Intoeing and knock knees. Common issues in kids. Should you worry?

Parents often worry about the position of a child's feet or knees and don't realize that many of the issues are simply the normal progression during growth. Parents may know of a family member who needed special shoes or a splint to help with a similar condition, so assume a child will need the same. We now know that the special shoes and splints are usually not needed. Some of the treatments  parents try can be harmful because they interfere with normal play and movement, so discuss any treatment you want to try with your pediatrician first. Most kids outgrow the conditions on their own, so no time or money needs to be wasted on "cures." Most of the time these conditions do not cause permanent disfigurement or joint disease.

photo source: Shutterstock

Feet

Intoeing is commonly called being "pigeon toed." Intoeing does not cause pain and should not interfere with walking. If there is either pain or trouble walking, be sure to talk with your pediatrician. The most common causes of intoeing include:

• Metatarsus adductus is when the toes and part of the foot turn in. This is usually seen at birth. We often call this "positional foot deformity" because it is due to the position of the foot in the womb. We may ask parents to gently stretch the foot to help it straighten. If it is very stiff sometimes working with a physical therapist is helpful. Metatarsus adductus usually goes away on its own by 4-6 months of age. Occasionally casting of the foot is needed to straighten it by the time a child walks. 
• Internal tibial torsion is when the tibia (shin bone) rotates inward. It usually becomes noticed during the early walking years. The position of the tibia makes the feet turn inward when standing. As the tibia grows, it usually straightens on its own. If a child has problems with walking due to this or if it persists after 8 years of age, a consult with an orthopedist might be helpful.
• Femoral anteversion is similar to tibial torsion, but it involves the femur (thigh bone). It tends to occur in kids from preschool through elementary school. If the thigh bone turns in, it makes it appear that the knees and feet turn in. It is common in young school aged kids and usually resolves as the bones grow and straighten. If it causes significant problems walking or lasts past 10 years of age, a referral to an orthopedist might be considered.

 For great pictures and more information on in toeing visit OrthoInfo.

Club feet may look similar to metatarsus adductus, but more severe. The entire foot is typically involved and misshapen. It requires repeated casting and sometimes surgery to repair.

Flat feet are also common in kids. The foot often has a good arch when sitting, but when a child stands, the arch falls. Sometimes the ankle also rolls in. Flat foot is normal in infants and young children. The arch develops in your child's foot until at least age 5. You don't need special shoes, wedges, inserts or heels.

Knees

Between birth and 18 months, an outward-turning (varus) alignment from hip to knee to ankle is normal. This makes babies and toddlers look like cowboys with their bowed legs. Between about 18 and 24 months, this alignment normally becomes neutral. When the child is between 2 and 5 years old, an inward-turning (valgus) alignment is normal. This makes young children appear knock kneed. The alignment returns to neutral as the child grows. A wide range of knee alignment is normal. Just look around at people-- they come in all shapes, including their leg position. Special shoes and wedges don't help bowed legs or knock knees. Special exercises are not needed to straighten the legs. Again, most of the causes are simply a normal progression during growth, but if there is pain, difference from one leg to the other, or difficulty walking, it is not normal.

More on bowed legs:

• Physiologic bowed legs is the normal bowed leg appearance of toddlers. Both legs are affected equally for a symmetrical appearance to the knees. I always joke that they need the cowboy-style bowed legs to fit the diaper. This usually goes away by 3-4 years of age.
• Bowed legs can make a toddler's walk look funny, but it does not delay learning to walk and it does not cause them to fall more or be less coordinated. 
• Teens who have persistent bowed legs can have abnormal pressure placed on hips , ankles and knees, resulting in pain. If pain occurs, they should be evaluated by their doctor.
• Blount's disease is an abnormal bowing caused by an abnormal growth plate at the top of the shin bone. It might not be symmetrical from leg to leg. In young children it might look like physiologic bowed legs, but by 3 years of age it worsens. It can be diagnosed by x-ray. You can see a picture of this on OrthoInfo. This is an abnormal condition and requires treatment by an orthopedist.
• Rickets is an uncommon cause of bow legs in the US. It is due to insufficient calcium, phosphorus, and vitamin D, either due to nutritional deficiency or a metabolic problem. X-rays and labs can help diagnose this condition. It is an abnormal condition, and treatment varies depending on the cause.
• Overweight children can develop a bowed leg appearance. Losing weight can decrease the stress on the hips, knees, and ankles to decrease the associated pain. Work with your doctor for help.

More on knock knees:

• Knock knees is a normal development in many kids. The knees seem to point inward. The knees can touch when the ankles are still apart. Knock knees usually straighten out by about 9 years of age, but in some families they persist into adulthood.

