One of the things you'll learn when working with the pediatric population is that they're a different species than adults. Some of the common diagnoses may overlap, such as chronic constipation, fecal smearing, or nocturia. The way they present may be similar and the treatment ideas and philosophy may also overlap. However, how these treatments are implemented may vary when treating a child versus an adult. When I think of treating the pediatric population, I like to divide my thought process and approach into five different groups.

To me, pediatrics can be babies/infants, toddlers, preschool-aged children, elementary school-aged children, and then tweens/teens. It may feel excessive to divide this population into so many subgroups, but each of those groups has its own treatment considerations based on the child's development at that time in their lives. An infant may be working on regulating their GI system as they transition from being in-utero to being born. Toddlers and school-aged children are working through various internal and social benchmarks to help them continue to grow and develop. Likewise, a tween or teen may be managing the changes to their genitourinary system as they work through puberty towards adulthood or grappling with their sexuality and sexual identity as they mature.

Regardless of what stage they are in life, patients will potentially present differently and also need a customized treatment plan to meet them where they are at. When I have colleagues jumping into pediatric pelvic health, I rarely worry they have the clinical skills to help with the physical and physiological challenges a child may face. The place I see many clinicians struggle is how to apply the skills they know to these tiny humans in front of them. Treating reflux in an eighty-year-old versus an 8-week old person is very different.

Children can't always tell us what they're feeling and how they're feeling it. An adult that has the ability for interoception can tell us what they're feeling, how they're feeling it, and how our treatment interventions are affecting their condition and goals. A pediatric patient may not be able to provide this feedback so subtle signs such as skin color, facial expressions, and body language may be your only clues. Likewise, being able to interpret a baby or child's negative reactions, such as crying, trying to get away, trying to hide, or otherwise avoiding therapy is a very necessary skill when working with pediatrics. Long story short, we can ask an adult if what we're doing is working, with a pediatric patient, we have to be more creative in determining our efficacy.

Children can't give consent. Children can give assent, meaning that they will comply with what you are asking them to do. This can feel tricky and if you struggle with this I recommend taking Ethics Considerations for Pediatric Pelvic Health on July 27, 2025. When working with pediatric patients, the take-home point is that the therapist will always have more power than the child that they are working with. This means that the therapist has to be very careful in how they wield their power dynamic, to be most beneficial and fair to the child.

Children usually can't be autonomous with their home programs. When I think about home programs, some of my adult clients even struggle to complete these correctly or regularly. Many times, especially when they're under the age of 10 years old, children cannot be autonomous with their home programs. This means that a practitioner has to consider what is going on in the home, the living situation that the child is in, their support system, the financial resources available to the child, and other factors that may act as help or hindrance to their home program activation.

Children need caregiver support and guidance. As we said above, most of the care that we're giving to a child in the home is going to be provided with the support or completely by a parent or caregiver. We have to make sure that the child's guardian is on board with the treatment plan, has the resources and ability to enact the treatment plan, and is being respectful to the child as they work on the program at home. As therapists, we have to help navigate bumps and challenges on this road to recovery for the child and their support system, or else we're not doing all aspects of our job. I am always asking myself questions like:

“Can this family afford this?”

“Do they have time for this?”

“Do they understand why I am asking them to do this?”

“Is me asking this of this family adding unnecessary stress to this child or the caregivers?”

Children deserve to be offered to “buy in” to their plan of care. One of the mistakes I see colleagues make is understanding the wisdom of children. Yeah, they're tiny. Yes, they sometimes eat their boogers and think poop jokes are funny. Still, children are much more intuitive than we frequently give them credit for. I've had kiddos as little as 3 years old be excited to drink their “poop juice” to help move their “poop train.” If we “make it make sense” for them, they become the biggest, most powerful part of their care team! Teaching lifelong good habits is something I know most therapists love about their jobs and working with kids provides this so easily.

If you're a provider who is jumping from adults to pediatrics or if you are new to pelvic floor with pediatrics in general, Pediatric Pelvic Floor Playskills is a class that walks you through challenges and solutions by age, sample treatment plans, and problem-solving case studies to build your confidence and efficacy in treating this population. Hope you decide to come play with us on January 25th!

AUTHOR BIO:
Mora Pluchino, PT, DPT, PRPC

Mora Pluchino, PT, DPT, PRPC (she/her) is a graduate of Stockton University with a BS in Biology (2007) and a Doctorate of Physical Therapy (2009). She has experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. She began treating Pelvic Health patients in 2016 and now has experience treating women, men, and children with a variety of Pelvic Health dysfunction. There is not much she has not treated since beginning this journey and she is always happy to further her education to better help her patients meet their goals.

