FF - pediatrics

What are the APGAR categories?

• appearance (color)

• pulse

• grimace (reflex irritability)

• activity (mm tone)

• respiration

What is the scoring for each APGAR category?

• A: 0=blue, 1=blue extremities, 2=no blue

• P: 0=absent, 1=<100 bpm, 2=100-140 bpm

• G: 0=no response, 1=grimace, 2=cry or withdrawal

• A: 0=flaccid, 1=some flexion, 2=active motion of extremities (kicking)

• R: 0=absent, 1=weak cry, 2=strong cry

What is the normal range for APGAR?

8-10

How often is APGAR assessed?

at 1 min, 5 min, 10 min

What are the typical patterns of gross motor development?

• primitive reflexes dominate movement before cortical control

• general before localized responses

• flexor tone before extensor tone

• once antigravity/upright: extensor tone progresses before flexor tone

• cephalic to caudal development

• proximal to distal development

• gross motor before fine motor control

What milestones do you see at month 3?

• prone on elbows

• can lift head in prone

• belly crawl (3-9 months)

• supine to sidelying (3-4 months)

What milestones do you see at months 5-6?

• prone to supine

• pull to sit w/o head lag

• sitting w/ UE support

• feet to mouth

• propped or ring sitting w/ high guard

What milestones do you see at months 6-7?

• supine to prone

• quadruped

• transfer objects b/w hands

• trunk rotation in sitting

What milestones do you see at months 9-10?

• quadruped creeping

• cruises (walking on furniture) to sideways

• plantigrade, pulls to stand

• upright, unsupported sitting

• improving grasping skills, 3 jaw chuck

What milestones do you see at months 10-15?

• begins to walk unassisted

• transitions in & out of squatting

• controls grasp & release

• stacks 2 cubes

What is the difference between the terms integrated and persistent?

• integrated: primitive reflex disappears to allow for normal development

• persistent: primitive reflex not integrated, indicating CNS dysfunction

What is the flexor withdrawal reflex?

When does this reflex become integrated?

painful stimulus to sole of foot → toes ext, foot DF, LE flex uncontrollably

• 1-2 months

What is the crossed extension reflex?

When does this reflex become integrated?

painful stimulus to ball of foot of extended LE → opposite LE flex, then ADD, then ext

• 1-2 months

When does the rooting reflex become integrated?

3 months

What is the traction reflex?

When does this reflex become integrated?

grasp forearm and pull up from supine into sitting → grasp & total flex of UE

• 2-5 months

When does ATNR become integrated?

4-6 months

What is the palmar grasp reflex?

When does this reflex become integrated?

maintained pressure to palm of hand → maintained finger flex (grasp)

• 4-6 months

What is the moro reflex?

When does this reflex become integrated?

drop pt backward from sitting position → UE ext & ABD, hand opening, crying, followed by UE flex & ADD

• 5-6 months

What is the STLR reflex?

When does this reflex become integrated?

• prone → limb flex

• supine → limb ext

• 6 months

What is the positive supporting reflex?

When does this reflex become integrated?

contact to the ball of the foot in standing position → rigid ext (co-contraction) of the LEs

• 6 months

What is the plantar grasp reflex?

When does this reflex become integrated?

maintained pressure to ball of foot → maintained toe flex

• 9 months

What is the STNR reflex?

When does this reflex become integrated?

• head flex → UE flex, LE ext

• head ext → UE ext, LE flex

• 8-12 months

What is the startle reflex?

When does this reflex become integrated?

sudden loud noise → sudden UE ext or ABD, crying

• persists

Summarize the integration of primitive reflexes

• 1-2 months: flexor withdrawal, crossed extension

• 3 months: rooting

• 2-5 months: traction

• 6 months: palmar grasp, ATNR, moro, sucking, TLR, positive supporting (PAMS TP)

• 9 months: plantar grasp

• 8-12 months: Babinski, STNR

Describe plagiocephaly

results from prolonged asymmetrical pressure on the premature skull → creates parallelogram shape

• ipsilateral occipito-parietal flattening, frontal bossing, anterior displacement of the ear

• contralateral occipital bossing

How can you treat plagiocephaly & torticollis?

