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Shoes are selected for protection, not correction. Myths often confuse parents who are buying shoes for their infants and children.
The Community Paediatrics Committee no longer accepts the old belief that a baby must wear shoes soon after birth. Keeping a baby out of shoes in warm, dry conditions is a good idea because walking barefoot develops good toe gripping and muscular strength. Indeed, there is increasing evidence to suggest that wearing shoes in early childhood may be detrimental to the development of a normal longitudinal arch.
Until toddlers have been walking for at least a few months, the only purpose of footwear is to protect the child’s feet and to offer some grip on a smooth surface. For prewalkers, shoes are not necessary. Ankle boots do not necessarily give more support than low-cut shoes, but are useful because they are harder for children to remove. Shoes must fit the foot properly at the heel and allow enough room for the toes, leaving about 1.25 cm between the longest toe and the tip of the shoe, measured standing up. This allows for sufficient movement of the toes and reasonable room for growth. Never buy shoes unless the child is present to try them on. Soft-sole footwear for protection and warmth is appropriate. For early walkers, shoes provide better fit, stability and safety than sneakers. Used shoes that have lost their shape should be avoided.
Corrective shoes are a misnomer and are rarely needed in physically normal children. The appearance of the foot changes with growth. Ninety-seven per cent of all children younger than 18 months of age present with flat feet, due mostly to a fat pad under the foot. At age 10 years, only 4% of children will still have flat feet. Children with mild or moderate flat feet need no specific treatment or corrective shoes. They should not be restricted from any physical activities. For severe flat feet, if accompanied by related pains in the legs or knees, longitudinal arch supports, scaphoid arches, Thomas heels and other orthotics may be tried.
Simple metatarsus adductus initially may be treated with passive stretching exercises. If the metatarsus adductus is not reducible, meaning that the forefoot does not return to a neutral position, a paediatric orthopedic surgeon’s opinion should be requested for the possibility of splints and/or cast treatment in early infancy. Intoeing with tibial torsion tends to improve with age. Patients with persistent intoeing with tibial torsion leading to functional impairment should be referred to a paediatric orthopedic surgeon.
Children’s feet should be left alone as much as possible. Prescribing shoes to attempt to ‘correct’ physiological flat feet, knock knees or bow legs may be harmful for the child and expensive for the family. Doctors can avoid overtreatment of mild to moderate variations by explaining this to parents in a reassuring way.
COMMUNITY PAEDIATRICS COMMITTEE
Members: Drs Fabian P Gorodzinsky, London, Ontario; Cecelia Baxter, Edmonton, Alberta; Denis Leduc, Montreal, Quebec (chair and principal author); Paul Munk, Toronto, Ontario (director responsible); Peter G Noonan, Charlottetown, Prince Edward Island; Robert Rosenfeld, Hampstead, Quebec (chair); Sandra Woods, Val-d’Or, Quebec
The recommendations in this Clinical Practice Guideline do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.