DRIVE INTO the Louisiana countryside on any Sunday morning, down Ellerbee Road to the Baptist church just outside Shreveport, and you'll see a trend in pediatric equipment reminiscent of a Norman Rockwell painting.

In its day-care center, 15 tall white cribs, with a gleam that suggests the underlying chrome, serve as gentle trampolines and nap sites for a bevy of babies and toddlers.

These cribs, made by Hard Manufacturing of Buffalo, N.Y., aren't designed for the church-going kids. They're made for infants with disabilities. But Ellerbee Road Baptist Church officials are singing their praises, right along with the Sunday hymns.

"When we deal with parents, we know that one of the things they really want in a room for young children is that it look 'hospital clean,'" says Ruth Farmer, director of preschool ministries for Ellerbee Road Baptist. "But I didn't want it to look antiseptic. And with these cribs, it doesn't."

Against the soft pastels of the rooms, she and the other teachers sit in rocking chairs, talking softly to the children. And although the cribs get frequent wash-downs, their sheen hasn't tarnished, as Farmer had feared. "But the thing I really like is that they put kids high-at eye level-so you can hold one baby and make eye contact with all the others," she adds.

Sales of Hard Manufacturing cribs are up 10 to 20 percent this year, the company says, and day-care facilities such as the one at Ellerbee Road Baptist Church are one reason why. They constitute about 15 percent of the company's selling volume, says Kevin Currier, head of corporate sales. "You never used to see this," he says, alluding to the hospital and health-network purchases that once were the near-exclusive driving force for commercial crib sales. "Now you see parental preferences taking hold."

A MAINSTREAM LOOK WELCOME TO THE pediatric marketplace in the new millennium, where mom and dad rule, right along with the Health Care Financing Administration coding manual, of course. It's a place where the industry is experiencing pent-up demand for what Catherine Mulholland calls "a more normalized market."

Her company, Mulholland Positioning Systems in Santa Paula, Calif., has seen the onset this year of a "shine-and-soft" trend. What's that? A parental penchant for the shiny framing and soft fabric that look as if they just popped out of a box from a trip to the local mall. Even with more sophisticated positioning systems, Mulholland says she has had many parents tell her, "I want something that looks more like a car seat than a piece of equipment ...just like what you buy in a department store."

That is just what Sunrise Medical is finding, as well. So to get ideas for its new line of stroller-like positioning systems, Kid Kart Xpress, company designers walked the aisles of the nation's most popular toy stores, including Toys R Us.

"We asked ourselves, 'What do moms and dads like to buy?'" recalls Tom Whelan, director of product management for Sunrise Medical's Home Healthcare Group in Longmont, Colo. The answer was plastic-molded products that are light and portable-and navy blue. Navy blue? "About 80 percent of the strollers in America, it turns out, are navy blue," he says.

Right along with its push-button and tilt capabilities, the new Kid Kart Xpress line features fabric of navy blue or mixed pastel hues and "candy colors" (teal, blue and pink) for the frames. Although the models have only just debuted, "we've seen an immediate interest in them," Whelan says. The number of phone inquiries and hits on the company Web site is a sign the new design is going to be a winner, he predicts.

THE MARKET GROWTH CUSTOMER DEMAND HAS never been higher-or more specific-according to recent trends reported by Wall Street-watching publications. Some niche markets, such as baby products for recent natal intensive care unit graduates, have seen gains of 30 percent or more in their debut years. Meanwhile, more traditional equipment, such as wheelchairs, has grown on average between 2 and 3 percent annually since 1990, according to a report by Frost & Sullivan.

Pediatric asthma treatment has also been a boom for home care companies in recent years, and early recognition of the disease is one reason why.

According to the National Heart, Lung and Blood Institute of the National Institutes of Health, the reported prevalence among children ages 5 to 14 has increased 74 percent in the last 14 years, from 42.8 per 1,000 in 1980 to 74.4 per 1,000 in 1994.

