worried about son's legs and feet

[meikman]

My son was born 8 weeks early he weight 3.12 lbs.  He did very well only on vent for less than 2 days.  He did have trouble with feedings and de-stats.  He was in the NICU for only 40 days.  While in the NICU they go over everything that could go wrong with a preemie and CP being one of them.

My son is now 19 months and is doing well.  He is at 100% on height and weight and is a very smart boy.  He always gibbers although you can't understand a word he is saying.  He smiles a lot and finally is starting to enjoy cuddles and being held.  For the longest time he was very stiff.  It was very hard to hold him.  He didn't start to lay his head on my shoulders until he was around 14-15 months and then it was only once in a while.  If he feel asleep in my arms he would be straight up and down.

I have a question about his walking.  He does do very well and actually runs a lot but he trips over his feet.  He is bowed legged and his feet turn inward.  Also it is still very hard to get his shoes on.  He curls his toes must of the time.  He curls them so tightly that I swear he could hold his on weight if you hooked his toes on a line.  We got him saddles that open around his ankles and toes to try to train his toes to straighten out.  To this point he hasn't been able to wear shoes.  He has been evalveted when he was around 12 months and they said that it was normal for babies to curl their toes and that he didn't need to wear shoes.  (Bad thing in the winter)   At his last Dr visit she still wasn't concern but I am.  Has anyone had experience with such a thing?

[Quixotic1]

Yes, I do have experience with premies and with some of the things you describe and I'll try to help you.  However, it's hard work at the screen today so I'll try to get back soon when I feel better.  Quix

[Quixotic1]

I haven't forgotten you.  I'll try to write tomorrow. Sorry, Quix

[meikman]

That's ok!  You look like this site keeps you very busy.  I hope you are feeling better.  Any thoughts will be greater appreciated.

[Quixotic1]

I have a couple comments.

After 40 days in the NICU - with very common premie problems - ei, nothing that sounds very serious, it isn't unusual for one to be a little adversive to being held, stiffening and pushing away.  If it had been persistent, I would watch carefully for signs of CP.

Does he walk with the toes uncurled or sleep with them uncurled?  Does he play with his feet or kick at objects while sitting without curling his feet ?  What I'm asking is the curling only in the context of shoes?

He is 19 months old, but his developmental age is 17 months.  For now you still have to subtract the 2 months prematurity in assessing his development.  Yes, it is common to curl the toes with stimulation in infants.  I don't really know when that reflex goes away, but it may still be part of an lingering adversive, reflex.  That is the touching of the shoes to his feet may be disagreeable to his nervous system and his body "shrinks" from it.  The goal if this is the case would be to desensitize his feet gradually.  If this could the case we could talk about ideas for it.

BTW - all the pediatric orthopods I knew disagreed with the stiff leather shoe or high tops.  They all recommended little tennies like the cheap ones at discount stores.  These allow protection for the toes and soles, a little support for balance and maximun flexibility to allow strengthening of the structures of the feet and ankles.  Also you can purchase new ones for a couple $ as the feet grow, and grow the certainly do.

Another real possiblitiy is he is playing you.  Babies learn to manipulate us long before we catch on.  Premies often get more anxious attention and worry than babies who who not had the worrisome beginnings. Attention is wonderful! They learn how to prolong attention from M & D.  They will refuse something or struggle against something that the parents want them to do.  This occurs even if the child appears to get attention 24/7.  The most common example is refusal to eat.  This can tear up a family, and the struggles to get a food refuser to eat are very entertaining for the toddler.  It is easily treated with behavioral therapy.

On to the bend/bowleg and the feet turning in.  Please remember that without seeing him I can' be sure.  How old was he when he pulled up and when he first walked?

In utero a baby sits with the legs and feet cross-legged. Because of the curve of the uterus the lower legs bend around and the ankles are bent inward and curled up against the body.  With your son on his back, like you're playing with him, fold his legs back up like he was still in the womb.  If you need you can find pictures on the internet for this position, but I think you'll recognize it.  

Does the curve of his lower legs and the turning inward of his ankles fold up into a nice, comfy package like the "in utero" position?  If so, then the probable answer to your question is that he has simple "tibial torsion."  This is a slight bend/rotation of the lower leg from the position in utero.  Very, very common.  The same is generally true for the ankles turning in, but the analysis is a little more complicated.  I'll have to discuss that later.