What to know about knock knees

• Knock knees are angular deformities at the knee, in which the head of the deformity points inward.
• A standing child whose knees touch but whose ankles do not is usually said to have knock knees.
• During childhood, knock knees are a stage in normal growth and development (physiologic valgus).*

* Between birth and 18 months, an outward-turning (varus) alignment from hip to knee to ankle is normal. Between about 18 and 24 months, this alignment normally becomes neutral. When the child is between 2 and 5 years old, an inward-turning (valgus) alignment is normal. The alignment returns to neutral as the child grows.

• The condition is slightly more common in girls, although boys can develop it, too.
• The condition usually becomes apparent when a child is 2 to 3 years old and may increase in severity until about age 4.
• Knock knees usually correct themselves by the time a child is 7 or 8 years old. Occasionally, the condition persists into adolescence.
• If the condition doesn’t appear until a child is 6 or older, she may have an underlying bone disease (pathologic valgus), and the condition may be more serious.
• Obesity can contribute to knock knees—or can cause gait (manner of walking) problems that resemble, but aren’t actually, knock knees.

How Boston Children's Hospital approaches knock knees
Doctors at Children's closely monitor your child’s leg development, to make sure that her legs straighten themselves naturally. In the unlikely event that the condition doesn’t self-correct, your child’s doctors may have her wear corrective leg braces. Only children with the most severe cases may need surgery.
Whatever observation or treatment your child needs, you can have peace of mind knowing that as a national and international orthopedics referral center, our Orthopedic Center has vast experience treating children with every kind of developmental condition, some of which few other pediatric hospitals have ever encountered. As a result, we can provide expert diagnosis, treatment and care for every severity level of knock knees.

- See more at: http://www.childrenshospital.org/health-topics/conditions/knock-knees#sthash.rE3S8TMp.dpuf

What to know about knock knees

• Knock knees are angular deformities at the knee, in which the head of the deformity points inward.
• A standing child whose knees touch but whose ankles do not is usually said to have knock knees.
• During childhood, knock knees are a stage in normal growth and development (physiologic valgus).*

* Between birth and 18 months, an outward-turning (varus) alignment from hip to knee to ankle is normal. Between about 18 and 24 months, this alignment normally becomes neutral. When the child is between 2 and 5 years old, an inward-turning (valgus) alignment is normal. The alignment returns to neutral as the child grows.

• The condition is slightly more common in girls, although boys can develop it, too.
• The condition usually becomes apparent when a child is 2 to 3 years old and may increase in severity until about age 4.
• Knock knees usually correct themselves by the time a child is 7 or 8 years old. Occasionally, the condition persists into adolescence.
• If the condition doesn’t appear until a child is 6 or older, she may have an underlying bone disease (pathologic valgus), and the condition may be more serious.
• Obesity can contribute to knock knees—or can cause gait (manner of walking) problems that resemble, but aren’t actually, knock knees.

How Boston Children's Hospital approaches knock knees
Doctors at Children's closely monitor your child’s leg development, to make sure that her legs straighten themselves naturally. In the unlikely event that the condition doesn’t self-correct, your child’s doctors may have her wear corrective leg braces. Only children with the most severe cases may need surgery.
Whatever observation or treatment your child needs, you can have peace of mind knowing that as a national and international orthopedics referral center, our Orthopedic Center has vast experience treating children with every kind of developmental condition, some of which few other pediatric hospitals have ever encountered. As a result, we can provide expert diagnosis, treatment and care for every severity level of knock knees.

- See more at: http://www.childrenshospital.org/health-topics/conditions/knock-knees#sthash.rE3S8TMp.dpuf

Nosebleeds

Many of us remember having a lot of nosebleeds as children, yet they bring fear to parents when their kids have them.

Why won't it stop?

Why are they getting so many?

Is there a bleeding disorder?

Does it need to be cauterized or packed?

Most of the time a nosebleed is just that. A nosebleed. 

Unfortunately, they are common in kids -- especially when they are sick or suffering from allergies (due to swollen nose tissues) or the air is dry. They often happen at night, when the head is at the level of the heart. They also start with a forceful blow of the nose, sneezing, or other things that cause sudden pressure in the nose.

The part of the nose that commonly bleeds is the center part separating the nostrils. If you look carefully up the nose toward the center on both sides, you can often see blood vessels close to the surface. After a bleed you can often see the scab. Trauma to the nose can cause bleeding higher up, but the most common bleed in kids is very close to the tip of the nose.

Once it bleeds, it is likely to bleed again and again until the skin completely heals. Sometimes it is just a few specks of blood when the nose is blown, other times it is full-on bleeding that seems to keep going and going.

