Bracing FAQ

There can be a small amount of swelling during the transition. You can treat this by laying your child down on their back and slightly elevating their legs.

Black Robin socks
Gap: Triple roll socks, in store & online
Hank and JoJo: online only
KeepingPace: online only
Old Navy: Triple Roll socks, online only
Smart Knit: online only
Target: Cat & Jack (formally Circo) brand bobby socks, in store & online
Wal Mart: Garanimals brand bobby socks, in store & online
Children’s Place: Basic Triple Roll Socks, in store & online
Hanes Infant/Toddler Turn Cuff Socks: online and in stores
Judanzy: www.judanzy.com

The inability to keep the heel down in the boot can be a sign of relapse. Please have your doctor check as soon as possible. When your baby first starts BNB the heel may not be all the way back in the boot and forcing the heel back can potentially cause more harm than good. About 50% of the heel should be visible through the window. You can also ensure proper fit by pulling up on the ankle above the boot and if the foot and toes stay in place, the foot is properly secure in the boot, regardless of how much heel can be seen in the window.

The first night in the brace is hard. Babies cry and parents worry. Some helpful tips:

• Providing the brace is fitted well, crying only indicates frustration at not being able to move their legs independently because of the brace. Once babies get used to wearing the brace, they become much more comfortable.
• Babies get used to the brace, usually after the first night or two, and a normal routine is established.
• If your baby is crying and you are worried that the brace may be damaging the feet, remove the brace. Rarely, the brace irritates the skin, particularly if it is improperly applied. Babies will then cry inconsolably. Check for signs of skin irritation, such as unusual redness, swelling, bruises, blisters, and sores. If you see these, do not reapply the brace and seek your doctor’s advice. Brace adjustments may be needed. If the skin looks okay, reapply the brace right away. This will prevent your baby from ‘learning’ that crying will result in parents removing the brace.

Most babies and children will be able to fit into standard clubfoot AFO’s such as Mitchell or Markell to comply with the bracing protocols of the Ponseti Method. Occasionally, a larger baby may have excessive tissue around the ankle that causes irritation and difficulties securing the brace without discomfort. It is important to discuss your child’s needs with your physician and orthotist to ensure your child is comfortable and successful with maintaining bracing. Your team may suggest a custom made AFO to attach to the rigid bar. As the custom AFO is made from a casting mold of your child’s food, the rigid shape can better accommodate areas of irregular size. It is important to ensure alternative bracing continues to follow Ponseti protocols and that you are confident your child’s clubfoot has been correctly corrected during casting.

Clothing with snaps in the inner legs of the pants will help prevent the need to remove the bar. If your child is wearing pull on pants, the bar should be removed to prevent pressure on the knees. There are quick release bars that make this fast and easy. When your baby is first starting BNB, it can be helpful to complete a “boot check” at each diaper change. This means checking the boot to ensure proper fit, and readjusting the boot several times to help you and your child adjust to putting the boots on.

Your baby can wear any kind of clothing. Pants with snaps on the inner legs are the easiest for accessing during diaper change. Many parents find that onesies with pants provide ease of use with the BNB.

It is not recommended to take the BNB off to help your baby sleep, because it is imperative that your baby learn to sleep in their BNB for long term treatment success. It can be difficult to determine why your baby is not sleeping well, but it is important to remember that there are normal sleep regressions that happen with all babies that might be impacting your baby’s sleep, not just the BNB. All parents struggle with trying to figure out what is causing sleep issues with their children, and clubfoot parents have an added layer of the BNB as something to be concerned about. But it is imperative that you find a way for your child to sleep in their BNB, especially when they are babies, to make things easier and consistent in the years to come.

Sleep challenges can be different for every child, but here are some tips from other clubfoot parents to try with your child:

• Set up a good routine to follow before sleep
• Place a pillow or rolled up receiving blankets under the BNB to provide extra support
• Use a swaddle or sleep sack
• Consider a sleep coach

Yes, Children are amazingly adaptable, and you can see so many videos of children crawling in their boots and bar. For many families, the 23 hour wear of BNB will be completed by the time child learns to crawl, as the age that crawling usually begins when the baby is in a nap and nighttime wear.

