Consultation with Dr. Kayes

July 31st was our consultation with Dr. Kayes, a pediatric orthopedic doctor at the Peyton Manning Children's Hospital at St. Vincent's Hospital in Indianapolis.  It felt like we had been waiting so long to talk to someone.  I was a nervous wreck before the appointment, but could not wait to get down there and meet him.

Up until about the week before, I had plans to go by myself.  That made me sad, as I already felt so lonely and overwhelmed by this choice, but it made sense.  Jay didn't need to take any time off of work that wasn't necessary.  However, after talking with Jay more about Oliver's feet,  he decided to take the afternoon off and we would take Oliver with us to see if the doctor would look at Oliver's feet also.  We weren't asking him to diagnose anything, but just wanted his opinion.  If he felt like something was wrong, we would come back for an appointment just for Oliver.  I prayed that he would tell us Oliver's feet looked good and that wasn't necessary.

I barely slept the night before the appointment.  I wasn't exactly sleeping much lately anyway, so that wasn't unusual.  Stress was really taking a toll.  The morning of our appointment, I took Oliver to his speech therapy and then dropped off Lucy with my mother-in-law.  Thanks to lovely pregnancy hormones I was so sad to drop her off.  I usually don't spend a lot of time away from her and I hated to leave her for the day.

Oliver and I came home and got Jay and headed to Indianapolis.  We had plenty of time which was nice since I wasn't exactly sure where we were going.  Once we got closer to the hospital, I realized I had been down there before (in college).  The hospital campus is pretty big but I recognized exactly where we were.  Thankfully there was a parking garage directly across from the entrance we were supposed to use, and the orthopedic office was right inside of that entrance.  Very, very easy.

We waited f.o.r.e.v.e.r.  Or at least it felt that way.  A friend of mine texted to see how our appointment went, and I vented about how we were still waiting.  We were in the waiting room almost an hour (we got there a little early, so probably 45 minutes past our appointment time) before we got called back.  I understand that doctors get behind, especially by that time in the afternoon, but I was such a nervous wreck that it was driving me nuts.  Plus, my back and my hips and everything else were hurting from the long drive down.  Cue the pregnancy crankiness.  Thankfully they had some pretty cool video games in the waiting area that Oliver enjoyed playing.

We finally got called back and the nurse asked us some basic questions.  Oliver was already starting to get wound up being in the room and climbing up and down on the exam table.  I could feel my stress level rising and I was just praying he wasn't going to be completely crazy during our talk with the doctor. We had explained to him how important this was and that we needed to be able to talk to the doctor.  We even let him bring in his Nintendo 3DS to hopefully keep him occupied.

Finally Dr. Kayes came in.  We introduced ourselves, and Oliver, and said that he was our first clubfoot child.  Oliver was sitting on the exam table with his shoes off, and right away Dr. Kayes started making conversation with Oliver and moving his feet around.  I kind of held my breath to see what he said.  After playing with them some more, he said Oliver's feet looked great! I think Jay and I both let out a sigh of relief.  I explained that he hadn't seen a doctor for awhile so we were hoping to hear that.  He had Oliver stand up and turn around and said although his right foot was a little tighter than his left that they looked great.  He was amazed by Oliver's treatment (no tenotomy, very early release from braces, etc) and asked a lot of questions about that.  He even looked at Jay's foot (Jay was wearing sandals) and asked a couple of questions about what we knew about his surgery and treatment as well.

Even though we had to wait awhile for our appointment, I felt like Dr. Kayes made sure that we had plenty of time with him.  He apologized that we had to make such a drive to get to him, and I kind of laughed and said, "Well, its either here to you or to St. Louis to see Dr. Dobbs...this is much closer."  I explained that I had been in touch with Dr. Dobbs, and Dr. Kayes said he had a couple of patients that he has actually sent to St. Louis to Dr. Dobbs for a second opinion.  He said he doesn't hesitate to get in touch with him if there is ever a situation where he feels he could use Dr. Dobbs' expertise.  He acknowledged that Dr. Dobbs is a clubfoot expert, and I thought it was great that he utilizes him when necessary.  Dr. Kayes was very humble, and kind.  He asked several times what other questions we had, and how he could help us feel comfortable with what to expect at this point.  I told him about how Oliver had KAFO braces, and asked if he ever used them.  He said no, not really, because of the long-term benefits of the bar and boots.  That brace is really the Ponseti standard, so I understand why he uses that.  I asked if we could get the Dobbs bar (which is hinged and the baby can move his feet independently instead of always together like with the solid bar), and he said we could.  That was good to hear.  He asked how we knew about the bar and boots if Oliver had used KAFO braces.  I had to laugh a little and say, "well, the Internet."  If he only knew how many hours upon hours I had spent researching!

