Lawn Mowers & Clubfoot – PediaCast 410
- Dr Amanda Whitaker visits the studio as we explore the cause, diagnosis and treatment of a common birth defect: clubfoot. We also consider lawn mower safety with tips and best practices for trimming the grass with children at home. We hope you can join us!
- Lawn Mower Safety
- Lawn Mower Safety Tips
- Center for Limb Lengthening and Reconstruction
- Clubfoot Information Page
- Clubfoot Helping Hand
- Tecumseh! Outdoor Drama
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital on Columbus, Ohio.
It is episode 410 for July 19th, 2018. We're calling this one "Lawn Mowers and Clubfoot". I want to welcome you to the program.
We are smack a dab in the middle of summer and even though we've covered lawn mower safety many times on this program, a reminder each and every year is an order because we continue to see way too may accidents and trauma involving children and lawn mowers.
I mean, some life altering injuries and even deaths.
So, we'll run down the safety guidelines once again and remind you when kids can safely begin to use push mowers and riding mowers that's all coming your way in a couple of minutes, lots of great safety tips for you.
We also have an orthopedic surgeon joining us today, Dr. Amanda Whitaker from Nationwide Children's. One of her expertise is treating clubfoot which is a fairly common birth defect involving the foot, you probably figured that one out.
It's an important one to recognize and treat early because as with many diseases and conditions, early diagnosis and intervention really leads to the best outcomes, so we'll explain exactly what clubfoot is, along with the cause and symptoms, diagnosis and treatment, and the long term outlook for those who are affected.
So, stay tuned for that a little bit later on in the program.
First so, I would like to remind you, PediaCast is on social media and we just love it when you connect with us there, engage, interact, share things. We're on Facebook, Twitter, also Google Plus, and LinkedIn. But really, mostly, we focus on Facebook and Twitter. That's where I am most active.
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And, just some examples of things that we have shared in social media here recently. Dr. Kristen Stuppy is a pediatrician in Kansas City. She has a fantastic blog. One of her posts was "Infant Poop: What's Normal and What's Not", that's always of interest.
Another, "My Child is Peeing All the Time..What's Up with That?", and then Dr. Christina Johns in Maryland.
She also has a blog. She is a former pediatric emergency medicine doctor who does primary care and urgent care kind of stuff now and she had a recent blog post "Helping after the Hospital: 10 things YOU can do".
So, this is if your neighbor, friend, relative, you know, someone has a child who is admitted to the hospital for whatever reason, once they're discharged from the hospital, you know, life gets pretty hectic and there are some things that you can do to help the family out that I'm sure they would appreciate and if, you know, the rules were reversed and you needed help, I'm sure that you would appreciate their help.
So, this just has some practical ideas of how you can help after the hospital and then "Lyme Disease Squeezing Western Pennsylvania: Is Ohio Next?", as reported by The PediaBlog which is Dr. Ned Ketyer and then he wrote another one called "Too Much Fruit". You know, is it possible for kids to eat too much of a good thing, too much fruit? Again, that's Dr. Ned.
And, so, these are the kind of things that we share on Facebook and Twitter, so if you haven't connected with us there, be sure to look us up. Just search for PediaCast and much more.
So, let's talk about lawn mowers.
Lawn mowers are dangerous pieces of equipment and they certainly make our lives much easier, they make our yards look much prettier, but they also injure kids. Now, the good news is the injuries are decreasing, and I think a lot of that is out of awareness that these things can be dangerous.
So, back in 2015, there were about 13, 000 children in the United States who were injured by lawn mowers. In 2016, that's the latest year that we have data, that came down to 4, 500 children. So, from 13, 000 to 4, 500 in just a year.
And, again, I do think we have them really sort of pushing lawn mower safety during the summer months and so, hopefully, some of that trend downward is because we're getting the word out.
But, still, you know, 4, 500 kids injured by lawn mowers, that's still thousands of kids and really, even just you know, one, is a tragedy. You know, when that one is your child, you certainly wish that it could have been prevented.
Adults, also, are injured by lawn mowers. In fact, in 2016, 86, 000 adults were injured by lawn mowers.
So, lots of lawn mower injuries that are out there, we still have work to do and it's up to each and every one of us as parents to protect our children.
So, what kind of injuries are we talking about? Of course, you know, the first ones that come to mind, you just have fast moving sharp blades that cut grass, since so they can also cut humans and so we see cuts, bleeding, and even amputation of fingers and limbs.
But, there are other injuries beyond cuts. You know, the equipment is hot. It's got a motor in it. And, the outside of the lawn mower can become very hot and so, we do see burns, you know, kids like to touch things and feel around.
They don't know that it's hot and so, we do see burns to the fingers, although kids are running and trip and fall into the lawn mower, you can see burns everywhere. And then, of course, thrown objects. Things in the yard become projectile like rocks and sticks, toys, pet toys, and so, these thrown objects, you know, become projectiles and cause head injuries, they can cause eye injuries, even bone fractures.
