Shaken Baby Syndrome

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Amniotic fluid problems

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Choosing a pre-school

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Newborn reflexes

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Mastitis

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Pelvic floor exercises

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Colic

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Antenatal Classes

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Strap-in-the-Future

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  • Shaken Baby Syndrome

    Tuesday, 21 July 2015 16:28
  • Amniotic fluid problems

    Thursday, 14 May 2015 12:54
  • Choosing a pre-school

    Friday, 10 April 2015 17:50
  • Newborn reflexes

    Tuesday, 03 March 2015 15:49
  • Mastitis

    Tuesday, 03 March 2015 15:41
  • Pelvic floor exercises

    Wednesday, 11 February 2015 17:20
  • Colic

    Wednesday, 11 February 2015 17:11
  • Antenatal Classes

    Monday, 03 June 2013 09:34
  • Strap-in-the-Future

    Thursday, 30 June 2011 13:52

Foot Problems

Young children's feet are very soft and pliable, so that any abnormal pressure can easily result in deformities. During the first year of life, a child's foot grows rapidly, reaching approximately half its adult size. This first year is therefore very important in the development of feet. The most common types of gait abnormalities include; in-toeing, out-toeing, flat feet, knock-knees, bowlegs, limping and toe-walking (Children's Hospital Boston, 2005-2010; epodiatry.com, 2004).

In-toeing and out-toeing are a frequent cause for visits to the pediatric orthopedist for infants and young children. Although these conditions are a cause for concern for family members and may occasionally cause minor difficulties for the child, in most cases they are merely variants of the normal toe position in infants and children. In order to ensure that this rotation of the lower extremities, falls within the normal range of variation, the child must be thoroughly evaluated to establish the cause for in-toeing or out-toeing (UMMS, 2009).

IN-TOEING

Most peoples feet point straight ahead or outwards, but in some cases the feet point inwards. This musculoskeletal condition known as in-toeing or pigeon toes is very common in otherwise healthy infants and young children. In most cases, in-toeing resolves itself without any treatment but in a few children, it does not get better on its own and requires medical intervention (American Academy of Family Physicians, 1994-2011).

Causes of in-toeing:

There are 3 causes of in-toeing in healthy children; arising from abnormalities in the growth or alignment of the upper legs, lower legs or feet. As a result doctors may also refer to this condition, as a rotational problem of the lower extremity (Columbiaortho.org).

1) Metatarsus adducts is a curve in the foot, that is probably present before birth, when the feet are pressed into this position inside the uterus. The foot may resemble a kidney bean, whereby the toes and heel curve in. Metatarsus adducts is the most common congenital foot deformity. In 9 out of 10 cases, the feet straighten as the child grows. Your doctor may show you how to stretch your baby's feet to help them straighten. If the curve is very pronounced or does not go away on its own, your doctor may recommend a cast or braces to help straighten the feet. This usually begins between 4-6 months of age and should be finished before your chid reaches normal walking age. A curve in the foot is not painful, and does not cause any problems with running or playing, but it may cause difficulties when it comes to fitting shoes (American Academy of Family Physicians, 2005-2011).

2) Internal tibial torsion is a twist in the tibia, or leg bone between the knee and the ankle. Tibial torsion affects boys and girls to an equal degree and is mostly asymmetrical, i.e. the one leg is rotated more than the other. If the condition is unilateral, it tends to affect the left leg more frequently than the right. Some inward twist of the tibia is normal in babies and this usually straightens out in the first year of life. In some children, the twist does not rectify itself enough for the feet to point straight ahead and outwards. Parents usually notice internal tibial torsion when their children still in-toe when they begin to walk. The child appears to be bowlegged and trips and falls easily. Leg bones generally continue to grow straighter until the child is 6-8 years old (American Academy of Family Physicians, 2005-2011; Columbiaortho.org; kidstherapycentre.com).

Doctors often do not prescribe any treatment for internal tibial torsion in young children because braces and special shoes are not particularly helpful. In some cases, a bar with shoes on it is used to make the child's feet point outwards. This kind of brace is expensive, not effective in all cases and children don't like to wear them. Also, if a twist remains, it has not been shown to cause arthritis and does not affect your child's running or jumping abilities. In exceptional cases, appearance is a problem and requires surgery. This involves cutting the bones and rotating them outwards, so that the feet point straight (American Academy of Family Physicians, 2005-2011).

3) Excess femoral anteversion is a twist in the femur or thigh bone. This cause of in-toeing is usually noticed after children begin walking in early childhood, between 2-4 years of age. It is twice as common in girls than boys and almost always presents symmetrically (i.e. affects both legs equally). A child with femoral anteversion is easily identifiable. She sits in what is known as a 'W' position, with her knees bent and her feet flared out behind her. In most children, excess femoral anteversion gets better on its own and  their feet will point straight ahead or outwards, by the time they are 6-8 years old. Braces and shoe modifications typically don't help. In severe cases, where children have a very strong twist of the thigh bone, surgery can be performed to cut the bone and twist it outwards, so that the feet point straight ahead (American Academy of Family Physicians, 2005-2011; Columbiaortho.org; kidstherapycentre.com).

OUT-TOEING

Out-toeing is much less common than in-toeing, but is caused by similar problems. Out-toeing occurs when the feet point outwards rather than straight. In most cases, children will outgrow this abnormal gait pattern naturally (Children's Hospital Boston, 2005-2010).

Causes of out-toeing:

Out-toeing generally presents itself within the first or second year of life. Out-toeing is most commonly due to ligamentous laxity (double joints) and generally resolves on its own. In rare cases, the leg bone (tibia or femur bone) is turned out. This is not usually seen in normal children, but is more common in those with neuromuscular abnormalities. Occasionally a normal child may have out-toeing due to the outward rotation of the leg bone. If this problem does not resolve itself by the age of 10 and there are functional difficulties, surgery may be required to cut the bone and rotate it into a normal position.  Another common cause, that usually resolves without medical intervention, is a hip muscle contractor that turns the hips and feet outwards. Most children are born with external rotation contractors of the hips. This problem usually resolves itself within a year from the onset of walking. Out-toeing may be exacerbated if children sleep on their stomaches with their feet turned out (Connecticut Children's Medical Centre, 2009; UMMS, 2009).

Symptoms:

Untreated out-toeing is associated with patella tracking difficulties that cause orthopedic problems, such as knee pain and muscular imbalances in adolescence and adulthood (kidstherapycentre.com).

Diagnosis of in-toeing and out-toeing:

In-toeing and out-toeing manifest at different ages, depending on the underlying musculoskeletal cause of the condition. If your doctor suspects a rotational problem of the lower extremities, he will perform a complete physical examination, to identify the condition, its cause, and to ensure there are no other deformities or orthopedic problems present. In older children, your doctor will carefully observe your child walking and running. He will also require a complete prenatal and birth history of your child, as well as information regarding any gait abnormalities within the family.  The assessment will establish if your child is developing normally. Occasionally, rotational problems are indicative of an underlying medical condition, such as cerebral palsy, limb length differences, hip disorders or angulation of the limb   (columbiaorthro.org; UMMS, 2009).

Other diagnostic tools that may be used include;

  •  A rotational/ torsional profile- this involves taking 6 different measurements of the angles of the hips, legs and feet, when the child is in various positions, walking and running. This assessment helps identify the cause of the rotational problem by detecting isolated abnormal angles.
  •  X-rays of the legs and feet may also be taken to make a definitive diagnosis.
  •  More sophisticated radiographic imaging techniques may also be performed, such as a CAT scan (computed tomography) and MRI (magnetic resonance imaging) (Connecticut Children's Medical Centre, 2008).