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An ongoing series of informational entries

CBD and the Pediatric Population

by Kat Joines PT, MSPT, DHSc, PCS

Updated and revised November 21, 2020


         Families/caregivers ask their clinicians questions regarding the use of CBD (cannabidiol) oils looking for guidance on how to best care for their children. Parents require education on the terminology and the quality of cannabis, which means clinicians need to be well versed in current research. Not only do clinicians need to know about the drug, but they also must follow the federal and state rules and regulations. In the state of Nevada, clinicians need to practice within their scope of practice. They can only recommend the use of CBD and NOT prescribe ¹. Caregivers are interested in which diagnoses the drug can apply to and what symptoms the drug benefits and adversely affect the child. Lastly, as clinicians, we are interested in how CBD and interactions with other drugs will affect our therapy sessions.

Recognizing the Terms

  • Cannabis (cannabis stavia, cannabis indica, cannabis ruderalis): part of the Cannabaceae family
  • Cannabinoids: a chemical found in cannabis, there are more than 100 other cannabinoids were identified besides THC and CBD
  • CBD (cannabidiol): a single compound in the cannabis plant
  • CB1R or CBR-1 (cannabinoid 1 receptors)
  • CB2R or CBR-2 (cannabinoid 2 receptors)
  • Hemp (cannabidiol-CBD): plants that contain less THC
  • Marijuana (cannabis sativa): type of cannabis plant or plant material and contains both THC and CBD
  • THC (delta-9-tetrahydrocannabinol)

What are Cannabinoids?

Cannabinoids are the chemicals found in cannabis. They bind to the cannabinoid's receptors in our bodies known as

  • cannabinoid 1 receptors (CB1R), located in the brain and skeletal muscles with CB1Rb in the liver and pancreatic islet cells for metabolism; and
  • cannabinoid 2 receptors (CB2R), located in the testis, brain reward regions, and spleen ² ³ (image 2).

There are three hemp plants known as cannabis sativa (marijuana), cannabis indica, and cannabis ruderalis, all also known as cannabis ³ ⁴. Cannabis is part of the Cannabaceae family ⁵. Marijuana contains both THC (delta-9-tetrahydrocannabinol) and CBD. The plant's parts used are the dried leaves, flowers, stems, and seeds ³ ⁴ ⁵.

Image 2. CB1R in the body (Zou & Kummar, 2018, p. 6).

Differences Between CBD and THC

          THC has psychoactive properties that produce the high experienced ³ ⁵ ⁷ ⁸. Research has linked the development of schizophrenia and a contributor to neurodevelopment deficits in adolescents ³ ⁵ ⁷ ⁸. At the same time, CBD is non-intoxicating and has shown to act as an anti-inflammatory, analgesic, anti-anxiety, and contain seizure suppressing properties ³ ⁵ ⁷ ⁸. Hemp is the second most prominent cannabinoid in any part of the plant, including the seeds ⁴ ⁶ ⁷. Hemp CBD has all the derivatives, extracts, cannabinoids, isomers, acids, salts, and salts of isomers, either growing or not, with a THC concentration of not more than 0.3 % on a dry weight ⁴ ⁶ ⁷. Hemp for CBD oil is explicitly grown from female-only crops ⁶.

Image 3. Staying on the path (Photo by Mark Duffel on Unsplash).

Current Nevada State Rules on Cannabinoids

          Always research the current State and Federal changes in CBD rules and regulations. CBD oil is legal if the manufacturers and sellers comply with the federal and state laws that define hemp and how it is to be licensed and produced. In Nevada, SB209 was approved by the governor in 2019. It required the Department of Health and Human Services to adopt regulations that test and label certain commodities and consumption of products (made using hemp) to obtain standard safety, testing, and labeling ⁷. Hemp-derived CBD is no longer a schedule 1 drug, but CBD from the marijuana plant is still considered illegal ⁷. The Federal Farm Bill of 2018:

  • legalized hemp production,
  • lifted the commercial restrictions,
  • required that the state monitors and regulates production,
  • that tests use post-decarboxylation or other similar reliable methods, and
  • if using the term marijuana is used that it does not include hemp ⁶.

