The ideal time to fit a prosthesis for a child with congenital limb deficiency is at the age of 6 to 7 months or whenever the infant is able to sit independently. Before that, however, it is necessary to orient the mother and father to the importance of prostheses and the various types and components available. Parents often have many questions and should be given adequate information early.

As an occupational therapist, I firmly believe that every child should have the opportunity to wear a prosthesis, especially early in life when, developmentally, it will be of the most benefit. If the parents wait until the child is perhaps 5 years old, the odds that the prosthesis will be sufficiently used are diminished significantly. Early fitting is clearly the most vital factor in achieving a successful outcome.

It is also essential that the person introducing prostheses to the parents be completely impartial in explaining the pros and cons of the different types. He or she should simply present all of the facts so that parents have comprehensive information upon which to base an informed decision for the child.

I have seen children do extremely well with both body-powered and myoelectric prostheses. The type of prosthesis prescribed for a child often depends on the opinions of the parents in conjunction with other members of the rehabilitation team. Each situation is highly individual.

I am personally seeing a definite trend to fit children with myoelectrics versus body-powered prostheses. Parents want "only the best" for the child and may feel that myoelectrics are the only acceptable option.

If finances are available through insurance or personal funds, I see no objection to prescribing myoelectrics.

A possible contraindication is if the deficient limb is particularly long – for example, one that includes bones of the wrist and/or hand, as in a partial hand amputation. These cases are extremely difficult to fit because of the space needed for the motor and battery of a myoelectric prosthesis. Without sufficient room, the prosthetic arm could be longer than the sound side, and that would be a problem.

I recall one incident in which a little girl was limb-deficient as well as severely retarded. In this situation, a myoelectric prosthesis was inappropriate because it requires sufficient cognitive skills to learn to use this type of prosthesis. Another reason not to use a myoelectric prosthesis might be inadequate family support. Substantial one-on-one attention is needed to help a child acquire myoelectric proficiency.

Generally, pediatric myoelectrics are simple and durable enough as long as the prosthetist and therapists have oriented the parents and child in the use and care of the prosthesis. Naturally, little children must avoid activities involving dirt, sand, and water when wearing a myoelectric arm; however, these factors should not deter prescribing this device.

Fitting both types

If enough money is available, the best option is to fit the child with both a myoelectric and a body-powered limb; however, because of restrictions imposed by managed care organizations (MCOs), usually only one is permitted.

Sometimes, it is difficult to get approval from an MCO for a myoelectric prosthesis. And some MCOs will only reimburse for one prosthesis in a lifetime, although that is more likely in adult cases.

MCOs are gradually recognizing that prostheses do wear out and are outgrown and that the one-per-lifetime limit is unreasonable.

Sometimes, it just requires a strongly worded letter of medical necessity from the physician to get approval for a myoelectric device. At other times, it may be hard to justify a myoelectric over a body-powered prosthesis.

Photo courtesy of Liberating Technologies, Inc

The first prosthesis prescribed for infants is usually a passive hand. Then, at approximately 9 months, the child may get a single control "cookie crusher." Not until perhaps 18 months would the child receive a more complicated two-stage device. The average life span of a child’s prosthesis is 1-1/2 to 2 years, depending on the child’s growth rate.

One economical way to replace prostheses is a limb bank – a collection of outgrown prosthetic parts. Several chapters of the Variety Club, an organization founded in 1928 by entertainers to serve children in need, maintain such resources throughout the country. Even with this recycling of components, however, the prosthetist still must recondition them and make a new socket so the price is not greatly discounted.

A child’s new below-elbow prosthesis costs approximately $12,000-$15,000. The price of an above-elbow prosthesis that incorporates an electric elbow is often twice as much or more. A new myoelectric prosthesis can only be adjusted for growth up to a certain point and then it’s outgrown. So, yes, the cost of pediatric myoelectric prostheses is surely a consideration.

Looks make a difference

Why do parents insist on myoelectric prostheses? Because of the way they look. They look far more like a real hand and arm. As far as the child is concerned, it doesn’t really matter – it makes a difference to the parents.

In terms of prosthetic use and proficiency, it’s fine to start a child on a body-powered prosthesis and then switch to myoelectric when the youngster becomes more aware of appearances and could be self-conscious about a limb deficiency.

Most parents, however, now start children with a myoelectric prosthesis and stay with it. Unfortunately, there have been few retrospective studies done to see if the young child continues wearing the myoelectric through adulthood. Most of our information on prosthetic use is merely anecdotal.

What we do know, however, is that early fitting is crucial. Waiting until a child is school age is not likely to be as successful. If a child is not fitted within the first two to three years after birth, the odds of successfully using a prosthesis decrease with each subsequent year.

About the Author:

Diane Atkins, OTR/L, FISPO, is a clinical assistant professor, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine. She lives in The Woodlands, Texas, and is in private practice. She may be reached via e-mail at djatkind@yahoo.com

© Amputee Coalition of America. Local reproduction for use by ACA constituents is permitted as long as this copyright information is included. Organizations or individuals wishing to reprint this article in other publications, including other World Wide Web sites must contact the Amputee Coalition of America for permission to do so.