Club Foot, Mcdonalds, and Diet Food – PediaCast 046

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  • Young Children Prefer McDonald's
  • Fewer Vaccines Available for Vulnerable Kids
  • Computer-Based Safety Advice
  • Diet Food + Kids = Fat Adults
  • Single Fathers Score Poorly on Health Care for Kids


  • Jose Morcuende, MD, PhD
  • University of Iowa
  • Department of Orthopedics and Rehabilitation
  • Discussion on Club Foot


  • Synagis and RSV Vaccine
  • Leg Bowing
  • Baby Shoes
  • Care of the Uncircumcised Penis

Research Roundup

  • HPV Vaccine vs. Cervical Cancer


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Announcer: This is PediaCast.


Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast, a pediatric podcast for parents. This is Dr. Mike coming to you from BirdHouse Studio as we usually do. I'd like to welcome everyone to the program.

It is episode number 46 "McDonald's Clubfoot and Penis Care". Yes. We can use the word penis and still keep our clean rating. Why? Because it's PediaCast. We're allowed to talk about that.

[Background Voice]


Dr. Mike Patrick: Right. This weekend our news segment "Young Children prefer McDonald's". Fewer vaccines are available for vulnerable kids. Computer-based safety advice.


Then we have a little math problem for you since so many are heading back to school.

Diet food plus kids equals fat adults. What's that all about? We will tell you.

Single fathers score poorly on health care for kids, shame on the dads out there. This if you're one of them that fit into this group then we'll talk about that.

Then we have our In-Depth segment. Dr. Jose Morcuende from the University of Iowa Department of Orthopedics and Rehabilitation is going to drop by to discuss clubfoot. So that's coming up.

I should also mention a special welcome to all of you from the "Nosurgery4clubfoot" Yahoo! Group who are joining us for the very first time. Welcome.

And then our Listener Question-and-Answer segment, we're going to discuss Synagis and the RSV vaccine. Synagis is not an RSV vaccine. We'll tell you what the difference between the two is.


Leg bowing and baby shoes and then care of the uncircumcised penis we'll talk about that, too.

And then we'll wrap things up this week with our research segment. How well does the HPV vaccine work at preventing cervical cancer? So we have some numbers for you on that and we'll let you know.

Don't forget if there is a topic that you would like us to discuss, or if you have a lead on a news story and actually, one of our news stories this week was submitted by a listener. So we're happy about that if you have a news story or a topic, or a great lead on the interview of the century or even of the week, [Laughter] just let us know. Just go to the and click on the Contact link, or you can email, or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.


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You can check out the results when they're available. It's supposed to be, I think, the 15th that the results will be available but just look at the results. Just follow the link in the side bar at

If you forgot to vote and you're feeling guilty because you're really sure that it would have been your vote that would put us over the top, there's something you can do to ease your guilt [Laughter]. Just go to iTunes, and if you haven't done so, leave us a review.

We finally broke the 100 reviews mark. Last check, we had a 102. And those reviews in iTunes are really important in order to advance the show and get the word out there about PediaCast.

Don't forget to listen for the code word during our interview segment this week. And again, we're going to be giving away three lifetime subscriptions and PediaCast T-shirts that's official now to the winners.


And in order to win, you just have to listen to let's see, two weeks ago, last week, this week and next week so four shows we're going to give you a code word or phrase during the interview segment.

And you simply put the words together to try to come up with a phrase that I am looking for and then I have a couple of week period where you can email what you've guessed it is. And we'll pick three people at random. And those three people will win a lifetime subscriptions and T-shirts from PediaCast.

What is Bundlo, anyway? Because that's what you get free lifetime subscription to What is it? Well, basically, it's like a baby book that's online.

So it's like a digital version of a baby book. You can post pictures. You can have actual blog for your baby and letting family and friends know what's going on in your baby's life.


And you can also journal and keep track of things, like when they had their first tooth, they said their first words, took their first steps that kind of things. So it's really an online a password protected very safe Internet site where you basically have a baby book. So it's a fantastic site. You can check them out at

Now, if you don't have a baby at home then you can still win the T-shirt. It's just pretty cool. Of course, I might be a little bias on that. If you do win and you don't have a baby at home, you can give that subscription to anyone that you'd like. So you just have to let us know who it is that you're giving it to and what their email address is and we will set them up.

OK. Before we move on, I'd like to remind you that 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, remember call your doctor and arrange a face-to-face interview and hands-on physical examination. That's right. We are not practicing medicine here. We are simply entertaining and educating.

Your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at So with that in mind, we'll be back with News Parents Can Use right after this short break.

[Short Break Music]


Our News Parents Can Use is brought to you in conjunction with the news partner, Medical News Today the largest independent health and medical news website. You can visit them online at

Young children prefer McDonald's. And I want to thank Jennifer from Detroit for bringing this one to our attention.

A new U.S. study suggests that preschool children prefer the taste of fast food from McDonald's branded packages to the same food from unbranded packages. The study is reported in the August issue of the Archives of Pediatrics and Adolescent Medicine.

The authors reported the food and beverage industries spend more than $10 billion each year marketing to children in the United States. By the time they are two years old, children already have beliefs about certain brands. And by the age of six, they can recognize brands and say which products the brand makes.


Thomas N. Robinson and his colleagues from the Stanford University School of Medicine in California carried out the study where 63 preschool children between three and five years of age tasted five pairs of the same McDonald's food.

One of each pair bore the McDonald's brand while the other was presented in plain packaging. All together, the children performed over 300 tasting comparisons. The food the children tasted included a McDonald's hamburger, a chicken McNugget, McDonald's French fries and baby carrots. They also tasted 1% milk.

The parents filled out questionnaires about the age, race and ethnicity of their children. They reported how familiar their kids were with McDonald's food and toys and also about their television viewing habits and preferences.

The results showed the following overall, children preferred the taste of food in the McDonald's packaging over the identical products in plain packaging. In fact, four out of five times the children preferred the taste of food when they thought the product was from McDonald's.


Also and really no surprise here, preschool children who have more TV sets in their home and children who eat McDonald's foods more frequently were also more likely to prefer McDonald's branded food to identical but plainly packaged items.

The authors suggest the study strengthens the justification for banning ads of high-calorie low nutrient food aimed at young children. They also suggest more studies are needed on how marketing and branding could be used to promote healthy eating in young children, and that food company is targeting youngsters could help reduce the growing problem of childhood of obesity by offering healthier alternatives.

The spokesman for McDonald's responded by saying, "Hey, we're already doing that." He went on to cite a recent campaign which features the animated character Shrek promoting fruit, vegetables and milk.

OK. Now, I have a couple of questions with regard to this. First, let me just say, where are the parents in all of this?


I mean, sure, the companies are marketing the kids but and the kids aren't driving themselves to McDonald's. They're not standing at the counter ordering a Happy Meal on their own, and they're not paying at the register, you know.

So I think marketing it may be a bit of a problem but it's certainly not the biggest problem. The biggest problem, at least in my opinion, is the parents making bad choices for their kids.

Now the other comment that I wanted to make on this is the two things that the kids had to choose from. It's identical food and one is in a plain package and one's got the Golden Arches on it.

OK, so the kids say the one is better with the Golden Arches on it. But what if it hadn't been a what if it had not been a plain package? What if it hadn't been between the McDonald's brand and you know, Thomas the Tank Engine or Elmo, or you know, or something really bright and colorful. Then which one would they have picked?

So, you know, having it between a plain package and the McDonald's so I'm not sure that really tells you anything other than they, you know, the food tasted the same to them and so they had to pick on something and they might as well pick the one that's got some yellow on it.