When the nose is bleeding:

• Sit or stand. Don't lay down-- that increases the pressure in the head, which increases the bleeding.
• Don't tilt the head back -- that causes blood to go down the back of the throat. You can tilt it forward slightly.
• Pinch the nostrils at the highest part the nose is soft (just below the hard part) with a tissue or cloth. 
• HOLD IT FOR 10 MINUTES. Do not peek. Do not check. Do not let go.
• Seriously, don't let go for 10 minutes. This is the step kids have a hard time with. One minute seems long. Ten is forever. Hold it for 10 minutes anyway.
• Some people like to put an ice pack over the nose, but if you do this, still try to hold pressure on the nostrils. Put the ice pack on top of the nose, above your fingers that are holding pressure.
• AFTER 10 minutes, gently remove the tissue or cloth. If it is still bleeding, hold for ANOTHER 10 minutes. Still don't peek during this time. 
• If after the two 10 minute holds (20 minutes of pressure total) it is still bleeding, it is time to go to the doctor. If you haven't tried a real 10 minutes of consistent pressure, that is what they will do first, so save yourself the trip and the money and HOLD IT FOR 10 minutes!

After the bleeding stops:

• Do not blow the nose for 24 hours if possible to allow the skin to heal under the clot.
• Do not pick the nose. 
• Add humidity to the air with a humidifier or vaporizer.
• Add petrolatum jelly to the nostrils. Use a cotton tipped applicator or a tissue. My kids loved the "Vaseline sword" -- we put vaseline on the tip of a tissue and pulled it into a sword shape. We put the sword in the nose, plugged it from the outside, and pulled the sword down, coating the inside of the nose with the petrolatum jelly.
• Treat allergies if needed to decrease the swelling in the nose tissues.

Remember that as long as there is a scab in the nose, it will re-bleed if the scab falls off before the skin completely heals underneath. Keep moisture in the air, the nostrils lubricated, and remind kids to not pick!

Most nosebleeds are simple nosebleeds, despite how scary they look!  

Red flags (or things to see a doctor about):

• Frequent nosebleeds that take 20 minutes of pressure to stop.
• Bruises that are not explained by injury. (In general, any child with bruises all over the shins is normal. Think of areas that don't often get bumped or hit -- if they are bruising for no reason, that is more of a concern.)
• Gums bleeding. This is commonly due to poor oral hygiene and gingivitis, but can be due to a clotting problem.
• Red or purple spots on your skin that don't blanch with pressure. These are petechia and can be seen when there is a clotting problem. 
• Blood in the stool. While the most common cause of this is constipation, if you have multiple sites of bleeding, you should be evaluated by a doctor.
• If you think your child stuck something up the nose that might have contributed to the bleed.
• If there was trauma to the nose or face that otherwise needs to be checked out.
• If your child seems pale, unusually tired or dizzy, or has unexplained weight loss or fevers.
• If your child takes any medications that thin the blood. (This is unusual in kids, more common in adults, but high doses of fish oil might increase bleeding risks.)

What do doctors do about nosebleeds?

• Usually all that is needed is home treatment and I simply reassure the parent and child with the above information.
• If there are frequent bleeds, I will sometimes recommend cauterization of the nose. This sounds scary, but it is a relatively easy procedure. One common method is using silver nitrate. It is applied to the areas where the blood vessels are close to the surface of the nose. In many people a single treatment is all that is needed. Some people require repeat treatments.
• Treat any underlying allergy to control the nasal swelling.
• If there is a family history of a bleeding disorder or signs of other bleeding (bruises or petechiae, rectal bleeding, gum bleeding, heavy menstrual bleeding) blood work can be done to see if there is a bleeding disorder.
• If the bleeding is from trauma, we make sure there is no hematoma or broken bones.

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Tamiflu: Guest blogger Dr. Mark Helm

Those of you who have spoken with me about Tamiflu or who have read my blog, To Tamiflu or Not To Tamiflu, know where I stand on Tamiflu. My online friend, Dr. Mark Helm, has written about Tamiflu in a very say-it-like-it-is way. Take the time to read and share!

photo source: PRWeb.com

Tamiflu is probably not going to help you.

Like all prescription medicines, Tamiflu (oseltamivir) can cause many complications. A large number of people who take oseltamivir have side effects which actually feel a lot like the flu (belly problems, headache, etc.). These side effects can be so bad that some people decide they want to stop taking the medicine and take their chances with the flu! Using oseltamivir in kids is very challenging. Children often can not understand or report that the medicine is making them feel bad or altering their thoughts or behaviors.