And then, overturning the mowers, especially the riding mowers. If you're on an incline, if you try to turn too fast as you know, wet, slipper conditions, we do see overturned mowers, which can cause cuts and amputations, burns, you know, all the things that we've been talking about, and more can happen. You can also get crushed by the riding lawn mower.
And then, the injuries, themselves, can have complications associated with them like wound infections, you may have to have rehabilitation if you have, you know, you've lost an extremity or fingers. Those kind of disabilities can really affect you and impact you, you're whole life, and then of course, kids and adults do sometimes die because of lawn mower injuries.
So, how can we prevent these? A lot of it's really common sense stuff, you know. Make sure you do read and pay attention to all the safety warnings that come with your lawn equipment, the manual, keep all the labels on there, you know, whatever it's telling you to do to be safe, pay attention to that and actually follow through and do it.
The biggest most important piece of advice that I could give you is if you're no the one mowing, stay inside during the mowing process. So, all kids absolutely should be inside the house while someone is mowing.
Also, other adults. You know, if you're within 20 feet of the lawn power, projectile can come out and cause serious injury, even a little farther away.
So, the best thing is just stay inside 'till the mowing is complete.
Pets can also be injured by lawn mowers, so keep them inside,as well.
If you are the on mowing, inspect the yard for debris before you mow. You know, just walk the yard, make sure there aren't any rocks, sticks, stones, toys, there's nothing there that's going to become a projectile because remember, you can have people who aren't a part of your family, just walking down the street on the sidewalk and you're going to be liable if something projects from your mower that was in the yard and strikes them and injures them , so, it's really important to check the yard for debris.
And, while you're mowing, pay attention to your surroundings. You know, people and animals may sneak up from behind. You don't want to mow on reverse. Ideally, the reverse control of a riding lawn mower, to activate, it should force the driver to look back. So, you don't know what's behind you if you just blindly thrown the lawn mower into reverse.
So, make sure that you're looking and don't mow on reverse unless you absolutely have to, you know, if you're maneuvering, you need to go on reverse. You should be looking backwards when you go backwards.
Make sure you wear sturdy shoes for obvious reasons, and then consider eye protection while you're mowing, again, 'cause you're worried about projectiles, hearing protection, consider that, especially if you mow frequently.
Maybe you have a job that you're mowing everyday. You really do need want to protect your hearing in that case, and no headphones. So, if you have to jack up the music so that you can hear it above the noise of the mower, you really can damage your hearing, especially if you're doing that, you ever repeated exposure to loud music that can be a problem.
And then, no passengers on the driving mower,even if you're not mowing. Really, young kids should not be on your lap when you're driving around the yard in a riding lawn mower. It's not safe at all. Kids fall off, mowers overturn, there's all sorts of opportunity for injury.
It's not a toy, it's not a form of transportation, it is a dangerous piece of lawn equipment that make our lives easy, but really can injure and kill kids, so child passengers, I cringe every time I see that.
And then, don't mow if the grass is wet or after dusk, or dark. You really do need great visibility and dry conditions so you have traction.
So, just some safety tips there for you. Again, we cover these every summer, but they are important.
When can your child mow the grass?
General guidelines say for push mowers, age 12, for riding mowers, age 16, but you really do want to supervise them, especially the first few times that they do it and use your judgment.
You know, you know your child's skills and their maturity level. There certainly are going to be 12 year old's who are not ready to `operate a push mower and there are 16 year old's who, you know, really are not going to be safe on a riding mower. You know you child, so use your judgment there.
But, the general guidelines are for push mowers, age 12 and for riding mowers, age 16.
In terms of emergency care, you know, what should you know if there is a cut or bleeding, apply gentle direct pressure to the bleeding. Lift the extremity above the heart if you're able to. If you suspect a fracture, keep the limb or the digit still over where you think the fracture could be, keep that area of the body as still as you can and, you know, if there's a lawn mower accident and there's blood involved, call 911\. You want help immediately, you don't know if there's more internal damage, there might be bleeding there that you're just not seeing.
And, okay, this may make you a little squeamish, if you are prone to that, turn the volume down for about 30 seconds.
If there is an amputated body part, so, you know, a finger is amputated or a part of a finger, bring that with you to the hospital because they might be able to reattach it.
Now, the best way to bring that with you is wrap it in a clean, damp bandage, just with some clean water, and then place the bandage with the body part in it in a sealed plastic bag, and put the sealed bag in a container of water mixed with some ice. You want it cold, but you don't want to freeze the part and take it with you in the ambulance because again, they might, and might not be able to reattach whatever it is that came off.
