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Louis DeCaro,DPM

Richard Jay,DPM

Karen Langone,DPM

Yaron Raducanu,DPM

Mark Caselli,DPM

Pediatrics is one of podiatricmedicine’s best kept se-crets. From afar, observerscould easily assume thatthe profession of podiatric

medicine and surgery involves purelyadult and geriatric care. That couldn’tbe farther from the truth. In fact, thetreatment of children and children’sfoot problems should be a vital partof common podiatric practice. Be-sides the direct benefit to those chil-dren impacted by foot problems,from a practice standpoint, podopedi-atrics can be a valuable source ofsustaining referrals in that once thecare of children is entrusted to a po-diatric physician, the care of otherfamily members will most likely soonfollow.

Acknowledging this important partof podiatric practice, Podiatry Man-agement has invited several leaders inthe field of podopediatrics to sharetheir thoughts on various topics, in-cluding conservative and surgicalhandling of conditions as well asvaluable practice management tips.They also graciously offered recom-mendations for those podiatrists inter-ested in expanding this potentiallystrong part of their practices.

Joining this panel are:Mark Caselli, DPM is adjunct

professor, Department of OrthopedicSciences, NYCPM, adjunct professor,

Ramapo College of New Jersey, fel-low, American College of SportsMedicine, fellow, American College ofFoot and Ankle Pediatrics, former

chairman, Department of OrthopedicSciences and director of Pediatrics,NYCPM.

Louis DeCaro, DPM specializesin pediatrics with a special interest insports medicine and biomechanicsfor both adults and pediatrics. He isvice-president of the American Col-lege of Foot & Ankle Pediatrics(ACFAP). He is currently in privatepractice with an office in West Hat-field, MA. He is a member of the sur-gical & medical staff at Franklin Med-ical Center and Holyoke hospital. Dr.DeCaro is the founder/director of anadult & pediatric biomechanics gaitlab, which takes place biweekly athis office.

Richard Jay, DPM has dedicat-ed the last three decades to his footand ankle surgical practice and tomedical education. He is a profes-sor in Foot and Ankle Orthopedicsat Temple University, former direc-tor of Pediatric Foot and Ankle Or-thopedics at Temple University,and former director of the Foot andAnkle Surgical Residency Programand Medical Education at the Grad-uate Hospital in Philadelphia. He isthe past president of the Ameri-

Our expert panelists discuss current topics in this subspecialty.

Building YourPodopediatric Practice

BY MARC HASPEL, DPM

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can College of Foot and Ankle Pedi-atrics and former pediatric surgery ed-itor of the Journal of the AmericanCollege of Foot and Ankle Surgery.Dr. Jay is presently in practice atCumberland Orthopedics RegionalMedical Center in New Jersey and isthe Chief of Foot and Ankle Surgery(Med. Ed.).

Karen Langone, DPM is treasur-er, American Association of WomenPodiatrists, past president, AmericanAcademy of Podiatric Sports Medicineand lead clinical director, NYS FitFeet, Special Olympics International.

Yaron Raducanu, DPM is fellow,current president and past vice presi-dent, American College of Foot andAnkle Pediatrics. He is board certifiedby the American Board of PodiatricSurgery, adjunct clinical professor,Temple University School of PodiatricMedicine, and attending podiatricphysician, Temple University Podi-atric Surgical Residency.

PM: What is your feelingabout the effectiveness ofsplinting to manage footdeformities once childrenbecome early ambulators?

Caselli: Once a child becomesambulatory, splinting can be very ef-

fective in managing certain foot de-formities, and should be used post-operatively or post-serial casting fortalipes equinovarus or metatarsusadductus correction. This can bewell into the child’s early ambulato-

ry period to maintain correction. Anopen-toed straight last or abductedlast shoe should be used for mosthours of the day and night. The shoecan be modified with a felt bar ex-tending from the base of the 1stmetatarsal to the distal end of theshoe to provide a snug fit and main-

tain the foot in a rectus alignment.This type of shoe can be used as theinitial treatment in the early ambula-tor with metatarsus adductus or inthe child with a residual adductus

Once a child becomes ambulatory, splinting can be veryeffective in managing certain foot deformities, and shouldbe used post-operatively or post serial casting for talipesequinovarus or metatarsus adductus correction.—Caselli

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deformity after other forms of treat-ment for talipes equinovarus ormetatarsus adductus.