Almost all of what we know about the safety of this medicine comes from the company which makes and sells it. Doctors know only what that company has revealed. When objective researchers have tried to discover if it actually helps, they have generally found that oseltamivir does very little, if anything, to treat the flu. Even the company concedes that the drug MAY shorten symptoms of the flu by one to one and a half days. Oseltamivir has not been proven to change the outcomes (death, hospitalization, loss of time from work,) of having the flu. It also has not been well-studied in people with significant chronic diseases - who are exactly the people we most worry about when it comes to flu infections. If the medicine is started very early (less than 24-40 hours after symptoms begin), then it may shorten the length of time a person is sick by an average of about 31 hours. Again, this medicine does not seem to affect the need for hospitalization or risk of death that comes from being infected by the flu virus.

Oseltamivir is expensive. It may or may not be covered by your health plan's pharmacy benefit. If it is covered you may only have to pay a co-payment, but your employer or insurance company will have a much larger bill to pay. They will pass those costs on to you next year with premium increases (or cuts in benefits).

A helpful and well-reasoned pamphlet regarding the flu and Tamiflu (oseltamivir) is here. Here's more good stuff on Tamiflu (oseltamivir), including a helpful tab outlining side effects and their frequency.

The challenge for physicians and other prescribers on deciding when oseltamivir may be helpful is balancing the relatively low risk of any individual developing the flu (maybe 1 in 20) against the facts that more like 1 in 10 people taking the drug will have significant side effects, and that there is not likely to be any difference in outcomes for the patient.

So, if you can’t count on Tamiflu, what should you know and what can you do?

Flu will hit you like a ton of bricks, and make you feel horrible. It generally will flatten anyone for about 5-7 days. It is particularly dangerous for "high-risk" people - that is people who have other chronic illnesses, the very young or the very old. However, for health professionals, the more scary illness is the “second sickness” that may follow the flu. If a person with the flu starts to get a little better but then starts feeling worse, they should be seen by a doctor as soon as possible. Additionally if a person with the flu starts to gets worse after 2-3 days of the start of symptoms this is also very concerning.

Flu is a very serious disease every year. 2014 is no exception. The flu strain that is most common this year is the same variety that caused the global epidemic in 2009.

Fortunately, flu is largely preventable with immunization - this is why we try to immunize everyone we can. Despite what some say, the flu vaccine - particularly the injectable vaccine can not give you the flu. The flu shot contains no live virus - only proteins made by the virus. The small dose of these proteins in a flu shot are enough to train our immune system to recognize and fight off the flu. The nasal vaccine does contain a live virus, but it is altered so that it can only reproduce and spread at temperatures lower than in the human nose. Both vaccines teach the immune system to recognize and kill the flu virus.

The vaccine is adjusted each year to match the strains which are believed to be most likely to circulate in the coming season. The vaccine for the 2013-2014 season contains proteins which match the “H1N1” strain that is causing 90% of the disease. People who received the flu vaccine this season have a much lower risk of catching the flu than those who did not get vaccinated - but even for vaccinated people, the risk for flu is not zero. It generally takes at least two weeks after a flu vaccination for the body to develop a good, fighting response. So plan ahead for your vaccine next year… Anytime between Halloween and Thanksgiving is a good time to get vaccinated for the flu.

If you have not had your flu shot this season, and you are worried about the flu, ask to be vaccinated. Assuming that there is still some vaccine supply left, vaccination, avoiding prolonged close contact with people with the flu, and washing your hands are your best defenses against the flu. If you already had your flu shot this year, you should not be worried - you have already taken your best chance to avoid the flu.

About Dr. Helm:

Mark E. Helm, MD, MBA, FAAP is a general pediatrician in Oregon at Childhood Health Associates of Salem. He is active with the state and national American Academy of Pediatrics, involved with the Section on Clinical Pharmacy and Therapeutics, and the Section on Administration and Practice Management. He is currently a member of the Committee on Child Health Financing. Prior to becoming a pediatrician, Mark was a pharmaceutical industry “insider” working in market research. After training at Arkansas Children’s Hospital, Dr. Helm worked with the Arkansas Medicaid program to develop an evidence based “preferred drug list” and to establish policies which promoted safe and responsible use of medications, including psychotropic medication for children. Dr. Helm gets his flu shot every year.

Baby Monitors… Are they safe or effective?