• parent education

• helmet

• tummy time (head ext)

What are the classifications of cerebral palsy (CP)?

Describe each

• spastic: high tone, synergy, crouched gait, toe walking

• ataxic: low tone, tremor, wide BOS, nystagmus

• dyskinetic: fluctuating tone, poor stability, hand tremor, athetosis

What are the levels of the Gross Motor Function Classification System of CP?

• level 1: pt will walk w/o restrictions but will have limitations in more advanced gross motor skills

• level 2: walk w/o AD but w/ limitations in walking outdoors & in the community

• level 3: walk w/ AD and limitations in walking outdoors & in the community

• level 4: self mobility will be very limited, children are transported or use power mobility outdoors & in the community

• level 5: self mobility will be very limited even w/ AD, requires caregiver

How can you treat a pt w/ CP?

• posterior walkers promote upright posture

• address tone

• standing frames should be used by age 2 to promote therapeutic benefits of standing

• AFOs for PFor contractures

• tendon lengthening procedures: WBAT & gentle PROM progressing slowly; avoid aggressive & end range & strengthening

What is the Pediatric Evaluation of Disability Index (PEDI)?

functional capability assessment for children 6 months to 7.5 years

• 3 domains: self care, mobility, social function

• normal score = 50 ±10 points

What is the Functional Independence Measure for Children (WeeFIM)?

measures development & disability for children 6 months to 7 years as they go through preschool & elementary school

• 3 domains: self care, mobility, cognition

• scoring: 1=total assistance, 7=IND

Describe Duchenne’s muscular dystrophy (DMD)

• X-linked recessive, common in boys

• dystrophin gene missing → mm cell destruction

• causes pseudo-hypertrophy (collagen & fat replaces mms), commonly in the calves

• (+) Gower sign

How can you treat pts w/ DMD?

• maintain mobility & preserve strength

• maintain joint ROM w/ active & passive

• don’t over-fatigue

Describe Down syndrome (Trisomy 21)

• results from presence of extra copy of the 21st chromosome

• increased risk w/ increased age of the mother

• hypotonia, ligamentous laxity

• weak quads & hip ABD

How can you treat pts w/ Down syndrome?

• encourage motor function

• avoid forceful neck flex & rotation activities d/t laxity of odontoid ligament and potential for subluxation of AA joint

• avoid hyperextension of elbows & knees during WB activities

Describe Scheuermann’s disease

Schmorl’s nodes & wedged thoracic spine

• pain w/ long periods of standing/sitting or physical activity

• pain w/ thoracic ext & rotation

• increased thoracic kyphosis & lumbar lordosis

How can you treat pts w/ Scheuermann’s disease?

• Schroth method

• stretch pecs

• strengthen thoracic extensors & scapular stabilizers

What nerves are damaged in Erb’s palsy?

What Sx’s do you see with this?

• C5-6

• loss of shoulder ABD/ER

• waiter’s tip deformity

What nerves are damaged in Klumpke’s palsy?

What Sx’s do you see with this?

• C8-T1

• paralysis of hand intrinsics

• claw hand

Describe Legg-Calve-Perthes disease

• ages 2-13, males

• short stature

• deformity or flattening of femoral head d/t loss of blood supply → femoral head necrosis, fragments, ossification

• pain worsens w/ activity

• limping, stiffness

• limited hip ext, ABD, IR (EABIR)

• conservative Tx, bracing

Describe slipped capital femoral epiphysis (SCFE)

• ages 10-17

• overweight

• displacement of femoral head d/t slippage from the growth plate

• pain worsens w/ activity

• limping, stiffness

• limited hip flex, ABD, IR (FABIR)

• requires surgery to stabilize hip joint

What hip orthosis is used for Legg-Calve-Perthes disease?

Scottish rite brace

What hip orthoses are used for congenital hip dysplasia?

• Pavlik harness

• Frejka pillow