During all of this, Oliver was much more...social, than I expected.  That's one way to put it.  He kept going up to Dr. Kayes and saying, "Hey! Look at my game, look at this level!"  and showing him something on his 3DS.  I wanted to crawl under my chair, and drag Oliver with me.  But Dr. Kayes took it all in stride.  He would smile and even ask Oliver, "Oh yeah?  Let me see that again."  He was so nice and easy-going with Oliver that it really put me at ease.

The treatment Dr. Kayes described was pretty much exactly what I expected.  He said just to give him a call after the baby is born, and we'll set up appointments.  The first cast will go on a week or two after he is born; whenever I feel up to making the trip.  We'll change out casts once a week for several weeks until the feet are positioned correctly.  There's a good chance Max will need a tenotomy, but I'm still praying we can avoid that like Oliver did.  If he does need it, it'll be an in-office procedure and not in an operating room. I was relieved to hear that.  A final cast will go on after that and stay on approximately 3 weeks.   After that Max will start wearing the bar and boots brace.  The first three months of brace wear will be 23 hours a day, 7 days a week.  After the first three months, we will slowly wean him down: one month 20-22 hours, one month 18-20 hours, one month 16-18 hours and one month 14-16 hours. Eventually he'll get down to just wearing them at bedtime until he is about 4 years old.  That is the part that I really struggle with.  I can't imagine having a child in braces at bedtime for that long when Oliver was done so early.  But I can't let myself go there.  Not yet.  Max isn't even born yet; I can't let myself imagine him as a toddler in braces at bedtime.

I left the appointment feeling much, much better than I expected.  I'll admit, I went in with a "this guy is going to need to impress me" attitude.  I really looked at the appointment as something to check off my list to say I had looked at all of our "local" options before deciding that we needed to see Dr. Dobbs in St. Louis.  How we were going to afford to get there, I didn't know.  How we were going to arrange childcare, I had no idea.  But I didn't expect to like Dr. Kayes, to be really honest.  I was surprised at how much I liked him and felt at ease with him.  Jay and I both felt comfortable with him, and I was so glad that Jay had been part of that day's appointment.  I needed his input.

I left the appointment feeling like a slight weight had been lifted.  Finally, we had a doctor.  I still had this nagging feeling that I wished we could be making the trip to St. Louis.  I really liked Dr. Dobbs, and I knew he was one of the very best.  But logistically, this made so much more sense.  And if we ever feel like we need some extra help or attention, we know we can go to St. Louis.  

After the appointment, I was able to meet up with a friend who lived in Indianapolis and had a bunch of nursing and baby stuff for me.  We had actually never met in person before despite being in touch pretty much daily on facebook, text messages, etc.  Amal was so super sweet to wait for us during our appointment.  It was lovely to meet her, and I hope that during some of our many other appointments we will be able to see her again.

The drive home was exhausting.  Physically I was in a lot of pain...Jay had gone into work at 2:30 that morning and worked 8 hours before leaving so, understandably, I did the majority of the driving that day.  I called both of my parents to let them know how our appointment had gone, but I wasn't as talkative as I normally would have been because I was just so drained.  It seemed like two months worth of stress, exhaustion, and anxiety had caught up to me.  We had hoped to make it home in time for Oliver to get to play in his soccer game, but we definitely did not.  I couldn't wait to pick up our Lucy girl and just get home.

I went to bed that night with somewhat of a clear mind for the first time in awhile.  I posted this as my facebook status:

An exhausting day, both mentally and physically. But a very good one. I'm so thankful for all the prayers and messages we received today. I feel so much relief that today is over! Two months ago I was devastated with the news we had just received and for the first time since then I am going to bed with some peace of mind. Thank you Lord.


I expected to wake up the next day and feel so much better.  But to be honest, the next day I felt awful. Physically, I was exhausted and hurting all over.  It was like I was forcing myself to just move and take one step after another.  Mentally it was like all I could think was very basic thoughts about what needed to be done and paid attention to in that very moment.  The kids and I got through the day with me functioning on a very basic "need to do it" level.  I think the stress, anxiety, build-up, fatigue, and worry of the past two months had left me stripped of everything.  I wanted to feel relieved and happy about the day before but felt very numb.  It had all certainly taken its toll.