Okay, the bend is caused by the position.  How is it fixed?  Bones can't change shape until the muscles pulling on them start really working.  Ususally, tibial torsion begins self-correcting over the first 8 to 10 months of a child's walking.  The muscles of the legs in standing and walking re-mold the bones into a straighter line.  That's why I asked when he started walking.  Maybe you could look at pictures of his "bowlegs" when he started walking and pictures now.  You'll likely already begin seeing a difference.

If the apparent bow-legs looks like a true bend at the knee joint, the legs won't fold up as neatly when you the test above, you should have the pediatrician look.  I don't think this sounds like your son's problems at all.  Rickets has been seen in premies, but usually only in extremely tiny premies that spent a long time (weeks to months) with IV feeding.

The old practice of putting little ones in braces to trun their feet out has been debunked.  The improvement rate is the same for braced kids as for kids allow to develop normally.

I'd like to hear your responses.  Quix

[meikman]

Thank you for your reply.  It is greatly appreciated.

Josh will walk without his toes curled but it seems to be rare and mostly when he is running.  I notice on the hard wood floors he will stand with his toes pressed to the floor.  You can see the the skin turning white from the pressure.  On the carpet he will walk curling his toes.  If touch anywhere on his feet his toes will automactally curl.  Just recently I have been able to to play this little piggy with his toes as he didn't like them to be touch.  He would get fussy and kick.

I remember reading something about a sensitive nervous system.  My oldest son was very sensitive to certain touches.  That was 15 years ago and you never heard about SNS.  It makes me wonder if that wasn't what was going on with him.  He to was early but just by 3 weeks.  He couldn't stand to get his hands dirty.  He wouldn't have a melt down if he got the slightess  amount of dirt on his hands.  He also couldn't stand  usual children "things" such as play dough, finger paints, sand and he wouldn't eat jello, popcicles, mac and cheese and such.

Josh developed quite quickly from starting to sit around the age of 10 months to walking at 12 months.  Our Peds didn't expect him to walk until around 15 months.
My daughter had the tibial torsion and yeah you could fold her legs up neatly it was like they were molded that way.  Josh doesn't fold so neatly.  If he stands foot to foot the inside of his legs are oval shape from the groin area to the feet.  With my daughter if she stands foot to foot her knees overlap.

I thought that if I could get the shoes on him that it would help stretch out his. At first he would have a fit if we got his shoes on and it would only last a few minutes before they came off.  I try to stretch his toes before trying to put his shoes on.  I put my hand on the bottom of his foot flat and apply just a little pressure on his toes until the relax and move to a slight upward way.  If I do this and have him distracted with something else I can get the first shoe on.  Not so easy with the next.  The sandles work the best because I can just apply the straps across his toes and ankles.

Thank you so much for your imput.  It is very good of to take time for me when you are so oboviously busy and your time is so valued.

[Quixotic1]

You are much further ahead in your understanding of physical development than I wrote for.  I hope I didn't sound condescending.  

It does sound like there is a neurological basis for yur son's toe curling.  And my guess is that it is hypersensitivity to touch.  Certainly he has shown signs of that in the past.  My understanding is that gradually working to desensitize them is the proper direction and the one which you are apparently following.  Playing with his feet, using different textures and pressures progressing from milder to more stimulating.  Walking on different surfaces, carpet, floor, dirt, sand, water.  Always trying to  make it pleasant and without putting too much attention on it.

You are correct also to work on strecthing his toes straight out a couple times a day if they are curled most of the time (do they curl in sleep or only with stimulation?)  Can he stand on his "tiptoes" to reach up for something without curling his toes under?

If his legs bow from the hip down he needs an evaluation,  especially if it is worsening.  This would include a thorough check by his pediatrician, and X-rays of his entire legs from the pelvis/hip to the ankles.  Does he have something of a "waddling" gait - a side-to-side rock as he walks?  If so, my first thought is an unusual one, but still occurs and I have seen it.  That is rickets, which can be a vitamin nutritional deficiency or congenital or have rare metabolic or physiologic causes.  Was (is) he solely breastfed?  Is he lactose intolerant?  Do you live in an area with less sun (northern latitudes)?  He has already lived through two winters in his 17 months, so if you live in a very cold climate, his exposure to sun will necessarily have been limited.  I only bring it up because everyone thinks with modern nutrition it is totally a thing of the past and it isn't, especially in solely brestfed infants. It isn't common and is sometimes missed. I will not ask you for the info, but it is more common in children of African descent because the dark skin produces less Vit D in response to the sunlight.

You should first have your son's Dr. evaluate his hips and entire legs.  Of course, here online I may be picturing the absolutely wrong thing.

Well, I've gone on-and-on again.  I hope this has been helpful.  Quix