Pediatric Positioning

Posted by Nurse Linda in Life After Paralysis on August 26, 2020 # Health

After your child sustains a spinal cord injury, it is important to position them correctly. At times, people underestimate the power of proper positioning, especially in younger children. At any age, proper positioning is a benefit. Proper positioning can aid in maintaining current status, improve functional gains, and prevent complications.

Positioning is placing your child in anatomical alignment. Thinking about the way bodies move and how they are when relaxed will help you position your child for the best outcomes. Children and teens need to have their bodies positioned when they are in bed and sitting. Keeping the body in alignment is key to activities such as bowel programs, catheterization, and maintenance of skin. It is also important in the maintenance of joint mobility.

It might not be easy to imagine the correct positioning. If your child is at the Rehabilitation Hospital or in therapy, take a photo of correct positioning. This will help you recall how the body should be in alignment and where equipment should be placed. Some children might have changes in their skeletons, which will make positioning a little different for them. Adaptive equipment can be used to help position any special needs. Also, you can google ‘positioning after spinal cord injury’ and click on the images section. The graphics will be of adults, but you can see how proper positioning can be accomplished.

As always, if your child has spinal precautions (special needs to protect an insecure spine), you must follow those instructions exactly.

Newborns and Infants

Most of the information provided in this blog will be for children and teens. Infant positioning is a bit different. Newborns typically require swaddling because they need to adjust to the world outside of the uterus. Providing the swaddle gives them security by mimicking fetal life. Even if your baby does not feel sensations due to spinal cord injury, their bodies will. Missing the swaddling period due to spinal cord injury might lead to an episode of the nervous system reaction of autonomic dysreflexia (AD). An exception can be if the baby is sedated or in an isolated space where their world’s environment is controlled.

Babies with little muscle tone still need positioning; to avoid damage to the joints, bones, and skin, proper positioning is critical. In both babies with little tone and extra tone (spasticity), special equipment such as splints may be needed. Check with your newborn’s healthcare provider for specific recommendations for your infant.

Newborn babies, infants, and small children have heads that are larger in proportion to their bodies. The use of a pillow under the head is not recommended as it will cause the head to be over-elevated, blocking the airway. Sometimes a small positioning block is used under the shoulders to help open the airway, but this should only be done as directed by your physician.

For the Older Baby, Child and Teenchild posing with doll

There are four basic positions in bed, on the back, on either side or on the stomach (prone). Stomach placement is not recommended for infants to avoid sudden infant death syndrome (SIDS). It should be carefully considered in an older child before attempting it with a child who has a spinal cord injury. In some cases, being placed on the stomach is beneficial to breathing, but in other cases, it is not allowed due to obstruction of breathing. For prone positioning, check with your healthcare professional before attempting stomach positioning in bed. They will instruct you in the proper method for your child’s individual needs. Do not attempt stomach positioning without permission and instruction from their healthcare provider!

When placing your child in bed on their back, be sure their spine is straight and aligned with the head. The hips should be straight, in line with the spine. This counteracts the flexing of the hip muscles when sitting. Legs should extend from the body and arms near the side. If edema or swelling in the arms and legs is present, a small positioning block can be used to elevate the extremity.

Positioning on the side takes a bit more effort. Start by looking at the spine to be sure it is straight by lining the neck, shoulders, and hips. The shoulder next to the bed surface should be positioned forward slightly so the weight of the body is not fully on the shoulder joint. The other arm should be placed on a pillow for support. To maintain the side-lying position, the hip on the bed surface is straight, but the top hip is slightly flexed. The legs should be placed with the top leg drawn forward and fully supported by a pillow or block.

Positioning when seated uses the same key of spine alignment with head and body. The wheelchair should be of a size that fits your child. The seat should be about two inches from the back of the knee, not up against the back of the knee. Leg rests should be adjustable to support the leg by placing the child’s foot on the footrests but able to adjust for growth. Not supporting the weight of the leg with leg rests but letting the legs dangle, negatively affects the hip joints.