She strives to help all of her patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at the present time. In 2020, She opened her own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. She has been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. She has also been a TA with Herman & Wallace since 2020 and has over 150 hours of lab instruction experience. Mora has also authored and instructs several courses for the Institute.

Dawn Sandalcidi will be a keynote speaker at HWConnect 2025 on March 28-30, 2025. You can also join her in upcoming courses: Pediatric Pelvic Floor, Diaphragm, and Postural Development: Intro to Core Function and Continence in Children on September 29th, Pediatrics Level 1 -Treatment of Bowel and Bladder Disorders on October 26-27, or Pediatrics Level 2 - Advanced Pediatric Bowel and Bladder Disorders on November 2-3.

As physical and occupational therapists, we aim to provide the best possible care for our young patients by understanding and addressing the underlying mechanisms affecting their health. The diaphragm is one of the most important yet often overlooked structures. This muscle plays critical roles in both respiratory and postural functions and has far-reaching implications for the stability and health of children.

In this blog, we’ll explore the anatomy, function, and clinical relevance of the diaphragm, its connections to the pelvic floor muscles, and the broader implications for pediatric therapy.

Anatomy Of The Diaphragm

In order to appreciate the functions that the diaphragm plays in breathing and movement, you must first understand the anatomy. The diaphragm is the thin, dome-shaped muscle that separates the thoracic and abdominal cavities. Its structure is divided into two primary components:

1. The Crural (Vertebral) Portion: The crural portion, or muscular “legs” of the diaphragm, originates from vertebrae of the lumbar spine, providing stability and anchoring the diaphragm in place.
2. The Costal Portion: The costal portion originates from the xiphoid process of the sternum and the upper margins of the lower rib pairs.

At the center of the diaphragm lies the “central tendon”, the non-muscular aponeurosis at which the muscular fibers converge. This tendon acts as a pivotal point during the contraction of the diaphragm.

When the diaphragm contracts during inspiration, the dome of the diaphragm descends, shortening the muscle fibers and increasing the volume of the thoracic cavity. This action decreases intrapleural pressure, allowing the lungs to expand and fill with air. At the same time, abdominal pressure increases as the diaphragm displaces the rib cage and moves downward.

The relationship between the diaphragm and the rib cage is vital for effective breathing and functional movement. Keep this in mind when working with kids who have low tone or poor strength. Breathing mechanics and diaphragm optimization are essential to assess. Proper contraction of the diaphragm not only facilitates lung expansion but also ensures that the core and extremities are stabilized, leading to efficient and stable movement patterns.

Let’s take a closer look at these functional connections.

The Diaphragm’s Connections To Posture And Pelvic Floor

A critical concept in understanding the diaphragm’s function is the Zone of Apposition (ZOA). The ZOA is the vertical area of the diaphragm that extends from the inside of the lower ribs to the top of the diaphragm. This zone maintains the diaphragm's dome shape, which is important for effective breathing.

When the ZOA is well-maintained, the diaphragm can contract efficiently without the need for accessory muscle recruitment. This efficiency prevents compensatory breathing patterns that can lead to respiratory and postural issues.

Conversely, a decreased ZOA can result in poor diaphragm contraction, leading to inefficient breathing and overuse of accessory muscles. Musculoskeletal effects on posture can include issues such as:

• Anterior rib flare
• Lung hyperinflation
• Hyperlordosis
• Protruding abdomen
• Weakness of the anterior core muscles with poor pressure system management

The diaphragm works in close coordination with the pelvic floor muscles (PFM) and the abdominal muscles. This interaction is vital for managing intra-abdominal pressure (IAP) and maintaining stability in both the thoracic and abdominal cavities when breathing.

1. During inspiration, the diaphragm descends, causing an eccentric lengthening of the abdominals and the PFM, which stabilizes the core.
2. During exhalation, the diaphragm relaxes and ascends, while the abdominals and PFM contract concentrically.

This basic overview of the diaphragm's connections is expanded upon in my live online course, Pediatric Pelvic Floor Diaphragm and Postural Development, where I delve deeper into how these relationships impact children with pelvic floor issues like constipation, diastasis rectus, and even cystic fibrosis.

The diaphragm, in coordination with the abdominal muscles and the PFM, helps to stabilize the spine and pelvis during movement. This stabilization is essential for maintaining balance and posture when learning developmental motor skills.

This coordination also ensures that pressure within the thoracic and abdominal cavities is managed effectively, influencing respiratory capacity and lymphatic drainage.

Furthermore, the fascial connections from the diaphragm establish healthy function of many organ systems. Let’s take a look at this in more detail, so you can understand how this directly affects your practice as a pediatric therapist.