CBD is illegal when companies market products that contain cannabis and cannabis-derived compounds that violate the Federal Food, Drug and Cosmetic Act (FD&C Act) or if the product places people’s health and safety at risk ⁹.

The Benefits of CBD

          Cannabis can affect people differently (bioeffects) and look for shifts in the disease process. . We need to focus on what is working since there will be variability in the plant, product quality, and responses from use. We see diversity in one plant, which is also vastly different between plants. CBD has been used as far back as 5000 years ago to treat cramps and pain in ancient China ². Some benefits of using CBD are seen in chemotherapy-induced nausea, vomiting, and now with epilepsy ² ¹⁰ ¹¹ ¹² ¹³ ¹⁴ ¹⁵ ¹⁷. The FDA approved Epidiolex (a drug derived from marijuana that is a purified CBD product) to treat Lennox-Gastaut syndrome and Dravet syndrome ⁴ ¹¹ ¹² ¹³ ¹⁵ ¹⁷. TBI (traumatic brain injury) is another group that is increasing in research with findings of helping stave off TBI post-injury. There is less reliable research to show the benefits of using CBD in treating spasticity, neuropathic pain, posttraumatic stress disorder, and Tourette syndrome ¹⁰ ¹¹ ¹². Most research is currently lacking the long-term adverse effects ¹⁰.

List of benefits in using CBD to treat:

  • Anxiety
  • Assist with decreasing opioid use
  • Chemotherapy symptoms
  • Chronic pain
  • Epilepsy
  • Glaucoma
  • HIV/AIDS symptoms
  • Inflammatory bowel disease
  • Irritable bowel disease
  • Multiple sclerosis symptoms
  • Posttraumatic stress disorder
  • Sleep problems
  • Tourette syndrome: movement disorder ² ³ ⁴ ¹⁰ ¹¹ ¹² ¹³ ¹⁴ ¹⁷.

Early-stage research shows promise in treating:

  • Aggression
  • Anxiety for children with ASD
  • Hyperactivity
  • Restlessness
  • Sleeplessness ⁴ ¹⁰ ¹¹ ¹².

Safety of CBD in the Pediatric Population

          CBD affects interaction with the endocannabinoid system (receptors). They affect and balance the biochemistry of the body. Our body does not see CBD as a toxin. CBD will bind to the CB1R and not allow THC to bind as strongly or not at all, and the THC effects will not be as strong. There are CBD to THC preparation ratios that work well with certain conditions, such as staving off seizures of 2:1, 5:1, and 20:1 as found in Israel/Japan research ¹⁵ ¹⁶ ¹⁷. List of potential adverse effects from CBD usage:

  • Liver injury,
  • Can affect how other drugs work,
  • Use with alcohol or other drugs can slow brain activity – seen when treating anxiety, panic, stress, or sleep disorders,
  • Increased risk of sedation and drowsiness leading to injuries, and
  • Male reproductive toxicity, infertility in males and male offspring of women who had been exposed ⁴ ⁵ ¹⁸.

When CBD is stopped, side effects can include:

  • Changes in alertness – drowsiness or sleepiness,
  • GI distress – diarrhea or decreased appetite, and
  • Changes in mood – irritability and agitation ⁴ ⁵ ¹⁷ ¹⁸.

Image 4. Children with cancer (Photo by National Cancer Institute on Unsplash).

Ensuring the Quality of CBD


         There have been reports of potential contamination of cannabis/cannabinoid products with microorganisms, pesticides, and other substances ⁴. Some products also had differing concentrations of CBD than what the labels reported – 26% had less CBD than the label professed and in comparison, 43% had greater CBD ⁴.

What does this mean? We will need to do the following:

  • Decide the reasons for why you are choosing CBD and in what form.
  • Read the labels and packaging: find out how much THC to CBD is in the product.
  • Find out the testing and labeling requirements.
  • Find out where the hemp was grown.
  • Ask for the test results of the product and the amount of CBD.
  • Avoid food products with CBD: CBD cannot be used as an ingredient in the food.
  • Avoid product health claims: CBD can be sold as oil but cannot make any medical claims.

