Amid the COVID-19 pandemic, many students remain in a distance learning arrangement or hybrid model with at least some schooling taking place from home. An ergonomically correct remote learning setup is important because it can help prevent long-term problems with posture and help avoid discomfort.
To help parents ensure their children and teens have the proper setup – and that their growing bodies don’t suffer unintended consequences of an at-home workstation – we spoke to two CHOC pediatric physical therapists, Ruchi Bagrodia and Adam Shilling.
What are the basic things parents should ensure are incorporated into their child’s virtual learning setup?
Sit in a chair with back support at the dining table or a desk instead of your couch, in bed or on the floor which promotes poor posture.
Place your computer or tablet on a table in front of your child, instead of letting them hold the screen in their lap. The top of the screen should be just below eye level.
Frequent changes in body position is the most effective way to manage back pain. Seta timer for 30-50 minutes depending on class duration and break times. When the timer goes off, encourage your child to stand up and stretch their arms up, walk a lap around the house, and do 10 squats or jumping jacks.
Changing position every 20 minutes is preferred, if that fits your child’s school commitments — even if it means standing up for 10 seconds at a time!
Encourage your child to sit with proper posture. Keep your feet on the floor, with your thighs fully supported on the chair. Knees, hips and elbows should be at 90 to 100-degree angles.
What could happen to children’s bodies if they don’t have a proper ergonomic setup for virtual learning?
Rounded posture, forward head, muscle tightness and weak back muscles are all possible physical side effects from a poor setup.
Long-term back and neck pain could result if poor posture from a young age is not corrected.
Poor attention or participation, becoming easily distracted, headaches or body aches are also potential side effects.
What warning signs or symptoms should parents look out for that may indicate the setup is not right?
Child complaining of pain or achiness in their back, neck or shoulders during or after screen time.
Rounded upper back posture
Shoulders shrugged up too high
What are some ways that parents can help ensure children stay active during this time when they are at home more often than ever?
Make a goal to do a family activity every day, such as a neighborhood walk, kicking a soccer ball around or going on a bike ride. Try to do at least 30 minutes of some kind of physical activity every day.
Activity trackers for the family can be motivational in terms of tracking goals and sparking a friendly challenge between family members. Each person’s goal can be slightly different, and everyone must strive to meet their goal each week!
By Dr. Katherine Williamson, a CHOC Children’s pediatrician
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Jennifer and Justin Charles had experienced a smooth pregnancy until 27 weeks, when doctors discovered that Jennifer had lost most of the amniotic fluid around their growing baby boy.
Worried there had been a rupture in the amniotic sac, Jennifer and Justin prepared themselves for a premature birth. Further testing showed the complications were caused by a condition in the baby’s developing kidneys. But due to having little to no amniotic fluid, ultrasounds during were difficult to interpret and an official diagnosis didn’t come until the baby was born.
“We were scared, overwhelmed, confused – unaware what next steps would look like, unsure if he would be viable outside the womb at that point,” Justin says. “We prayed a lot, hoped for the best and prepared for the worst.”
Jennifer was admitted to the hospital quickly after that. She was monitored until baby Shiloh was born at 35 and a half weeks’ gestation.
“He made everyone wait to find out what was going on,” Jennifer says. “He’s had that drive since the beginning; he’s not one to go on anyone’s timeline but his own!”
Multiple diagnoses after a premature birth
Shiloh’s diagnoses include end-stage renal disease, and renal cysts and diabetes syndrome. Though still concerned about the future, Jennifer and Justin were relieved to know what was going on in Shiloh’s kidneys and to have a better picture of the journey ahead.
Shiloh’s first two years of life have included a 60-day stay in CHOC’s neonatal intensive care unit (NICU) at birth; two abdominal surgeries in his first month of life; a 90-day stay in CHOC’s Josie Y.S. Lee Pediatric Intensive Care Unit (PICU) later on; ongoing care with a variety of CHOC specialists including nephrology, gastroenterology, hematology, cardiology, endocrinology, pulmonology and rehabilitation; nightly dialysis; monthly blood draws; weekly Epogen shots to maintain his red blood cell count; a G-tube insertion for feeding; learning to swallow; and several medications. Eventually, Shiloh will require a kidney transplant, for which he is currently on the transplant list.