Do you know what I'm saying? So I'm not sure that was the greatest study.

OK, moving on, before I get myself into too much trouble.

Fewer vaccines available for vulnerable kids due to limited federal and state funding for vaccines, underinsured children in the United States are increasingly at risk for not getting needed vaccines, according to a new study published in the Journal of the American Medical Association.

The study led by Dr. Grace Lee of Harvard Medical School found that many underinsured children are unable to receive publicly purchased vaccines in either the private or public sector.

The authors state "The most commonly cited barriers to implementation in underinsured children were lack of sufficient federal and state funding to purchase vaccines. Childhood immunization is ranked as one of the most important preventative health services we can offer," says Dr. Lee.


Due to the increased cost of recently recommended vaccines and the lack of available funding, many states have been forced to adapt more restrictive policies for the provision of publicly purchased vaccines.

Under insured children who used to be able to rely on public health clinics as the safety net in the past are now at risk of not getting immunized for serious childhood illnesses.

Childhood vaccines are funded by a patchwork of public and private sources. While some private health insurance plans cover recommended vaccine for children, an increasing number of plans require patients to pay out-of-pocket for many shots.

However, children who are either uninsured or publicly insured through Medicaid can receive vaccines to the federal vaccine for children program.

Declines in funding coupled with increases in the number and cost of vaccines has put under insured children at risk for not receiving important shots. For example, in one part of this two-phase study, immunization program managers from 48 states were interviewed.


The researchers found that 30 states in the private sector and 17 states in the public sector were unable to provide one or more vaccines to underinsured children. But in other way, roughly, 2.3 million U.S. children could not receive one or more vaccines even if they were referred to public health clinics.

Studies suggest that many private clinicians refer underinsured children to public health clinics for vaccination, says Dr. Tracy Lieu, another author involved with the study. Unfortunately, a growing number of states no longer provide the most expensive vaccines to these children.

The problem may become worse since the trend in private health insurance is to shift to higher deductible plans. And in many cases, vaccines may not be covered unless the deductible is reached. This could put children from economically vulnerable families at risk of not getting vaccinated.

According to Dr. Lieu, many survey participants voiced concerns about their inability to provide immunizations to under insured children.


In fact, since 2004, 10 states have revised their policies in order to restrict under insured children access to selected new vaccines.

Dr. Lieu warns that the situation is creating significant ethical dilemmas for public health clinicians for being forced to turn children away or ask families to pay for needed shots.

"Despite the ability of vaccines to prevent illness and death our current public safety net for these services is under considerable strain," says Dr. Lieu.

Strategies are needed to enhance immunization benefits for underinsured children in private health plans and to support the public sector's safety net in order to ensure the protection of this vulnerable group of children.

OK. Now I have a couple of things to say about this one, too. Even if your insurance pays for immunizations, you are still affected by this problem. And the reason we've talked about this before in other episodes, there's this concept of "heard immunity".


The vaccines are not a 100% effective, and we partially rely on those around us being protected. That way, they won't spread germs to you or me, if we happened to be one of the unlucky few whose shots basically didn't take.

So there's going to be a percentage of people in which the vaccines just doesn't work, but they're still protected because there's no one to give them the disease, as long as everyone is getting vaccinated.

So when there's a section or a sector of the population not getting immunized, then it really affects you even if your insurance is paying for immunizations. At least, it can.

Now, the other thing I want to point out is, there's certainly are underinsured folks who don't have anyone to pay for their shots and the health department is not giving it to them. But to some degree, and I'm sure that there'll be some political stones, sort of, thrown at me for this.


It's one of these things were, as country, we feel entitled to health care. And if it were just about anything else that was creating an expense, you would find room for it as a priority in your budget.

But because we pay for health care, you think everything should be covered and then get upset when certain things aren't covered.

But yet, some families who are complaining that they are able to pay for their immunizations, they still have cable TV and they still, maybe smoking and doing this or doing that. And I'm not suggesting that everyone is like that.

But we have to keep in mind that if we're going to protect our children, our children have to become priorities in our lives and sometimes you have to make the tough decision to pay for something that they need and sacrifice in other areas of your life.

It's called responsibility and it goes along with being a parent. OK, let's move on before I really get myself into trouble.


Customized computer-based child safety advice computer technology that provides parents with customized safety information can be ineffective way to help their children avoid injury, according to a study by researchers at the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins Center for Children.

Parents who received the safety information tailored to their family's specific circumstances were significantly more likely to follow safety advice compared to parents who received just general information. This is a study that was published in the August 2007 edition of the Journal of Pediatrics.

"Injuries are the leading cause of death for children in the United States. We have effective ways to prevent injuries, like smoke detectors and car safety seats, but many families, especially low income families, remain unprotected," said Dr. Andrea Carlson, lead author of the study and director of the Center for Injury Research and Policy at the Bloomberg School of Public Health.


Our study shows that parents respond best when safety messages are tailored to their specific needs and beliefs. The randomized controlled trial of the "Safety in Seconds" program involved 759 parents of young children, ages 4 to 66 months.

The participants in the "Safety in Seconds" program used a computer kiosk set up for parents in the emergency department of the Johns Hopkins Children's Center to answer a series of questions about their children, their own experiences and personal beliefs about safety.

After parents complete the questionnaire, the computer generated a personalized safety report for them based on their responses. The control group just received a generic health report on safety.

The researchers conducted follow-up interviews with the parents two to four weeks later to see how they responded to the safety messages.

According to the results, the parents who received the customized safety reports scored significantly higher on knowledge of smoke alarm use and safe poison storage.


They are also more likely to report correct child's safety seat use. Ninety-three percent of the parents in the tailored group said they read at least some of the safety report while 57% said they read the entire paper.

Lower income parents who read the tailored report were more likely to store poisons in the home safely compared to the control group. And higher-income parents in the tailored group were more likely to report correct child's safety seat use than parents in the control group.

The intervention was equally effective for those with injured children and those who are being seen in the emergency department for a medical problem.

"Every year, millions of families visit an emergency department, providing an important opportunity to deliver injury prevention services. We're encouraged by these results which suggest that computer technology holds promise for efficiently delivering the patient education in busy health care settings," says Dr. Allen Walker, co-author of the study and director of Emergency Medicine for the Johns Hopkins Children Center.


And then there's one. Children raised on diet food can turn into obese adults. A team of scientists in Canada suggest that raising children on diet foods and drinks could inadvertently turn them into obese adults.

They said that children's bodies learn to connect the taste of different foods and drinks with whether they are high or low in calories. And if they only have diet food and drink, this connection becomes distorting, leading them to overeat as they develop into adults.

The study will be published in the journal Obesity. And it's the work of Sociologist Dr. David Pierce and colleagues from the University of Alberta.

"Based on what we've learned, it is better for children to eat healthy, well-balanced food with sufficient calories for their daily activities rather than low-calorie snacks or meals," says Dr. Pierce.


He and his team showed that feeding young rats yes, rats, a low calorie substitutes of food and drink, so they're feeding rats diet food, lead the rats to overeat, whether they were lean or genetically obese.

Eating too many calories is more of a health risk for obese animals. However, adolescent rats, yes, teenaged rats [Laughter] they were also fed low calorie substitutes of their regular food and drink. And they did not overeat.

The researchers conclude that the older rats did not overeat because by this age they had learned to assess the caloric value of different foods and drinks using their sense of taste. And this regulated their intake. And they called this process "taste conditioning".