Effects of CBD and Therapy Sessions


         CB1R and CB2R control and release neurotransmitters to excite or inhibit synapses. CB1R is responsible for psychologic effects of pleasure, memory, thoughts, concentration, sensory and time perceptions, and coordinated movements ³. CB2R can act as an anti-inflammatory and immunosuppressive role ³. It can directly release and control neurotransmitters regulating cytokines ³. Cytokines are substances like interferon, interleukin, and growth factors secreted from the immune system that affect other cells.

          THC can exacerbate conditions and anxiety ³. Clinicians may see tachycardia, hypertension, dry mouth, dry throat, elation, euphoria, heightened perceptions, irritability, poor coordination, and balance ³. CBD can treat these conditions and will not bind to the CB1R and CB2R but will exhibit neuroprotective and anti-inflammatory effects ³. If given CBD through oral administration, you will get a longer duration of the drug’s impact because it will last longer in your system. Through inhalation, you will see immediate relief. Some other side effects to consider are tiredness, diarrhea, and changes in appetite and weight ¹⁹. However, with a better side effect profile, CBD use could improve compliance and adherence to treatment ¹⁹.

Image 5. Child’s attention (Photo by Jeremy Alford on Unsplash).


1. Conner, A. N. (2020, October 16). Marijuana 1: The law [Live in-service]. Touro University Nevada, Las Vegas, NV, United States.

2. Zou, S., & Kumar, U. (2018). Cannabinoid receptors and the endocannabinoid system: Signaling and function in the central nervous system. International Journal of Molecular Science, 19(3), 833-856.

3. Campbell, C. T., Phillips, M.S., & Manasco, K. (2017). Cannabinoids in pediatrics. The Journal of Pediatric Pharmacy and Therapeutics, 22(3), 176-185.

4. NIH. (2019, November). Cannabis (Marijuana) and cannabinoids: What you need to know.

5. FDA. (2020, March 5). What you need to know (and what we’re working to find out) about products containing cannabis or cannabis-derived compounds, including CBD.

6. Jeppson, A., & Willhelm, R. (2019). Industrial hemp: 2019 season and 2018 farm bill updates.

7. Weedmaps. (2020, August 8). Is CBD oil illegal in Nevada?

8. Cerne, K. (2020). Toxicological properties of delta 9-tetrahydrocannabinol and cannabidiol. Archives of Industrial Hygiene & Toxicology, 71(1), 1-11.

9. FDA (2020, October 1). FDA regulations of cannabis and cannabis-derived products, including cannabidiol (CBD).

10. Wong, S. S., & Willens, T. E. (2017). Medical cannabinoids in children and adolescents: A systematic review. Pediatrics, 140(5), e20171818.

11. Barchel, D., Stolar, O., De-Haan, T., Ziv-Baran, T., Saban, N., Fuchs, D. O., Koren, G., & Berkovitch, M. (2019). Oral cannabinoid use in children with autism spectrum disorder to treat related symptoms and co-morbidities. Frontiers in Pharmacology, 9, 1-5.

12. Elliot J., DeJean, D., Clifford, T., Coyle, D., Potter, B. K., Skidmore, B., Alexander, C., Repetski, A. E., Shukla, V., McCoy, B., & Wells, G. A. (2018). Cannabis-based products for pediatric epilepsy: A systematic review. Epilepsia, 60(1), 6-19.

13. Simonian, J. S., Varanasi, S., Nguyen, A. V., Diaz-Fong, J. P., Richards, G. J., & Le, J. (2020). A critical narrative review of medical cannabis in pediatrics beyond epilepsy, part 1: Background. Pedaitric Medicine, 3(14), 1-8.

14. FDA. (2018, June 25). FDA approves first drug comprised of an active ingredient derived from Marijuana to treat rare, severe forms of epilepsy.

15. Perucca, E. (2017). Cannabinoids in the treatment of epilepsy: Hard evidence at last? Journal of Epilepsy Research, 7(2), 61-72.