Open-toed straight last shoes aremade in sizes to accommodate two tothree year old children. They shouldbe worn 22-24 hours a day to be ef-fective. I often provide two pairs ofshoes, one for day and one clean pairfor night use. The child’s foot shouldbe evaluated weight-bearing monthlyand the shoe re-modified. This shouldbe continued until the foot remainscorrected for at least four to sixmonths. I then recommend that theshoe be worn in the evening until itno longer fits. Night splints or AFOsshould be used at nap time and in theevening, following ankle equinus cor-rection in an early ambulator for atleast four to six months after the equi-nus is resolved.

DeCaro: With reference to mostearly foot deformities, I am a big be-

liever in controlling the calcaneusbecause, until the age of six, thecalcaneus plays a huge role in creat-ing forces on the rest of the foot.Therefore, in a patient with juvenileHAV/hammertoe, controlling theheel in varus in a very early ambu-lator will prove effective at slowing

down whatever deformity may bethere or waiting to worsen. In otherwords, I splint with a deep heel cup.I don’t think that taping joints to

change angulations is particularlysuccessful. I would, however, neverdiscourage parents from keepingcertain joints splinted in improvedpositions.

As long as the biomechanics arenot being compromised throughsplintage, allowing the ligaments

and joint capsule to sett le in amore corrected position during ma-turity can only help the situation.

In cases of metatarsus adductus, in particular,I am a frequent user of the Wheaton brace. I find thatsplinting the foot nightly in a more correctiveposition helps to reshape and/or hold themidtarsal ligamentous structure.—DeCaro

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In cases of metatarsus adductus, in particular, I am afrequent user of the Wheaton brace. I find that splint-ing the foot nightly in a more corrective position helpsto reshape and/or hold the midtarsal ligamentousstructure.

Langone: I agree that splinting can play an impor-tant role in treatment but it should never limit ambula-

tion or impair the young walker’s investigation of move-ment.

Raducanu: I too believe there is a use for splinting,but would prefer to get these kids in casts before theystart ambulating. There is an advantage to splinting ifthere is no other alternative, age wise, but my feeling isthat, at that point, you are only trying to reduce the de-

formity somewhat until you can address it surgically.I’m quite sure that just about any deformity, if ad-dressed soon enough, and when the child is youngenough, can be cast out. The trouble is that these prob-lems are either not identified early enough or the par-ents are told that the child simply “will grow out ofthem.”

PM: What new or available techniques are youselecting in the treatment of plantar verrucae inchildren?

DeCaro: I use duct tape therapy (weekly ap-plication directly over the wart for six treatment cycles)and oral cimetidine (300mg/kg given TID in divideddoses over four to six weeks). I try to stay as conserva-tive as possible. I find that most verrucae in kids pos-sess similar traits, which allows me to avoid possiblesurgical complications such as scarring, infection, andfurther discomfort. Overall, I feel that by stimulating animmune response by both the duct tape and oral cimeti-dine, I achieve rapid resolution of the warts. There aretimes, however, when I must resort to less conservativemeasures.

Caselli: There are many factors in an individual’ssusceptibility to developing and resolving a wart infec-tion, including the child’s immune system and the con-dition and environment of their skin. This often leadsto a great variation in the time involved in treatmentand the success of any type of treatment. It has alsobeen my experience that most treatments over a periodof time result in success. Because of this observation, Iselect a treatment plan with two main goals. Firstly, inorder to do no harm, I do not use any treatment thatcan result in scarring of the skin, especially the plantarsurface.

Secondly, I attempt to cause minimal to no discomfort.I employ gentle sharp debridement to “pinpoint” bleeding.With good technique, the child should experience minimaldiscomfort. I stop as soon as the child complains of pain. Icauterize the bleeding with silver nitrate. If that stings, Iimmediately dab the area with cool water. If the child’sskin is hyperhydrotic, I have the parent apply a dryingagent. If the skin is excessively dry, then a moisturizingagent is used. This appears to help resolve the infection.For young children, weekly visits are necessary. Patienceis vital, on both the part of the child, parents, and treatingdoctor.

