Student Pages

Lecturer: Craig Payne

Introductory comments and considerations:

* What is paediatrics?

* What is podopediatrics?

* What is the role of podiatry in the management of the paediatric patient?

Books in the library of relevance:

Tax's Podopediatrics

Is your child walking right? : Parents' guide to little feet

The Child's foot and ankle

The child's foot

Introduction to podopaediatrics

Pediatric foot & ankle surgery

Complex foot deformities in children

Foot and ankle disorders in children

Foot therapy for children

Footwear and footcare for disabled children

Paediatric Development

Podiatrists often confronted with paediatric patients whose problems a variation in the usual landmarks of development -- importance of understanding of normal development process.

Phases of growth:

Early embryo    0-2 weeks

Embryo           2-8 weeks

Foetus            8 weeks-birth

Infant             Birth-2 years

Normal prenatal development of the lower limb:

Relationship of prenatal development to foot pathology:
* Arrest of development
* Clubfoot
* Metatarsus adductus
* Joined toes

Please revise and study your first year biomechanics notes on the evoluation of human gait

Relationship of evolutionary development and foot pathology:

Many of the changes that the foot is assumed to have gone through during phylogenetic development can be seen in the developing ontogenetic development.

Recapitulation:
'During embryological development, an organism passes through stages which resemble the structural form of several ancestral types of the species as it evolved' (Haekel's Law)
* evident in the early stages of development of the human embryo and foetus

* possible explanation for the existence of structural anomalies in the lower limb

Tax (1982) suggests that our technological environment has evolved more rapidly that the structure and function of the foot. The hard unyielding surfaces that we walk on put the contoured foot at a functional disadvantage as it is not designed for use on a hard flat surface -- the foot has to pronate excessively to reach the ground.

Post natal development

1 month:
Spontaneous motor activity generalised; holds head up slightly when prone and can rotate head to either side; poor supine head control; beginning to notice surroundings; follow objects to midline; rounded back (flexed) when sitting; holds hands tightly clasped; reciprocal kicking when supine

2 months:
Motor activity generalised; smiles and coos socially; follows objects past midline; raises head and chest when prone – can hold position.

3 months:
Follows well with eyes; may wave at toy; beginning to regard hands – can hold hands in front of face; Good control of head when prone and looking around – can follow an object; Head control improved when in sitting position; Moro’s reflex disappearing; Smiles – coos in a more sustained fashion; kicking when supine

4 months:
Beginning to reach for toys symmetrically; Regards toys and may pull them to mouth; removes cloth from face; control of head good when sitting – looks around; plays with hands; laughs; rolls from prone to supine

6 months:
Reaches with either hand and begins to transfer objects; elevates trunk with elbow extension; rolls over; may sit briefly when placed in sitting position; laughs and plays with examiner; rolls from supine to prone and back; can bring feet to mouth

8 months:
Sits alone and unsupported – can raise self to sitting; beginning to creep reciprocally; vocalises with infantile rhythms and polysyllabic vowel sounds; regards self in mirror

10 months:
Crawls reciprocally; pulls up on rail; may begin to cruise with external support; uses thumb and index finger in opposition; may say ‘mama’ or ‘dada’; feeds self biscuits and holds own bottle.

12 months:
Walks with support; stands alone; places cube in cup; tries to build tower of two cubes; may have two words in addition to ‘mama’ or ‘dada’; begins to feed self with fingers

15 months:
Walks alone; creeps upstairs; 4 to 5 word vocabulary; pats picture; drinks from a cup; beginning to feed self with a spoon; makes wants known by pointing or vocalising

18 months:
Walks well; sits on a chair; throws a ball; climbs on furniture; stacks 3 – 4 cubes; 10 word vocabulary; begins to identify pictures; pulls toys on string; may be toilet trained during day

2 years:
Runs well; negotiates steps one at a time; jump off low step; uses pronouns and 3 word sentences; feeds self with a spoon; refers to self by name; toilet trained during day; can kick ball forward and throw ball overhand

2.5 years:
Can jump of step with one foot landing; can mount a tricycle; undresses self partially; attempts to put on socks; draws horizontal or vertical lines but does not cross them; refers to self as ‘I’; knows full name; helps to put things away

3 years:
Alternates feet going up stairs; jumps off step with two feet landing; pedals tricycle; builds tower of cubes; names drawings; uses plurals and obeys propositional commands; feeds self well; buttons clothes and puts on shoes

4 years:
Runs and climbs well; walks downstairs alternating feet; hops on one foot; throws a ball overhead; attempts to catch a ball or kick it in the air; pedals tricycle rapidly; draws a man with head, trunk and arms or legs; counts 3 objects; names one or more colours

5 years:
Skips, alternating feet; draws man; copies a square, cross, and a circle; dresses and undresses without assistance; knows the name of 4 or more colours; counts to 10 or higher

6 years:
Draws a man with hands and clothes; repeats 4 digits; knows morning and afternoon; knows left from right

Gait Milestones

10 – 11 months:
Jerky hip and knee motions; centre of gravity moves out of the base; increased time of knee extension

12 months:
Accelerates body by circumducting the legs

15 months:
Wide base of support; lacks arm swing (flexed arms); external femoral position, knees face externally; catches up with their centre of gravity; limited control over velocity; abducted, flat foot; full foot strike.