And, this does happen. So, I mean, we're mentioning it because it's a real possibility when we're dealing with lawn mowers. So, this is why we want to avoid that from happening in the first place.
If you would like to see and share these recommendations in more of a printed form, I'll provide a link for you in the Show Notes for this episode 410 over at PediaCast.org.
Alright, let's move on with a couple of quick housekeeping items. Don't forget it's easy to get in touch with me if you do have a suggestion for the show, you have a topic idea, want to point me in a direction of a news article or journal article, whatever it is that's on your mind. Just head over to PediaCast.org and click on the contact link.
I do read each and every one of those that come through and we'll try to get your thoughts and suggestions on the program.
Also, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.
So, if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands on physical examination.
Alright, let's take a quick break and then, I will be back with Dr. Amanda Whitaker. We're going to explore clubfoot. It's coming up right after this.
Dr. Amanda Whitaker is a pediatric orthopedic surgeon at Nationwide Children's Hospital and an associate professor of orthopedic surgery at the Ohio State University College of Medicine.
Dr. Whitaker is director of our Gait Lab and her clinical interest include the treatment of pediatric neuromuscular conditions, and limb deformities, including clubfoot, that's what she's here to talk about today, clubfoot. So, let's give a warm PediaCast welcome to Dr. Amanda Whitaker. Thank you so much for stopping by today.
Dr. Amanda Whitaker: Thanks, Dr. Mike, for having me today.
Dr. Mike Patrick: I really appreciate you taking time and stopping by.
So, I think one of the things that folks think about right off the bat is, what is the Gait Lab?
Dr. Amanda Whitaker: So, our Gait Lab, the way I describe it to my families, it's like a video game. So, we have kids that may have some difficulties with walking, we put little markers all over their body and through a series of cameras, we have them walk up and down a path and the videos pick up those markers and let us recreate the kids almost as video games and analyze their hips, their knees, their feet, all of their joints, their muscles and then, figure out different ways that we might be able to help them walk better, whether that's through bracing, or stretching programs, or, sometimes, surgery.
So, it's just a technical way to get more data and figure out how to help kids walk better.
Dr. Mike Patrick: And, it almost sounds like this technology came out of Hollywood, you know, in terms of a mapping where actors are and then animating, and of all seen, you know, the suits with the balls on them, and so, it's kind of like that.
Dr. Amanda Whitaker: Absolutely. The camera system that we're using was created for Hollywood. So it's very precise down to millimeter that we can pick up some of these fine motion analysis. And, that's why we're able to do so much with it. Not only with Gait, but one of my partners is interested in how the spine moves and another one of my partners is interested in adaptive equipment where kids with wound deficiencies.
So, there's a lot of uses that we can have with this technology.
Dr. Mike Patrick: Very interesting. So, we're talking about clubfoot today. Tell us, what does that mean? What is a clubfoot?
Dr. Amanda Whitaker: So, clubfoot is a general term that a lot of people use for foot deformity, but there is four basic positions of the foot that come up with the clubfoot.
So, one is cavus, so, that is a high arch in the foot. The next one is adductus. It's when the toes or the mid foot comes over towards the middle and the foot almost curves around and looks like a bean, if you could imagine a kidney bean. And then, the hind foot or the heel bone is tilted in towards the middle and then, the foot is pointed down in what we call in a technical term, inguinas.
So, those are the four things that I look for, that the foot has a high arch, it's curved in like a bean, the heel is tilted inwards, and then, the foot is pointed down.
But, people will call clubfoot different things and sometimes, it can be associated with syndromes and not quite be a clubfoot, but may have some of the similar treatment principle.
Dr. Mike Patrick: Sure, and this is usually something that's present at birth.
Dr. Amanda Whitaker: Correct, there are cases when kids have different neuromuscular conditions that whole of the muscles can make the foot come into the same similar position, but in general, when people say clubfoot, it's something that children are born with.
Dr. Mike Patrick: And, really, there's a range of severity in terms of what we see. So, it can be kind of mild, but then, there can be severe forms of it, as well.
Is one more common than the other? Do you see an equal number of sort of mild forms that are easier to correct versus the more severe ones?
Dr. Amanda Whitaker: Let's say it ranges, you know, everything's on a bell curve that I don't have a whole lot that are very severe. They don't have a whole lot that are super easy. Most of them fits somewhere in the spectrum, and I usually tell families that it takes about 5-7 weeks to correct, and usually after a couple of casts, I can determine whether not this is going to be an easier foot to correct and will take less cast or a harder foot to correct.
It just all depends on the stiffness, also if there's any underline conditions that contributed to the clubfoot, and sometimes, kids just have really stiff difficult feet to correct.
Dr. Mike Patrick: Is it typically one foot or both feet?
Dr. Amanda Whitaker: It's 50-50\. So, 50% of kids will have both feet and 50% of kids will just have one foot.