Langone: Put simply, I have been using cryotherapyor having 60% salicylic acid compounded for my warttreatments.

Raducanu: One of the doctors I work with intro-duced me to using topical Aldara under occlusion, and Ihave seen great results with kids if their parents arediligent with the treatment protocol. I also happen to

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QIhave been using cryotherapy or having60% salicylic acid compounded for my

wart treatments.—Langone

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think that oral Cimetidine is under-utilized. I find it really helps.

PM: How are you treatingcases of pediatric ony-chomycosis and do you ap-prove of oral medicationfor that condition?

Langone: I use manual debride-ment and topical meds. I do not useoral meds in the pediatric population.

DeCaro: I also do not approve oforal medication in children for thetreatment of onychomycosis. I actu-ally like topical Formula 3 for kidswith onychomycosis. I find the ther-apeutic reasons for selecting Formu-la 3 in pediatric therapy include: itis non-systemic, safe, and it’s effec-tive. In addition, for active kids, theoils in that product restore the nail’snatural mechanical properties allow-ing the nail unit to absorb impactand micro-trauma, preventing thetearing of the plate from the nailbed. These tears become naturalportals of entry for fungus to ad-vance proximally.

Caselli: It appears that mostcases of pediatric onychomycosis in-volve an underlying nail pathologywhich results in a nail deformitymaking the nail susceptible to a fun-gal infection. Some of these patholo-gies include conditions such aspachyonychia congenital, ectoder-mal dysplasia, and psoriasis. Anoth-er common etiology is nail traumacausing a subungual hematoma anddamage to the nail matrix, which re-sults in deformed, thickened toe-nails. Chronic paronychias can alsocause nail matrix damage and de-formed, thickened toenails.

My primary approach is to deter-mine the etiology of the deformedtoenails. If it is a congenital prob-lem, and cannot be corrected, thentreatment is directed to maintain thenails in as good a cosmetic andfunctional condition as possiblewith careful debridement, filing,and use of high concentration ureapreparations when the child isolder. Permanent removal of thetoenails may also be an option in

the older child. If the nail deformityappears to be traumatic in origin,then I address footwear and/or footfunction that may contribute to thenail trauma and allow time for thenails to re-grow. In either case, I donot recommend oral (systemic) anti-fungal medication in children. Thesemedications are not addressing theprimary etiology of the problemand, if they do result in some im-

provement in the nail, they wouldhave to be used for long periods oftime, which is contraindicated forthe present medications.

PM: What is your recom-mendation for children re-garding hard versus softshoes?

Jay: It is not a matter of a softflexible shoe versus a rigid shoe;shoes are meant to protect against theenvironment. By maintaining thechild’s foot in its proper biomechani-cal alignment internally during devel-opment, foot function improves anddeforming forces are limited.

It is essential that excessivepronation be neutralized as soon asa child is old enough to stand. Thegoals are to improve the child’sfunction and to prevent future footproblems associated with flatfoot;this is accomplished with properalignment of the foot during devel-opment. Inner-support systems tocontrol the three biomechanicalplanes are essential. Unfortunately,the shoes in production now do notprovide this support. It is the podi-atric physician’s job to constructthis inner support with custom or-thoses, which may be expensive,but are needed.

Raducanu: I really think thatchildren should be in harder shoes.I know certain companies profess

that kids should be in softer shoes,but my gut tells me otherwise. Nei-ther of us have hard data to show,but new walkers need support andprotection. A softer shoe certainlydoesn’t offer as much protectionand, as children are learning towalk, a firmer support base justmakes sense to me. Someone oncementioned that children need softershoes to help with normal gait pat-

terns, but new walkers’ gait pat-terns are nothing like their adultcounterparts. Until there is a compa-ny willing to fund a good study, allof this is just conjecture in any case.It’s just a bunch of us throwingaround opinions.