Quick Overview of Clubfoot and the Ponseti Method

When I mention that we have a son who was born with clubfoot, or when I say that we are expecting another baby with the same condition, many people ask what exactly it is.  I wanted to do a quick post here to give some basic information about what clubfoot is, the treatment for it, and a bit about our family history with it.  Forgive me for not being too specific or scholarly with this...my history major background is cringing at the lack of citations and proof reading. :)  One thing I have learned is there is a lot of variation with how things can happen with clubfoot.  Each case is unique.

Most of my information has come from Ponseti International website.  You can visit it here:  http://www.ponseti.info

Clubfoot is a treatable birth defect that occurs in approximately 1 in every 1,000 live births.  About half of all of those affected with clubfoot have it in both feet, known as bilateral clubfoot.  It occurs in males twice as frequently as females.  I find this especially interesting since Oliver had bilateral clubfoot, Lucy wasn't affected, and now we have another son on the way who is expected to have a right clubfoot.

Physicians have observed that fetuses that develop clubfoot start with a normal foot and then the foot begins to turn inward around the third month. Most children born with clubfoot are not missing any bones, muscles, or connective tissue. It is a congenital condition, meaning that when it occurs it is always present at birth. (http://www.ponseti.info/clubfoot-and-the-ponseti-method/what-is-clubfoot/learn-about-clubfoot.html)

It is not known exactly what causes clubfoot.  While it is not always genetic, there is a family history in some cases. My husband, Jay, was born with clubfoot.  He had casts and an extensive surgery on one foot. 

Thankfully, the surgery that Jay had as a baby is no longer the norm for treatment of clubfoot.  Jay has a lot of pain in that foot, especially if he is on his feet for a long period of time.  The "gold standard" for treating clubfoot now is called the Ponseti method. 

The Ponseti method is mainly non-surgical.  It is recommended that it begins within the first week or two after birth to take advantage of the baby's flexibility.  The baby's foot is turned into a specific position and casted.  The casts are then changed every 5-7 days.  Most clubfeet can be corrected with 5-7 castings (sometimes less, sometimes more). At the end of the castings, a minor surgery is usually needed to lengthen the baby's tendon(s).  This is called a tenotomy and the baby will be casted again afterwards. This cast is left on for a longer period of time (usually 3 weeks, although this can vary).  Some doctors do this surgery in office with a local anesthetic; others prefer to do it in an operating room under general anesthesia. 

After the last casts come off, the baby wears a brace.  Called "bar and boots", this is a brace that keeps the baby's feet in place.  A pair of "shoes" (special orthodic shoes called AFOs) is placed at a specific degree keeping the baby's feet turned outwards and set onto a bar.  There are different types of bar and boots braces.  Some are a fixed bar, in which the baby must move their feet simultaneously.  Others are a hinged bar (called a Dobbs bar, developed by Dr. Matthew Dobbs, one of the nation's leading experts in clubfoot) and allows the baby to move their feet separately.  It is recommended that the child wear the brace for 23 hours a day for the first 3 months and then slowly work down to wearing the brace just while they are sleeping.  Children usually wear the brace during the night for up to 4 years (sometimes more) to prevent relapse.  This website shows the Dobbs bar and some adorable children wearing them! http://www.dobbsbrace.com/
 
Oliver's treatment seemed to follow the Ponseti method except for the bracing.  He was also one of the few who did not need the tendon surgery.  Oliver wore KAFO braces and was done just after his first birthday.  As I read about stories of relapse, I am amazed at how God took care of our little guy.  I'm not sure why our orthopedic doctor at the time varied from the Ponseti method when it came to Oliver's bracing treatment.  I'm just thankful it all worked out.

While it is said that the Ponseti method is not exactly difficult to learn, it is very precise.  We live just outside of a major city in Indiana that has a large orthopedic practice.  However, there are no orthopedic doctors sub-specialized in pediatrics within this group, so none of them know how to treat clubfoot.  Each cast has to be set a specific degree and variation.  The doctor that we saw with Oliver is no longer practicing due to health issues, so we are in the process of looking at our options.  In about a week and a half I have a consultation with a doctor about two hours away.  I have also been in touch with Dr. Dobbs who is located in St. Louis.  After my consultation with the doctor who is located in our state, Jay and I will discuss what option would be best for our family.