Shiloh’s premature birth and medical complexities meant that he might face some developmental delays. As part of Shiloh’s care, Jennifer and Justin began taking Shiloh to regular physical therapy appointments at CHOC.
Virtual visits during COVID-19
Once COVID-19 hit, however, they found that their rehab visits would have to look a little different than they had grown used to.
The CHOC rehab team turned to telehealth visits to ensure the health and safety of their patients. Rather than in-person appointments, the Charles family began seeing the rehab team via video chat.
“Telehealth requires participation and adjustments on both ends,” says Jennifer. “That looked like Dad holding the iPad to capture Shiloh’s movements and projecting our therapists onto our TV for Shiloh to see.”
The trio also had to be creative about which toys and exercises they could do from home using their own equipment, since they did not have access to CHOC’s outpatient rehab gym due to COVID-19.
For exercise, the family took walks outside, practicing on the steps in front of their house. As Easter approached, Jennifer and Justin placed plastic eggs around on the ground for Shiloh to pick up and put into a basket. They also played with a baseball, basketball and soccer ball to engage with him in a fun way.
Looking back at taking on telehealth rehab appointments at home, Jennifer acknowledges there was a learning curve, but noted how she developed an even deeper appreciation for Shiloh’s care team during this time.
“We developed so much more appreciation for how much effort the therapists put in on a daily basis, Jennifer says. “They spent time connecting with us during each session to make sure we were comfortable and adapted to what worked best for us and best helped Shiloh thrive.”
As the weeks passed, Shiloh’s parents and therapists took note of his development. Being able to work using his own toys and in his own home helped keep him comfortable.
“It gave us a chance to see even more of his personality shine through and to see him develop an even better sense of self confidence,” Jennifer says.
Despite the challenges of adjusting to a new normal in the time of COVID-19, Shiloh’s parents look back on telehealth as a great bridge for him to achieve his final physical therapy goals. He grew from crawling to assisted walking, then from unassisted walking to climbing stairs. They even caught his first steps on video, thanks to his telehealth physical therapy appointment.
Shiloh takes some of his earliest steps after learning to walk doing CHOC telehealth physical therapy appointments.
“It was wonderful being able to show our therapists the progress from appointment to appointment and to share in the excitement of his first steps together,” Jennifer says. “It was almost like getting to bring our CHOC family into our home after spending so much of our time in theirs at CHOC. Telehealth is such a great tool not just in times of quarantine but overall. We are thankful for this technology and for the rehab team being able to adapt to it so quickly and without compromising the level of care that CHOC is known for.”
Although Shiloh has graduated from physical therapy, he continues to see other CHOC specialists as he awaits a kidney transplant. In the meantime, his parents are cherishing his growth and development into what Jennifer affectionately calls her “tank of a two-year-old.”
Justin is likewise appreciating this time with his son.
“This kid is my hero,” Justin says. “His resilience is second to none. He’s a full-blown toddler, make no mistakes about that. But he is so kind and brings so much joy to everyone he meets. He carries a special light within him – that is for sure.”
By Dr. Rahul Bhola, pediatric ophthalmologist and medical director of ophthalmology at CHOC Children’s
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Johanna and her husband Graham were expecting a healthy baby. Already parents to one little girl, they were looking forward to expanding their family.
At Johanna’s 33-week anatomy scan, she and Graham were thrilled to learn they were expecting a girl, but shocked to learn she might have club foot, a birth defect where the foot is twisted out of shape or position. They learned there was a chance it could be due to a neurological defect since everything else was showing up as normal.
“We started mentally preparing ourselves for our baby to have a club foot,” Johanna said. “We had another anatomy scan, but they couldn’t say for certain what was going on.”