DeCaro: Those of us who spe-cialize in podopediatrics are com-monly faced with the challenge oftreating not only by proper orthoticor brace control, but also finding thecorrect shoe to complement the care.The common goal with all pediatricfoot orthoses is to help children gainmobility, ultimately giving them abetter quality of life. Proper supportgives a child the gift of running,jumping, and playing with confi-dence and stability. Providing theorthotic device is only half of the so-lution; proper shoe fit is equally im-portant. Most children with mild tomoderate flexible flat foot benefitfrom sturdy shoes to adequatelyhold a pre-fabricated or custom or-thotic device as an important part oftheir treatment. If the shoe is tooflexible and they wear an orthoticdevice, it can be analogous to tapingorthotic devices to the feet and hav-ing the patients walk on the couch.The sheer instability created can jamthe hard devices into the feet andcause pain.

If children do not need an orthoticdevice, then the sturdiness of the

It is essential that excessive pronationbe neutralized as soon as a child isold enough to stand.—Jay

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shoes should depend solely on the ac-tivity they are performing. Similar toadults, children should wear sport-specific types of shoes to help withthings such as lateral stability insports like basketball and tennis, tomore firm-lasted shoes for sports suchas those that involve fields with un-even surfaces.

Casell i : The most importantconsideration in children’s shoes,far out-weighing hard versus soft, is

proper fit. First walkers’ feet growvery rapidly. It is not uncommon forthem to outgrow shoes every two tothree months. There appears to beno harm in using either type ofshoe. There are advantages and dis-advantages to each type of shoe,however, for certain situations. Themain purpose of a shoe is to protectthe foot from the environment. Thesize of first walkers’ feet are dispro-portionally large compared to thelength of their legs, and coordina-tion is immature.

In normally functioning chil-dren, I recommend soft shoes. Firstwalkers appear to function betterwith less tripping and falling in softshoes. This is especially true if thechildren have internal rotationalalignment (in toe) disorder. Thosechildren with low muscle tone andextreme ligamentous laxity, as seenin Down syndrome, or those whohave excessive external alignment(out toe) problems seem to functionbest in early ambulation with broad-soled rigid shoes. These shoes givechildren greater initial stability forstanding independently and takingtheir first steps.

As children mature, I gauge therigidity of the shoes necessary forthem by their ability to maintainthe lower extremity in a relativelyrectus al ignment. With greaterpronation, ligamentous laxity, and

lower muscle tone, I feel that morerigid types of shoes or sneakers arerecommended.

PM: Turning to pediatricsurgery, what is your feel-ing about performingTALs versus gastroc reces-sions in children for cer-tain conditions?

Jay: Determination of ankle jointdorsiflexion range of motion is per-

formed with the patient in the supineor prone position. If dorsiflexion isless than ten degrees beyond the per-pendicular, the muscles producing theequinus are identified by the Silver-skiold test. When ankle dorsiflexionwith the knee flexed is adequate, gas-trocnemius lengthening alone is per-formed. Gastrocnemius recession orAchilles tendon lengthening is themost commonly used adjunctive pro-cedure to the subtalar arthroereisis.The gastrocnemius recession, howev-er, should be performed as the prima-ry procedure to address the equinus.Studies have shown that the effect oflimited ankle dorsiflexion from a tightAchilles cord results in the collapsingof the medial arch. The gastrocne-mius and soleus muscles, through theAchilles tendon, provide the mostpowerful dynamic arch deformingforce on the foot

DiGiovanni and colleagues stud-ied patients who had triceps contrac-ture and foot pathology to distinguishbetween gastrocnemius equinus ver-sus gastrocnemius soleus equinus.They found that ankle dorsiflexion offive degrees or less with the knee ex-tended is evidence of gastrocnemiusequinus, and dorsiflexion of ten de-grees or less with the knee flexed isevidence of gastrocnemius soleusequinus. Root and colleagues foundthat a minimum of ten degrees of pas-

The most important consideration inchildren’s shoes, far out-weighing hardversus soft, is proper fit.—Caselli

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sive ankle joint dorsiflexion in thepropulsive phase of gait is needed inan individual, or else compensatorysubtalar joint pronation will occur.Passive dorsiflexion range of motionof the ankle between five and ten de-grees results in no significant changein frontal plane rear foot kinematicsduring the stance phase of gait. Rootand colleagues found that the maxi-mum amount of dorsiflexion in thestance phase of normal gait occursjust before heel lift with the knee ex-tended. Thus, it is important to haveadequate dorsiflexion, which is insuf-ficient with equinus deformity, mak-ing this a significant factor to addressin flatfoot deformity.

