Recommendations are based on best evidence, and interpretation of this evidence by the OBPI Working Group

1. Physically examine newborns for OBPI if upper extremity movement is asymmetric or delivery was complicated by shoulder dystocia, humeral fracture or clavicular fracture.
   A primary care physician with experience in newborn assessment should perform a focused physical examination on newborns with an identified deficit or risk factor.

2. Refer all newborns with OBPI to a multidisciplinary centre by 1 month of age.
   A proportion of newborns will completely recover within days of birth and do not necessitate referral to a multidisciplinary centre. Newborns with complete recovery as assessed by primary care providers experienced in the assessment of musculoskeletal and neurological deficits do not necessitate referral.

3. With referral, provide complete pregnancy and birth history, and physical exam findings (including Horner's syndrome) at birth.
   Clinical records should indicate risk factors, severity of injury, and course of recovery. While clinical records are important, they are not necessary; do not delay referral to a multidisciplinary centre to obtain records.

4. Teams at multidisciplinary centres should include:
   - A dedicated therapist with experience in the assessment and treatment of OBPI
   - A peripheral nerve surgeon with experience in microsurgical repair of OBPI
   Teams at multidisciplinary centres are responsible for the assessment, treatment, rehabilitation and education of children with OBPI and their parents/guardians. Teams should include the personnel necessary to deliver the highest level of treatment available in Canada. The recommendation does not pertain to healthcare providers involved in diagnostic investigations or secondary treatment. A therapist is a physio- or occupational therapist, or equivalent. Ideally the therapist will have paediatric experience and/or be mentored to develop skills to manage OBPI patients. A peripheral nerve surgeon is a plastic, neuro- or orthopaedic surgeon, or equivalent. The peripheral nerve surgeon will have the training, experience and infrastructure to perform microsurgical nerve reconstruction procedures on paediatric patients.

5. Nonoperative therapy delivered outside of a multidisciplinary centre should be advised by a multidisciplinary team.
   

6. Offer microsurgical nerve repair:
   - For injuries clinically consistent with root avulsion injury
   - For all other injuries meeting centre-defined operative criteria applied beginning at 3 months of age
   Total plexus injuries with clinical evidence consistent with T1 root avulsion (eg. Horner’s syndrome) should be offered nerve repair as soon as the injury pattern is apparent and the child is fit for the procedure.

7. For objective outcome collection, a common data set includes:
   - Clinical distribution using Narakas classification at initial multidisciplinary centre assessment.
   - Limb length (Bain, 2012), Active Movement Scale (AMS) (Curtis, 2002) and Brachial Plexus Outcome Measure (BPOM) when age applicable (Ho, 2012) at 1 month, 3 months, 6 months, 12 months and 24 months of age, then annually for the duration of follow-up.
   The common data set provides consistent baseline stratification and outcome measurement, facilitating multicentre research. Data set outcomes are not operative indications. Alternatively to Narakas classification, injury distribution can be classified by involved nerve roots and evidence of Horner’s syndrome. For consistency, each outcome should be measured as defined in the primary literature (eg. limb length to nearest 0.5cm).