It is normal for your baby to cry while you are doing stretching at the beginning, they are adjusting to the movement of their feet which are typically stationary in the casts and BNB. It also may take you, as the parent, a while to adjust to doing the stretches as well. Review the materials or videos you took of stretching, to help you feel confident in what you are doing, and keep trying. Most babies adjust to their stretching routine within the first couple of weeks of BNB.

Yes, as long as their hips and legs make the recommended M shape and are well supported as per your carrier’s recommendations. There is an entire support group on Facebook dedicated to this topic if you are looking for recommendations on carriers and would like further support on the correct positioning of your child in the carrier.

You can give your child a toy to play with to distract them or hang a mobile above where you change them. Try to make the boot application fun by singing, talking, and making funny faces. Soon it will just become routine. It is sometimes helpful to have someone dedicated to interacting with the baby, such as a partner or older sibling, while someone puts the boots on. As your baby gets older, it can be helpful to have easy access to toys and books that the baby can play with to help distract them when the BNB is being put on.

The boots are not effective without the bar as it holds the feet at the appropriate angle. While it may be tempting to use the boots without the bar in the hopes of helping your baby adjust to the BNB, the boots are not effective with the bar and it may make it more difficult to adjust to the BNB overall if the bar is left off.

Try to pull the shoe off. If the heel rises, it is not tight enough. Re-tighten the shoe using the above technique until the foot is secure in the shoe. It must be snug, probably tighter than you think it should be, without cutting off circulation. You will be surprised at what your child can tolerate. To check circulation, cut the toe area out of a pair of socks. Press on the child’s toenail – the nail will whiten – then remove pressure to confirm that colour returns quickly to the toe. The middle strap of the boot needs to be the tightest to ensure proper placement of the foot. The upper and lower straps may fit looser if needed.

Correctly worn, the brace must be quite tight on your child, especially across the middle of the foot. You may notice red marks in this area, which is common. During the hour out of full time wear you will notice these marks fade. Do not put lotion on these marks as the skin can break down (become macerated).

Blistering on the heels can be a sign that the shoe was not worn tightly enough. The heel must stay down in the shoe.

If you notice blistering, or signs of an infection, your doctor and/or orthotist should be notified so that this can be corrected as soon as possible. These issues need to be addressed right away to ensure your child’s comfort. There are several items that can be used to protect blisters and help them heal, such as duoderm, bandaids, and moleskin. If you are seeing consistent red spots that do not go away during your baby’s free time, you can work with your medical team to see if any items can be placed on the boot or the foot to prevent blisters or sores.

The time can be split or it can be at one time, you can determine what is the best fit for you and your child. Some families choose to break the hour into four 15 minute segments, while others choose to do three 20 minute segments. A free time break is also a good time to give your baby a bath. Let them play and explore with their feet. This can be a good opportunity for your child to utilize a playmat that may have limited use while their BNB is on. You can also massage their feet, and do simple stretches to increase the blood flow.

Use the time out of the brace for bathing and playing. There is no need to do any special exercises if the foot is corrected. This may be dependent on your treating doctor. Some doctors provide stretches that can be performed several times a day. Work with your medical team to determine if stretches are recommended for your child.

If you notice blistering, or signs of an infection, your doctor and/or orthotist should be notified so that this can be corrected as soon as possible. These issues need to be addressed right away to ensure your child’s comfort. If you are unable to reach your medical team right away, use your best judgement to determine whether or not the blister warrants taking the boots off. Some blisters can be covered and the boots can still be placed on the foot, while others may require a full break from the boots. If there are any signs of infection, make sure to discuss with your doctor before placing the boots back on.

The bar should be shoulder-width in length. The distance between the backs of the shoes should be the same distance as between the outside of the child’s shoulders. You can place bar across your child’s back and place your index fingers on the middle screw of the boot to see if the bar is the correct length.