Dr. Pierce said the use of diet food and drinks from an early age may induce overeating and gradual weight gain through this taste conditioning process.

The author suggests taste conditioning could explain what has been puzzling scientists who have conducted studies in this area.


For instance, one particular study at the University of Massachusetts found drinking diet soda in childhood was linked to higher risk of obesity, diabetes and heart disease later in life. The scientists say more research is needed especially in older animals and using a range of taste related cues.

However, Dr. Pierce wishes to make clear that this research shows that "young animals can be made to overeat when low calorie foods and drinks are given to them on a daily basis and this affects their bodies' energy balanced system."

Parents and health professionals should be made aware of this and know that the old fashioned ways of keeping children fit and healthy by providing well balanced meals and encouraging regular exercise are the best ways.

Diet foods are probably not a good idea for growing youngsters, especially, at least, according to this particular study, if the growing youngsters are of the rodent variety. But no, I joke. It is serious and I do think I agree with this.


No, I don't think I agree. I do agree in thinking [Laughter] that you really best off giving your kids well balanced meals and encouraging regular exercise.

And finally in our News segment, children of single fathers often missed out on health care so shame on some dads out there. Children living in the custody of single fathers are less likely to have access to affordable health care and visit the doctor less often compared to children living in families with a single mother or both parents.

A study in the Journal Health Services Research finds that many children in single-father families are slipping through the cracks when it comes to access to health care. Although single fathers are less likely to be poor and generally earn more money than single mothers, their children are more likely to visit the doctor only when sick.

Of the more than 62,000 children in the study, about 80% of children in single-father families visited the doctor in the past year compared with 86% in single-mother families and 87% in two-parent families.


Nearly half the children of single fathers did not have a wellness checked during the year or more than two-thirds of children in single mother household did, according to the meta analysis of several published studies.

"It might be that men are more risk takings," said study co-author Kathleen Ziol-Guest of the Harvard Center for Society and Health. She said the difference also might be the result of men thrust into solo parenting with little information about public programs available to them.

Men are more likely to get their children as a result of the divorce than they were in the past. Regardless, single-father families are no longer just a footnote in health policy studies. In fact the number of single-father families in the United States has quintupled since 1970 to approximately 6% of all families and the numbers continued to grow.

Until recently, most research on single-parent families focused on single mothers and the effects of an absent father on the children.


"The public safety net seems to be working for single-mom families," said Mikaela Dufur, an Assistant Professor of Sociology at Brigham Young University. Single fathers, however, have not gotten much attention from scholars, health policy advocates and social service agencies that coordinate public health insurance. "And they may be cut off from that information," said Dufur.

Besides reduced access to health care, children in single-father families have a higher risk of drug use, have more problems in school and take part in risky behavior more frequently than children and families with a single-mother or both parents, according to the study.

So all you single dads out there, don't let the women beat you. Don't let the moms beat you. Do the right thing. Get your kids in for their well check-ups when they're due. And if you are not sure when they're due, not a problem, just call your doctor and ask them. Sure they'd be happy to tell you.

OK. We're going to take a quick break and we'll be back right after this.


[Short Break Music]

Dr. Mike Patrick: OK. We are back. And I did get an email from Allie in Minnesota and Allie says, "Hello, Dr. Mike. I'm a nursing working mom and I listen to your podcast while pumping. You have saved me from hours of boredom."

Anyways, my nine-month-old baby girl was born with bilateral clubfoot. I would love it if you did a piece about this. It seems to be more common than I would have thought. I belong to a Yahoo! online support group called nosurgery4clubfoot and have learned a lot about clubfoot and treatment options.


It seems that some doctors are still doing surgery instead of using the Ponseti Method to fix clubfoot. And I wonder why this is, when casting would seem to be so much better in the long run.

Anyway, my question is this. We have seen a doctor since she was born who guided her through treatments the text to the actual casting. But this doctor is on the list of Ponseti-certified doctors, which I take to mean that Dr. Ponseti trained him in some way.

We have gone through the castings, the tendonotomy and now she's wearing the Ponseti/Mitchell brace at night. We have an appointment to check on her progress next week and I'm concerned that her right foot is not completely corrected and therefore may relapse at some point.

I brought my concern to the doctor last time we went and he said it was fine. But I'm wondering should I get a second opinion from the master himself, Dr. Ponseti.

Iowa isn't very far away from Minnesota and it is possible to get an appointment with him. If I do, how would I tell my doctor that we are choosing to do this? So it's not to insult him.


I don't want to break all ties with him, just one little piece of mind. I wonder if we went to Dr. Ponseti and everything is fine. When we go back to our doctor, would he be insulted and not want to treat us?

Thanks for caring enough to help us parents out. And it signed Allie.

Oh, first, Allie I'd say don't worry about insulting the orthopedic person because you're going to be involved with this orthopedic doctor for a short period of time. In the scheme of things, you're probably not going to be involved with him for years and years and years.

And so you are though going to have to worry about your own guilt, your own inner feelings about this, your child, you know wondering if you did everything that you could do. So I wouldn't.

If it's something that's really going to make you sleep better at night, getting a second opinion is really just fine. And what you could do. I mean you could talk to the orthopedic guy and just tell him how you're feeling and that you're going to yes, you know, just put yourself out there as you know, look, I'm a crazy mom.


I need some piece of mind. It's nothing personal. I'm just going to sleep better at night having a second opinion over this. And I think if you're kind of jovial about it, for the most part, your doctor is not going to get too upset about this.

Now if you really don't want to do it that way, you can also just talk to your pediatrician and explain the whole thing to him. Certainly, we, as pediatricians are pretty easy targets, so we could say, "OK, we're going to do a referral to Iowa. I think it's a good idea. Why don't we do this?" And then you can just blame your pediatrician if the local Ortho guy says, "Why do you go there?" "Well, my pediatrician wanted me to go." "That's fine. You can do that, too."

You know, I think, personally, I think, piece of mind is worth it. Now, probably, if you go see Dr. Ponseti, probably, he's going to say, "Yes, everything's great. You're doing he's doing it just the right way, you know." But if you sleep better at night knowing that, again, I think it's worth it.

Now in terms of doing a segment on clubfoot, I agree.


I tell you. It's a great idea. Not only because it's such a common problem but also, you know, it's an interesting issue. And I think that even if you don't have a child with clubfoot, you're going to come across at some point in your life, whether it'd be a relative or someone at church or someone that you know in some other way who has clubfoot.

And like I said, it's an interesting disease process. So being one to just sort of go out on a limb, I emailed Dr. Ponseti and he declined. He didn't want to come in the show. But look, he's over 90 years old and he still holds clinic every day.

So, God love him. He's over 90 years old, like 93 or 94. But he was kind enough to put me in touch with one of his partners, Dr. Jose Morcuende at the University of Iowa.

And he kindly agreed to stop by and chat with us about clubfoot. So we're going to take a quick break and then Dr. Jose Morcuende is going to join us. And we're going to talk all about clubfoot.


It's going to be exciting. So stay tuned. Stay with me, OK? Don't go anywhere.

[Short Break Music]

All right, in our In Depth segment this week, we're discussing clubfoot, a common congenital defect, which means kids are born with it. It involves one or both feet.

With clubfoot, the foot is tightly stuck in an abnormal position with the heel severely flexed and the sole of the foot twisted sideways so that it faces the opposite leg. This disorder affects approximately 1 in 1,000 babies.


And joining me today to talk about clubfoot is Dr. Jose Morcuende, Associate Professor of Orthopedics with the University of Iowa's Department of Orthopedics and Rehabilitation.