The effectiveness of performing agastrocnemius recession with subtalararthroereisis was shown in the studyperformed by Cicchinelli and col-leagues. Gastrocnemius recessionwith subtalar arthroereisis hasshowed a correction of nineteen de-grees (range eleven to thirty-four de-grees), in the transverse plane;whereas arthroereisis alone showseight degrees (range from negativeone degree to fourteen degrees), ofcorrection. This pattern of correctiondid not affect the sagittal plane,which could indicate that equinus hasa clinically important effect on trans-verse plane deformation of the subta-lar and midtarsal joints. Furthermore,they found the results to be surprisingfor the combination of arthroereisiswith gastrocnemius recession and me-dial column stabilization. The resultsshowed a smaller degree of correc-tion, median four degree (range fromnegative nine to nineteen degrees),compared with the other two groups,especially with the results from thegastrocnemius recession with subtalararthroereisis. These results show thatthe gastrocnemius recession with sub-talar arthroereisis has a statisticallysignificant effect on the degree of ra-diographic correction of transverseplane elements of pes planovalgus.Therefore, gastrocnemius recessionwith subtalar arthroereisis seems tobe a good choice for the correction oflarge transverse plane deformities.

Raducanu: I am a firm believer ingastrocnemius recession for the pedi-

atric population. In my lecture on thetopic, I discuss literature that pointsto the fact that you have much morecontrol of the outcome on range ofmotion with that procedure. There isless risk for rupture post-procedure. Itend to favor percutaneous Achillestendon lengthening in patients whoneed it due to co-morbidities, but findthat, with pediatrics, that is not muchof a consideration.

PM: What is your preferredtechnique for subtalar im-plants in children?

Jay: The flexible flatfootis made worse by equinus, whichprevents normal dorsiflexion. Equi-nus may be the primary deformingforce in the flexible flatfoot. Regard-less of the origin of the equinus, itmust be addressed at the time ofsurgery. As the talus assumes a morevertical and medial position, the cal-caneus is forced to rotate posterolat-erally from its position under thetalus. The sustentaculum tali loses itssupporting position beneath the neckof the talus as the calcaneus sublux-ates laterally. Because the hind partof the foot cannot be dorsiflexed, dor-siflexion then occurs at the mid-foot.A breach of the mid-part of the foot(a rocker-bottom foot) may result,with the hind part of the foot in val-gus angulation and the fore part inabduction.

The sinus tarsi increases in size asthe child matures, making the ab-sorbable implant practical for usesince it takes about fifteen months forit to resorb. This allows adequatetime to maintain the correctionachieved with the gastrocnemius re-cession. With the gastrocnemiuslengthening, the patient does nothave instability at the knee joint dur-ing gait. Once a tendon is lengthened,the strength is reduced by approxi-mately twenty-five percent. When the

gastrocnemius is cut, however, andthe soleus is spared, the loss of powerto the gastroc-soleus complex is ap-proximately ten percent. Post-opera-tively, these patients do well becausethey have the adjunctive control ofthe arthroereisis implant. The gastroc-nemius recession eliminates thepronatory force and prevents the se-qualae associated with the pronatoryforce of equinus.

Again, it is my opinion that, incases of pediatric flatfoot, it is essen-tial to correct the equinus by perform-ing a gastrocnemius recession andsubtalar arthroereisis as an adjunctiveprocedure. Surgery performed at ayoung age provides a lasting correc-tion of the deformity, and improvesthe biomechanics, preventing prob-lems associated with equinus and ex-cessive pronation of the foot. No mat-ter what subtalar implant is chosen, ifused in the correct patient, these pro-cedures will prove to be effective withthe lengthening.

Raducanu: I recently startedusing the Hyprocure Implant(Gramedica) and have had great re-sults with it. There is a learningcurve, and it does take a bit moretechnique to implant it correctly, but Ido find that so far I haven’t seen asmany slip, thereby needing fewer re-movals. They are also very well-toler-ated, and once you get the techniquedown, they are quick to put in.

