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Diaphragmatic paralysis in the newborn

Ian J Griffin, MB ChB
Section Editors
Joseph A Garcia-Prats, MD
Gregory Redding, MD
Deputy Editor
Melanie S Kim, MD


The most important of the respiratory muscles is the dome-shaped diaphragm, which separates the thoracic and abdominal cavities and is innervated by the phrenic nerve. Injury to the phrenic nerve associated with birth trauma or cardiothoracic surgery can result in diaphragmatic paralysis, which may lead to respiratory distress in newborns. The initial treatment is supportive, and spontaneous recovery occurs in most cases.

Before addressing the clinical features, diagnosis, and management of the disorder, reviewing the embryology and physiology of the diaphragm is useful.


The diaphragm develops from four embryologic structures:

Septum transversum

Pluripotential membranes

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Literature review current through: Sep 2017. | This topic last updated: Aug 19, 2016.
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  1. Schumpelick V, Steinau G, Schlüper I, Prescher A. Surgical embryology and anatomy of the diaphragm with surgical applications. Surg Clin North Am 2000; 80:213.
  2. Tarver RD, Godwin JD, Putman CE. Symposium on Nonpulmonary Aspects in Chest Radiology. The diaphragm. Radiol Clin North Am 1984; 22:615.
  3. Roussos C, Macklem PT. The respiratory muscles. N Engl J Med 1982; 307:786.
  4. Rochester DF. The diaphragm: contractile properties and fatigue. J Clin Invest 1985; 75:1397.
  5. Yellin A, Lieberman Y, Barzilay Z. Postoperative unilateral diaphragmatic paralysis in children, a plea for early plication. Thorac Cardiovasc Surg 1991; 39:221.
  6. Mearns AJ. Iatrogenic injury to the phrenic nerve nerve in infants and young children. Br J Surg 1977; 64:558.
  7. Devlieger H, Daniels H, Marchal G, et al. The diaphragm of the newborn infant: anatomical and ultrasonographic studies. J Dev Physiol 1991; 16:321.
  8. Gibson GJ. Diaphragmatic paresis: pathophysiology, clinical features, and investigation. Thorax 1989; 44:960.
  9. Celli B. The diaphragm and respiratory muscles. Chest Surg Clin N Am 1998; 8:207.
  10. Keens TG, Bryan AC, Levison H, Ianuzzo CD. Developmental pattern of muscle fiber types in human ventilatory muscles. J Appl Physiol Respir Environ Exerc Physiol 1978; 44:909.
  11. Rehan VK, Nakashima JM, Gutman A, et al. Effects of the supine and prone position on diaphragm thickness in healthy term infants. Arch Dis Child 2000; 83:234.
  12. Sivan Y, Galvis A. Early diaphragmatic paralysis. In infants with genetic disorders. Clin Pediatr (Phila) 1990; 29:169.
  13. Bergen BJ, Sangalang VE, Aterman K. Isolated myopathic involvement of the diaphragmatic musculature in a neonate. Ann Neurol 1977; 1:403.
  14. Volpe JJ. Injuries of extracranial, cranial, intracranial, spinal cord, and peripheral nervous system structures. In: Neurology of the Newborn, 4th ed, WB Saunders, Philadelphia 2001. p.813.
  15. Donn SM, Faix RG. Long-term prognosis for the infant with severe birth trauma. Clin Perinatol 1983; 10:507.
  16. McFarland LV, Raskin M, Daling JR, Benedetti TJ. Erb/Duchenne's palsy: a consequence of fetal macrosomia and method of delivery. Obstet Gynecol 1986; 68:784.
  17. Gilbert WM, Nesbitt TS, Danielsen B. Associated factors in 1611 cases of brachial plexus injury. Obstet Gynecol 1999; 93:536.
  18. Stauffer UG, Rickham PP. Acquired eventration of the diaphragm in the newborn. J Pediatr Surg 1972; 7:635.
  19. Van Smith C, Jacobs JP, Burke RP. Minimally invasive diaphragm plication in an infant. Ann Thorac Surg 1998; 65:842.