So welcome to PediaCast, Dr. Morcuende.

Dr. Jose Morcuende: Hi! It's a pleasure to be here.

Dr. Mike Patrick: Great. And as I was preparing for this discussion, I was trying to come up with a way to describe clubfoot. And I realized that without being able to draw a picture or looking at a diagram, it's kind of a hard thing to do. So hopefully I did it well.

Can you give the listeners a little better idea of just exactly what clubfoot is?

Dr. Jose Morcuende: Yes. Clubfoot is a congenital deformity as you mentioned, in which the foot during, usually, the second trimester of pregnancy becomes abnormally shaped and in wrong position.

And when the kid is born, the foot is turned inwards with the heel turned to the inside as well as the midfoot, and the forefoot to the point that in some kids the toes can be touching the anterior aspect of the leg.


This deformity has different grades of severity and is usually present as a unique deformity in most kids, although it can be also associated with other syndromes.

Dr. Mike Patrick: Now when we talked about it being one in a thousand, are there certain ethnic groups that are more affected than others?

Dr. Jose Morcuende: Yes. The statistics in United States and some parts of South America and also in Europe are a little bit better than other parts of the world. In general, it's 1 in 1,000. However, there are ethnic groups difference. For instance, in Africa, some areas, they might have 1 in 500.


In the Polynesian Islands, for instance, the number can be 1 in 125. So we have some variations depending on the ethnic groups. In general, we use 1 in 1,000 as the average for the world population.

Dr. Mike Patrick: And what about boys versus girls, do you see it equally or is there a difference between the two sexes?

Dr. Jose Morcuende: There seems to be a difference between the two sexes. And in most of the statistics in papers published about the incidence and prevalence of the deformity in different parts of the country, actually the numbers are very close, in general, is two boys for 1 girl will have the deformity.

Dr. Mike Patrick: OK. And does this usually affect both feet or one foot or the other, or can it be either way?

Dr. Jose Morcuende: Yes, 50% of the time, both feet are affected. When there's only one foot, usually, it's either the right or the left. There's no difference between the two.


Dr. Mike Patrick: OK. And what exactly causes it?

Dr. Jose Morcuende: We really don't know what the cause of clubfoot in cases in which this is the abnormality that is present at birth.

Clubfoot is associated with very different syndromes like classic syndrome and arthrogryposis in which the kid has different contractures in different joints and myelomeningocele, spina bifida cases.

But the majority of the cases that we will see in the clinics are called idiopathic, which means that we don't know entirely what is the cause of the deformity. We have several hypotheses with respect to the causation. But despite big deal of research, we still don't know why this happens.

One thing that we know is that in about 25% of the families, clubfoot might run in different members of the family.


So we think that in some families, there's a genetic component.

Dr. Mike Patrick: Of the kids that you see, is that the majority of kids where there's a family history, or is that still something that you just see here and there?

Dr. Jose Morcuende: Yes. I will say that 70% of the time, the deformity just happened by chance.

Dr. Mike Patrick: OK.

Dr. Jose Morcuende: And there's no family history of a clubfoot. And about 25% to 30% of the time, there might be some members in the family that will have a clubfoot.

Now, it's a type of inheritance that is a little bit different from other inheritance in the men, most of the time, when the inheritance is in every single generation so maybe the father has clubfoot and then the son and then the grandson, or so.

In cases of clubfoot when it runs in families, sometimes it skips generations.


So it might be the grandfather, there's nothing, and then the grandson might have the deformity, and then they might skip another generation. The characteristics of the inheritance are a little bit more complex.

Dr. Mike Patrick: Sure. Now when should it be? And I assume, of course, once the baby is born, the parents it's obvious that they have a clubfoot. I guess there's also more and more prenatal diagnosis of this as well.

Dr. Jose Morcuende: Yes. Most now with the ultrasound during pregnancy, we are finding that clubfoot usually develops around 16 to 20 weeks of pregnancy. And now, this is a very important context to keep in mind because it has a strong influence about the deformity and also about the prognosis and the treatment.

The first nine week of pregnancy, which is called the embryonic period, and that is when all the bones, joints, ligaments, tendons and skin, et cetera, is formed during this time.


That period of time is when in other cases where there's an abnormality then where you have which is called a malformation something is wrong on the shape or the structure. Now clubfoot actually is not a malformation.

The foot is normal. It grows during that period of time as a normal structure. And then around 12th, 13th, 15th, 16th weeks of pregnancy, the foot starts turning in to develop the classic deformity of clubfoot. And it will stay in that position and for the life of the patient if it is untreated.

Now if you correct the clubfoot during the first few weeks or months of life, the problem with clubfoot is that it has still a tendency for relapses.


It can come back if it is not properly maintained. You will do that for about three to four years. After four years, it's very rare that the foot will the clubfoot will relapse again. So clubfoot is now considered, although the kid is born with the deformity so it's congenital, but that implies like a malformation.

Now we consider clubfoot as a developmental problem. It's something that happened during development. It has a life span of three or four years. And then if the foot is corrected at that age then it will be normally functional for the rest of the life of the patient.

So this is a very important concept because malformations in general, you can treat with one surgery, and you can correct the malformation. And the patient will do fine. In cases of clubfoot, what you have to do is to treat the patient for three or four years in order to get a good result.


Dr. Mike Patrick: Sure. Now we talked a little bit about treatment or how exactly you approach the baby that has a clubfoot that comes to you. What exactly do you do to correct this?

Dr. Jose Morcuende: In general, what we recommend is if the baby born with the deformity and is very evident and then what we recommend is to wait for a week or 10 days and allow the baby to bounce with mom and dad, go back home because there's no any rush on starting the treatment right away. It's not an emergency.

Deformity can be corrected actually for a long period of time. So the best is just to go back home and arrange things for the baby. Many times this is the first baby of the family so that implies some stresses in the family.

It is better just to start the treatment when things are settled down at home. The treatment is based on very gentle manipulations, stretching of the foot in a very specific way following the normal biomechanics of the foot.


Although the clubfoot is abnormal, the joints follow the mechanics of a normal foot so you want to force the manipulation in a very specific way. And this way is called the Ponseti method.

Every time you see the patient, you can stretch a little bit the ligaments and then you maintain the correction with a cast. And the cast goes from the toes to the groin with the knee bend to a 90 degrees, is very well molded following the shapes of the bones and foot and the leg and just to allow the precise correction of the deformity.

Usually it takes four to five casts that can be changed every four to seven days to get the foot pretty much fully corrected.


One of the components of deformity is, as you said before, that the ankle is down and that is because the heel cord is, in many cases, very tight. So in order to provide full correction of deformity, we perform, which is called percutaneous Achilles tenotomy. What that mean is that you clip the tendon from very small incision is done with ophthalmologic knife actually. And you just clip the tendon so it lengthens so you can correct the foot to the normal position and then you place this in a cast.

This last cast is maintained for 2-1/2 to 3 weeks to allow the tendon to heal. And up to that period of time, the foot is fully corrected.

So the key now is that if you do the correction every four or five days, the foot can be fully corrected in about 16 to 20 days, although you have to use a cast for two weeks to allow the healing of tendon.


And it is very important to maintain this correction. And in order to do so, what's recommended is to use a special brace. It's called foot abduction brace which consists in two shoes or boots that are together bind up by a bar in the middle.

The main reason for this is to maintain the foot looking face into the outside so it keeps the stretching as you accomplish with a casting. The brace is usually worn for about 23 hours for about 3 months. And then you slowly decrease the number of hours to adjust to when the kid is sleep, and usually doing that for 12 to 14 hours a day, usually at night and nap time.


