Pediatrics (0-21)

Kids are not little adults, but are bundles of energy going through growth and that requires ongoing attention.  Infants, Toddlers, Children, and Youth are all at different stages of development, both with mobility and emotions.  Orthotics (bracing) and prosthetics for children requires focus and assessment every time they require new bracing due to growth.  We take the time to re-assess your child every time we are designing a new brace to see what developmental changes they have had, and we work closely with your therapist for better feedback on what they are seeing with your child.  Most importantly, you need to become as much of an expert as you can for your child, because you are the first line of defense to alert providers of changes in your child so that we can keep working towards the best outcomes!

Cranial Remolding Orthoses:  Some infants develop plagiocephaly or brachycephaly and require a helmet to reshape the head.  The FDA has approved helmet use from 3 to 18 months of age, with the best age range for helmet treatment around 5 months of age.  Treatment begins with referral to therapy (preferably at the 3 month pediatrician appointment) to see if Active Repositioning can resolve the head deformity without need for a helmet.  If it is not able to resolve this, then helmet treatment is the next tier of treatment.  

Cranial deformity can be caused from: 

• head position in the womb (ie, jammed against the ribs, pelvis, or a twin)
• a tight neck muscle (Torticollis of the Sternocleido-mastoid) which tethers the head to one side causing excessive pressure on one side of the head leading to flatness
• low general muscle tone leading to lack of movement of the head and trunk  and excessive pressure in one area of the head
• Syndromes
• in very rare cases (~1%) a fused suture of the plates of the skull.  This usually requires surgery and a helmet post-operatively.  

Helmet treatment usually lasts for about 3 months.  A scan is taken of your child’s head, then the digital shape is corrected to symmetrical.  The helmet is made over this corrected shape, and the helmet is then worn 23 hours a day to contain growth and direct it into the void.  It also blocks the head from resting on the flat spot to help break the cycle of flattening.

We currently use Orthomerica and have experience with all styles of helmets from clear helmets (Surlyn), Foam padded helmets, and post-operative helmets, and recommend between all of them based on the needs of your child’s diagnosis.  We have tackled any and every diagnosis from Torticollis to Brachycephaly to Metopic Craniosynostosis to Craniectomy secondary to Meningitis inflammation.  If your infant is in need of a helmet, we are able to handle it all!

Ankle Foot Orthoses are braces that support the joints of the foot and ankle but do not extend past the knee.  They are commonly referred to as “AFOs”.  They provide control of the ankle to hold them in a good position for standing and walking and will make up for balance and weakness issues while your child is developing.  

Reasons for use of AFOs 

• low tone / Hypotonia
• clubfoot
• cerebral palsy
• spina bifida
• toe walking

The variety of design styles for AFOs are numerous.  A few are:

• Supra Mallolar Orthoses (SMOs)are just above the ankle height, like a high top shoe.
• Articulated AFOs (AAFOs)  use joints to allow controlled bending of the ankle to allow more motion and use of certain muscles while blocking undesirable motions.
• Solid AFOs are braces that go up just below the knee that control the ankle in all directions.
• Posterior Leaf Spring AFOs (PLS) have some flex and give to them and are good for progressive support and resistance.  
• And many, many more variations on all of these!

The goal of braces in pediatrics is to get patients mobile and as functional as possible.  Often times as a patient grows it means that designs will need to be changed to allow more movement and less control from the brace, and more from the child’s muscles.  Some of the things that require changing brace designs are:

• Increases in weight
• Tightening of muscles (contracture)
• Strength gains
• More patient control of their joints/ankles
• Changes in tone/spasticity patterns

With nearly 20 years in full time pediatric care, we are able to tackle any diagnosis that your child has for bracing, and are capable of looking at the big picture of progress of your child in life and to help make the best braces to help them be active and mobile.  

Scoliosis is a condition of the spine that usually presents with bending, shifting, and rotation of the spine.  Scoliosis can occur at all stages of development: Infant, Adolescent, Youth, Teen, and even as an adult secondary to posture and deformity.

Scoliosis bracing is the least invasive way to prevent the scoliosis from getting worse.  Studies have shown evidence that 16 or more hours of bracing per day is necessary to prevent progression of a scoliotic deformity.  Additionally, for those that desire to see correction of the curve maintain, it has been our experience that 20 hours of wear a day is required for hope of reversal of the curve when not wearing the brace.  The window for bracing is usually up to about age 15 or 16 because the bones in the spine are soft and are still prone to deformity.  After hormones in puberty occur, the bones harden and deformity occurs much more slowly, about 1 degree per year.  

Growth is the enemy of scoliosis because growth undirected will compound the curve into a worse curve.  In order for true correction to occur, it is important to drastically correct the gross position of the spine by Elongating, Derotating, and Shifting the spine.  This is best done through CAD processes, which we are well familiar with, since Peter was able to initiate and pioneer this while at Shriners. We make braces in the Cheneau family of brace For the greatest correction.

It is our recommendation that you consider Schroth-style physical therapy to learn ways that you can train your appropriately aged child to learn how to self-correct through posture.  It will also work later in life when bracing is less effective and will remain a life-long tool to address spinal deformity.  There are several good therapists in the Spokane area that are trained in this technique and we are happy to direct you to them.  

*Warning* A scoliosis that has attained a 50 degree magnitude will progress at double the rate of curves under 50 degrees in adult-hood, which is about 2 degrees a year instead of 1 degree.  This will compromise the plural cavity and your breathing, and will require adult surgical intervention in many cases.  This is why pediatric orthopods will recommend surgery at 50 degrees, and will save you further deformity and complication with breathing as you age.  With this in mind, it behooves you do do all that you can now to prevent your scoliosis from getting worse.

There have been some recent studies showing that adult scoliosis bracing reduces pain and progression of the curve.  

Should you be in need of a consultation, please reach out to Peter directly at 509 359 5329 to discuss your case.  

Prosthetics in kids is an ongoing process to keep up with them as they get more active, heavier, and tend to jump and break components.  

Pediatric prosthetics is trickier than adult prosthetics because often times there is minor deformities of alignment in the tibia, knee, or femur with congenital (born with it) amputees.  Traumatic pediatric amputees tend to have bone spurring during growth due to growth plates, which is why surgeons will take disarticulations into serious consideration.  

Some common causes of pediatric amputation are fibular hemimelia, proximal focal femoral deficiency (PFFD), sarcomas and other cancers, trauma (looking at you, lawnmowers!  No barefoot children in the yard when cutting the lawn!  No children in the lawn when using a riding lawnmower!).  

In my nearly 2 decades of doing Peds prosthetics, I have found that once able to fit a posterior mount foot that is appropriately sized on a child (around age 6ish), they excel for running, walking, off trail, and just daily living due to energy return.  When I created the O and P department at the Spokane Shriners I started doing these, directed our staff to follow suite and never looked back.  I believe that every child all the way up to most active adults benefit from this because of the massive amount of energy return with so much less weight.