Dr. Mike Patrick: And, we were talking before we started. Here in the United States, we call this clubfoot, but I have had some listeners right in asking questions about this and they use some different terminologies. So,what else do we know this as?
Dr. Amanda Whitaker: Yes, so it's sometimes called "talipes equinovarus" which has more of a Latin term and describes the position of the foot as I described it earlier with the cavus. Talipes is the foot, equinus is the position of the foot when it is pointed down and then the cavovarus, the cavus of the midfoot, and then the varus of a hind foot.
Dr. Mike Patrick:So, we take the lazy way out here in United States and just call it clubfoot.
Dr. Amanda Whitaker: Absolutely.
Dr. Mike Patrick: So, how common is this problem?
Dr.Amanda Whitaker: It's actually one of the most common congenital deformities that we take care of in orthopedics. It's about 1-2 out of a thousand kids are born with clubfoot.
Dr. Mike Patrick: Is boys versus girls in terms of numbers or is it about equal?
Dr. Amanda Whitaker: Yea, so I think it's a little bit more common in boys and girls.
Dr. Mike Patrick: And, genetic, if you have a parent with that history of clubfoot, is it more likely that their children will have it? We see it sort of running in families?
Dr. Amanda Whitaker: It does run in families, but it's not what we call a hundred percent penetrance.
So, let's have what we think about genetic conditions. You know, if it's a dominant condition, if mom or dad have it, there's a 50% chance that your child will also have that condition or recessive, if both parents have the gene, it's not clear cut like that.
So, if your parents have clubfoot, it's not a hundred percent chance that your child will have a clubfoot, but maybe your grandchildren were or your great grandchildren will.
So, I have a fair number of families who's, you know, grandfather has a clubfoot that was treated and now they're child has or they have a cousin. So, it's hard to predict, but there is a generic component to it.
Dr. Mike Patrick: Sure, and at the same time, you can have a family who's never had anyone with clubfoot, and suddenly, here it is.
Dr. Amanda Whitaker: Absolutely. And, as I said, there's also clubfoot that's associated with other conditions like arthrogryposis, myelomeningocele, larsen syndrome, down syndrome, which have a whole, another way of forming, but all clubfoot has kind of a neurologic condition that we believe is associated with it.
Because usually, the foot when it develops, even after correction, it's usually a little bit smaller, a little bit wider, and that calf muscle's a little bit smaller than, especially if you notice a little bit more, if its one side versus bilateral because you have another leg to compare it to, but that calf will usually be a little bit smaller than the other side.
And also, usually, it corresponds with the stiffness of the foot, so really stiff feet, you'll notice it a little bit more one side versus the other.
Dr. Mike Patrick: In terms of the cause, so, we've determined that there is a genetic component, but in terms of sort of what's happening in the tissue level, what is it that causes clubfoot?
Dr. Amanda Whitaker: So, you know, there's a lot of fibrosis in the tissues,so basically, it's just tight, connective tissue that's on the medial or the inside of the foot. So, they're looking into genes that are attached to connective tissue. There have also been some associations in neuro smoke exposure. So, moms who smoke and also, alcohol exposure. So kid with fetal alcohol syndrome have a higher tendency to have clubfoot.
So, they think that there maybe some genes that process smoke and alcohol that also may lend kids to more likely develop clubfoot.
Dr. Mike Patrick: And, one of the terms that I came across as I was researching this is that you can kind of divide clubfoot into extrinsic types versus intrinsic types? Is that something that we still think about or is that more of an older thought?
Dr. Amanda Whitaker: So, I think about it when I first see a baby who comes in. There are some kids who look like they may have clubfoot that is more of a packaging thing. Kids are scrunched up in their mom before they're born and their foot is turned in.
And, if the foot is flexible where after and after a couple of minutes, I'm playing with the foot, I may be able to put it into a normal position. That's what I call positional clubfoot and that will get better on its own whereas a true clubfoot, it's still stiff after playing with it and usually, they have a deep crease in the back of the heel that will need casting.
So, I guess that would be an extrinsic. An extrinsic cause would just be packaging whereas and intrinsic cause would be a true clubfoot and then there are those what are said, idiopathic or we don't know why they have a clubfoot and there's the clubfoot that are associated with the other conditions.
Dr. Mike Patrick: And that packaging, just if there's a low amniotic fluid for example, or kind of a smallish uterus and a largish baby, or maybe if there's twins and you're in there, you're kind of more packages when you come out and things can be a little stiff, but you're able to loosen it up pretty easily.
Dr. Amanda Whitaker: Absolutely. And that's why there is a low association with other sort of packaging orthopedic things like hip dysplasia.
About a 1% of kids with clubfoot also will have hip dysplasia, which is also though to be a packaging issue, so things we look for.
Dr. Mike Patrick: Is that an official orthopedic term, packaging? Do you guys use that a lot?
