By Elisa de Jong, CPO, LO
Pediatric O&P is a subspecialty of our profession that can be fulfilling, albeit demanding and challenging—especially as it pertains to the orthotic management of infants. While it may appear that an infant, particularly an infant in the neonatal intensive care unit (NICU), would be easier to manage orthotically, since gait analysis is not applicable and x-rays may not be necessary, the opposite is frequently true. This population offers an entirely new set of considerations and issues. Patient size, homeostasis, and essential medical equipment can create unique challenges. As a result, it is important that the treatment plan be tailored to this population.
At Children's Memorial Hospital, Chicago, Illinois, we treat a diverse pediatric patient population, where age can be a key factor in the challenges that arise. Orthotic treatment for a pre-term infant in the NICU is likely to require a treatment plan that is considerably different from a full-term infant. In addition to age, developmental milestones are important and necessary factors to consider when evaluating neonatal patients. Without an understanding of these milestones, a clinician is unable to distinguish between what is and is not age-appropriate treatment (Figure 1). That said, when treating an infant in the NICU, the orthotist must be cognizant of the patient's birth age and gestational age. For example, a premature baby born before 31 weeks gestation does not present with an appropriate level of body fat. This can influence the type of material used to fabricate an orthosis as well as the desired wear schedule, since the inadequate level of body fat makes the skin integrity especially fragile. Another important milestone to consider is the development of the infant's respiratory system. The lungs are not fully developed until the final weeks of pregnancy. Due to the underdevelopment of the lungs of a premature infant, the heart rate and oxygen-saturation levels are constantly monitored, and the orthotist must be aware of these values during evaluation or orthotic molding to prevent over stimulation that can result in respiratory distress.
Our orthotics team is regularly consulted by the inpatient care team to evaluate infants in the NICU. One of the first details addressed in the initial evaluation is the patient's overall health status. If the patient is unstable to the degree that external stimuli could adversely increase his or her heart rate, orthotic treatment is moved down the priority list of care. Once it is determined that the patient is stable enough to tolerate handling and benefit from occupational or physical therapy, an orthotist is typically consulted to discuss treatment goals.
Many patients in the NICU present with global tone or multiextremity flexion contractures due to neurological involvement (atypical from the normal flexion that is present with fullterm infants). Early contracture management is important for maintaining range of motion (ROM) but is even more critical for the prevention of pathological modeling of the bone. Though we are able to use multiple, prefabricated orthoses, such as pressure-relief AFOs (PRAFOs) or wrist-hand orthoses (WHOs) for full-term infants, the available infant size is typically not small enough for our NICU population. Instead, a custom-made orthosis fabricated from low-temperature plastic provides the ability to support the affected limb in a desired position while having adjustability as the patient gains ROM or grows.
Low temperature AFOs on an eight-week-old patient diagnosed with positional clubfoot. Photographs courtesy of Elisa de Jong.
Even if a custom-sized orthosis can be fabricated, treatment might still be delayed or affected by other challenges. Working with inpatients, orthotists frequently encounter impediments caused by the placement of medical devices, such as intravenous (IV) lines, pulse-oximetry tubes, or blood-pressure cuffs. These impediments can usually be solved by relocating the port or position of these devices through proper communication with the patient's treatment team. If relocation is not possible, consider a change in orthotic design. Unfortunately, when the medical device is too large and cumbersome to work around, orthotic treatment has to be postponed until the device is relocated or discontinued. For instance, a patient might require bilateral resting WHOs but is receiving antibiotics through an IV line inserted into the dorsum of the right wrist. If the left upper limb is free of monitoring equipment, the standard procedure would be to mold the left WHO. Waiting for the right IV line to be removed before molding either WHO could easily result in finding a left-side IV line during a follow-up visit. By providing the WHO on the currently unencumbered side, the nurse is also made more aware of how the WHO fits and can usually encourage IV-line placement in a different area so that the patient can be fit for and use both orthoses. If that is not the case, when the antibiotic regimen is completed, the right side IV line will be removed, freeing that side for molding and fitting of the orthosis. Again, communication with the care team is valuable so that all parties can provide the care necessary to achieve each treatment goal.
Despite creative attempts to mold and fit these tiny orthoses, the greatest challenge working with incredibly small limbs is trying to influence all the affected joints. For premature infants that require WHOs, manipulation of the metacarpophalangeal joints (MCPs), proximal interphalangeal joints (PIPs), and distal interphalangeal joints (DIPs) may have to be sacrificed in order to achieve a neutral position at the wrist. It simply becomes too difficult to try and manipulate each individual joint. In this situation, communication with the occupational therapist helps to establish reasonable and agreed-upon goals for the fit and function of the orthosis.
Low temperature WHOs for a four-week-old patient diagnosed with neurological complications and secondary hypertonia.
In spite of the challenges that come with caring for such a fragile population, orthotic treatment is not only possible, but it can also be successful. The key to success is based on many factors, which include a knowledgeable medical team, opportunities for early orthotic management, a clear understanding of the infant's clinic presentation and developmental stages, reasonable and clear clinical goals, alternative orthotic treatment options and orthotic designs that can be readily adjusted, and routine and thorough follow up. It is important for the orthotic practitioner to view this population not as merely part of the pediatric population, but as a true subspecialty within the pediatric population itself. This will encourage the practitioner to develop and optimize appropriate orthotic treatment for this unique area of pediatrics.
Elisa de Jong, CPO, LO, works at the Moira Tobin Wickes Orthotics Program at Children's Memorial Hospital, Chicago, Illinois.
Case Study
The patient is a 34-week-old male with multiple congenital abnormalities including right clubfoot who requires respiratory support due to underdeveloped lungs. The primary treatment goal is to provide respiratory support until the patient's lungs develop well enough to function on their own. A secondary goal is to address the right clubfoot. While positioning of the foot/ ankle complex is similar to the full-term infant presentation, how it is achieved orthotically is different. Due to the patient's age, size, and inpatient status, standard treatment for clubfoot is not yet an option. The process of taking an impression of the lower limb can create an environment that puts the infant at risk for cardiopulmonary distress (i.e. temperature change of the casting material, removal of the impression, etc.). A high-temperature AFO creates additional challenges with regard to limited adjustability in the presence of a rapidly growing foot. Use of a prefabricated device is also typically not possible because the foot is roughly the size of an adult thumb. Given the patient's presentation, the most reasonable option is a custom-molded, low-temperature, plastic AFO to position the ankle and foot as neutrally as possible while preventing increased deformity. It can be readily adjusted, but particular attention should be given to avoid high temperatures of the plastic that could trigger cardiopulmonary distress or damage to the fragile patient. While a 23-hour wear schedule might be ideal for a full-term infant, this patient population typically uses orthoses at designated intervals. The repetition helps nurses incorporate the orthosis into their regular routine while also providing the opportunity for more frequent skin inspections.