During the day, the kid usually wore shoes and can be running around and generally doesn't require any physiotherapy. And in general the kids are doing really, really well without any problems.

Dr. Mike Patrick: OK.

Dr. Jose Morcuende: And you maintain the brace for three or four years and the kid gets to that age and the foot is normal looking. Then it will be functional full force for the rest of the life of the patient.

Dr. Mike Patrick: Great. Great. Now going back a little bit to the manipulation stages of this so early on in the treatment, is there any pain associated with that with the infants?

Dr. Jose Morcuende: Actually, no. It's a very gentle manipulation and you should not create any pain on the manipulation. In general, what we do is like very gently stretching the foot in the specific position.

When the patient, the kid, starts kind of making faces that is going to start hurting because you're stretching the ligaments and just stop.


And then you repeat that for only around minute or so. I mean, you don't require that much. And you usually gain about 10 to 15 degrees over a 90-degree angle that you have to get the foot corrected.

So it's not painful, is very gentle and usually the kids start to sleep. And it usually helps a lot if the kid during this period is taking the bottle and drinking some juice or something because it keeps them distracted. And they usually don't bother too much.

Dr. Mike Patrick: Great. Now the incision or when you cut the tendon, of course for everyone so they kind of picture this we're talking about the Achilles tendon and the back of the heel, right?

Dr. Jose Morcuende: Yes.

Dr. Mike Patrick: OK. And then when you cut that, is that all the way through kind of cut?


Dr. Jose Morcuende: Yes. The Achilles tendon is a structure that is relatively complex. It has two morphological units, to say. One is what's called the heel cord or the Achilles tendon, which is very hard. It's like a rope. But then surrounding that structure, there's another structure called peritenon.

When you do the clipping of the tendon, what you cut is the hard part the Achilles, the heel cord that is like a rope. The other part, which is a little bit softer and is actually integrated into the soft tissues, that area of the tendon stays the same.

You cannot cut it because it's very soft. So the tendon relaxes but the structure is maintained the cells that will regenerate the tendon because tendon and bones are actually two tissues that regenerates to form a structure that is exactly the same that it was before the injury.

The cells are coming actually from that soft tissue part and they just fill the gap between the two ends.


Usually in the newborn to three or four months of age in a couple of weeks, two and a half weeks, the tendon is fully restored to normal. So it's a very simple procedure that we usually do under local anesthesia with a little bit of sedation in the clinic. And the usual it has very minimal risk of complications.

Dr. Mike Patrick: Great. Now has this always been the way that clubfoot was approached, or was there a time there were other surgeries that were involved? What's the evolution of how we've come to treat it the way that we do?

Dr. Jose Morcuende: Yes. This is a very interesting question. Actually the history of clubfoot has been in dark ages for many years. Initially it was not treated. And actually in developing countries, which 80% of kids with clubfoot are born because the birth rates are higher.


Most cases don't get treatment because it's been, in general, very complex.

Traditionally, the treatment is being based on the same concept of manipulation and casting. However, the methods that were used were based on wrong assumptions actually of how the mechanics of the foot were working.

And because of that, most of these methods, pretty much all the methods that we know, were not able to accomplish a full correction of deformity. And therefore, when the kids get one to six, eight months of life and after three or four months of weekly casting usually requiring 20 or 30 casts, then the foot was now corrected, and then the indication was for surgery, to do release of the different tendons and ligaments around the ankle in order to put the foot in the straight position.


So this has been the treatment, actually, over the last thirty or forty years. It's a treatment that is successful in the meaning of the foot is put straight, however it's a treatment that has long term residual complications and problems.

And the most important one is the stiffness. You have to cut pretty much all the tendons and ligaments around the ankle and around the heel, in order to put the foot straight. And that leads to a scar tissue.

And scar tissue is not as pliable and elastic as the normal ligaments. And so the foot is usually very stiff. And over a period of years, usually early adulthood, 20 to 30, then the foot becomes painful and develops arthritis.


That has been the standard treatment in the world, not just here in the United States or Europe. However, and this is important. And this is a new change in the way of thinking about clubfoot.

Dr. Ponseti, which is a professor emeritus here in the University of Iowa, he's 93. And he is still working every day of the week. And he still has his clinic and see patients in the clinic.

Dr. Mike Patrick: I'd love him. [Laughter]

Dr. Jose Morcuende: Yes. At the age of 93, he's a wonderful role model. I wish I will get to that age and doing what he's doing, which is wonderful things.

And he actually studied this problem in the 40s because he did a study of looking at patients that have surgery in many years.


And when they get to 23 years of age, he realized that these patients were really impaired in their function because the foot was stiff. And it will become painful.

So, at that time, he started thinking about the problem and did some dissections and studies with x-rays and some biomechanical studies. And he realized how you can correct the foot by following the normal range of motion of the foot and how the joint works.

And then he developed this method in the 50s and published his first paper actually in 1963. Unfortunately, the orthopedics community in every country, did not really understood at that time the complexities of the concept, although it's a very simple way of treating.

And unfortunately, the method has been really only practiced here in United States in Iowa and the people that graduate from our program for 50 years.


It has not been until the last 10 years or so that people have realized that surgery is not an option for clubfoot. And they would start looking for other options and then they discovered Dr. Ponseti method. And now it's becoming the standard of care in United States and really around the world.

Dr. Mike Patrick: How is it that doctors in developing countries learned the technique for doing this?

Dr. Jose Morcuende: Because you know this is a very unique situation and the history of orthopedic and specifically for this deformity, there was only one person in the whole world and just a very small set of people, including me and Dr. Weinstein and others that knew how to do it.

So, 10 years ago, we started teaching here in our hospital and doing training sessions.


And then in 2001, working with the United States is going to join the initiative. We established a clubfoot project that was designed first for United States since it was the United States government.

And now, we are in the process of making a worldwide initiative for the teaching of the Ponseti method and then for clubfoot to be treated.

And the important thing is the importance of this method as a public health initiative.

This is a method that has a 98% correction rate. Very few cases, very, very few will require a little bit of surgery after the correction. In our hands, we are in 99.9 today.


So if you perform the method very carefully in the way Dr. Ponseti described, pretty much all the cases can be treated.

So this is something that has completely changed the way we approach clubfoot and it has tremendous implications, especially for developing countries, where clubfoot is usually not treated because people cannot afford to have surgery.

Now, you introduce a new method that only requires four or five casts that can be changed every four or five days. So in four weeks the foot is fully corrected.

And most developing countries the only thing they have for treating any orthopedic problem or fractures is plastic cast. So it's very inexpensive. It's very safe. It has no complications pretty much and is low tech. It can be taught to any health care worker.


We have several studies in Australia. The physiotherapists, podiatrists, nurse practitioners can learn the method and apply the method and have exactly the same results, 98% to 100% correction rate.

So it's actually changing the way we think clubfoot and the impact that will have around the world. And we'd like to put in the context that it's like the polio vaccine immunization.

There were a lot of cases. We had very difficult surgeries to correct deformities. And when the vaccine came with three doses, polio is pretty much eradicated around the world.

Dr. Mike Patrick: Right.

Dr. Jose Morcuende: And we're saying that clubfoot, with the Ponseti method, can be the same. Apply cast, which are kind of like doses of treatment over a period of three or four weeks can change the life of a person. And we see that all the time.

So we started teaching around four or five years ago in different countries.


We have about 40 countries right now with programs. And we have about three or four countries that have actually national programs in which they are teaching and developing that program to eradicate clubfoot, mostly neglected clubfoot in those countries, including Brazil, China, Uganda, Malawi and others.

