Non-invasive Ventilation in Diaphragmatic Paralysis Associated With Neonatal Brachial Plexus Palsy

Obstetric brachial plexus injury (OBPI) is an uncommon yet well-recognized complication of childbirth, occasionally accompanied by phrenic nerve involvement, causing diaphragmatic paralysis. Management of these cases often requires advanced respiratory support, with limited reports describing the use of early non-invasive ventilation (NIV) as first-line therapy. We report a full-term female neonate, delivered by vacuum-assisted birth complicated by shoulder dystocia, who developed right upper limb flaccid paralysis, Horner syndrome, and respiratory distress at birth. Imaging confirmed right hemidiaphragm elevation and brachial plexus root avulsion (C7-T1). She was managed exclusively with early NIV, starting with nasal continuous positive airway pressure and subsequently bilevel ventilation, avoiding invasive support. Enteral feeding and physiotherapy began promptly. By 10 months, NIV was required only during sleep; brachial plexus repair and diaphragmatic plication were performed, with complete weaning by age 2. At 4 years, she shows mild thoracic asymmetry, limited wrist mobility, and a mild speech disorder, with otherwise normal growth and age-appropriate development. This case supports early NIV as a first-line option in neonatal diaphragmatic paralysis secondary to OBPI, challenging conventional reliance on invasive ventilation and promoting a less invasive, outcome-focused approach.