Even so, Medicare, Medicaid and private payers still hold the trump cards. And with so many changes among third-party payers (not to mention their rules and regulations), no one seems able to say with precision why there has been such reliable pattern of growth in demand for pediatric health care products over the last 10 years.

One possible explanation has been the trend toward disease management, which seeks to provide a level of care necessary-including family-friendly devices and kid-oriented equipment-to keep patients out of hospital beds and emergency departments.

"Disease management doesn't pretend to be groundbreaking science; it's common sense deployment of scarce resources," intoned Fortune magazine this summer when it published an overview of the trend. "In theory, it offers a clean solution to the problems of rising costs and rebelling consumers that are plaguing the managed-care industry."

The pediatric market is also a stable one. The population of babies who need neonatal intensive care, many of whom require follow-up, has been-and is likely to remain-about 10 percent of all births, says William Bonello, a senior medical analyst with U.S. Bancorp Piper Jaffray in Minneapolis.

THEIR SPECIAL NEEDS BUT CHILDREN ARE not just pint-sized adult patients. As a result, truly "downsized" equipment that encourages kids' self use-and ease for parents-is driving demand. "There is a trend toward use of smaller pieces of equipment," says Alisha Baldassano, vice president of Adaptive Design Labs in West Orange, N.J., which sells the miniaturized Positot seating system.

In pediatric health care, manufacturing products for the youngest consumer can bring an upward swing in sales, Baldassano says. She expects sales of her company's pediatric seating system to be 30 percent higher this year than in 1998. "I think we are having such success because no one thought in terms of seating for a 1-year-old," she adds. Families like the tiny seating system, which goes from 5 to 12 inches-and can take the child from birth to his or her first birthday.

That kind of success is what Cindy Nicholas has seen, too. She founded KidsMed in Hinsdale, III., a company that has seen an explosion in sales of a nebulizer mask known as Nic the Dragon, which encourages children with asthma to behave like the fire-breathing reptile when they take their treatment.

About 700 a month are shipped to home care agencies, hospitals-particularly emergency departments-and private homes, says Nicholas, who still works 30 hours a week as a respiratory therapist. In fact, her day job helped hatch Nic. "I used to draw the face of a dragon on nebulizer masks to try to get kids to use them," she says.

Like Hard Manufacturing's cribs, Nic has found favor among day-care centers, too, where more than one child may require a treatment during the day. Another one of Nicholas' buyers told her that the children at the facility have actually asked for aerosol therapy so they can play with Nic.

Of course, there were a few bumps along the entrepreneurial road toward customer satisfaction. Nic's first incarnations looked a little scary, according to Nicholas. "We had to make the dragon a little more goofy-more like a toy-so we crossed his eyes a little bit."

A similar product making a big splash is Bubbles the Fish, a pediatric aerosol mask produced by Pari, an international company with its U.S. headquarters in Midlothian, Va. "We are seeing great growth," reports Janie Kitzmiller, manager of customer service. In the past six years, she says, gains have been as high as 30 percent; this year, Kitzmiller expects a 10 to 20 percent increase.

"Kids just love it," she says of the mask's little red, white and blue fish, which resembles a flounder not unlike the one that followed "Ariel" around in the movie The Little Mermaid.

LAUNCHING NEW PRODUCTS DOES ALL THIS suggest that customer-pleasing strategies guarantee a good market for new pediatric equipment? It shouldn't because it doesn't.

It can take a long time for innovations, particularly costly ones, to "go mainstream" and earn approval for government-backed reimbursement, says Judith Hickey, president of the Princeton Reimbursement Group, Bloomington, Minn. Indeed, when it comes to paying for new technology, the firm's forecast for the near future is gloomy: It will be hard to get, says Hickey.

"Things do seem to have gotten worse," affirms Dave Anast, publisher of Biomedical Marketing Newsletter, Costa Mesa, Calif. So just how long do new products take to secure inclusion in HCFA coding? The move can take years, he says.

