Warming Up to Wound Care: Nico’s Story

Nico’s birth was full of surprises for his mom Jennifer. The biggest one being that he was a boy, when all along she had been expecting a daughter. That wasn’t the only unexpected realization. He lacked a fully-formed tibia (the bone that connects the knee and ankle), was missing his left thumb, and had several structural heart disease defects, none of which had been diagnosed prenatally.

Unexpected heart defects

Nico was diagnosed with unbalanced AV Canal (AVC), Anomalous Pulmonary Venous Connection (APVC), and Ventricular Septal Defect (VSD) due to the underdevelopment and abnormal formation of his heart and major blood vessels. Jennifer learned early on that her son’s heart conditions were treatable with a series of open heart surgeries and/or cardiac catheterization procedures.

The day after he was born, Nico was transported to CHOC Children’s. He underwent his first heart surgery when he was only three days old, under the care of Dr. Richard Gates, a CHOC Children’s pediatric cardiothoracic surgeon and co-director of the CHOC Children’s Heart Institute. Nico’s second heart surgery happened before his first birthday, and he’ll have a third heart surgery later this year.

nico-today
Nico, who is today a happy pre-K student, has already endured several surgeries.

“Despite Nico’s significant heart condition, he has responded well to each surgery, becoming stronger right before our eyes,” says Dr. Gates. “I look forward to his final surgery which should allow him to continue to be active and happy.”

Jennifer knew that someday Nico would need to have his leg amputated below the knee, Since Nico’s tibia bone connecting his knee and ankle wasn’t fully formed, it meant his ankle didn’t have the support it needed. Her original plan was to have that surgery performed at another facility closer to their home, when she was told they weren’t comfortable operating on his leg due to his heart conditions. Soon after, she and Nico were at CHOC meeting an orthopaedic specialist to discuss a prosthetic for his leg.

“I didn’t know what we were going to do, but during his prosthetic appointment, we learned CHOC would be comfortable performing his surgery, and could schedule it for just a few weeks later! I was thrilled we could do it earlier because I don’t want him to get to a point later on in life when he remembered or missed when he had more of a leg,” Jennifer recalls.

Shortly before his third birthday, Nico underwent surgery to amputate his leg below the knee under the care of Dr. Francois Lalonde, a CHOC Children’s pediatric orthopaedic surgeon.

nico-toy-after-wound-care
In addition to stocking our holiday toy store, donations that pour into our annual holiday toy drive bring joy to patients year round. After one wound care appointment, Nico is surprised with a new toy for being so brave.

After spending just one night in the hospital ―including a checkup with his cardiologist, Dr. Nafiz Kiciman, to make sure his heart looked alright after surgery― Nico was discharged.

“Nico is a brave and courageous young boy with an easy-going personality,” says Dr. Lalonde. “He has demonstrated great resilience and coping skills following surgery and wound care, and is already adapting well following the amputation of his left ankle.”

His doctors told his mom he should take it easy for a few days, but as soon as his cast was removed, he was quickly back to his old habits of climbing on furniture and jumping on pillows.

“I never want my son to have the mentality that he is limited,” Jennifer says. “Kids can sense if their parent is worried or scared, and I didn’t want him to feel like that. He’s too young to feel anxious on his own, so I made sure I didn’t bubble wrap him and let him play like his normal self.”

The importance of pediatric specialists for wound care therapy

The week after surgery, Nico and his mom started coming back to CHOC a few times per week for wound care, where specially-trained pediatric physical therapists would clean and rebandage his leg. In between those appointments, Jennifer cared for the wound at home.

“At his first appointment, he saw a new person walking into the room with all these supplies he had never seen before, and it was a lot for him to take in. He covered his eyes and wiggled around during the appointment,” Jennifer recalls.

To make Nico feel at ease, his physical therapist Sandy started letting him help her care for his wound.

nico-before-and-after-wound-care
Left: Nico was naturally apprehensive during his first wound care appointment, before he realized it didn’t hurt and could even be fun. Right: Nico during a subsequent wound care appointment, where he was rewarded for his bravery with a larger-than-life Mickey Mouse balloon.

“I wanted to be honest with him about what they’re going to do at this appointment, but frame it in a positive way so he knows it’s for his own good and he doesn’t have to be scared. It’s important to explain things in a way that he will understand,” Sandy says. “If you’re honest with the child, they’ll start to trust you. If you say, “this won’t hurt” and it hurts, then you’ve lost their trust.”

Once Nico was involved, he immediately understood that he didn’t have to be scared of wound care, and that it could even be fun.

Now, when Sandy finishes one step, he grabs the next supply that she’ll need. He almost sees it as a game. “Ok Nico, we’re done with this part. What part is next?” Sandy says to him.

nico-during-wound-care-appointment
To help calm Nico’s fears during wound care, his pediatric physical therapist involved him in the process.