The Diaphragm’s Fascial Connections To Organ Systems
Beyond its muscular and respiratory functions, the diaphragm is also deeply interconnected with the body’s fascial system. Fascia surrounds every structure in the body, providing support and facilitating movement. Fascia has contractile properties, so a problem with the diaphragm or its related structures can cause dysfunction along the entire fascial chain.

The diaphragm has direct fascial connections to several key organs, including:

• Heart
• Lungs
• Liver and Colon
• Esophagus

These fascial connections highlight the diaphragm’s role in managing information between the chest and abdomen, as well as its influence on organ function. When kids have dysfunction in their diaphragm or its associated fascial structures, this can lead to a range of issues, such as digestive, breathing, and swallowing problems.

The diaphragm also influences postural stability through its relationship with the glottis, which controls airflow through the vocal cords. Engagement of the glottis during upright perturbations or stability tasks enhances thoracic stability. The proper function of the glottis needs to be considered when working with kids on breathing mechanics, trunk stability, or pelvic floor engagement.

You must also look at neurological connections to the diaphragm, such as those involving the phrenic, vagus, trigeminal, and hypoglossal nerves. What many therapists often see as classic mechanical issues or classic digestive issues, can actually have distal neurological origins. This includes mechanical conditions such as headaches and thoracic outlet syndrome, and autonomic digestive conditions such as gastroesophageal reflux, aerophagia, and functional gastrointestinal disorders.

Get good at connecting the pieces and understanding the root causes of dysfunction, rather than simply treating the kids’ symptoms.

Clinical Implications For Pediatric Therapy
For pediatric therapists, understanding the diaphragm’s role in respiration, postural stability, and its broader connections within the body is essential for effective treatment. Children with conditions such as cerebral palsy (CP), respiratory issues, constipation, and musculoskeletal pain can benefit significantly from interventions that target the diaphragm and its associated structures.

For example, in children with CP, research has shown that kids with better diaphragmatic function exhibit greater ambulatory mobility, abdominal expansion, and respiratory function compared to kids with impaired diaphragmatic function. You should prioritize treatment of the diaphragm for children with CP, especially those who are non-ambulatory. [1]

Similarly, addressing diaphragmatic function can play a critical role in managing pediatric patients with respiratory conditions, such as asthma. Ensuring that the diaphragm maintains its dome shape and ZOA can improve the child’s breathing efficiency, reduce the reliance on accessory muscles, and enhance overall respiratory function.

Lastly, the diaphragm’s role in maintaining intra-abdominal pressure and coordinating with the pelvic floor muscles is crucial for managing conditions like constipation and urinary incontinence. By optimizing diaphragmatic function, you can support children’s pelvic floor function and help improve their bowel motility and urinary continence.

There are many widespread health implications that you have the power to influence as a pediatric therapist! If you are looking to deepen your understanding of the diaphragm and its role in pediatric health, join me virtually for my live Pediatric Pelvic Floor Diaphragm and Postural Development course on September 29, 2024.

This course will provide you with the knowledge and tools you need to enhance your practice and improve outcomes for your young patients. Don't miss this opportunity to expand your skill set and make a meaningful difference in the lives of the children you treat.

Reference:

1. Bennett S, Siritaratiwat W, Tanrangka N, Bennett MJ, Kanpittaya J. Diaphragmatic mobility in children with spastic cerebral palsy and differing motor performance levels. Respir Physiol Neurobiol. 2019 Aug;266:163-170. doi: 10.1016/j.resp.2019.05.010. Epub 2019 May 21. PMID: 31125702.

AUTHOR BIO

Dawn Sandalcidi PT, RCMT, BCB-PMD

Dawn Sandalcidi is a trailblazer and leading expert in the field of pediatric pelvic floor disorders. She graduated from SUNY Upstate Medical Center in 1982 and is actively seeing patients in her clinic Physical Therapy Specialists, Centennial CO.

Dawn is a national and international speaker in the field, and she has gained so much from sharing experiences with her colleagues around the globe. In addition to lecturing internationally on pediatric bowel and bladder disorders, Dawn is also a faculty instructor at the Herman & Wallace Pelvic Rehab Institute. Additionally, she runs an online teaching and mentoring platform for parents and professionals.

In 2017, Dawn was invited to speak at the World Physical Therapy Conference in South Africa about pediatric pelvic floor dysfunction and incontinence. Dawn is also Board-Certified Biofeedback in Pelvic Muscle Dysfunction (BCB-PMD). She has also been published in the Journals of Urologic Nursing and Section of Women’s Health.

In 2018, Dawn was awarded the Elizabeth Noble Award by the American Physical Therapy Association Section on Women's Health for providing Extraordinary and Exemplary Service to the Field of Physical Therapy for Children.