16. Hausman-Kedem, M. , Menascu, S., & Kramer, U. (2018). Efficacy of CBD-enriched medical cannabis for treatment of refractory epilepsy in children and adolescents – An observational, longitudinal study. Brain Development, 40(7), 544-551.

17. Ali, S., Scheffer, I. E., & Sadleir, L. G. (2018). Efficacy of cannabinoids in paediatric epilepsy. Developmental Medicine & Child Neurology, 61(1), 13-18. https://doi/org/10.1111/dmcn.14087

18. Huestis, M. A., Solimini, R., Pichini, S., Pcifici, R., Carlier, J., & Busardo, F. P. (2019). Cannabidiol adverse effects and toxicity. Current Neuropharmacology, 17(10), 974-989.

19. Iffland, K., & Grotenhermen, F. (2017). An update on safety and side effects of cannabidiol: A review of clinical data and relevant animal studies. Cannabis and Cannabinoid Research, 2(1), 139-154.

Juvenile Idiopathic Arthritis and Glucocorticoids

by Kat Joines PT, MSPT, DHSc, PCS

November 30, 2020

Studies support that early diagnosis of juvenile idiopathic arthritis (JIA) is key to ensuring prevention and improved overall health and quality of life outcomes (James & Wedderbrun, 2016; Nigrovic et al., 2018; Tarkiainen et al., 2019). A 10-year old child with JIA had a primary treatment that consisted of nonbiological disease-modifying antirheumatic drugs (DMARD) (Methotrexate) to decrease synovitis, decrease bone erosion, and allow for ample joint space, with glucocorticoids to control pain and inflammation (prednisone) as the first-line treatment (Batu, 2019; Ciccone, 2016; Dundar et al., 2020). While in physical therapy, she exhibited weight gain, a rounded face, and had missed visits due to being ill.

After investigating further into her long-term medication regime, these were common findings when given prednisone and Methotrexate prescription. Prednisone can assist with pericarditis but can affect normal growth, while Methotrexate can block immune chemicals and enzymes (Zelman, 2019). Adverse reactions/side effects from the medications include methotrexate toxicity, severe and fatal bone marrow suppression (weakened bones) and fatal systemic moniliasis, elevation in hepatic enzymes, lung problems (infection), and low blood cell count (, n.d.; Zelman, 2018). In the clinic, this may show up as:

  • nausea,
  • vomiting,
  • diarrhea,
  • stomatitis,
  • sore throat,
  • chills,
  • fever,
  • rash,
  • unusual bruising or bleeding,
  • jaundice,
  • dark urine,
  • swelling of the extremities, or
  • shortness of breath (, n.d.).

Other adverse effects from glucocorticoid use, refer to table 1. Treatment in the new onset of JIA is varied, but Nigrovic et al. (2018) noted that successful outcomes require physicians and caregivers to work together. Delaying treatment leads to increased risk and complications with joint erosion, limb-length discrepancy, bony overgrowth, experiencing pain longer, swelling, morning stiffness (James & Wedderburn, 2016). Quick diagnosing and prescribing the appropriate medications can decrease joint erosion and damage, slowing the JIA progression.

Taking non-steroidal anti-inflammatory drugs (NSAID) such as Aspirin was considered part of the first-line defense but has since changed due to the risk of children developing Reye syndrome (Ciccone, 2016). When taking an NSAID before or concomitantly with a high dose Methotrexate can prolong serum methotrexate levels resulting in death from severe hematologic and gastrointestinal toxicity but requires more exploration (Pfizer, n.d.). The 10-year-old was not taking any NSAID as part of her treatment regime. Prednisone with NSAIDs (such as ibuprofen) can increase the risk of gastrointestinal tract inflammation, bleeding, ulcerations, and potentially fatal perforation (, n.d.a).

Table 1: Adverse events while using glucocorticoids (Batu, 2019, p. 18).