PM: How do you ensurecompliance in the pediatricpopulation in terms ofparental and/or guardianinvolvement?

DeCaro: Compliance is really notmuch of an issue at all. Most par-ents/guardians advocate for theirchild and, with thorough education,

Gastrocnemius recession or Achilles tendon lengtheningis the most commonly used adjunctive procedure to the

subtalar arthroereisis.—Jay

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there is usually no concern aboutcompliance. The one issue that I dofind is that when the patient is im-proving, often times par-ents/guardians forget to make an ap-pointment for re-evaluation. I try tostress the importance of follow-upvisits and give them the timeline forthe next appointment. When I do allof these things, especially the educa-tional part, non-compliance is seldoma problem. In fact, after their visitwith me, parents often make an ap-pointment for themselves and/or sib-lings of the patient.

Jay: To ensure compliance, I rec-ommend having parents be carefulnot to telegraph their anxiety to theirchildren. Parents should try to be up-beat, positive, and supportive. Par-ents who display the most fear andanxiety by words or actions oftenhave the most fearful children. It isimportant to relay this to them priorto the examination. While the familyis waiting for their appointed time,help distract the children by havingbooks in the waiting room and toys toencourage them to play quietly. Helpchildren refocus their anxiety by com-ing to the office prepared with a fa-vorite book or toy from their home, Ihave my staff request this of parentsof patients at the time the appoint-ment is made. Don’t try to stop chil-dren from crying. Try to let parentsknow that this is okay. If children arehurt or upset they will cry. It is a nat-ural release.

The parents should realize this aswell. Just support the children andhave the parents either touch or qui-etly reassure them. If children ask forinformation in preparation for the ex-amination or treatment, offer asmuch detailed information as is avail-able. As the physician, if you are theone to initiate the discussion, thenoffer minimal information. Don’t givetoo much information to childrenwho do not ask for it. Do not misin-form them about what is going totake place during the office visit.Children should receive accurate,honest, and matter-of-fact informa-tion. The parents should be advisedthat you, as the physician, are tryingto provide proper care to them, not

only technically but also psychologi-cally. The parents should be awareand tell you if there are any specialneeds for their children.

Raducanu: Sadly, compliance is aproblem whether you’re dealing withadults or children. The best way tomanage this situation is to write ev-erything down for the parents or pro-vide documentation that explains the

treatment protocol. Even in those sit-uations, compliance is an issue. I canusually tell almost immediately if theparents are involved with their chil-dren, and then if I notice that theyare, I worry less about compliance.Families are busy, and things tend toslip through the cracks even more,even if the intention is there.

Langone: Most of our pediatricpatient visits are initiated by parentsor pediatricians. Therefore, most par-ents are present at the office knowingthat some type of intervention will benecessary. Young children easily ac-cept treatment, as well as our youngathletes. Some adolescents, particular-ly severely fashion-conscious ones,worry about footwear if we initiateorthotic therapy. We have worked,however, to find shoes that keep ev-eryone happy. Similar to adolescentsand parents accepting the psychologi-cal trauma of orthodontics, they aregenerally accepting of our treatmentas well.

Caselli: I invite both parents, ifpresent, into the treatment roomeven if only one of them brings thechild in. This gives both of them achance to ask questions if they don’tunderstand the diagnosis and/ortreatment plan, and both to agreewith the doctor that this is whatshould be done. It is important toknow that both parents are “onboard” with the plan in order for the

treatment plan to be successfully car-ried out. For older children, pre-teensand teenagers, who might initiallycome into the treatment room ontheir own (either their preference, ortheir parent’s preference), I invite theparent into the treatment room. I willask permission from the patient(though not necessary) and explainthat the parent is paying the bill andthey should know what they are pay-

ing for. This maintains thechild’s/adolescent’s feeling of inde-pendence and at the same time in-creases the parent’s involvement inthe child’s treatment. If the child isfrom a divorced home, even thoughthey usually present with one parent,most often their mother, I will re-quest that the diagnosis and treat-ment be discussed with the other par-ent. This greatly improves both thedoctor-parent relationship and treat-ment compliance. At every visit I askthe patient to explain to me whattreatment has been performed sincethe last visit. I conclude each visit bybriefly re-explaining the diagnosis,treatment and goals. This can be assimple as stating “For this problem,we are doing this, and we hope to ac-complish that”.