So it's been over the last four or five years a tremendous interest on the method. In developing countries actually most of the doctors are thrilled because

Dr. Mike Patrick: Yes.

Dr. Jose Morcuende: now they have the option to do a treatment that before, sometimes, they couldn't even afford.

Dr. Mike Patrick: Great. Let's say someone is born. Let's say Massachusetts or some place far away from Iowa, how can a parent know that their orthopedic doctors have been trained in this method?


Dr. Jose Morcuende: What we have done over the last four or five years is that we have kept tracked of the people that have been trained here or have been trained with, doctors that were trained here.

So we have now a list of doctors, qualified doctors, that we know that they do perform the Ponseti method right. And they got very good results. So the list is on the University of Iowa page and anybody can have access to this Web page.

Dr. Mike Patrick: Great.

Dr. Jose Morcuende: The only way is also there are several support groups in the Internet of parents. And there's one specifically which is called nosurgery4clubfoot at Yahoo! in which there's a group of clients that help other clients to make a decision about where to go and they know who are the doctors in the areas that perform the Ponseti method.


The good news is that now in United States, I would say that many, if not most of the orthopedic surgeons, do perform the Ponseti method. The only problem is sometimes they don't there are cases that are more difficult and they don't have the ability and the hands to modify as they go. Sometimes the foot is not fully corrected.

And we have seen now the University of Iowa about 50% of the patients are coming for second opinion to finalize the treatment if the foot is not fully corrected. But that will be the two ways is through Internet to get information on how to find the doctors.

Dr. Mike Patrick: Great. And we'll discover where those places are for sure and I'll put links in the Show Notes. So any parents out there who are interested in looking that up can find it easily.


And that brings me to another thing. You said that a lot of the people that you see in Iowa are coming for second opinions. Do you find that their primary orthopedic doctor who's been taking care of them refers them for this? Or is this something that the parents seek out themselves?

And if the parents are doing it, how's the relationship between their orthopedic doctor back home and what you're doing?

Dr. Jose Morcuende: Well, actually, it's a very interesting question because what happened at the beginning, which is about six years ago, the Web page was developed in 1998. And we actually this semester, we published a paper in which will show that the number of hits in a Web page and the number of patients we were seeing and where the patient was coming from were all correlated and go together.

At the beginning, I think, it was a little bit distressful for the doctors and the patients.


There's been a change on the relationship between patients and doctors with the introduction of the Internet. The Internet has changed the way we think about medicine and the way we think about information in medicine.

For the first time, parents will have the chance to look information at home and night at the pleasure without having to go to the public library or got any information through phone calls, et cetera.

So the parents were actually the driving force or one of the driving forces for the change of how the clubfoot has been treated over the last 10 years.

Dr. Mike Patrick: [Laughter] Yes, that's great.

Dr. Jose Morcuende: And the parents are the ones who go to the doctor and then they started treatment. And usually what happened in the cases that we see is that when they get to a couple of months of casting, they get the cast, and the foot is not fully looking good and some doctors started talking about surgery, most of the parents will go to the Internet and start looking for why this happened.


And then they find out about us or they go to other parents in the support groups and then they decided to come to visit us and ask for second opinion.

And the only way sometimes doctors, they feel that there are some feet that are much more difficult. And the good news is that instead of saying "Well, you need surgery and we can correct it" you know, we used to do, they will refer the patients to us or to some of the doctors that centers are more specialized because we see more difficult patients for second opinion and usually that relationship with the patients are very good.

Most likely what we do is we follow the patients together and we use the Internet all time in sending pictures, videos and communicate through the Internet.

Dr. Mike Patrick: Great.


Dr. Jose Morcuende: So the Internet has been actually a wonderful resource for parents and for doctors.

Dr. Mike Patrick: Yes. And that's what PediaCast is all about. [Laughter]

Dr. Jose Morcuende: Yes. And this is exactly. I'm so happy that we have the chance to talk today because this is one of the ways that everything started for the change.

Dr. Mike Patrick: Yes. We really appreciate you stopping by. We've been doing a special thing in the last three weeks where we have a code word that parents have to write down, and then at the end, they're going to unscramble the code words. And we're going to be giving some prizes away.

So if you could just let everyone know what the code word is this week that would be great.

Dr. Jose Morcuende: The code word is Ohio.

Dr. Mike Patrick: Yes, so Ohio. OK.

Dr. Jose Morcuende: Yes.

Dr. Mike Patrick: [Laughter] Thanks again, Dr. Morcuende for stopping by.

Dr. Jose Morcuende: Thank you very much. It's been a pleasure talking to you.



Dr. Mike Patrick: OK. Before we move on to our Listener's segment, I do want to let you know that we do have the links that Dr. Morcuende talked about in the Show Notes. So we have a list of the U.S. doctors qualified in the Ponseti method. And there's a link for that, and then also a link to the nosurgery4clubfoot Yahoo! Group.

And I could just hear like a collective applause from the audience if it were possible. I'm sure there would have been when Dr. Morcuende mentioned that Yahoo! Group by name so that was pretty cool.


Also, I came across the blog called "The Six Feet" blog that is really well done. And there's a link to that in the Show Notes as well. But this is a mom who basically has three kids and all three of them had bilateral clubfoot. So it means clubfoot on both legs.

So, basically, she had six fee t to deal with the casting and all of this. So she's been through a lot and she shares her experiences and lots of great resources that are available there. So you want to check that out.

It's the "Six Feet" blog and there's a link in the Show Notes for that as well.

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OK. And first in our Listener's segment, this comes from Sheryl in Utah. Sheryl says, "Hi, Dr. Mike. I really enjoy your podcast. I have a question about your recent talk on RSV. You mentioned the vaccine would help with RSV.

I thought there was an RSV vaccine. When my son was born, he had to be on oxygen for six weeks and we were approved for a monthly RSV shot for three months until the winter season was over.


The cost was covered by our insurance, but they were $1,000 each. Was isn't this shot more available and why is it so expensive? Little ones who were born in the winter should be given this as a standard shot.

Thanks for your podcast and keep up the good work. Sheryl."

Well, Sheryl, this is a great, great question. RSV, I don't think I actually mentioned what it stood for. RSV stands for respiratory syncytial virus. And it's a virus that goes around mostly in the winter months.

And for most kids, it just causes mild, cold-like symptoms so most kinds who get RSV do just fine with it. But there's going to be a small number and particularly in kids who have some kind of underlying lung issue, like asthma, or if they were premature and on ventilator and needed extra oxygen.

So they have some underlying lung issue and those kids they're more likely to get severe disease with RSV, which then leads to severe wheezing.

And each year, 125,000 infants, that's right, 125,000 infants are hospitalized for RSV infection, making it the leading reason for infant hospitalization.

And it's responsible for up to 500 childhood deaths each year. So it is a serious disease and the vaccine for it would certainly prevent lots of childhood hospitalization and death.

Now there is work being done to develop a vaccine for RSV but it's not yet available. So what is available is an injection called Synagis. And this is the shot, I'm sure, that Sheryl is talking about.

Now, Synagis is technically not a vaccine. Remember how vaccines work. Basically, you are injecting something into the body that is not going to cause disease but it sort of fakes the body into thinking that disease is there so that the body will form antibodies against it.


So that when the actual disease comes, the antibody will attack that. So you're basically fooling the immune system into making an antibody that will protect you.

Now Synagis is the actual antibody. Basically, your child's body won't have to make his or her own antibodies. It will already just sort of passively have this antibody that we inject into them to fight off the RSV.