On January 26, 2018 Johanna delivered a baby girl named Angelina via c-section. A neonatologist was in the delivery room in case Angelina needed immediate medical attention after birth. She was having trouble swallowing and was monitored in that hospital’s neonatal intensive care unit (NICU).
Three days later, a CHOC neonatologist rounding at the delivery hospital recognized that Angelina needed a higher level of care and a bigger team of specialists. He suggested that she might need an MRI to give doctors a better look at her brain, and determine if her condition was neurological.
“Even though I’d never been to there, I knew that when it was an option to go to CHOC, you go to CHOC,” Johanna said.
Their older daughter Genevieve had been born at St. Joseph Hospital in Orange, next door to CHOC Children’s Hospital.
“I was so freaked out before I had my first child, because of all the things that can go wrong during childbirth. I delivered Genevieve at St. Joseph because I liked knowing that CHOC as right next door if we needed them” Johanna said. “When they gave us the option to send Angelina to CHOC, there was no question—we just immediately went.”
Angelina was admitted to CHOC’s NICU and evaluated by neonatologist Dr. John Tran, of CHOC’s neurocritical NICU. Special rooms of CHOC’s NICU are designated for the neurocritical NICU, where neonatologists and neurologists have the expertise and equipment to carefully treat babies with neurological issues.
An MRI showed that Angelina had polymicrogyria, a condition characterized by abnormal brain development. Johanna and Graham had never heard of this condition and had a hard time processing the diagnosis. Then they met with Dr. Donald Phillips, a pediatric neurologist at CHOC.
He explained to the family that typically, the surface of the brain has many ridges and folds, called gyri. In babies born with polymicrogyria, their brain surface has too many folds that are too small to process information received, which leads to problems with body functioning, similar to the effect a stroke can have on the brain.
Dr. Tran explained the spectrum of care for polymicrogyria. Some patients are nonverbal, some go to school, and some even live with this condition and never know. It was too soon to tell where on that spectrum Angelina would fall.
“Caring for babies with neurological conditions can be difficult. Not only are you medically treating a newborn baby, but you are also counseling a family and giving them an uncertain prognosis,” says Dr. Tran. “In the neurocritical NICU, our first goal it to treat the baby’s underlying condition. The second goal is to educate the most important members of our care team― the parents. We know that the NICU is not a part of the birth plan, but our job is to help alleviate some of the anxiety that comes with uncertainty. We strive to optimize the potential of our patients, whatever it might be, as they go home.”
The diagnosis was a lot for her parents to take in.
“We knew we were getting the best care for our daughter, but it was such heavy news,” Johanna said. “Even with a typical kid, we don’t really know what their life will be like. Every life is a gift. Once I started going towards that mentality, I realized that nothing is certain, even with typical kids.”
At her delivery hospital, one of the red flags that Angelina needed a higher level of care was that she kept crashing when she was breastfeeding.
“It made me freaked out to feed my daughter,” Johanna said.
Soon after coming to CHOC, Angelina began swallowing therapy. When someone experiences swallowing difficulty, they are at risk for food or liquid entering their lungs, called aspiration, which may lead to pneumonia. Karin Mitchell, a speech and language pathologist who specializes in the NICU setting, worked with Angelina on swallowing safety. Karin guided baby Angelina through exercises for her mouth and tongue to learn how to properly swallow saliva. Then, they could work on breastfeeding support and syringe feeding.
Angelina couldn’t move her legs when she was born, and her parents weren’t sure if she ever would. Thanks to physical therapy, today she can bend her legs more than 90 degrees.
Throughout their stay in the NICU, Johanna and Graham were thankful to have the ability to sleep overnight in their daughter’s private room. Because Angelina was born during flu season, her 3-year-old sister couldn’t visit the NICU. Her parents would stay at CHOC all day, go home to do their older daughter’s bedtime routine, and then one parent return to CHOC to sleep alongside their new baby.
“We had the privacy we needed, and I felt comfortable doing kangaroo (skin to skin) care,” Johanna said. “I hadn’t planned on my baby staying in the hospital, and at least having our own room, and even something as small as being able to watch TV gave me a small sense of normalcy.”