2 years:
Arms by side although lack co-ordination; flat foot, fails to supinate; hips still externally rotated

3 years:
Internal hip position; decreased base of gait; increased arm co-ordination reciprocal arm swing; tibial valgum; some foot slap although resupination occurs

5 – 6 years:
Heel to toe gait with active propulsion; knees in frontal plane

Online resources:

ePodiatry's resources on paediatric development

Check these resources from the Centers for Disease Control:

Assessment of Children

(Please read and study the relevant section of the course manual)

Working with children:
First impressions are important. Fear may be the predominant emotion. Children are often quick to “sense” an atmosphere and the reactions of those in it.

Practical tips:
• Sit close to child
• Listen carefully (avoid temptation for abrupt interruptions)
• Maintain good eye contact (conveys understanding and caring)
• Children may not understand discussion between Podiatrist and parent
• Avoid jargon
• Have toys available
• Avoid patronising language
• Show concern and care for the child
• The introduction in the waiting room should be addressed to both parent and child
• On the way to the consulting room – simple enquires, such as the child missing school or mode of transport to the clinic ? show an interest in the child – make it personal
• Examine small child on parents lap
• Examine by making it a ‘game’
• Attention spans are short in children ? make examination specific and quick; may help to interview parents while child is playing
• Not wearing a white coat may also help put children at ease (‘dress the part’ – look like everyone else as children will relate better – improves ‘approachability’)

History taking

Extra attention needs to be taken with regards to the following, when indicated, when taking a history from the parents/caregiver/child (the relevance of these questions and the need to ask them should be explained to the parents):

• birth history (normal pregnancy; medications during pregnancy; adverse events during pregnancy; delivery problems)
• problems in siblings; any family traits
• age at which developmental milestones achieved
• immunisation history
• achievement at school
• childhood behaviours of relevance to presenting complaint (eg nail biting, bedwetting, constipation, nervousness, speech problems, hyperactivity)
• history of childhood illnesses (eg measles, chicken pox, hospitalisations etc)

Be aware that parents can differ from the child in their interpretation of the signs and symptoms of the child.

Neurological Assessment of Child

Gross motor abilities:

Standing posture:
Adult posture is not developed until 10-11 years; <7 years have a protruding abdomen; <8-9 years scapulae winged; <10-11 years lumbar lordosis is exaggerated

Walking forward along a straight:
>5 years - place heel immediately in front of toe of opposite foot; >7 years and up to 9 years - some deviations from straight line would be normal; note any persistent deviation to one side

Walking on toes:
Can do >3 years; >4 years can run on toes

Walking on heel:
Can do >3 years

Jumping:
Ask child to keep feet together and jump 20 times along the floor; note arm movement; is balance maintained; do feet move together in time and space; note symmetry.
At 2 years a child begins to jump, usually with one foot leading; at 3 years jumps with two feet together; by 5 years should be more rhythmical and efficient with assistive upper limb movements.

Hopping:
At 3 years some children can hop and generally on the preferred leg; by 4 years, 5 to 8 hops is normal; by 5 years, 9 to 10 is normal; by 6 years can hop on the spot; by 7 to 8 years can hop on either leg

Running:
At 18 months, stiff, flat footed, little knee movement, arms held up; by 2 years – more flexibility at knees and ankle but little spring; by 2 to 3 years – true running with a period when both feet are off the ground, longer stride and heel usually contacts the ground first; by 3 – 5 years – extended airborne phase, smooth progression with less vertical movement; knees bend; reciprocal arm movement; by 5 years – body leans forward, arms swing in straight line with elbow bent.

Reflexes:

3 types of abnormal reflexes:

1) Asymmetry of response
2) Absence of response
3) Persistence of response

Deep tendon reflexes:
• Patellar and achilles
• Can be variable due to the corticospinal pathways not being fully developed
• Asymmetry is more important than degree of presence or exaggeration

Plantar response or Babinski’s sign/reflex:
Stroke plantar surface along outer border with blunt object – a positive response is spreading of the toes with hallux dorsiflexion
Normal from birth to age 6 years (sometimes up to 2 years)
After one year this reflex should not exist – response should be plantarflexion
If persists ? disorder of pyramidal system

Oral reflex:
Finger placed in infant’s mouth - should initiate sucking reflex

Grasp reflex:
Fingers should automatically grasp object placed in had – also foot should respond similarly.
Present up to about age 9 months.

Online resources:

ePodiatry's resources on pediatric history and assessment