It never ceased to amaze me how happy this little guy was. He has brought us so much joy!

Tiny Baby in Leg Casts

It was definitely an adjustment seeing Oliver in casts.  He was so tiny (he was only 6 lbs 14 oz when he was born) and his casts felt so big.  When I was out with him, I would often get questions and stares from strangers.  Thankfully no one ever said anything rude (I've heard from other clubfoot parents who have some horror stories).  But its still felt so strange to have anyone say, "Oh, what a sweet baby. Oh gosh, why does he have casts on his legs?!"  When I had the chance to actually explain to them what was going on, they were always surprised that the casts were not, in fact, a result of foot surgery but instead a series of castings that would hopefully correct his feet without surgery.

One part of Oliver's treatment that was unique and that we will not experience with Max is that each week I had to soak off his plaster casts at home.  I have recently found out that this is not recommended, and the doctors I have spoken with do not have parents do this.  It is because they want as small of a window of time in between casts as possible to prevent the feet from turning back in.  I completely understand this, but I have to admit I'm a little sad.  It was always so nice to  have that one night a week with baby Oliver and his "free" feet and legs.

The first night I had to soak off his casts was a complete disaster.  Jay was working nights, and Oliver was two weeks old.  I really had no idea what I was doing...I had read some suggestions and the nurse had told me a few ideas but it was so awkward!  I was paranoid because his umbilical cord "stump" was still on and I was trying not to get it wet.  I thought doing it in the kitchen sink would be best. Um, no! Our sink was small and I couldn't get him in a comfortable position.  I got out a bucket that fit well into our sink and put water in it, along with some vinegar because that was supposed to help soften the casts.  (This was the only time I used vinegar.  I didn't think it worked that well and it smell was just too strong for me!)  So here I am, trying to hold a 2 week old infant in a bucket of water, up to the top of his thighs without getting his belly button wet.  Ha!  He screamed, I cried, and it took close to two hours!!  We were both soaked by the end.  I started unwrapping his casts at the top and worked my way down.  By the time I got close to his feet I could just slip the bottom "foot" part off. I have never felt such relief as when I was able to get those casts off!  I cried seeing his precious little feet again.

After our first night of soaking off his casts. AMAZING progress! I have recently found out that most doctors do not recommend parents soak the casts off the night before a new cast is put on because of the risk of losing progress, so I am especially grateful that Oliver did so well.  I really looked forward to our one "free" night a week of loving on his little legs and feet.

That first night of no casts I spent so much time just looking at his feet and legs and touching them.  The doctor had warned us that his feet might be especially sensitive, since they weren't used to any stimulation, but Oliver never really seemed to experience this.  As soon as I got his casts off, I wrapped him in a towel and he curled right up on my chest.  I sat with him in the recliner in his room for over an hour just loving my little boy.

On our way to get his second casts put on.  Funny, once they were on it was hard to remember them ever being off.  They quickly became part of our new "normal."

The second casting was emotional as well.  I really, really dreaded that appointment again.  His feet looked so different, and so good, that I hated that they were going to be covered up again.  I just wanted to have a "normal" experience of a baby without casts.  He felt so much smaller without his casts on and I started to feel like I was really missing out on so much of having a newborn. Just the little things really bothered me, like not being able to give him a normal bath and having to really watch what kind of clothes we bought for him to make sure they would fit over his casts.

He seemed to be in a lot of pain with the second castings also.  The doctor did some stretches with him and he cried during those.  That night went better than our first night, though, and each week seemed to get easier and easier.  Well, as easy as it can get when your infant is in casts.  Sometimes I hate saying its "easier".  I don't want people to think it isn't as big of a deal as it really is.  Its all relative.

PJs that did not have feet, and snapped all the way down both legs, became a staple of Oliver's wardrobe. This was his second set of casts.

Grandpa holding a tiny Oliver.

Adding a little bit of love to those plaster casts.

For whatever reason, this set of casts did not go up as high on his legs as some of his earlier ones.  Its kind of hard to tell at the angle of this photo but with each casting, his feet were set at a different degree according to the Ponseti method of treatment.