Dr. Amanda Whitaker: I don't know if it's technical, but…
Dr. Mike Patrick: You know, I like it because it describes.
Dr. Amanda Whitaker: Yeah, it's a packaging deformity.
Dr. Mike Patrick: Exactly. So, if a baby is born and you're playing around with it and seeing if you could move it or it's definitely stiff.
We talked about the calf muscle being a little bit of a different size and are there other signs that kind of go along with it that would make you think about clubfoot?
Dr. Amanda Whitaker: So, the calf muscle, you really can't see until kids are older and they're walking.
But, I'd look for a big crease in the back of the heel. Usually, it's a big deep crease.
I'd also look at the bottom of the foot if there's a big deep crease on the bottom of the foot, especially if the foot is flexed downward.
I know that's it's going to be a difficult clubfoot to fix, but if you that high arch, once again, the cavus that I'm looking for, then I know that's it's a clubfoot.
The foot shaped like a bean, and then the hind foot or the heel tilted inward and as I tried to move and stretch the foot and bring it back around. If I'm able to correct those, and then bring the foot up dorsiflexion.
So, usually the foot, especially in babies is quite flexible and you must be able to take the foot and touch the leg bound.
If I'm not able to do that, I know it's a stiff foot and likely, it's a clubfoot, especially with that deep posture crease.
Dr. Mike Patrick: So, this is really a clinical diagnosis, just using your eyes and your hands to figure out what's going on. Do you ever need x-rays?
Dr. Amanda Whitaker: Occasionally, we use x-rays, especially towards the end of cast treatments to look at the position of the hind foot and one of the bones, it's called the talus, that's just below the tibia, and the position of that to see how much what we call equinus or plantar flexion, how much the foot is pointing down, whether or not we need to do a small procedure called the achilles tenotomy where we cut the achilles tendon.It grows back and to reposition the foot.
But a lot of times, just by feeling, we're able to determine whether not we need that procedure.
Dr. Mike Patrick: Speaking of imaging, are these generally picked up on prenatal ultrasounds or are they often not seen?
Dr. Amanda Whitaker: It can be, but very rarely. I asked my families if they knew on ultrasound whether not they had clubfoot and most of them tell me "no", but they can be seen on ultrasound and we do have one of our nurse practitioners, as well as myself, do prenatal counseling for families to try to go over what to expect when the baby's born and in general, with clubfoot treatment.
Dr. Mike Patrick: Yeah, but again, with that packaging, a baby may sort of look like they have clubfoot just because they're scrunched in there.
Dr. Amanda Whitaker: Exactly. There's been some studies that look at the ultrasound diagnosis of a clubfoot and whether or not kids actually have a clubfoot and they're pretty accurate, but there's always a chance that we may say they have a clubfoot and it's just a packaging positional clubfoot.
Dr. Mike Patrick: So, once we've determine that the baby does have clubfoot after birth, then how do we treat it?
Dr. Amanda: Great question. So, I usually like to see kids about within a month of birth. It all depends on if they, too are born at term, so the younger kids, sometimes they're small or in a nick, I actually like to get them a little bit bigger, so that they can undergo casting, but typically, within a month of birth, we'll start casting. It's usually about 5-7 casts and the first thing I do is, I turn the food and I warn families that I'm going to make the foot look a little bit worse because I bring the big toe up and I place in a long length cast and they come back the next week, they gradually work on correcting that adductus or the bean shape of the foot, and then as the bean shape of the foot corrects, then the heel gradually follows and when the foot is turned almost in the opposite direction, we then start working on correcting the foot pointing down or the equinus, and that's when whether not we need a small procedure in the office.
I warn families that about 90% of kids do need this small procedure. As I mentioned, it's called an "achilles tenotomy" where we numb up the back of the heel and lengthen the achilles tendon. It grows back in kids under the age of two, it grows back, actually, like quickly.
Dr. Mike Patrick: Do you completely severe it?
Dr. Amanda Whitaker: Completely cut it, but it's through a very, very small incision in the back of the leg and we numb it up before hand and then put them into another cast. That cast we leave on for about 3 weeks and every other cast before that is 1 week at a time.
And then, after they get done with casting, they go into a boots and bars where the foot that was once clubbed is placed to about 70 degrees of extra rotation where if they have a unilateral clubfoot, the non-clubfoot is also placed in the same boots and bars at about 45 degrees and they remain in these boots and bars for about 3 months full time, and then we transition them over the nights and naps.
So, they wear those boots and bars until about the age of 4 because that has shown that we wear them 'till the age of 4, a decrease rate of occurrence.
But that's just at night time and/or during naps. So, it's really at the full time. Wearing the boots and bars is just for a few months.
Dr. Amanda Whitaker: Yes, for 3 months after cast treatment.