Left image: <span>Photo by <a href=";utm_medium=referral&amp;utm_content=creditCopyText">Michał Parzuchowski</a> on <a href=";utm_medium=referral&amp;utm_content=creditCopyText">Unsplash</a></span>

Batu, E. D. (2019). Glucocorticoid treatment in juvenile idiopathic arthritis. Rheumatology International, 39(1), 13-27.

Ciccone, C. D. (2016). Pharmacology in rehabilitation (5th ed.). F. A. Davis Company. (n.d.). Drug interaction between methotrexate and prednisone. (n.d.a). Drug interactions between ibuprofen and prednisone.,-Applies%20to%3A%20ibuprofen&text=Using%20predniSONE%20together%20with%20ibuprofen,ulceration%2C%20and%20rarely%2C%20perforation.

Dundar, H. A., Acari, C., Turkucar, S., & Unsal, E. (2020). Treatment of systemic JIA: When do we need biologic? Real world data of single center. Journal of Modern Rheumatology, 1-16.

James, R. A., & Wedderburn, L. R. (2016). Modern management of juvenile idiopathic arthritis. Prescriber, 27(6), 37-43.

Nigrovic, P. A., Beukelman, T., Tomlinson, G., Feldman, B. M., Schanberg, L. E., & Kimura, Y. (2018). Childhood arthritis and rheumatology research alliance systemic juvenile idiopathic arthritis consensus treatment plan workgroup. Bayesian comparative effectiveness study of four consensus treatment plans for initial management of systemic juvenile idiopathic arthritis: FiRst-Line options for systemic juvenile idiopathic arthritis treatment (FROST). Clinical Trials, 15(3):268-277. https://doi,org/10.1177/1740774518761367

Pfizer (n.d.). Methotrexate (methotrexate): Drug interaction.

Tarkiainen, M., Tynjala, P., Vahasalo, P., Kroger, L., Aalto, K., & Lahdenne, P. (2019). Health-related quality of life during early aggressive treatment in patients with polyarticular juvenile idiopathic arthritis: Results from randomized controlled trials. Pediatric Rheumatology, 17(80), 1-6.

Zelman, D. (2019). How are corticosteroids used to treat used to treat juvenile idiopathic arthritis.,into%20joints%2C%20or%20by%20mouth

Zelman, D. (2018). Is methotrexate ok for my child?

Children with Anxiety

by Kat Joines PT, MSPT, DHSc, PCS

November 30, 2020

           Children with and without disabilities can exhibit fears and worries that are often overlooked by adults and not recognized as mental health issues because they exhibit behaviors that adults who may not work with children interpret as “typical bad behavior” and “excessive.” Examples include seeing toddlers cry when left with other family members even though they are safe with them or a child asking his parent over and over again who wants a candy bar at the store but was not given it so throws a tantrum even though they have food security. Anxiety symptoms can also include sleep disturbances, fatigue, headaches, or stomachaches and lead to additional psychopathology that interferes with social, emotional, and academic development to being diagnosed with obsessive-compulsive disorder or post-traumatic stress syndrome (AHRQ, 2016; CDCa, 2020). Diagnosis of childhood anxiety disorder affects one in eight children, 7.1to 25.1% of children aged 3-18 years old (4.4 million children), 3 in 4 children aged 3-17 years with depression also have anxiety (73.8%), 1 in 3 aged 3-17 years with anxiety have behavioral problems (37.9%) and 1 in 3 have depression (32.3%), and those with behavior problems aged 3-17 years, more than 1 in 3 have anxiety (36.6%), which all continue into adulthood with a severe prevalence of 5.9% (AHRQ, 2016; CDCb, 2020).

Figure 1: (CDCb, 2020, para. 8).

          Early intervention is key to addressing mental health issues such as anxiety in children where multiple treatment options are available. They include psychotherapy, pharmacotherapy, and combined treatment approaches, which the first line of treatment usually involves cognitive-behavior therapy (CBT) and selective serotonin reuptake inhibitors (SSRI's), but other approaches should be considered, such as:

  • psychoanalysis,
  • behavior therapy,
  • family therapy,
  • educational support, and
  • medications (when psychotherapy is not available or unsuccessful and exhibits moderate to severe symptoms at initial evaluation) such as selective reuptake inhibitor (SRI), serotonin-norepinephrine reuptake inhibitor (SNRI), benzodiazepines, and others (AHRQ, 2016; CDCa, 2020).