One thing that did get easier each week was being able to soak off the casts.  I just now remembered that Jay was home for one of the weeks of soaking them off, and he videotaped it.  I haven't watched it since we filmed that, so I will have to try to get that out sometime and watch it.  After that first time of attempting the kitchen sink, I said forget it and just got in the bathtub with him and did it that way.  By this time I was pretty much healed from childbirth and didn't mind getting in the tub in a bathing suit to unwrap the plaster.  I remember one week I was unwrapping his casts and I noticed blood on them.  I immediately started checking everywhere to see where he could possibly be bleeding. I was freaking out that he was hurt somewhere. It took me a couple of minutes to notice the cut on my finger and realize it was MY blood! The plaster could occasionally be sharp as I unwrapped it and I cut my fingers a few times over the weeks.  Of course being in the water made it look much worse than it really was.  I actually grew to really enjoy those nights of getting his casts off.  I always tried to stop unwrapping them once I got to his foot so I could slip that part off and keep it.  I have a whole bag full of little Oliver foot casts and cast wrappings.

This was the second night I soaked his casts off.  He had been in casts for two weeks at this point. It never ceased to amaze me the difference in his feet and how quickly it happened.

On our way for more casts again.  The better his feet looked the more I hated having to cover them in casts.  They began to look so normal!

Its hard to remember each casting appointment because they were just a way of life for awhile.  I do remember one particularly great appointment for him.  The nurse was so happy when she saw his feet before the doctor came in.  No one usually said too much about his feet, just that they were looking good.  This time you could tell Nurse Deb was really surprised and excited with how great they looked.  When she came back in with Dr. Cummiskey it was like she couldn't wait for him to see them.  He kept saying how great they looked, and it made my heart soar to know that all we were going through was worth it.  During that casting, Oliver was crying, and I just kept whispering, "Its ok, baby, its ok" and Dr. Cummiskey said, "Oh Oliver, its beyond ok! Your feet are looking amazing! Seriously, we rarely see this much progress this fast.  I am just in shock."  At that appointment, we thought we might only need one more set of casts.  I was SO excited.  It turned out he needed two more sets, and even though it was disappointing at the time, I am now able to look back and really see how awesome his progress was.

After three weeks of casts. I remember worrying that his feet were "over"corrected this time, but it was all just part of the process.  The next morning Dr. Cummiskey was thrilled with how they looked.

I've always loved this picture of little Oliver.  This was a very good appointment for him!

October 30, 2008. Oliver was just over two months old, and we were thrilled at that day's appointment to learn that he didn't need any more casts. His last two sets of casts had stayed on for two weeks each. The doctor hadn't told us for sure when he would be done, and we had gone in prepared for another set.  Dr. Cummiskey was so pleased that he decided Oliver was done with casts and would not need a tenotomy.  That was the biggest relief.  Most children (I have read as many as 80%, sometimes more) need this surgery once they are done with castings.  We had prepared ourselves for the possibility of it.  Basically they cut the baby's achilles tendon to release the foot, then cast it again while it heals.  I was so, so relieved that Oliver didn't need it.  Dr. Cummiskey commented again with how great Oliver's feet had responded to treatment.  All I could say was, "God is good."

October 29, 2008.  I didn't realize it at the time, but I had just soaked off his last set of casts! We were expecting one more set and got exciting news the next morning.

Such an exciting day! Oliver was *DONE* with casts earlier than expected!! It was the day before Halloween, so I celebrated by putting some adorable pumpkin socks on him.

Oliver had several days in between casts and braces.  Again, this is not something we will experience with Max as the doctors I have spoken to want as little time between casts and the brace.  Also, the brace that Oliver went into (KAFO...knee, ankle, foot, orthodics) is a brace that I have not seen used again.  Of all the clubfoot parents I have talked to and the doctors I have spoken with lately, they all use a bar and boots system.  I'll talk more about Oliver's braces in another post.

It was hard to believe we were done with casts.  It seemed like we had just started, and we were so used to going to these appointments.  I was so proud of our little boy, and so so relieved to be done with this part of his treatment.

One incredible thing was how quickly Oliver met milestones even with his casts on.  We were at his one month well check-up, and the doctor put him on his belly to see how he did.  The doctor told us that he might experience some delays because of the casts, and to not be concerned if it took him a bit longer to do things like roll over.  Right after he said this, Oliver rolled from his belly to his back! We had to laugh, and at first thought it might have just been an "accident."  But no.  Oliver proved us all wrong, and at just one month old was rolling over like crazy.  Especially for first time moms, it can become an obsession if your baby isn't meeting milestones right on time.  I was so glad to have one less thing to be worried about at that time.