Shoe size depends on the size of the foot. This should be assessed by your clinician if you are unsure.

Children typically wear the BNB until they are four or five years old. Studies report higher rates of relapse if brace wear is discontinued earlier.

It won’t hurt your child’s feet, but the child will get used to sleeping without the brace and may cry and fuss when you go back to the BNB at night. It is best not to leave the brace off unless there is a medical reason to do so. Having a cold or mild illness is not a reason to leave the boots off either. Children do not need breaks from the boots.

Socks should be snug, as smooth as possible, have no seams inside the boot, and be higher than the boot. The best sock will depend on your child. Some children will do better with a double ply sock while some will need a thinner sock. You may have to do some trial and error to determine which sock provides the best protection and comfort, while not bunching or wrinkling inside the boot. If the sock bunches or wrinkles under the straps of the boot, it can cause skin issues, so ensure that there is a smooth fit before donning the boot.

Depending on the brace type, in warmer weather, socks may not be completely necessary. Socks can help to prevent skin irritation; check with your doctor before choosing to go without socks. This will be dependent on the child. If you are planning to forgo socks, make sure to discuss this decision with your doctor at your child’s BNB fitting appointment to determine the best plan forward.

Check with your doctor’s brace supplier, many sell directly to clients or check out BNB exchange programs.

Socks are good at absorbing the sweat and preventing skin irritation. If you notice they are getting damp from sweat you should remove them and put on a dry pair. Some parents switch to clean socks a couple times a day, while others put new socks on every 24 hours. Damp socks can cause a fungal infection, so always ensure they are dry.

It will not hurt your baby to stand in the brace, but it should not be encouraged for long periods of time. As children get older some may even try to walk in the BNB, which should be discouraged as it can cause harm if the child falls.

It is best to put the boots on when your child is relaxed and calm. You will find out through trial and error what works best for you and your child, but always ensure that the child’s heels are all the way down to the bottom of the heel cup in the boots. Initially, you may find it easier to put the shoes on your child separate from the bar, and then reattach the shoes to the bar. You may want to mark the shoes and bar with “right” and “left” to ensure the marks on the bar correspond to the correct footplate. Open the shoe up as much as possible by loosening the strap(s) and/or removing the laces.

• Insert the foot into the shoe with the knee bent to 90 degrees and the ankle flexed so that the toes point upwards. Make sure the heel is completely down and back in the shoe. There should be a hole in the heel of the shoe to allow you to check foot position.
• With the knees still bent and the toes pointing up, use your thumb to apply pressure to the tongue and strap while tightening the buckle, and if applicable, the laces. Follow the same procedure, one foot at a time, starting with the clubfoot, or weaker of the two.
• Try to pull the shoe off. If the heel rises, it is not tight enough. Re-tighten the shoe using the above technique until the foot is secure in the shoe. It must be snug, probably tighter than you think it should be, yet without cutting off circulation. You will be surprised at what your child can tolerate.
• Make sure your baby’s toes are not curled under, and that wrinkles are smoothed out of the socks. To smooth wrinkles, pull the socks from the top and toe when the boot is on.
• To check circulation, cut the toe area out of a pair of socks. Press on the child’s toe nail – the nail will whiten – then remove pressure to confirm that colour returns quickly to the toe.
• Once the shoes are snug on both feet and laced or strapped up, the bar is attached, making sure the shoes are set at the right degree of abduction (outward turn), and well-fastened.

You can use a jumper if your child is developmentally ready around 5 months of age, being able to fully control their head and neck as well as roll over. Jumpers should only be used without the Boots and Bar.

If the bar is not shoulder width apart you need a bigger size. You will know if the shoes are too small if the toes are over the end of the boot, the boot seems to be too narrow, and/or if your baby is getting red marks on the edges of their feet. At first it can be difficult to determine if your child needs to size up in boots, but you can look at the over fit and feel of the boot to determine if the next size is needed. Some indicators that it might be time for new boots are if your child’s foot becomes wider than the boot or the toes are hanging off the end of the boot. It is better to keep the foot in a boot that might be a little snug then switch to a new boot that is too large for the foot, as it will provide more opportunities for friction and potential skin issues.