Johanna and Graham also appreciated the sense of normalcy provided by a Super Bowl party thrown for parents on the unit. An infant CPR class offered on the unit helped them feel more prepared to eventually take their baby girl home.
For big sister Genevieve, CHOC offers an innovative webcam system so family members can be together and bond with their newborns when they can’t be at the bedside. The system allows families to see real-time, live video of their infant remotely, from anywhere they can securely log onto the internet.
“CHOC had a lot of things in place, like the secure camera in Angelina’s room, to make things easier on us as a family,” Johanna said.
A month after she was born, Angelina got to go home for the first time.
“We were so ready to take her home, and finally be together as a family,” Johanna said. “But it was still a little nerve-wracking. We bought four different types of baby monitors; we were used to seeing her surrounded by machines.”
A few weeks later, Angelina began swallowing therapy twice per week and physical therapy three times per week. Now 15 months old, the amount of progress she has made has made her parents proud.
She couldn’t move her legs at birth, but a year later she is rolling and reaching. Her parents credit her CHOC physical therapist Lauren Bojorquez.
“Lauren didn’t just think of what Angelina was doing now; she was always thinking ahead about what would benefit her in the future,” Johanna said.
For example, Lauren and Angelina worked on rolling because it would eventually help her learn to sit. When babies roll, it helps develops muscles that will later help them sit.
Meanwhile, Angelina was working with CHOC speech and language pathologist Annie Tsai to learn how to cough, swallow, and accept food by mouth. Swallowing therapy focused not on quantity of food consumed but on quality of how the child feeds or swallows safely. Angelina’s work with Annie focuses on movement, strength and coordination within the mouth to prepare for eventually swallowing food.
Angelina still receives most of her nourishment through a feeding tube, also called a g-tube. The tube can stay in a patient’s stomach for months or years and allows the child to receive fluids, medicines and nutrition when they can’t take in enough nutrition by mouth. Every few months, Angelina sees gastroenterologist Dr. Jeffrey Ho for follow-up appointments for nutrition, feedings and g-tube care. Dr. Ho remains in close contact with Annie, her speech and language pathologist.
“Being able to eat in a typical manner is always the goal,” says Dr. Ho. “Every baby and child are different. Right now, we are focusing on what we can do to better optimize her potential to orally feed.”
Now, Angelina can sit in a highchair, bring her hands to her mouth, accept small tastes by mouth and better clear her congestion especially when she’s sick.
“Something I hadn’t realized before Angelina was how big a part food plays in our culture. As people get older, going out to eat or meeting for coffee is a social activity. I was sad that she wouldn’t get to have those same experiences,” Johanna said. “When she started to accept tastes by mouth, it made me think of her in the future, and being able to go out with friends and at least taste something, and still participate socially.”
To further practice feeding therapy at home, Angelina has a mesh pacifier typically used to soothe teething babies. Her parents often put the same foods in her pacifier as the rest of the family is eating. So far, there hasn’t been a food she’s tried that she hasn’t liked.
Angelina’s paternal grandma was an adult speech and language pathologist by training. When Angelina started speech therapy, she updated her license and certification to help her granddaughter at home. She comes to some of her sessions at CHOC and learns from Angelina’s care team.
Also participating in therapy is big sister Genevieve, who helps hold the pacifier and can even spoon-feed her baby sister, with a little bit of help.
“I am super grateful for CHOC,” Johanna said. “That’s why our family started participating in CHOC Walk when Angelina was born.”
These days, Angelina likes playing with toys, playing with her big sister, and listening to all types of music.
“I had a lot of preconceptions about disabilities and special needs,” Johanna said. “Having a child with special needs is not what I thought it would be. It’s better than that.”
Lily’s big sister, Makenna loved her before she was even born. She was actually the one who chose Lily’s name. Their bond only grew stronger when Lily was born with a rare chromosomal abnormality requiring specialized treatment and extra help at home.