PM: What tips can youoffer for creating a welcom-ing office environment forchildren?

Raducanu: A clean, well-lit officeis a start, but that should be a gener-al rule anyway. It is important thatthe staff can handle the pediatricpopulation as well. In a pediatrician’soffice, that’s a given, but in our of-fices, perhaps not so much. I’m alsoless and less concerned with the“white coat” issue, as little childrentend to be more fearful of the nursingstaff than the doctor these days. The

The one issue that I do find is that when the patient isimproving, often times parents/guardians forget to make

an appointment for re-evaluation.—DeCaro

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nurses are the ones giving shots atthe pediatrician’s office, so the chil-dren are less afraid of the doctor. Un-less a patient is being seen for an in-grown nail, I always will show thechild both my hands, open withpalms facing them, to show themthat I have no shots in my hands. Ialso tell them “no shots” and thatusually puts them right at ease. I alsolook them in the eyes when talkingand involve them in the conversation(age appropriate of course). I don’tlie to them either. If something isgoing to hurt, such as an injection, Itell them so. I don’t scare them, buthonesty is the best policy. I thinkthey appreciate the honesty. If chil-dren catch you in a lie, they’ll nevertrust you again. If it’s going to hurt,prepare them and they won’t mind itso much.

Langone: We generally holdblocks of time for younger patients.Entering a waiting room where otherchildren are present is helpful in cre-ating a friendly environment. We alsokeep children’s books and lots of newmarkers and coloring books for pa-tients. We are parents ourselves andtruly enjoy having children in the of-fice. We have fun with them and theyenjoy their time in the office.

Caselli: My waiting room is sup-plied with a variety ofbooks/magazines for children of dif-ferent ages. When a parent presentswith the child, they are directed tothese by our office staff. I only keepitems that require some parental as-sistance. This deters parents fromleaving the child alone while theycatch up on reading “People” maga-zine. I then encourage thechild/parent to bring the book intothe treatment room. At the end of thevisit, the child is given an age-appro-priate toy or sticker. In order to ob-serve the child’s gait, I will ask theparent to have the child walk withtheir shoes on in the waiting room assoon as they present to the office.While the child is happy/content sit-ting in the waiting room, the parent isasked to remove the child’s shoesand lower extremity outer clothing, ifappropriate. When it’s time to be ex-

amined, the treatment room door isleft open and the parent is asked tolet the child walk through the waitingroom and down the hallway to thetreatment room. This allows the doc-tor to observe gait without shoes anddetermine weight bearing foot align-ment. This may be the only chance todo this if the child becomes fright-ened and uncooperative. I will alsoencourage the child to walk into and

around the treatment room onhis/her own (under a watchful eye)while I am speaking to their parents.What often happens is that the child(toddler) will often attempt to climbonto the treatment chair and will behappy when the parent assists. Overthe years, to my surprise, this is amore common than not scenario,thus presenting both the child andparents with a more welcoming officeexperience.

Jay: My recommendations for theoffice of a general foot and ankle sur-geon who also caters to the pediatricpopulation are as follows. Keep achild-friendly environment for theconvenience of the parents. Whatmight be advisable, if affordable to apractice, is to have a child-friendlyarea where children can play in thereception area. This will welcome andtransition them into your practice.This will establish a nice, comfortablecontrol for children prior to their ex-amination. Always make sure thatthis child area is conveniently situat-ed so that the parents can supervisetheir children and not rely on yourstaff.

It will not be necessary for you tocreate an elaborate play area butrather just some furnishings that willallow children to integrate withinyour practice. Originally, I thought aseparate area for children to play wasa good idea to keep them away fromthe remaining population of my prac-

tice; however, this just allowed a free-for-all environment. After realizingthis, I found that integrating the chil-dren into the normal practice wasbeneficial as the other patients no-ticed that my practice also caters toyoung children.