Dr. Mike Patrick: In the cast treatment, so, you're moving the foot a little bit at a time, you're recasting it to keep it there, and then take the cast off after a week or so, and then move it a little bit more, put another cast on and you say, wear from 5-7 casts or typically what you see.
Dr. Amanda Whitaker: Exactly, that's a typical cast treatment. Some kids are a little bit less like we talk about on the spectrum. Some kids are a little bit more, especially if they have a deep crease on the bottom of their foot, which we call typical clubfoot. They may take a lot more cast just because it's a harder, stiffer foot to treat.
And also, some of out kids that have arthrogryposis, myelomeningocele, another diagnosis that's associated with the clubfoot that kids have a tendency to be tighter, their cast treatment may very as well, but for idiopathic clubfoot, that's a typical course.
Dr. Mike Patrick: A little bit of a medical history knot, and so, this is called the "Ponseti method". Dr. Ignacio Ponseti in 1948 at the University of Iowa first described this and started using it and it kind of low tech, but it works.
Dr. Amanda Whitaker: Absolutely, so, yeah, Ignacio Ponseti had an amazing story that he's originally from Spain, and then came over to Mexico, and then ended up in Iowa and developed this method and it was really the internet revolution of the late '90's that it became widespread.
He would go out and talk, and then the way clubfoot used to be treated was mainly through surgery, that they would undergo a big soft tissue released. You'd pin the foot and the foot would be straight, but we were noticing that kids would get really stiff and have stiff, painful feet when they got older.
And, families start to talk as they do now. They get on these groups and they say,"Well, you know, my child had this procedure, my child had this done". They say, well, the ponseti method. My child now, they'll be there flat, they may have had, you know, achilles tenotomy.
Sometimes, they needed tendon transfer when they're about five or six to bring the foot over about a third of kids do, but not the big soft tissue released that they used to, they don't have this stiff, painful flat feet, and then people started catching on 'cause more people said,"Hey, I want this ponseti method". And then, everybody started saying,"Well, let's go learn from Dr. Ponseti".
Dr. Mike Patrick: So, we have an example of social media in the internet and digital communication's really helping spread something good.
And, I think a lot of parents probably ask you this: When you're moving the foot and casting, does it hurt? Is this a painful process for babies?
Dr. Amanda Whitaker: No, it's not and I would worry if it's a painful process. It's that you know, because casting, while it's a common thing is not benign. You know, you can get pressure sores underneath the cast, but it's really a gentle manipulation and that's why I like to play with the foot before hand as you kind of get it stretched out, you know where it's going to go, so you put them into a cast.
Sometimes, kids, while they're casting, they're irritable. So, I usually ask families to bring a bottle of milk, whether it's formula or pumped milk. Sometimes, we'll have a little bit of sugar water to put on their pacifier just to help relax them because they don't like their leg being played around with the cast sock and sometimes be loud when we're removing the cast.
But, after the cast is done, they should be comfortable and happy, and relaxed. And, they shouldn't be too upset.
Dr. Mike Patrick: When the babies are in the cast, there are some important things like bathing, for an instance. It can become difficult. How do you advice parents to wash their kids?
Dr. Amanda Whitaker: Yeah, I usually say sponge baths are the best to try to keep the cast dry. If the cast gets wet and all, they must call us immediately and sometimes, you can get a little plastic bag, especially if you know that there's a huge diaper blowout, you know, a grocery sack, place it around the cast so it doesn't get too dirty, but inevitably, since they're little babies, they're going to get lots of stuff on them.
I've had a few kids even pee on their casts immediately after casting and we just change it out right there. I also tell families to take a picture of the toes right after the cast is done because another important thing is I don't want those toes slipping back in the cast. Some of these babies are squirrelly and they like to slip their toes back in the cast and that means that their foot is getting wedged up in the cast and they're getting pressure sores for that.
So, if they see the toes backing up, I want to know immediately because that cast starts to come off and some of my families are coming from several hours away, so I advice them to go to their local emergency room.
Just have them cut the cast off. Do not have them put another cast on and come see me whenever they can.
Dr. Mike Patrick: Yeah. And speaking of travel, having the cast on does not change any car seat recommendations, correct?
Yeah, very important to have your babies rear facing in a car seat in the back for sure, even if they have those casts on.
Now, you talked about the importance of doing the shoes and the bars at night time up until age 4\. What happens if parents don't follow that plan? And, you know, I can imagine there are a lot of 2,3, and 4 year old's who, you know, can let their feelings be known, that they don't want these things on when they're sleeping and then once they're able to start taking them off and this can become a behavioral problem, but what are the consequences of that?
Dr. Amanda Whitaker: Yeah, it's really tough. Yes, you said between that 2 and 4 year age, a lot of my kids can take them off themselves, but I just hope to know that there's increase chance of occurrence. Now, what I do for occurrence is we'll then go back into a series of casts like we did before.