  20. Watanabe T, Trusler GA, Williams WG, et al. Phrenic nerve paralysis after pediatric cardiac surgery. Retrospective study of 125 cases. J Thorac Cardiovasc Surg 1987; 94:383.
  21. Mickell JJ, Oh KS, Siewers RD, et al. Clinical implications of postoperative unilateral phrenic nerve paralysis. J Thorac Cardiovasc Surg 1978; 76:297.
  22. Shoemaker R, Palmer G, Brown JW, King H. Aggressive treatment of acquired phrenic nerve paralysis in infants and small children. Ann Thorac Surg 1981; 32:250.
  23. Zhao HX, D'Agostino RS, Pitlick PT, et al. Phrenic nerve injury complicating closed cardiovascular surgical procedures for congenital heart disease. Ann Thorac Surg 1985; 39:445.
  24. Hamilton JR, Tocewicz K, Elliott MJ, et al. Paralysed diaphragm after cardiac surgery in children: value of plication. Eur J Cardiothorac Surg 1990; 4:487.
  25. Kunovsky P, Gibson GA, Pollock JC, et al. Management of postoperative paralysis of diaphragm in infants and children. Eur J Cardiothorac Surg 1993; 7:342.
  26. Mok Q, Ross-Russell R, Mulvey D, et al. Phrenic nerve injury in infants and children undergoing cardiac surgery. Br Heart J 1991; 65:287.
  27. Pleasure JR, Shashikumar VL. Phrenic nerve damage in the tiny infant during vein cannulation for parenteral nutrition. Am J Perinatol 1990; 7:136.
  28. D'Netto MA, Bender J, Brown RT, Herson VC. Unilateral diaphragmatic palsy in association with a subclavian vein thrombus in a very-low- birth-weight infant. Am J Perinatol 2001; 18:459.
  29. Arya H, Williams J, Ponsford SN, Bissenden JG. Neonatal diaphragmatic paralysis caused by chest drains. Arch Dis Child 1991; 66:441.
  30. Odita JC, Khan AS, Dincsoy M, et al. Neonatal phrenic nerve paralysis resulting from intercostal drainage of pneumothorax. Pediatr Radiol 1992; 22:379.
  31. Man D, Wheildon MH, Eckstein HB. Paralysis of the right hemidiaphragm following primary anastomosis for oesophageal atresia and tracheo-oesophageal fistula. Z Kinderchir 1982; 37:32.
  32. De Reuck J, Hooft C, De Coster W, et al. A progressive congenital myopathy. Initial involvement of the diaphragm with type I muscle fiber atrophy. Eur Neurol 1977; 15:217.
  33. Bertini E, Gadisseux JL, Palmieri G, et al. Distal infantile spinal muscular atrophy associated with paralysis of the diaphragm: a variant of infantile spinal muscular atrophy. Am J Med Genet 1989; 33:328.
  34. Heckmatt JZ, Placzek M, Thompson AH, et al. An unusual case of neonatal myasthenia. J Child Neurol 1987; 2:63.
  35. Bosman C, Bachelet V, Boldrini R, Bertini E. Diaphragmatic paralysis due to partial diaphragmatic hypoplasia mimicking a localized muscular dystrophy: a case report. Clin Neuropathol 1988; 7:33.
  36. Aldrich TK, Herman JH, Rochester DF. Bilateral diaphragmatic paralysis in the newborn infant. J Pediatr 1980; 97:988.
  37. Commare MC, Kurstjens SP, Barois A. Diaphragmatic paralysis in children: a review of 11 cases. Pediatr Pulmonol 1994; 18:187.
  38. Tönz M, von Segesser LK, Mihaljevic T, et al. Clinical implications of phrenic nerve injury after pediatric cardiac surgery. J Pediatr Surg 1996; 31:1265.
  39. Greene W, L'Heureux P, Hunt CE. Paralysis of the diaphragm. Am J Dis Child 1975; 129:1402.
  40. BISHOP HC, KOOP CE. Acquired eventration of the diaphragm in infancy. Pediatrics 1958; 22:1088.
  41. Nichols MM. Shifting umbilicus in neonatal phrenic palsy (the belly dancer's sign). Clin Pediatr (Phila) 1976; 15:342.
  42. Smith BT. Isolated phrenic nerve palsy in the newborn. Pediatrics 1972; 49:449.