And this is called passive immunity. So vaccines provide the active immunity because you are actively making your immune system make antibodies that are going to protect you, but in this case, we have passive immunity where we are providing the antibodies for them.

Now the reason that Synagis is dosed once a month during RSV season, it should be like November through about March, right around that time, is that these antibodies have a limited lifespan in the body.


And what's happening in your own body is that these antibodies are necessarily always around. They have, like I said, a short lifespan but when you need them here, immune system builds. There's memory cells that can rapidly make the antibodies when you need them.

But, again, with RSV, the babies don't already have this on their own and because there's no immunization for it, we have to provide those antibodies, and you have to do a once a month since these antibodies have a limited lifespan.

Now, why is it so expensive? If we have to look at how this stuff is made, I'm going to break this down just as simply as I can.

But what they did is they took human cells which make the antibody against RSV. And they isolated the DNA code for that antibody so the code, the DNA code that allows the cell to make anti-RSV antibody. They took that.


And then there are special bacteria that they can use to clone the human DNA. So basically, you get this bacteria that's just going to make lots and lots and lots of this DNA strands that will be able to make that protein, that anti-RSV antibody.

Now, so you got the DNA. Now you need a cell that can make the protein. And what they use actually are mice cells. And the reason for this is then it's not really a human blood product because you just isolated out the DNA which it's just a copy, kind of multiplicity. [Laughter]

We just watched that the other night so I kind of have it on my brain, sorry.

Anyway, they clone the DNA so now you really have this it's not even human DNA. It's the same code and then you put it into the mice cells. So it's not really blood products. You don't have to worry about transferring human disease because of it.


Also, you need cells to do this. And obviously, using human cells is going to be an ethical issue. So, basically, you can get rid of the ethical issues. You can get rid of, and I should say legal type issues as well. And you're able to make a lot of it without having to you don't have to pay the mice money to use the cells.

So it's a cheaper way to do it. But still this is a lot of technology in order to isolate the DNA, to clone it, to trick the mouse cells into making this antibody and then collecting it and packaging it up as the Synagis. It is an expensive process.

Now, I should also point out why is it an injection? You can't do it as an oral medicine because the stomach acid will basically destroy the antibodies.

And in terms of the expense, again, you can see why this and just with the process that's involved.


But the expense is certainly, if you look at a thousand dollars a dose, it's certainly less than a prolonged intensive care unit stay for a baby with severe RSV who's on the ventilator. It's still going to be cheaper to give them this injection than if they actually had the disease and ended up in the intensive care unit dealing with RSV.

But because it's so expensive, it does make sense at this point only be given to the infants with the highest risk of severe RSV disease.

Is the mark up too high, a thousand dollars? And again, I'm going to hopefully not get myself into too much trouble here. But you have to remember. We live in an economic system that's a free market and the drug companies are public companies and they have to answer to stockholders.

And every day Americans do rely on these companies for performance of their 401K plans. I'm not trying to be apologetic to the drug companies here. But it is a complicated relationship for sure between drug companies and consumers.


So it's very complex. There's a lot of politics involved, and some of it comes down to you get what people are willing to pay. And the insurance companies are willing to pay it for select infants.

But it is an expensive process to do. How much is the mark up on it? Probably quite a bit.

Synagis, by the way, is made by a company called MedImmune and that's the same company that is working on an RSV vaccine. But again, that's not available.

That would be one that stimulates a baby's body to make their own antibodies against RSV. So hopefully that makes sense. It didn't get too technical on you.

There will be a link in the Show Notes for more information on Synagis. So if you wanted to see, see how it works on your own, there's a link in the Show Notes for you.

OK. Listener number two, this is Anne in Missouri and Anne says, "Dr. Mike, I've been listening to your podcast for about nine months now. My daughter is turning one year old this Sunday. So happy birthday!


She was born premature by about six weeks but as healthy as a full-term baby. Your podcast has been so helpful. As in December, she was diagnosed with urine kidney reflux stage 4, which is the worst.

And Ruth went through all the tests such VCUG, talks with the surgeon all the things that you talked about in your podcast. I was so glad to know we were doing the right things.

I have listened to all the old podcasts and have missed and may have missed this. I don't remember any talk about when to put shoes on your baby.

Ruth isn't walking on her own yet though she loves to nearly a sprint, if she is holding on to her daddy or myself. I have never heard it is bad to put shoes on your baby until they are taking their first steps on their own, as this will allow for their arches to form properly.

But I also have women in my circles who shake their finger at me for not putting shoes on her from day one. Also something to know and I hope it is normal, her legs are slightly bowed.


Is this normal? Until she starts walking, her doctor doesn't seem to be too concerned. Thanks again for great podcasts. Doesn't everyone say that?

It has been very helpful as I have been going through the stages with my first baby. And this is signed, Anne in Missouri.

Everyone who writes and does say it's a nice podcast. But you can keep saying it because I'm just as egocentric as the next guy [Laughter], all right?

Let's talk first about the leg bowing. We see this often and my old bowing of the legs between the knee and the ankle. It can be normal and typically this will resolve as the bone lengthens.

However, there are some disease processes that can result in bowing of the legs. For instance, rickets, which is a disease caused by Vitamin D deficiency, can do it.

There are some other things as well. So your best bet is to bring it up with your doctor each time you go in. If you're really worried about it and your doctor saying "No, everything's OK," it's fine to ask for an orthopedic referral, if it's going to help you sleep better at night. You know my feelings on this.


There are plenty of kids that I refer that I know what the orthopedic doctors are going to say. I tell the parents exactly what they're going to say. But for the parents to hear it coming from two different doctors one being the specialist, one being their regular doctor if they sleep better at night, that's fine with me.

So again, I would trust your doctor, but if there's something, you know, if you're worried about it and you keep bringing it up and it seems like it's getting worse to you, by all means, ask for a referral.

I do in the Show Notes so I have a link to, an information sheet, on bowed legs from the American Academy of Orthopedic Surgeons. It's aimed at parents, easy to understand, and there's a link in the show notes to that.

And with regard to baby shoes, I'm going to punt this one and direct you to PediaCast episode number eight because we did cover baby shoes in that episode. It's still on the feed and I'll put a link to it in the Show Notes as well.


OK. And then listener number three, this comes from Crista in New Jersey. Crista says, "I took my son to his pediatrician and he pulled back my son's foreskin." So we're talking penis here.

Jacob is only six months old. I thought it was early but assumed the doctor knew what he was doing. However, I was a little concerned because he had the expressed concern over my decision not to circumcise my son.

And now I wonder if he is unaware of the proper care of an intact penis since he seemed to think my decision was strange. He told me to clean it at every diaper change. And when I asked, "Really?" he said, "Well, at least at every bath." [Laughter]

When my husband and I were bathing our son this evening, we attempted very gently to pull back the foreskin but it didn't move. It's possible we're being overly gentle for fear of hurting him.

But I am inclined to believe that he is not ready to retract easily and therefore we should leave it alone. I am worried that my son's doctor forced his foreskin to retract.


If this is true, what do I do? Is it too late to leave it alone until he is older? Now that it has been retracted, do we have to retract it regularly to clean it? I am very fearful of my son getting an infection, as it was my decision not to have him circumcised.

I really blame myself for not making sure our pediatrician knew the facts. I had read prior to having my baby. We didn't know what we were having and decided if the baby was a boy that we didn't want to have him circumcised.

And everything I read said that the foreskin would not pull back for a few years and that at point we would need to teach our son proper cleansing of the area. I unfortunately assumed doctors had this information as well.

