The importance of communicating with parents

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The recent publication from ‘Walk for Life Clubfoot’ (WFL) in Bangladesh shares data identifying Factors Affecting Parents to ‘Drop-Out’ from the Ponseti Method treatment and the ramifications for Children’s Clubfoot Relapse and future mobility (http://dx.doi.org/10.31031/oproj.2020.06.000638).

This paper explored the stories and circumstances of 72 family groups from 3/32 WFL clinics in Bangladesh. The issue of ‘drop-out’ from clubfoot clinics is relevant globally, and especially in low-middle-income-countries (LMICs) where 90% of births of children with clubfoot occur.

Relapse of clubfoot deformity in the years following the initial stages of Ponseti method correction is well known. The use of the correction maintenance foot abduction brace is repeatedly cited as the peak time/block of treatment cessation, and children being lost to follow up.

From the outside, it may be hard to understand why parents would discontinue a treatment course that will transform their child from clear disability to normal, active gait.

This study uncovered new ground, finding that relapse could be predicted by problems with the initial casting – a phase that is generally regarded as straight-forward and rewarding, as foot deformity is visibly eliminated week by week. What may be straight-forward for clinicians, was found to be anything but for some young parents, especially if their child cried a lot. Importantly, problems at the casting stage predicted the outcomes of worse foot posture and reduced physical functioning.

Figure caption: What a difference treatment makes; two six year old boys, two very different future lives without effective intervention [the boy on the left, did receive corrective care, and at review at age 11 years, both boys had good plantigrade feet, were attending school and playing soccer – https://www.facebook.com/walkforlifeclubfoot/ ].

So what to do, if drop-out from clubfoot treatment is to be maximally reduced?

In consultation with the parents feed-back, WFL have adopted their practical recommendations:

  • appointment reminders
  • parent support groups
  • cost sharing
  • staff updates.

For clinicians, the data from this study is relevant on two levels:

  1. understanding the parents’ concerns (children do not bring themselves to the clinics)
  2. working to reduce clubfoot relapse form incomplete treatment

Surprisingly, relapse of clubfoot deformity occurred in just 15/72 ‘drop-out’ cases. What does this mean, given that none of the 72 cases had fully completed treatment?

Again, this study uncovered new findings and raised areas for future enquiry, viz. is a critical ‘dosage’ of treatment relevant for clubfoot deformity, beyond which relapse of deformity is less likely?

Another factor identified and very relevant was a notable lack of discernment of postural clubfeet from typical or ‘true’ clubfeet. Postural clubfeet (positional, not structural) generally reduce without treatment, so the inclusion of these at one clinic potentially lowered the relapse rate. This is clearly an area for staff update, which was only discerned as a finding of this study, and can prevent unnecessary treatment and associated waste.

 

How might this help you in your practice, even if you do not see clubfoot cases?

Listening to parents is absolutely essential for any clinician seeing children.

Given that flatfoot is a more common presentation than clubfoot, by virtue of prevalence, it is worth incorporating assessments that have ‘parent-friendly’ versions.

Both the triage tool – the ‘Three Quick Questions’ – 3QQ  and the paediatric FPI normative data have easy-to-use versions to assist shared decisión making between clinicians, parents and children.

“Listen to your patients, they are telling you the diagnosis”

Sir William Osler, Physician
1849 – 1919

Thank you for viewing this 2020 Evidence Essentials blog.

Kind regards,

Angela Evans

Dr Angela Evans AM
PhD, FFPM RCPS(Glasg)
www.evidenceessentials.com