Without the appropriate interventions, persistent or extreme forms of fear and sadness lead to behaviors that can manifest as anger and irritability are interpreted as "bad" behavior, and can be because of anxiety or depression that can lead to further mental health issues when the child becomes older (CDCa, 2020; Center on the Developing Child, 2015). We need to identify the child's instability to connect them with trained people to support the family/parents in reducing the conflict, reducing dysregulation, and improving their future outcomes (Center on the Developing Child, 2015). Encouraging skills of responding to stressors and the interactions they will need will improve/progress their social-emotional skills to decrease anxiety and become a healthy functioning adult (, n.d.).

          As clinicians, there are therapies and strategies we can include in our session and education that are feasible and successful to decrease anxiety, such as:

  • Education on sleep regulation (CDCa, 2020),
  • Education on nutrition (CDCa, 2020),
  • Implementing predictable routines (CDCa, 2020),
  • Magic therapy in inpatient care: caregiver magic group’s anxiety was reduced by 24% (n = 34; P < .001), which also suggest that anxiety reductions lasted through at least 1-hour posttherapy (Pravder et al., 2019),
  • Playing music: When utilizing music during pediatric ultrasounds examinations, the study demonstrated a significant decrease in heart rate variability from pre to post-procedural (Kesselman et al., 2016),
  • Tablet distraction: the tablet distraction group displayed significantly less anxiety during the procedure compared to the control group, and the tablet distraction group returned to baseline after the procedure while those in the control group displayed higher anxiety post-procedure (Burns-Nadar et al., 2017),
  • Exercise: subjects performed a low-to-moderate exercise program that focused on associating movement with pleasure, encouraged positive and non-competitive interactions between participants, and found that anxiety levels decreased (Pilippot et al., 2019), and
  • Providing/identifying social support systems (CDCa, 2020).


Left Image: <span>Photo by <a href=";utm_medium=referral&amp;utm_content=creditCopyText">Zachary Kadolph</a> on <a href=";utm_medium=referral&amp;utm_content=creditCopyText">Unsplash</a></span>

AHRQ (2016). Evidence-based practice center systematic review protocol. Project title: Anxiety in children.

Burns-Nadar, S., Joe, L., & Pinion, K. (2017). Computer tablet distraction reduces pain and anxiety in pedatric burn patietns undergoing hydrotherapy: A randomized trial. Burns, 43(6), 1203-1211.

CDCa (2020). Anxiety and depression in children. Retrieved November 7, 2020, from

CDCb (2020). Data and statistics on children’s mental health. Retrieved November 7, 2020, from

Center on the Developing Child (2015, June 19). InBrief: Early childhood mental health [Video]. YouTube.

Kesselman, A., Bergen, M., Stefanov, D., Goldfisher, R., & Amodio, J. (2016). Impact of music in reducing patient anxiety during pediatric ultrasound. Pediatric Reports, 8(1), 6-8.

Philippot, A., Meerschaut, A., Danneaux, L., Smal, G., Bleyenheuft, Y., & De Volder, A. G. (2019). Impact of physical exercise on symptoms of depression and anxiety in pre-adolescents: A pilot randomized trial. Frontiers in Psychology,10(1820), 1-11.

Pravder, H. D., Leng-Smith, A., Brash, A. I., Elkin, D. J., Attard, M., Rose, B., Messina, C. R., & Chitkara, M. B. (2019). A magic therapy program to alleviate anxiety in pediatric inpatients. Hospital Pediatrics: An official Journal of the American Academy of Pediatrics, 9(12), 942-948.

The National Scientific Council on the Developing Child (2012). Establishing a level foundation for life: Mental health begins in early childhood: Working paper 6. (n.d.). 12-24 months: Social-emotional development.