Instead of using plaster, which I typically use, it will be more likely fiberglass which we usually use for kids that break their arms or break their legs, but it'll be few casts, and then if they reoccur again, we'll talk about having doing that tendon transfer that I mentioned.
So, sometimes, kids with clubfoot, when they get older, go walk and their foot will kind of scoop up and then will start looking like that bean shape again and by transferring the tendon that makes the foot scoop up to the outside of the foot, this can prevent recurrence and improve their overall function.
So, in Ponseti's long-term study is looking at his kids that he took care of way back in the 1940's. About a third of kids had this kind of recurrence and needed a tendon transfer and the risks were not being able to wear the boots and bars and education, which is why this PediaCast is great because we can educate families on the importance of wearing these boots and bars at night time until the age of 4.
Dr. Mike Patrick: One other thing we were talking about before we started recording that I definitely wanted folks to hear is that from one family to another, their experience may be a little bit different, in terms of how easy this is to correct.
And so, you know, some families can think,"Why is my child having such a difficult time with this, whereas other families that I have come across, it's been fairly easy?" Can you speak to why in some kids, it's more difficult than in others?
Dr. Amanda Whitaker: Absolutely. So, you know, we have out, in general, what we base this on is our idiopathic clubfoot or we don't know why it happens. There may be a congenital or there may be a genetic reason for the clubfoot. You know, maybe grandfather had one, which is our typical presentation for clubfoot that require 5-7 casts, then you have that eighth typical clubfoot, which is incredibly stiff that has that deep crease down the bottom of the foot.
When I see that, I tell families this is going to take a lot longer. We likely will need, you know, not only that achilles tenotomy, but that tendon transfer, maybe a few other procedures. We may have to do the achilles tenotomy, again, and then we have the clubfeet that are associated with some sort of neuromuscular condition. Myelomeningocele, arthrogryposis, you know, even cerebral palsy.
So, those feet are usually a little bit more to do because the abnormal muscle pull that comes along with the underlining condition.
So, we can talk about in general, but every kid is going to be different, especially when you have that difficult, atypical clubfoot. They're really, really stiff clubfoot, and then associated with different syndromes.
Dr. Mike Patrick: Yeah. We talked about cutting the tendon, and then you mentioned tendon transfer. What is that?
Dr. Amanda Whitaker: So, that's when taking the tendon in the front of the foot that makes the foot scoop up when they walk and moving it to the outside of the foot. This is that I usually do that around the age of 4, 5, 6, but I've done it in some of my earlier kids that I know they're difficult clubfeet.
They've already had some recurrences, we've done lots and lots of casting, and I need that internal brace and that muscle is really, really tight and overactive. And so, if I move it to the other side of the foot, then that helps with the foot positioning and the kids being able to get a nice, flat foot, and then walk better.
Dr. Mike Patrick: And that, again, is just reserved really for the more difficult cases. It's not…
Dr. Amanda Whitaker: Difficult cases in the kids that reoccur, so that one third of kids that will have some sort of recurrence of their clubfoot when they get older and I kind of tell my families right off bat that I look forward and that's what I almost expect, but two thirds of kids, especially with good brace wear won't have it.
I have some that wear their braces every single night. Kids don't have problem with it and they still may have a small recurrence and made a tendon transfer.
Dr. Mike Patrick: And, you don't know which kid's going to need it or not, right?
Dr. Amanda Whitaker: No.
Dr. Mike Patrick: What if treatment is delayed?
Dr. Amanda Whitaker: So, you know, that's a good question. You know, what is delayed?
There's been some studies out there showing that clubfoot treatment within the first year that you can cast out a child with a clubfoot and there's no problem. My question about that is that I wonder if some of those kids were a little bit more mild and I've casted out kids that are, you know, 14-16 years old, even some nearly adult with foot deformities.
Usually, they have an underlining condition like cerebral palsy or arthrogryposis, but usually can cast out in older deformity, too, so I like to get them younger. I'm not too worried about having an older kid, but the sooner I can get to, the better, I think.
Dr. Mike Patrick: Speaking of the older kids, so once they sort of graduate your age range and they enter adulthood, does this continue to be a problem for them as adults?
Dr. Amanda Whitaker: I have to laugh because I don't think anybody graduates from me. my oldest patient is 72 years old just because I take care of adults with difficult conditions, too, like cerebral palsy and osteogenesis imperfecta, but they can't, especially those more difficult clubfeet, the clubfeet associated with neuromuscular conditions and a really stiff clubfeet that we don't know why they're really stiff. They can continue to have problems, decreased angle range motion and also pain.
Also, our kids that have had lots of surgery when they were younger, also can have pain and issues with range of motion as adults and those are very difficult problems to fix.