Any advice you have for me would be appreciated. Thank you, Crista.

Crista. Crista. Crista. [Laughter] Just take a deep breath.

I can tell you know by that tone of that that you are very upset over this. When the foreskin overlies the glans, which is the tip of the penis in infants, the two layers tend to stick together and that we call them "adhesions".


And this is what makes it difficult to retract the foreskin in a young infant. Now even if your doctor fully retracted the foreskin, it's likely that once they're back on top of one another, they're going to form new adhesions and everything's going to stick back together.

It's a good idea, basically, just to simply clean what you can see on the outside of the penis during infancy. And as you had mentioned, generally, the advice is that you just leave it alone.

So you don't have to pull it back and retract it until it's ready to do that. And that's usually not until they are going to puberty. And they do need to learn how to pull that back and keep everything nice and clean.

But until it's ready to pull back, you just leave it alone. And even if it got pulled back at some point, everything is probably going to just stick back together, so it's not really going to be too big of a deal.

Now, basically, as long you know with infection, you're going to see redness, swelling, discharge, pus these sort of things.

So there's not going to be infection in there if it looks normal to you. And if it doesn't look normal, then you definitely want to bring that up to your child's doctor.

So if it's changing in any way, otherwise, just leave it alone. And even if your doctor didn't pull it back, I wouldn't really worry about it. So just relax.

I'm going to include a couple of useful links in the Show Notes. There's a sheet complete with a diagram which is Care of the Uncircumcised Penis. And you might want to print that out and share it with your doctor [Laughter], exactly how you're supposed to care for it.

I'm teasing. See, I'm going to get myself into so much trouble here. I can just see you're taking that in. "Here, Dr. Mike said this is what you're supposed to do."

So anyway, that's something to look at. Also, this is maybe of general interest. It's not necessarily on circumcision care.

But the American Academy of Pediatrics does have a policy statement on circumcision so their official stand on whether you should do it or not, what are the pros, what are the cons.


And I have a link in the Show Notes to their policy statement on circumcision as well. So you can check that out.

OK. We are going to take a quick break and be back with a real quick research roundup right after this.

[Short Break Music]

And we're moving on to our research roundup. We just have one research article to add to the roundup this week because we're running a little bit short on time.


This is the effectiveness of the HPV vaccine in preventing cervical cancer. This was done by the FUTURE II Study Group which was spearheaded by the Department of Epidemiology at the University of Washington in Seattle. And it was published in the May 2007 edition of the New England Journal of Medicine.

Now, human papillomavirus or HPV is linked to cervical cancer. It is a sexually transmitted virus. And basically, viruses use human cells to replicate themselves. And basically what happens with the HPV is that then the cell goes crazy, starts replicating itself over and over and out of control. And you get cancer.

HPV types 16 and 18 are associated with 70% of all cervical cancer worldwide. And the HPV vaccine currently licensed is a quadrivalent vaccine, meaning it protects against four types of HPV.


And those are numbers 6, 11, 16 and 18. So it's 16 and 18 that are most commonly associated with cervical cancer. So the question before the researchers was how effective is that vaccine at preventing cervical cancer.

And not just cancer but also what we call cervical dysplasia, which is an abnormal Pap smear so the precancerous type lesions and then cancer itself.

So what they did is, this was a randomized, double-blind study so that means that women were put into one of two groups the control group and the research group and the study group. And they were randomized between so it was just by luck of the draw which group you went in.

And it was double blind meaning that the doctors and the women they did not know which group they were in.

Now all together they looked at 12,167 women and all these women were between 15 and 26 years of age.


And they all received three injections of HPV vaccine one at the very beginning, one two months later and one six months later just like is now recommended.

And of course one group received the HPV vaccine. The other group, the injections were just placebo. Now the first group or the first phase, I should say.

The first phase of this study, the groups were sort of thinned out to include only individuals who would be susceptible to getting HPV, so that basically means the sexually active women were first just looked at for this first phase.

It was also thinned out in this first phase just to look at those women who had no evidence of HPV 16 or 18 through one month after the third dose.

So in other words, they didn't want to count those who might already have been infected with HPV virus number 16 or 18 prior to the study because we want to see how well this does at preventing HPV infection with 16 or18 and then how well is that going to associate with less of a chance of cervical cancer.


Even with weaning out the women who had no evidence of prior infection with HPV and weaning out ones who weren't sexually active, that still left over 5,000 women in each group.

And then the women had serial checks for evidence of cervical dysplasias. They had Pap smears and they also had looked to see if they had evidence of HPV 16 or 18 infection. And they looked at this over a three-year period.

So what were the results?

Over the three-year period, the group that had the HPV vaccine, there was only one new case of cervical cancer related to HPV number 16 or number 18. And there's one person was noted to be positive for HPV number 52 at the study's onset.


But because they were only looking at 16 and 18, that did not disqualify her. So the question then becomes, did the shot not work for her and she still got HPV 16 or 18 and that's what caused the cervical cancer? Or did the HPV having that to begin with, is that what caused it and not the other?

So the HPV 52 is that what caused it? So in any case, over 5,000 women, only one in the HPV group was diagnosed with cervical cancer over that three-year period.

In the placebo group, 42 new cases of cervical cancer related to HPV 16 or 18 was noted. Then in the research or the study group, there was just one new case. So it looks like the HPV vaccine did work and 42 new cases in the placebo group and this was statistically significant.


Now there were many other arms of the study. For instance, it looked at the efficacy of preventing progression of disease and those who already had cervical dysplasia at the onset.

It also looked at the beginning of the study. So in other words, if they already had cervical dysplasia or cervical cancer and then they got the set of shots, did that help stop the process of the disease?

It also looked at side effects of the vaccine, effects of the vaccine on pregnancy.

And I'm not going to go into all of those because my point here was just to show that it is effective at preventing cervical cancer.

If you're interested in the results of those other aspects of the study, you can check out the original article. And there'll be a link in the Show Notes.

So the others concluded that in young women who had not been previously infected with HPV 16 or HPV 18, those in the vaccine group had a significantly lower occurrence of high-grade cervical dysplasia related to HPV 16 or HPV 18 than those in the placebo group.


Now just a couple of comments, this of course was a pretty short duration. I suspect that if you follow these women out for longer period of time, you're probably going to see an even larger difference between the two groups.

There were two other studies that have had similar results that had followed the women for five years. And all of these studies currently planned to follow the women for 15 years.

So we don't know if or when immunity will wear off and if boosters might be needed. But it looks like it does last at least five years. And as time goes by, we'll know more.

So stay tuned for more information.

OK. We are going to take another quick break. And we'll be back to wrap up the show, right after this.

[Short Break Music]


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OK. As we've been doing the last few weeks, we're going to end with a little bit of music. This is my prior experience as a disc jockey when I was a teenager and in college. So there's just a part of me that really likes putting a little bit of music in the show.

So this week's featured music is brought to you, as it has been in the last few weeks, by Iota Promo Net. The record label in this case is Artisan Media Group. And if you like the song, there will be a link to download this particular track absolutely free for your personal use.

You play it how many times you want. Spread it around. Copy it for people. It's DRM-free MP3.


And if you really like the music and would like to support the artist by purchasing the entire album, there will be a link in the Show Notes for that as well.

So this is Rick Braun. It is from the album Sessions, Volume One, and the track is called Cadillac Slim.

So if you like smooth jazz, this is a great one.

And until next time, Dr. Mike saying, stay safe, stay healthy and stay involved with your kids.

So long everybody!

[End Music]

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