These days, before each appointment, when Jennifer asks Nico if he wants to go see Sandy, he squeals and claps with delight.

“I tell him, “Let’s go see Sandy! She’s going to clean your owie and make it feel better.” My positive mentality was contagious for him. I was excited, so he was excited,” Jennifer says. “If the kid sees the parents squeamish during wound care or sees a worried expression on their face, then the kid will be apprehensive. Whenever we come to wound care appointments I make sure I speak to him in a very upbeat, positive way so he feels like physical therapy is fun and not something to be scared of, which helps him to relax. Positive energy is contagious.”

Continuity of care has also helped Nico feel more comfortable.

“It has helped him to have the same one or two physical therapists each time, so it’s a familiar face.”

nico-prosthetic
Nico’s Star Wars-themed prosthetic.

Once Nico’s leg was fully healed from surgery, he resumed physical therapy, was fitted for a prosthetic, and started walking. In between all of that, he continues to love anything Star Wars, playing Ninja Turtles, coloring and attending pre-Kindergarten classes.

Read FAQs about pediatric wound care at CHOC

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Meet Dr. Kelly Davis

A board-certified physician in pediatrics and sports medicine has recently joined the CHOC Children’s Orthopaedic Institute. Dr. Kelly Davis specializes in sports injuries, injury prevention, concussion management and advanced musculoskeletal ultrasound medicine for children, adolescents and young adults. Among the most common diagnoses she sees include overuse injuries and knee pain in athletes of all ages who play a variety of sports.

dr-kelly-davis-choc-childrens
Dr. Kelly Davis, a pediatric sports medicine specialist at CHOC Children’s

Her passion for helping young athletes comes from her own experience growing up playing sports. She played tennis, soccer, basketball, and also swam and water skied. She continues to play competitive tennis today and thanks her mom, a huge tennis enthusiast, for getting her into the sport.

“My mom played in college and has been my coach my whole life. I think what I love about tennis so much is that no matter your age or skill level, there is always someone you can play with and it is a great way to meet new people,” she says.

Dr. Davis completed her undergraduate studies at the University of California, San Diego, followed by medical school at Temple University School of Medicine, in Philadelphia. She completed a pediatric residency at CHOC, and stayed an additional year to serve as chief resident. She completed a fellowship in pediatric primary care sports medicine at Vanderbilt University in Tennessee.

During her time at Vanderbilt University, she served as a team physician for a local high school and for several collegiate teams including football, baseball, cross country, track and field, tennis and soccer. She was also team physician for the Nashville Sounds, a minor league baseball team.

Today, she continues to have the same commitment and enthusiasm for her patients.

“These kids have a certain drive. They’re really motivated and fun to work with,” she explains. “I also know what it’s like to sustain an injury, put in the rehab work and come back to the sport you love.”

Her patient care philosophy is straightforward: She treats each patient and their family as she would want one of her own family members to be treated. As a new mom mom, she says she has gained an added appreciation for her patients’ parents and their questions or concerns.

In her spare time, Dr. Davis loves spending time with her husband and their baby boy. She also enjoys playing soccer and tennis, hiking, camping and exploring the outdoors.

Learn more about sports medicine at CHOC

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Personalized Spinal Implants: Nikki’s Story

Four. That’s the number of days it took for Nikki Clark to return home following scoliosis surgery at CHOC Children’s Hospital. Dr. Afshin Aminian, an internationally-recognized expert in pediatric orthopaedics and medical director of the CHOC Children’s Orthopaedic Institute, performed the surgery using the latest techniques and technology to minimize pain and yield the best outcome for his teen patient.

A customized approach to care

Nikki was among the first patients at CHOC to benefit from personalized spinal implants. Based on detailed measurements and perioperative planning, customized rods were created to the precise length and shape of Nikki’s spine. The goals of this approach are better alignment and accurate correction of the patient’s spine. Customized implants and patient-specific rods decrease surgical time. In addition, they have the potential to improve recovery time and minimize future problems related to scoliosis.

scoliosis surgery
X-rays of Nikki’s spine, before and after receiving custom spine implants during scoliosis surgery.

“Our specialists have fine-tuned the most innovative, effective treatments for scoliosis, with a focus on maximizing each patient’s ability to function, grow and enjoy quality of life,” says Dr. Aminian. “Most of our patients are active teens, who are eager to return to their sports and activities. We want to do everything we can to help them do that.”

Making the jump

A swimmer and competitive water polo player, Nikki was thrilled to hear Dr. Aminian’s approach to care. Less than a year after being diagnosed, she decided to pursue surgery rather than wait. Her focus:  being ready for the upcoming season.