Congestive Heart Failure in Pediatrics

by Kat Joines PT, MSPT, DHSc, PCS

Updated and revised December 1, 2020

           Congestive heart disease (CHD) occurs 8 in 1000 births, and congestive heart failure (CHF) is associated with CHD in about 20% of all patients (Jayaprasad, 2016). There are 10,000-14,000 children hospitalized for CHF and of those, about 3,000 have abnormalities in the heart muscle as an underlying cause and presents with edema, respiratory distress, growth failure, and exercise intolerance, with circulatory, neurohormonal, and molecular derangements (Jayaprasad, 2016). The first-line therapies include diuretics and angiotensin-converting enzyme inhibition (Masarone et al., 2017). In therapy, we must be cognizant of signs and symptoms for very young children, such as difficulty in feeding, cyanosis, tachypnea, sinus tachypnea, and diaphoresis (Masarone et al., 2017). For the older child and adolescent, fatigue, shortness of breath, tachypnea, and exercise intolerance (Masarone et al., 2017). Other signs, such as edema, abdominal pain, oliguria, and leg pitting edema (Masarone et al., 2017).

Staging CHF would be ideal in determining the appropriate features and to assist in dosing therapy sessions, such as the Modified Ross classification for pediatric heart failure (table 1) (Masarone et al., 2017, p. 305).

  • Class I Asymptomatic
  • Class II Mild tachypnea or diaphoresis with feeding in infants
  • Dyspnea on exertion in older children
  • Class III Marked tachypnea or diaphoresis with feeding in infants. Prolonged feeding times with growth failure
  • Marked dyspnea on exertion in older children
  • Class IV Symptoms such as tachypnea, retractions, grunting, or diaphoresis at rest

Table 1. Pediatric heart failure Modified Ross classification (Masarone et al., 2017, p. 305).

The goal is to prevent deconditioning that often occurs in children with CHF/cardiomyopathy (Figure 1). Research has found that exercise is safe, feasible, and beneficial in cardiac rehab to increase:

  • exercise capacity,
  • improve heart rate recovery following peak exercise,
  • increase respiratory muscle oxygenation, and
  • improve the quality of life in adult and adolescent populations (Du et al., 2015; Somarriba et al., 2008).

Figure 1. Pediatric cardiomyopathy – deconditioning (Somarriba et al., 2008, p. 18).

In younger children, short, low-dose intervention programs have improved overall gross motor ability and development (Du et al., 2015; Somarriba et al., 2008). Evidence has shown that passive movement and active exercise (such as aerobic exercise, resistance training, and flexibility training) help promote motor development, growth, heart function, and bone quality (Du et al., 2015; Somarriba et al., 2008).

Aerobic exercises result in the lungs and heart functioning at higher levels providing muscles to work over an extended period and should be performed at least five days per week (Somarriba et al., 2008). Resistance training comprises dynamic movements with progressive overload increasing and improving muscle strength (not focused on muscular hypertrophy), performing higher repetitions, and recommended to do 2-3 times per week (Somarriba et al., 2008). Flexibility training increases the range of motion over a period using both static and dynamic positions for 30-60 seconds and is performed 2-3 times per week (Somarriba et al., 2008) (Figure 2).

Figure 2. Children’s activity pyramid (Somarriba et al., 2008, p. 19).


Left Image: <span>Photo by <a href=";utm_medium=referral&amp;utm_content=creditCopyText">camilo jimenez</a> on <a href=";utm_medium=referral&amp;utm_content=creditCopyText">Unsplash</a></span>

Du, Q., Zhou, X., Wang, X., Chen, S., Yang, X., Chen, N., Liang, J., Deng, W., & Sun, K. (2015). Passive movement and active exercise for very young infants with congenital heart disease: A study protocol for a randomized controlled trial. Trial, 16(288).

Jayaprasad, N. (2016). Heat failure in children. Heart Views, 17(3), 92-99.

Masarone, D., Valente, F., Rubino, M., Vastarella, R., Gravino, R., Rea, A., Russon, M. G., Pacileo, G., & Limongelli, G. (2017). Pediatric heart failure: A practical guide to diagnosis and management. Pediatrics & Neonatology, 58(4), 303-312.