Some babies and children may develop a Haglund’s bump or “pump bump” when transitioning into their brace wear. A haglund’s bump in an enlargement of a bony section of the heel, where the achilles tendon is inserted. This bony bump rubs against rigid shoes and the soft tissue can become irritated. A variety of factors play into the root cause including hereditary, but a tight achilles tendon plays a role. Typically a haglund’s bump is treated by altering footwear (bracing and regular footwear) to provide more cushioning and comfort in the area. Your physician can diagnose the bump and determine if it may be the cause of any pressure sores. Your orthotist can help add additional padding with foam or silicone in the back of the shoe to provide more comfortant and reduce rubbing in that particular area.

No, the BNB does not cause pain. Children usually cry because they are frustrated by having their legs attached. They typically adapt quickly.

Babies cry for many reasons. If their feet are properly corrected it could be because they are tired or hungry or just generally unhappy being strapped into boots. But they are necessary if the feet are corrected. Distraction is a wonderful tool! It can help to play with your baby with their BNB on, showing them how to bring their feet up and down.

It is best to not take the boots off when your child is crying, or they will learn that the boots come off when they cry. You should wait until your child is calm to remove the boots. There may be times when it is unavoidable taking the boots off while your baby is unhappy, but consistency and routine are key to long term adjustment to BNB and successful outcomes of treatment. Creating a routine of when boots come on and off, may make it easier for everyone to have consistent BNB wear.

Ponseti bar is a static bar, meaning it is straight and doesn’t have movement. The Dobbs bar is a dynamic articulating bar, which allows a small amount of independent leg movement.

Is your baby able to be comforted and distracted easily? If yes, then they are most likely not in pain. If your baby is inconsolable, unable to calm down with comfort or distraction, you will want to contact your doctor to determine if there is an issue that needs to be addressed. Some babies take longer than others to adjust to the BNB, and it is important that you trust your instincts about whether your baby is simply frustrated with the brace, or if they are in pain.

You know your child best. If you believe your child is in pain and is not just frustrated or bored, speak to your doctor.

There is no need to remove the braces if the child is sick or had an injection. Give them lots of cuddles and soothe them as you would any other child. There are some illnesses, such as Hand Foot Mouth Disease, that may cause symptoms that warrant the brace be removed. If this occurs, contact your medical team to determine the best course of action.

Barefoot is best, but soft sole shoes are great for new walkers, so let your child walk barefoot as often as possible. When you need to protect the feet, especially when venturing outside, look for wide flat soles and ankle support if possible. Some clubfoot kids have smaller than typical feet, so you may have to search for footwear that is the appropriate size for your baby’s feet.

You can change the length of the bar. Your practitioner will advise you of the proper distance. In some locations, this is completed by your healthcare team. If you are in between appointments and notice that the bar needs to be adjusted you will have the ability to adjust the length on both the Dobbs and Ponseti bar. You can contact your provider if necessary to determine how to do so.

As the BNB phase of treatment spans over several years, there may be times that you encounter resistance from your child for wearing the BNB. If this occurs, it is most important to discover why your child is not tolerating BNB and troubleshoot these issues with your doctor. As a clubfoot parent it can be hard to tell what is the root of the issue that is causing the intolerance to the BNB, but it is important to explore all reasons and potential solutions to achieve the most successful treatment outcome. If you do not feel supported, you may seek a second opinion.

It is not recommended to take the BNB off to help your baby sleep, because it is imperative that your baby learn to sleep in their BNB for long term treatment success. It can be difficult to determine why your baby is not sleeping well, but it is important to remember that there are normal sleep regressions that happen with all babies that might be impacting your baby’s sleep, not just the BNB. All parents struggle with trying to figure out what is causing sleep issues with their children, and clubfoot parents have an added layer of the BNB as something to be concerned about. But it is imperative that you find a way for your child to sleep in their BNB, especially when they are babies, to make things easier and consistent in the years to come.