“I knew my life was going to get busy and really wanted to make sure I could play water polo during my junior and senior years. I wasn’t afraid of the surgery or the pain. I was more worried about not being able to play,” explains Nikki.

The morning of her surgery, Nikki began feeling anxious; not scared, as she pointed out to the child life specialist who came to check on her in pre-op. “I knew I had the best doctor, at the best hospital in California, and was ready to get the surgery over and done,” recalls Nikki.

A few hours after surgery, Nikki was surprised she wasn’t experiencing as much pain as she anticipated. The next day, a physical therapist helped her sit up for the first time. “It felt so good to finally be able to move,” says Nikki, who also enjoyed ordering milk shakes from CHOC’s room service menu. The chocolate banana one was her favorite.

scoliosis surgery
After scoliosis surgery to receive personalized spinal implants, Nikki was surprised she wasn’t experiencing as much pain as she anticipated.

She continued to follow all the guidelines, including getting out of bed to walk. Her physical therapist and nurses were among her biggest cheerleaders, praising her for quickly reaching the milestones required for her to go home. On Nikki’s fourth day at CHOC, Dr. Aminian proudly announced she was going home.

Nikki’s recovery at home continued to progress at a record pace. A month later, she returned to school. Two months later, she was back as a junior life guard in Newport Beach. The determined athlete surprised everyone by finishing the “monster mile,” which includes running a mile and swimming a mile. By the end of summer, she had also completed eight jumps off the pier.

scoliosis surgery
Nikki loves being outdoors, and quickly returned to her active lifestyle after scoliosis surgery.

Back in competitive water polo, Nikki proudly shows off her surgical scar. She’s been approached by other players, who have scoliosis. She encourages them to “make the jump.”  “You’re strong and in great shape. You can handle surgery,” she tells them.

Learn about scoliosis services at CHOC now.

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Return to Learn Concussion Guidelines Every Parent Should Know

When a child has a concussion, the rules for getting back to sports are laid out by state Return to Play laws. But when it comes to getting back to the classroom, the rules aren’t as clear.

A recent study in the journal Pediatrics found that only a few states have Return to Learn concussion laws, and these varied in terms of responsibility. Some of the laws were restricted to student athletes, excluding students who sustained non-sport related concussions.

“When returning a student to the classroom after a concussion, we try to balance stimulation levels and worsening of symptoms,” explains Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s. “While too much cognitive exertion can lead to headaches, problems concentrating, fatigue and trouble with emotional control, over restriction from classroom and academic activities can result in social isolation and anxiety about falling behind or lower grades that can also slow the recovery process.

return to learn
Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s.

“Returning to the classroom after a concussion optimally takes a team approach including the student, family, medical and education teams,” Dr. Koutures says. “Flexibility and creativity in paying attention to individual student needs and concerns can make this process more rewarding for all parties.”

Dr. Koutures advises the patient’s care team, including parents, to follow CHOC’s recommended six stages for returning a student to school after a concussion, including the following added guidelines:

Step-wise Return to Learn Progression

Step 1: No formal academic activity

  • Recent studies suggest that full or prolonged limitations in cognitive activity may actually delay recovery
  • In first few days after concussion, allow 15-20 minute intervals of single-task activities that do not provoke symptoms and are not excessively taxing
    • Listen to light music
    • Draw or color
    • Journal writing
    • Audiobooks
    • Passive television or movies (at home), larger screen preferred, lower volume
    • Some texting, smartphone use; want to balance maintaining key social contacts with not having symptom-flare
    • Conversations with 1-2 other people
  • Separate the 15-20 minute bursts of activity by 30-40 minutes minimum of non-cognitive activity
  • If symptoms flare before 15-20 minute limit, stop activity and try again later
  • If patient can handle 2-3 periods of 15-20 minute activity over the course of day, can consider advancing toward partial return to school

Step 2: Light academic activity

  • Attend 1-2 periods or 1-2 hours of school
  • Select consecutive classes; have child help make decision
  • No physical education or other activity classes
    • Caution with more noisy classes such as woodshop, music/band, chorus
  • Tend to avoid first class in morning to allow more sleep and arrival at school without busy parking lot and hallways
  • Main goal: be in class; no responsibility for note-taking, participating in class /responding to teacher, in-class work, homework or testing
    • Audible learning (most kids handle this better than visual learning after a concussion)
    • Should have pre-printed notes for reference or have others take notes and share
  • Sit away from louder students, windows, projectors, or other light/noise stimulation
  • Sit close to teacher
  • Allow to wear earplugs and sunglasses as needed
  • May allow brief 1-2 minute periods of putting head on desk for rest
  • May leave class early to avoid the noise and commotion of hallways during passing periods