Somarriba, G., Extein, J., & Miller, T. L. (2008). Exercise rehabilitation in pediatric cardiomyopathy. Prog Pediatric Cardiology, 25(1), 1-22.

Supplemental Oxygen

by Kat Joines PT, MSPT, DHSc, PCS

December 1, 2020

 Hypoxemia decreases the partial pressure of oxygen in the blood (Sarkar et al., 2017; WHO, 2016). It is interesting to find that the Centers for Medicare & Medicaid Services (CMS) use the same indicators for oxygen levels in both adults and pediatrics, which include:

“1) partial oxygen pressure (PaO2) less than 55 mmHg . . ., 2) arterial hemoglobin oxygen saturation as measured by pulse oximetry (sPO2) less than 88%, or 3) PaO2 55-59 mmHg or SpO2 89% accompanied by cor pulmonale, a hematocrit greater than 55% or a history of edema” (Artinian & Millard, 2020, para. 3; Hayes et al., 2018, p. e7).

The new guidelines suggest that the diagnosis of hypoxemia in children younger than one year when their oxygen levels are 90% or less and children older than one year old with 93% or less (Artinian & Millard, 2020). When comparing normative values (Table 1) to hypoxemia, hypoxemia diagnosis occurs when their oxygen is measured:

  • continuously: exhibiting 5% or more below the threshold,
  • intermittently: with three independent measurements found below the threshold,
  • overtime: two weeks or longer are considered chronic (Artinian & Millard, 2020).

The goal is to maintain SpO2 levels between 95-99% and or based on congenital heart disease and can be determined through oxygen titration via nocturnal/daytime pulse oximetry study or sleep study (Artinian & Millard, 2020; Hayes et al., 2018). Table 2 exhibits the recommendations for oxygen therapy for home use. Clinicians and caregivers need to be trained to monitor oxygen levels through pulse oximeters and recognize the signs and symptoms of respiratory distress. Other things to consider are environments such as altitude that can alter levels and mislead a hypoxemia diagnosis (Crocker et al., 2020). 

Table 1. Normative Values (Hayes et al., 2018, p. e8).

Table2. Recommendations for home oxygen therapy in children Hayes et al., 2018, p. e11).


Left image: <span>Photo by <a href=";utm_medium=referral&amp;utm_content=creditCopyText">Victor Garcia</a> on <a href=";utm_medium=referral&amp;utm_content=creditCopyText">Unsplash</a></span>

Artinian, H. K., & Millard, S. L. (2020, January 15). Panel offers guidance on home oxygen therapy for children with chronic respiratory conditions. AAP News & Journals.

Crocker, M. E., Hossen, S., Goodman, D., Simkovich, S. M., Kirby, M., Thimpson, L. M., Rosa, G., Garg, S. S., Thagavel, G., McCollum, E. D., Peel, J., Clasen, T., & Checkley, W. (2020). Effects of high altitude on respiratory rate and oxygen saturation reference values in health infants and children younger than 2 years in four countries: A cross sectional study. The Lancet: Global Health, 8(3), e362-e373.

Hayes, D., Wilson, K. C., Krivchenia, K., Hawkins, S. M. M., Balfour-Lynn, I. M., Gozal, D., Panitch, H. B., Splaingard, M. L., Rhein, L. M., Kurland, G., Abman, S. H., Hoffman, T. M., Carroll C. L., Cataletto, M. E., Tumin, D., Oren, E., Martin, R. J., Baker, J., Porta, G. R., . . . & Deterding, R. R. (2018). Home oxygen therapy for children: An official American thoracic society clinical practice guideline. American Journal of Respiratory and Critical Care Medicine, 199(3), e5-e23. httsp://

Sarkar, M., Niranjan, N., & Banyal, P. K. (2017). Mechanisms of hypoxemia. Lung India, 34(2), 47-60.,of%20oxygen%20by%20the%20tissues.

WHO. (2016). Oxygen therapy for children.;jsessionid=A8A3125AC92E63A0EF9CD565377DE555?sequence=1