In this day and age with videogames and electronic components, Idon’t feel that it is absolutely neces-sary to occupy children with these

items within an office setting. Cer-tainly, they will distract them, but itmay make them too dependent uponthe electronic game, making it moredifficult for them to exit for the exam-ination. It looks and sounds great forchildren, but keep the area simple;it’s just a temporary spot. Childrenare to be supervised by the parents atall times, and strangers are not to in-terfere with their activities duringthis temporary distraction. Be surethat your staff cleans the toys, workareas, desks, or little seats that thechildren use.

Parents want to know that youhave respect for their children andalso respect for them. Another goodpractice to make parents and childrenwelcome in your practice is to neverhave children unattended; the parentsshould always be present or visible.

PM: What recommenda-tions do you have for podi-atrists looking to expandthe podopediatric portionof their practices?

Langone: I recommend that podi-atrists talk to their local pediatriciansand nurse practitioners about whatthey are able to do for pediatric pa-tients. They should educate themabout the need for foot exams andgait exams as part of the annual pedi-atric exam and their ability, as podi-atric physicians, to aid pediatric pa-

Entering a waiting room where other childrenare present is helpful in creating afriendly environment.—Langone

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ing children in the office, podiatrists should also send theletters to the pediatricians with their clinical findings andtreatment plans. Lastly, podiatrists should not forget tomention in their advertising that they treat children’s footconditions.

Jay: I have been in practice for 35 years and I truly be-lieve the only reason that I have built a formidable pediatricpractice is my respect of children, their parents and the re-

ferring pediatricians. It is a team effort to treat children andall too often, we forget this mission. I direct my interviewand examination with the children in mind, I want the par-ents to know I understand their concerns and I want thechildren to know that I am treating them as people. Thechildren, just like the parents, are fearful of podiatrists, asof any strangers; a comfort level must be established. I feelpodiatrists must talk to the parents and the children onequal levels. They should not be dismissive of their con-cerns. When treatment is completed, podiatrists shouldmake sure to send complete reports to the pediatricians,even if the children were not referred in the first place.

Raducanu: The first thing to do is for podiatrists to re-alize whether that’s a population they want to help. Kidsare amazing little people who can sense right awaywhether podiatric physicians are the kind of people theywill like or not. As soon as they see them, they’ve alreadymade up their mind. If podiatrists are not the type to un-derstand and accept that, they will be at a disadvantage.The other thing is to really make the parents comfortable.If podiatrists can do that, their practices will start to over-flow with pediatric patients.

It also helps if podiatrists have little ones themselves.They meet more people that way and spend more time atpediatricians’ offices(for better or worse).Truly, podiatrists justhave to love workingwith children. It makespodopediatrics mucheasier than most col-leagues in our profes-sion make it seem.There used to be a gapin that niche, but todaythat gap is closing. PM

Kids are amazing little peoplewho can sense right away whetherpodiatric physicians are the kind ofpeople they will like or not.

—Raducanu

tients when problems are noted.

Caselli: The two major recommendations that I haveon building the podopediatric part of a podiatry practiceare: heavily marketing in the areas of podopediatrics thatthe interested podiatrists would like to pursue, and obtain-ing as much knowledge and clinical training in these areasof podopediatrics as possible in order to provide the bestcare to pediatric patients when they present to the office.

Marketing the pediatric part of a practice may includepodiatrists presenting themselves to local children’s shoestores. I recommend speaking to owners and asking toleave business cards; offering to set up times to give talkson children’s foot problems at the shoe store. Also, con-sider contacting key individuals of the local children’ssports teams and offering to give lectures to the parents onfoot health and safety. Both local public and privateschools should also be approached. In addition, podiatristsshould contact local physical therapy groups or earlychildhood intervention centers that treat children withneurological or myopathic diseases such as cerebral palsy,Down syndrome, or muscular dystrophy. Many of the chil-dren in these programs require foot orthoses as well asother podiatric foot care. Moreover, podiatrists should in-troduce themselves to the local pediatricians. After treat-

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Dr. Haspel issenior editor ofthis magazineand is past-presi-dent of the NewJersey PodiatricMedical Society.He is a memberof the AmericanAcademy of Po-

diatric Practice Management.