If the child requires armrests, they should support the arm without stressing the shoulder due to arm weight. Armrests need to be adjustable for height as well. If a headrest is required, ensure that it does not push the head forward or backward but keeps the head in alignment with the spine. Younger children have larger heads compared to older children and adults, so the headrest might be back a little further to accommodate the younger child’s head.

The same parameters should be used for seating on the commode. Do not let the feet dangle, which can put added pressure on the hip joint by the leg-pulling on the hips. If arm support is needed, it is also needed when using a commode chair to avoid pulling on the shoulder joint. A headrest might be necessary if it is used in the child’s wheelchair.

Be sure you use medical grade surfaces for positioning of your child when in bed or seated. Medical equipment is designed to disperse pressure away from boney prominences, which will decrease the risk of pressure injury. It would be best if you still turned your child at a maximum of every two hours or less depending on their skin tolerance. Younger skin appears very resilient. However, it is still subject to pressure injury, so always check for a dark or ashy spot in darkly pigmented skin or a red spot in lightly pigmented skin. Keep off that area until the spot disappears, then observe the area more frequently. Use of non-medical grade equipment such as a pillow or a craft foam that is not pressure dispersing and increases the risk of developing pressure injury because it collapses under the boney prominences creating more pressure as opposed to dispersing weight.

Benefits of Proper Positioning

Proper positioning benefits your child in many ways. It maintains their body in anatomically correct alignment. This is important to avoiding contractures or muscle tightening that is so strong that it can pull the bones out of alignment in the body. Contractures begin with tone (spasticity). Most body muscles are arranged with one set of muscles for pulling and another set of muscles for pushing. The pulling muscles are typically a bit stronger. These muscles can overpower the pushing muscles. Continuous tone causes one set of muscles to grow stronger. Eventually, a range of motion exercises are unable to restore the balance. A contracture then develops, which inhibits the joint from the full range of motion. The affected body part becomes ‘contracted’ in this situation. More information about contractures will be the discussion next month.

When in proper body alignment, the child’s body is better able to take advantage of the movement that they have. It is easier to reach when your body can move then when that advantage is removed due to improper positioning. Think about your own moving. If you want to reach for a plate in your cabinet, you can if you are not restricted from moving your arm. The same is for a child who might want to reach for a toy or feed themselves. The more positioning is set for alignment, the better able the child is to move.

Functional ability might even improve. With any spinal cord injury, some natural improvements develop over time. Even those these might be slight or seemingly non-purposeful when first discovered; these chance movements can be harnessed into functional ability with therapy and perhaps some adaptive equipment. Since children are growing, developing, and increasing in strength, they may discover new skills. This development would not be noticed if the child is out of position, so they are unable to attempt or see new abilities.

Consequences of Improper Positioning

There are consequences of improper positioning. At the top of the list is pressure injury. Keeping the body in alignment is the first line of defense in reducing pressure over boney body parts. Also, the key is turning, pressure reduction equipment, and pressure release movements. However, keeping the body in alignment is the first step in evenly dividing pressure. If a child is positioned toward sitting on one side, the pressure is on those bones to support their entire body weight instead of dividing it over both sides.

Breathing is easier when in alignment. If the child is hunched over to one side, the airways are less able to inhale and exhale. If the head has fallen forward, the main airway is constricted. Much like infants sleeping in their car seats, the weight of the head and force of pressure on the airway can become occluded.

Improper positioning can lead to constrictions in the blood vessels as well. Crossing legs, hooking an arm around the back of the chair, improper use of restraints for spasticity or positioning can cause constriction of blood vessels. This can lead to blood clots, which, if left unattended, can travel to the heart, lungs, or brain, leading to heart attack, pulmonary embolism, or stroke.

Proper positioning is one of the most basic care needs of any aged individual with spinal cord injury. It is also an issue that is often overlooked or more of a second thought. Be sure to think about proper positioning for your child. If you think a position does not seem correct to you or a piece of adaptive equipment does not appear to be working, call your healthcare professional, therapist, or nurse.

You know your child best, what is working, and what is not. Your child may have outgrown the equipment. Equipment easily gets bumped out of the correct position. Equipment that fits your child’s abilities or development advances is essential. These are all reasons for needing adjustments or alterations. You are your child’s best advocate. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.