Yes, it is important to let the sore heal. If there is a sore on the foot, you are advised to speak to your healthcare practitioner as it should be determined why the sore is developing in the first place. They can advise you on when and how long to leave the BNB off.

Yes! Once your baby’s feet are corrected, he/she is like every other child. Your child should only use the jumper when they are not in their BNB, as the extra weight can cause harm to their hips and knees. Remember moderation is key.

You can add time before and after sleep, depending on how many hours are needed. For example, you could put them on an hour early and read books before bed, or take them off after breakfast to extend the time, or during a period where the child is quiet and playing, or during a nap. Some families find it easiest to have the BNB on when the child is eating and in their highchair as they are typically immobile during this time as well. This can be different for each family depending on their needs, but it is important to wear the brace as prescribed.

Yes, even if you have missed a few days of BNB or are struggling to find a routine, it is important to keep trying. The main reason for relapse is non-compliance with the recommended brace wear. It can be hard to reintroduce the BNB after an extended period out of the wear, but it is possible. You can reach out to your medical team and ask for suggestions on how to start the BNB again, and you can gather tips and advice from other parents on social media groups and other clubfoot resource pages.

The issue with removing the brace when a child cries is that they learn that if they cry, the brace comes off. It is more important to figure out why they are crying. Remember that children have sleep regressions and good sleep patterns is something they learn as well. Consider reading up on infant sleep patterns and regressions.

While in public with your child, you may encounter looks or questions about your child’s casts or braces. Some people are curious and others can say things that are unkind and unhelpful. It is important to remember that you did not cause your baby to be born with clubfoot and you are doing the best possible thing for your baby by helping them through treatment. It might be helpful to spend time processing your own emotions about your child’s diagnosis and treatment and then thinking of how you would respond to people who ask questions or make comments in public. It can help you feel more confident if you are more prepared.

Yes, it is great to take all babies out to socialize. By not hiding the brace, and by teaching those who ask about it, it helps to normalize clubfoot treatment and reduce the stigma associated with the deformity. This can be a great opportunity to bring awareness to clubfoot and its treatment, and frequently you will connect with other people who have a clubfoot connection in their own lives. You will be surprised how many people know of someone who had clubfoot or had it themselves when they were a child.

Once you are in a good BNB routine, the BNB can be left on during diaper changes, you will just want to make sure that you do not pull too hard on the bar as it could cause the feet to move in the boot. You can check the heel placement after the diaper change to determine if a boot needs to be readjusted.

You can lift or carry your baby as you usually do. You may have to slightly adjust how you carry your baby to accommodate the BNB, but it will not impede your ability to hold your baby. There are some helpful instructions for using a carrier and different wraps. There are Facebook groups dedicated to assisting you in baby wearing that are full of helpful information and advice.

It is important to make sure the skin stays dry. Change your child’s socks regularly. A rash could be due to rubbing or a possible fungal infection. If your baby has developed a rash that you do not believe is caused by the BNB, consult with your doctor about how to best proceed.

You can use thicker socks when it is cold outside, as well as put booties or large socks over the boots. If it is hot outside, dress your child in thin socks and change them regularly if they get damp. You should choose socks that are smooth with no ridges or seams to reduce the chances of sores developing on the foot.

It is recommended that babies sleep on their backs on a firm surface until they are able to roll over by themselves. It is the same recommendation for a child in BNB. A child that can roll over can sleep however is most comfortable for them. Many parents are surprised by the positions their babies sleep in, but if they are comfortable and safe, then feel free to let them explore what is most comfortable for them.

It is okay to add pillows for support under braces if it makes your child more comfortable. Some parents also roll up receiving or muslin blanks to help support the BNB.

It is important to follow the advice of your doctor to recommend time for wearing the braces. The braces do not inhibit a baby’s ability to move. At the time of crawling, the baby will most likely be napping and nighttime wear so this should not be a major concern. The BNB will not impede your babies ability to crawl, unless it gets caught on something, then you will have to help them out.