The uses and applications of baby monitors have grown over the years. There are audio-only versions, video monitors, and now motion sensors. Soon they will be able to tell you baby's oxygen level and temperature or predict how long your baby will sleep. How did parents ever have kids before these? (Big sarcasm here!)

photo source: Shutterstock. Baby on a hospital monitor

Some of the newer baby monitors claim to be able to help a parent learn a baby's sleep patterns to help with sleep training. I think it is wonderful to have all the research that is being done on sleep and I know that it is hugely important for babies and their tired parents to sleep, but I wonder how we did it for so many centuries by just paying attention to our babies and learning their cues? I don't think it is a good thing that parents rely on gizmos to "learn" about their babies.

Unfortunately monitors are sold with the hint of prevention of SIDS. Parents often feel a sense of comfort when they sleep with a monitor to alert them when baby cries. When I was a new mother the monitor was rarely used. I had more anxiety when it was on and I couldn't sleep as well. I could hear the cry just as well without the monitor, but the monitor allowed me to hear every deep breath, grunt or sighing noise common to a sleeping baby. The monitor highlighted every sound, keeping me awake. I know our neighbors used a monitor when we would gather outside on their driveway or deck and their baby was asleep or if they were in the basement and baby was upstairs on the 2nd floor. I can actually see a benefit to that, but I hope parents would never use the smartphone app to use it when they stray far from home.

Parents are starting to ask about the newer generation monitors that sense baby's movement and alarm if no movement is felt. Some will even vibrate the baby if no movement is sensed after 15-20 seconds. Before you think these are the answer: the FDA has NEVER approved a baby product to prevent or reduce the risk of SIDS. I know of one product that is working with the FDA and projects that by 2015 they will get FDA clearance. At this point, their sock only tells parents the vital signs and oxygen. It doesn't even look like it alarms when the level gets low. Until it has been shown to work and be safe for general use, I would not waste money on any device. And yes, some of these devices have actually strangled babies to death, so they are not without risk!


If you really want to help prevent SIDS, use the precautions recommended by experts. (For more, see my previous blog on SIDS Prevention Guidelines.)

• Before baby's born: get regular prenatal care and do not smoke, drink alcohol, or use illicit drugs during pregnancy. 
• Put baby on his back to sleep. Every time. Even if you're in the room. When baby can roll on his own, he can sleep in the position of comfort he finds. 
• Use only a firm sleeping surface made for infant sleep. Never leave baby on the couch, in an adult's bed, in a car seat, in a sleep positioner, or in a swing.
• Check your crib and bassinet for recalls. 
• Pacifiers have been shown to help prevent SIDS, so it is okay to use one for baby's sleep times. If your baby won't take one, that is okay. You cannot force it. Some breastfeeding experts say to wait until 3 weeks to allow breastfeeding to be established, but I do not find that it interferes with breastfeeding if you use a pacifier earlier.
• Keep all soft objects (pillows, loose blankets, bumper pads, stuffed animals) out of the bed until your baby is over 1 year of age.
• Keep baby out of your bed, but in your room.
• Breastfeed as long as possible. Yes, it has been shown to help prevent SIDS!
• Vaccinate your baby. Research shows immunizations may protect against SIDS and we know they prevent illnesses that cause death.
• Get baby regular health checkups to insure proper growth and development.
• Keep baby away from smokers and places where people smoke. If you smoke, talk to your doctor about ways to quit. If you cannot quit, never smoke in your home or car. Always go outside where the smoke is less likely to settle on your hair, clothes and furniture.
• Keep the room at a comfortable temperature and avoid over wrapping your baby. When babies get too hot, they are more likely to suffer from SIDS.
• Do not use home cardiorespiratory monitors to prevent SIDS. Some babies leave the hospital with these due to heart or lung problems, but they have never been shown to decrease SIDS.
• Do not use other products that claim to reduce the risk of SIDS. As stated above, none have been shown to prevent SIDS. 
• Give baby tummy time when you can watch and play with him. This strengthens baby's muscles to allow him to learn to roll over safely by 4-6 months.
• If you are overly tired or are under the influence of certain drugs or alcohol: you may not be alert enough to care for your baby. Ask for someone else to help until you are more alert and able to wake to baby's cues.

Baby Safe Sleep Resources

• AAP Policy Statement on SIDS
• NIH Back to Sleep Campaign
• NIH Preventing Sudden Infant Death Syndrome and Suffocation
• National Institutes of Health. Eunice Kennedy Shriver National Institute Of Child Health And Human Development. What Does a Safe Sleep Environment Look Like? 2006. No. 06-5759
• Changing concepts of Sudden Infant Death Syndrome: Implications for Infant Sleeping Environment and Sleep Position. 2000 Mar, 105(3 Pt 1):650-656
• A Parent’s Guide to Safe Sleep
• Dear Fisher Price is an open letter to Fisher Price from KCKidsDoc regarding their Rock n'Play Sleeper