Step 3: Increased academic activity

  • Expand day to 3-4 periods or hours per day
  • Incorporate break periods (nutrition break, lunch)
    • Have quiet place to rest
  • Recommend against assemblies or rallies due to noise stimulation
  • Continue to avoid physical education or activity classes
  • Main goal is to be in class and handle longer day; still not responsible for note-taking, participating in class/responding to teacher, in-class work or homework

Step 4: Full-time attendance

  • Full-day attendance without activity or other higher-stimulation classes
  • May expect some increased fatigue at end of school day
    • If student wants to nap after school, limit to no more than one hour
  • May start to take own notes, though helpful to have pre-printed teacher’s notes or other student notes
  • Incorporate “to do” lists with short-block (10-15 minute) work periods followed by short (5 minute) breaks
  • Break period and breaks in class (especially if block schedule) may still be needed
  • If possible, move most challenging courses to time of day when student feels the best

Step 5: Return to Majority of Academic Activities

  • Once handling full day attendance, can resume taking notes in class, verbal responses to teacher, and in-class work
  • May begin homework starting with limits to 30-60 minutes a night and priority on essential concepts that are needed for eventual testing or continuity of learning
    • Waive any projects, papers, essays or other assignments that are not required for future learning needs
    • Try to limit burden of make-up work; focus should be on those assignments that are necessary for future learning
      • Sequential classes (math, foreign languages, science) tend to be the most challenging for make-up work
    • No tests or quizzes at this stage
    • Audible learning – listen/speak responses vs. writing, dictating work, audiobooks may be more favorable at this point

Step 6: Return to Full Academic Activity

  • Full-day attendance without symptoms, fulfilling all in-class duties and completing usual homework assignments
  • Can resume tests and quizzes
    • Strongly consider waiving missed tests or quizzes
    • Combine missed tests or quizzes to allow more quick completion of make-up work
    • Allow student to take missed tests/quizzes to gain exposure/mastery of material without being graded, or only receive grade if results are in usual level of achievement
    • Assign grades at end of grading period based on level of work prior to concussion
  • May need more time for test completion
  • May need individual room placement for testing
  • May limit testing/make-up testing to one test per day
  • May allow open book, use of notes, word banks or home-based testing
  • Consider alternate forms of testing such as spoken test, or multiple choice vs. longer essay responses that might be more taxing for the student
  • Students may still benefit from more audio learning
  • Can resume physical education (with physician release) and activity courses
Learn about the CHOC Children’s Concussion Program now.

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Nursemaid’s Elbow in Kids Caused by Common Activities

Nursemaid’s elbow is one of the most common injuries in small children, and it can happen during the most innocent activities, like swinging a child by the arms or playing tug-of-war.

“There is a natural looseness in the ligaments of little kids’ elbows,” according to CHOC Children’s pediatric orthopaedic surgeon Dr. Jessica McMichael. “Nursemaid’s elbow happens when the arm gets tugged or pulled, which can partially dislocate the radial head portion of the elbow.”

The injury can happen when a baby or small child is lifted by the hands, or when a child tugs their arm while holding someone’s hand. It can also happen when an object is pulled from their hand, when a baby rolls over or because of a fall.

What are Symptoms of Nursemaid’s Elbow?

Parents can look for these characteristic signs of nursemaid’s elbow in their child:

  • The child stops using their arm normally or treats their arm gingerly
  • The elbow appears straight and the child doesn’t want to bend it
  • The child holds their arm limply and away from the body, “like a paralyzed arm”
  • The palm is rotated inward, rather than facing out toward the front of the body
  • The child complains of pain in the elbow, forearm or wrist
  • Someone holding the child’s hand may feel a pop in the child’s wrist when the injury happens

Nursemaid’s elbow is a very common orthopaedic condition treated at CHOC, according to Dr. McMichael. It is likely to happen multiple times after a child has it once.

“Nursemaid’s elbow is not threatening to the limb, but it does need to be treated,” Dr. McMichael says. “It’s okay to wait until the next morning if your child is acting okay. If your child is not acting like themselves, get it checked out.”

How to Fix Nursemaid’s Elbow

To fix nursemaid’s elbow, a medical professional will gently and quickly pop the elbow back in place. A child might feel pain for a brief moment during the procedure but should start using their arm normally within a few minutes.

If a child’s elbow pops out of place three or more times in a month, a cast may be put on to immobilize the arm and promote stiffness.

Nursemaid’s elbow can be treated by a pediatrician, a pediatric orthopaedic specialist or at a pediatric emergency department. Parents should not correct the elbow themselves unless instructed by a doctor.

Dr. McMichael encourages parents to educate people who are around their child, like grandparents, daycare staff and preschool teachers, about the safest ways to lift a child, hold their hands and play with them.

Nursemaid’s elbow is less likely to occur after age four, when the elbow ligament starts to tighten up and improves with age and growth.

To make an appointment with a CHOC orthopaedic specialist, call 888-770-2462.

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