) is recommended if the infant shows no improvement after one month or if respiratory deterioration occurs. If surgery is needed, it typically provides excellent outcomes with quick improvement in breathing function.
Can phrenic nerve injury result from medical negligence?
Some phrenic nerve injuries result from negligent delivery practices, such as improper use of forceps, failure to recognize complications like shoulder dystocia, or inadequate monitoring during difficult labor. If your baby’s injury appears related to substandard obstetric care, it may be considered medical negligence, and families may have legal options to pursue compensation for medical care and damages.
What should we expect during hospitalization?
During hospitalization, your baby will receive continuous monitoring and supportive respiratory care. Doctors will assess whether conservative treatment is effective. If your baby shows steady improvement, discharge may occur within days to weeks once safe feeding and breathing without supplemental support are achieved. If surgery is needed, the hospital stay extends through the surgical recovery period.
Are there any long-term complications from phrenic nerve injury?
Most infants with phrenic nerve injury have no long-term complications if treatment is appropriate. They develop normal or near-normal breathing function and continue with typical growth and development. However, if the injury is part of broader birth trauma affecting other systems, those may require ongoing management separate from the phrenic nerve injury.
How is diaphragmatic plication performed?
Diaphragmatic plication is performed by surgeons who fold and secure the paralyzed diaphragm tissue, creating a mechanical advantage that allows breathing despite nerve paralysis. Modern approaches typically use minimally invasive thoracoscopic (camera-assisted) techniques with small incisions rather than large open incisions, resulting in faster recovery and less pain.
Connect with Qualified New York Birth Injury Attorneys
Your Baby Deserves Expert Care and Answers
If your newborn has been diagnosed with phrenic nerve injury or diaphragm paralysis, you may have important legal rights and options. Our free service connects New York families with qualified birth injury attorneys who can evaluate whether your baby’s condition resulted from medical negligence and help you understand compensation options.
This article provides educational information about phrenic nerve injury in newborns. It is not a substitute for professional medical advice. All parents should work with their pediatric medical team for diagnosis, treatment, and ongoing care of their infant. As an educational resource publisher (not a law firm), we provide free information to help New York families navigate birth injury challenges.