It is advisable to wear the BNB as prescribed by your practitioner. There is generally no need to remove boots if the child is not feeling well. It can be tempting to take a break from the BNB when your child is not feeling well, but maintaining consistency and routine with the BNB is also very important to long term success. Many children who take extended breaks from the BNB have to readjust again when they go back into their routine wear. It is important for you to determine what is best for your child by considering all your options.

Yes, kicking and lifting their legs is great exercise for babies.

No, there is no special diet needed for a child with clubfoot.

A child can start preschool. Bracing is usually only worn when sleeping at this stage. By the time your child reaches preschool they will most likely be in 12 hour wear, which means that your child’s school will not need to handle the BNB at all. It is your decision on the extent at which you tell your child’s preschool about their clubfoot diagnosis and treatment. Braces can also be worn at daycare if the early child care worker has been properly trained of how to put them on by parents.

You should have socks that are smooth with no ridges or seams and pants with wider legs to go over the boots. Outfits with snaps in the crotch are handy for diaper changes during the 23 hour wear. Other items that can be helpful are bar covers, blister care items (duoderm, bandaids, etc.) and pressure saddles if using Mitchell Ponseti boots.

Do give yourself grace. Be patient with yourself and your baby and know that there is a learning curve with the BNB as with any other major transition. It is important to create a routine and maintain consistency. A big reason for 23 hour wear is to allow your baby to adjust to the BNB and learn to sleep in them, which is necessary for long term compliance and success. Take the time to learn to put boots on, it is not natural for everyone, and give yourself plenty of time and space to learn with your child. While the initial transition may be difficult, it is important to remind yourself that you are doing the best possible thing for your child. It will become easier as everyone adjusts to the BNB and take comfort in the fact that you will become an expert in BNB wear soon enough.

Children will become very uncomfortable if the bar is too narrow and it can affect their hips and knees. If the boots become too small you may notice wounds on your child’s feet. If you do not adjust the boot size and the bar length accordingly, it can make your child uncomfortable and lead to resistance to wearing the BNB. If your child starts to act differently towards the BNB, take a quick assessment of the bar length and boot size and see if there are adjustments that need to be made.

It can not be said enough for clubfoot parents to understand how vital their role in clubfoot treatment is for a successful outcome. Parents are responsible for maintaining the correction achieved through casting by consistent and diligent BNB wear. This means that the parents have to become confident about everything involved with BNB wear. It is important that when you leave your baby’s first BNB appointment that you have a clear understanding of how to put the boots on and have the contact information of someone on the medical team to contact in case you have questions after the appointment.

This is not advisable. The look of boots and bar is more uncomfortable for parents than the child. Removing the boots and bar, or taking breaks, only disrupts the habit and routine. It can impede the understanding that it is necessary to the child.

Braces are very safe on a baby and should not cause any problems.

You can wash the braces by placing them in a pillowcase or mesh laundry bag, place them in the washing machine with a towel or two, on a gentle cycle with warm water, and no laundry soap. Take them out of the washer and place them in a sunny place to air dry. Or wash them by hand with a minimal amount of soap, rinse well and air dry. If the bar needs to be cleaned, do not place it in the washing machine, but use wipes to spot clean where necessary.

Stretching is beneficial for all people, not just those with clubfoot. There is no harm to continuing in your child’s stretching routine once they are mobile. Stretching is also a great way for parents to have direct contact with their child’s feet and watch for any signs that indicate decreased flexibility or mobility in the foot.

Stretching through play is encouraged. As your child becomes more mobile, encourage them to explore their strength and mobility through natural play like walking on an incline, walking on couch cushions or a mattress, riding a bike or tricycle, and climbing up a slide. Some products that can assist with stretching are: dorsi ramps which can be used when the child is brushing their teeth or standing at a counter, wobble boards, Pikler triangles, Cushy Couch or the Nugget couch, or foam blocks.

Many families do stretches after the boots are removed, or create a play routine that includes stretching.