  43. Miller SG, Brook MM, Tacy TA. Reliability of two-dimensional echocardiography in the assessment of clinically significant abnormal hemidiaphragm motion in pediatric cardiothoracic patients: Comparison with fluoroscopy. Pediatr Crit Care Med 2006; 7:441.
  44. Mills JF, Dargaville PA, Coleman LT, et al. Upper cervical spinal cord injury in neonates: the use of magnetic resonance imaging. J Pediatr 2001; 138:105.
  45. Rafferty GF, Greenough A, Dimitriou G, et al. Assessment of neonatal diaphragm function using magnetic stimulation of the phrenic nerves. Am J Respir Crit Care Med 2000; 162:2337.
  46. Diament MJ, Boechat MI, Kangarloo H. Real-time sector ultrasound in the evaluation of suspected abnormalities of diaphragmatic motion. J Clin Ultrasound 1985; 13:539.
  47. Shardonofsky FR, Perez-Chada D, Milic-Emili J. Airway pressures during crying: an index of respiratory muscle strength in infants with neuromuscular disease. Pediatr Pulmonol 1991; 10:172.
  48. Zajkowski EJ, Kravath RE. Bilateral diaphragmatic paralysis in the newborn infant: treatment with nasal continous positive airway pressure. Chest 1979; 75:392.
  49. Bucci G, Marzetti G, Picece-Bucci S, et al. Phrenic nerve palsy treated by continuous positive pressure breathing by nasal cannula. Arch Dis Child 1974; 49:230.
  50. Raine J, Samuels MP, Mok Q, et al. Negative extrathoracic pressure ventilation for phrenic nerve palsy after paediatric cardiac surgery. Br Heart J 1992; 67:308.
  51. Weisman L, Woodall J, Merenstein G. Constant negative pressure in the treatment of diaphragmatic paralysis secondary to birth injury. Birth Defects Orig Artic Ser 1976; 12:297.
  52. Brouillette RT, Ilbawi MN, Hunt CE. Phrenic nerve pacing in infants and children: a review of experience and report on the usefulness of phrenic nerve stimulation studies. J Pediatr 1983; 102:32.
  53. Haller JA Jr, Pickard LR, Tepas JJ, et al. Management of diaphragmatic paralysis in infants with special emphasis on selection of patients for operative plication. J Pediatr Surg 1979; 14:779.
  54. Jog SM, Patole SK. Diaphragmatic paralysis in extremely low birthweight neonates: Is waiting for spontaneous recovery justified? J Paediatr Child Health 2002; 38:101.
  55. Affatato A, Villagra F, De Leon JP, et al. Phrenic nerve paralysis following pediatric cardiac surgery. Role of diaphragmatic plication. J Cardiovasc Surg (Torino) 1988; 29:606.
  56. Ribet M, Linder JL. Plication of the diaphragm for unilateral eventration or paralysis. Eur J Cardiothorac Surg 1992; 6:357.
  57. Schwartz MZ, Filler RM. Plication of the diaphragm for symptomatic phrenic nerve paralysis. J Pediatr Surg 1978; 13:259.
  58. Smith CD, Sade RM, Crawford FA, Othersen HB. Diaphragmatic paralysis and eventration in infants. J Thorac Cardiovasc Surg 1986; 91:490.
  59. Gallagher PG, Seashore JH, Touloukian RJ. Diaphragmatic plication in the extremely low birth weight infant. J Pediatr Surg 2000; 35:615.
  60. Stone KS, Brown JW, Canal DF, King H. Long-term fate of the diaphragm surgically plicated during infancy and early childhood. Ann Thorac Surg 1987; 44:62.
  61. Alonso Calderón JL, Garrido García H, Pérez Domínguez T, Mazaira J. [Simultaneous, bilateral and permanent ventilation with a diaphragm pacing in childhood: the implantation technique and indications]. Cir Pediatr 1994; 7:3.
  62. Brouillette RT, Ilbawi MN, Klemka-Walden L, Hunt CE. Stimulus parameters for phrenic nerve pacing in infants and children. Pediatr Pulmonol 1988; 4:33.
  63. Brouillette RT, Marzocchi M. Diaphragm pacing: clinical and experimental results. Biol Neonate 1994; 65:265.
  64. Radecki LL, Tomatis LA. Continuous bilateral electrophrenic pacing in an infant with total diaphragmatic paralysis. J Pediatr 1976; 88:969.