But, the majority of kids, I'd say 80-85% that have clubfoot as a baby. You know, we treat it with the ponseti method, with casting, probably needs an achilles tenotomy, may or may not need a tendon transfer when they're 5 or 6.
The majority of them do fantastic. They go on to live happy productive lives, they are active, they run, they do sports, and they don't have any problems.
Dr. Mike Patrick: So, if there are adults out there who have a history of clubfoot and having difficulties with it, make sure you're seeing someone.
Dr. Amanda Whitaker: Yeah, and there are a lot of adult foot and ankle surgeons out there that have specialties and expertise in treating adults that have had clubfoot and have multiple procedures with.
Dr. Mike Patrick: Is there a way to prevent clubfoot from happening in the first place?
Dr. Amanda Whitaker: Not really, the only thing I would advice is if you're pregnant, not to smoke and not to drink because we do know it is associated with fetal alcohol syndrome and maternal smoke exposure, but we don't really have a clear cut. If you do this, you can prevent.
Dr. Mike Patrick: So, as long as you're not smoking, you're not drinking alcohol, it's not mom's fault that this happens. Some sure that there's some guilt you know, for some folks.
Dr. Amanda Whitaker: Exactly. It's absolute. This is one of those things that happens and easily affects.
Dr. Mike Patrick: And, even if you do slip up and you did smoke, or you did drink a little alcohol still doesn't mean that that was the absolute cause.
Dr. Amanda Whitaker: Correct. There are researching certain genes that may be associated with a higher likelihood of kids having clubfoot with maternal smoke exposure or alcohol exposure.
Dr. Mike Patrick: So, tell us about the management of clubfoot here at Nationwide Children's in addition to orthopedic surgeons. There's some other professionals that get involved in helping these kids, too, right?
Dr. Amanda Whitaker: Absolutely. So, we have wonderful physical therapists that eventually put together clinical guidelines on treatment of clubfoot and trying to get some of those muscles in clubfoot that are weaker, trying to strengthen those, work on their Gait, and we have a lot of orthotics and prosthetics specialists in the area that help with the boots and bars and are integrally involved with our clubfoot treatment.
Dr. Mike Patrick: Great. And, we'll have some links on the Show Notes for folks if you head to PediaCast.org and look for the Show Notes for this episode 410, we'll have links to the Center for Limb Lengthening and Reconstruction here at Nationwide Children's Hospital. We have a Clubfoot Information Page, a Clubfoot Helping Hand which has lots of information that primary care docs can use and give to their patients. So, we'll have all of those links for you in the Show Notes.
One last question for you not related to orthopedics considering whether some fun family activities that folks can do, do you have particular things that you like to do on a summer that you would recommend for families that they may not be thinking about?
Dr. Amanda Whitaker: Yeah! Would you want us having a conversational fun of our physical therapist the other day who gave me a fantastic list of adaptive sports and things to do as families? She now volunteers with a group that does kayaking throughout Columbus and they have adaptive kayaks for families.
Biking is an amazing thing, and then we have a big Pedal-With-Pete event coming up at Hilliard Darby High School to raise money for cerebral palsy research and that's a really fun event. They also have a parade for kids and adapted bicycles for kids and adults to use and try out.
Just getting outside and walking, and enjoying. I know it's been hot lately, but anything that you can do outside is fun.
We also have with our cerebral palsy program a Cerebral Palsy Day at the Recreation Unlimited and we'll be fishing and boating, and kayaking, and doing a bunch of fun things.
Dr. Mike Patrick: The zoo is a great place to go walk around to some animals, absolutely.
Dr. Amanda Whitaker: The zoo is a great place.
Dr. Mike Patrick: And then, I mentioned this last week, but one of our must-do family activity for us this summer, we haven't done it in a few years, is to go see Tecumseh! Have you ever seen that in Chillicothe?
Dr. Amanda Whitaker: Yeah, I have. So, I actually grew up in Washington Corp House. So, not to far away from Chillicothe and I have gotten to see Tecumseh a few times.
Dr. Mike Patrick: And for those of you who haven't seen it, it is an outdoor drama and lots of horses and it's basically the life of Tecumseh who is a Shawnee leader and the setting is the European expansion in the Ohio in the late 1700's, but's it's been running like 45 seasons and I'll put a link in the Show Notes for that, as well so folks can take a look.
So, again, Dr. Amanda Whitaker, a pediatric orthopedic surgeon here at Nationwide Children's Hospital, thank you so much for stopping by today.
Dr. Amanda Whitaker: It's good. Thanks for having me.
Dr. Mike Patrick: We are back with just enough time to say thanks to all of you for taking time out of your day and making PediaCast a part of it, really do appreciate that.
Also, thanks to our guest this week, Dr. Amanda Whitaker, a pediatric orthopedic surgeon here at Nationwide Children's Hospital and fixer of clubfeet. Really do appreciate her stopping by and sharing her expertise with all of us.
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