“Even though Lily is different than Makenna and her brother, Ethan, they just see her as their sister,” says mom, Danielle. “They’ve helped Lily learn sign language and practice pronouncing words.”
Lily’s entire family has been involved in her care from day one. Makenna, age 11, would regularly tag along to Lily’s physical and occupational therapy sessions. She was keen to learn how she could help take care of her sister. She watched closely as physical therapist Cathy Lopez taught Lily how to move her body, and occupational therapist Lauren Newhouse taught her how to eat solid food (her favorite is avocado).
Seeing the way CHOC’s rehabilitation services team cared for Lily and the progress she made in therapy inspired Makenna to give back.
When Makenna’s school hosted a fair for students to showcase causes important to them, she chose to honor CHOC. She and a few friends watched YouTube videos to learn origami and created dozens of animal and emoji-themed bookmarks. She quickly sold out of them and donated the proceeds to the rehabilitation department at CHOC.
“Raising money for CHOC is the least I can do to thank them for taking such good care of my sister,” Makenna says. “Whenever we are there for an appointment, all the doctors, nurses, therapists and security guards are so nice to us.”
Organizing this fundraiser has inspired Makenna to continue her philanthropic streak.
“It was feels good to do it and it was so easy. It makes me want to do more to raise more money for CHOC,” she says.
Lily’s diagnosis and early days
When Danielle and her husband, David, found out they were expecting their third child, they were thrilled. A few months into Danielle’s pregnancy, a blood test showed that Lily had Turner Syndrome, a genetic condition affecting a female’s growth and fertility. That turned out to be a false positive, but a follow-up amniocentesis correctly diagnosed Lily with Mosaic Trisomy 12, a rare chromosomal abnormality about which not much is known.
Lily was born full-term via C-section at a local hospital. Immediately after birth she had trouble breathing and turned blue, and she was quickly whisked away to that hospital’s neonatal intensive care unit (NICU).
Lily needed a ventilator to help her breathe. She also required use of a CPAP, also known as continuous positive airway pressure, which helped keep her airway open. Danielle pumped her breastmilk so Lily’s care team could nourish her through a feeding tube.
Just outside the hospital, CHOC geneticist Dr. Neda Zadeh was starting to make her way home for the day when she heard about Lily’s condition.
“Dr. Zadeh was on her way out, but she turned around and came back to the hospital to run more tests and get a better idea of what was affecting her,” Danielle recalls. “Dr. Zadeh is amazing.”
In the first few days of Lily’s life, her parents weren’t sure if she would make it or not. When she was 3 days old, she was transferred to CHOC’s NICU for a higher level of care.
Lily spent the next 24 days in the NICU. When she learned how to breathe and eat on her own, she was ready to go home for the first time.
While the family spent much of their daughter’s first month in the hospital, NICU nurses made sure the family didn’t miss out on their first holiday together — Father’s Day. With her nurses’ help, Lily created a special Father’s Day craft for David using her footprints.
These days, Lily sees a mighty brigade of pediatric specialists at CHOC on a regular basis. Although not much is known about her Mosaic Trisomy 12, her care team remains fully committed to ensuring she is safe and healthy. In addition to Dr. Zadeh, Lily is under the care of neurosurgeon Dr. William Loudon, endocrinologist Dr. Timothy Flannery, and otolaryngologist Dr. Nguyen Pham. She also sees a neuro-ophthalmologist at UC Irvine.
Danielle is proud of the progress Lily has made during therapy at CHOC and seeing how that progress sparked Makenna’s giving spirit makes her proud as well.
“Makenna probably doesn’t realize this, but Cathy and Lauren at CHOC really cared for our entire family, not just Lily,” Danielle says. “The entire rehabilitation team at CHOC was incredibly supportive to our entire family. They were the weekly and sometimes daily reminders that we could do it. They impacted our entire family in a way that words simply cannot express. When we look back on Lily’s first years, they are in our memories and always will be!”
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.
“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.
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.
“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.
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.”
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.