Although the Federal Drug Administration has made good on its pledge to give new technologies the green light in far less time-the average duration for approval is now down to less than 190 days-the same is not true for the HCFA review process, Anast notes. And financially speaking, he says, "you really need that to hit a home run."

To increase the chances that a new product launch will be a hit, the new products are often versions of their former selves, models with variations that can slip back under the same coding labels. Nic the Dragon, for example, just changed shape-not categories. In addition, companies such as Sunrise, Invacare Corp. and Pride Mobility Products all have adjustable seating systems for children that are somewhat homologous to the adult counterparts.

"There have been so many cutbacks, we find we can't call a stroller a 'stroller' anymore," said Dalena Ganakes, director of national sales for Torrance, Calif.-based Convaid Inc. "Instead, we call it a 'positioning system.'

What's more, she says, a child for which one of the company's products was prescribed often has reimbursement problems when a different model is prescribed at a later date. "There is pressure to make a one-size-fits-all kind of product," says Ganakes. "And in some cases, this forces the family to go to a wheelchair sooner."

According to Ganakes and others in the industry, this has resulted in a move to concentrate on certain "easily serviceable" areas of the country, while placing less emphasis on others. Because the South is more restrictive in terms of reimbursement-with flat-rate reimbursement for wheelchairs in some states-the West and East coasts are more popular sales destinations. "You have to be more aware of where you're selling and who is buying," she says. "We tend to concentrate where the funding seems good."

There is also less incentive for incremental advancement of technology, manufacturers say. Product enhancements need to be simple to produce a return on investment. "There is a trend for additions that would make a piece grow with the child," Ganakes says, "but you just can't develop better additions to a stroller right now."

Other similar stories are told across the industry, as classifications known as "growth possibility" and "reimbursement potential" cast their shadow over marketing decisions.

AROUND THE WORLD FOR THIS VERY reason, some new technology-and some old-makes its appearance in some rather exotic places now. A look at the pediatric home and rehabilitation industry across the pond and down under includes several leading U.S. companies, such as Elyria, Ohio-based Invacare Corp. It markets its products through more than 25,000 providers around the globe and has manufacturing plants in Australia, Canada, Germany, France, Mexico, New Zealand, Portugal, Switzerland and the United Kingdom.

Minneapolis-based Otto Bock, another worldwide company, has opened a branch in Tunisia to market a line of its more basic products. Why would a company want to move to a place where English isn't the native language and even automobiles can be a relative rarity? It gets back to the fact that U.S. reimbursement can be tough for new technology, says John Himmelstein, director of sales and marketing for the medical division. "Our pediatric market is still growing here," he says, but given the reimbursement rates, "R&D is too expensive."

Otto Bock's strategy was to hook up with a local vendor that now displays some of its product models, such as prosthetics, in a storefront window. Such a move often is the first toehold into a market, Himmelstein says. "It is like a franchise in that way."

What will drive international growth of pediatric product sales? A relatively virgin marketplace. Cheryl Vogardus, director of marketing for Respironics HealthScan Asthma & Allergy Products in Cedar Grove, N.J., notes that the same forces that fuel domestic sales-improved identification of a prospective patient population-will mean demand overseas, as well. "We expect our sales to increase dramatically in the international market," she says, adding that likely spots for expansion are South America, Europe and the Far East. "We are refocusing our efforts in those places and adding additional salespeople."

THE MARKETING DIFFERENCE PARTS OF EASTERN Europe are heating up, too, as are some South American countries, according to business experts. Poland, for instance, is moving abruptly toward more privatization in many industries, which is likely to translate into vigorous importing.

Previously, for example, Polish hospitals operated in a centralized way under a state budget overseen by the government. In a significant shift, hospitals and clinics there are now being given more freedom to make individual purchasing decisions. Brazil, for its part, is in the process of creating an entirely new health system, which could mean a more lucrative market for health care products, industry experts say.

But the Polish border and the Brazilian rainforest may not be as formidable as the cultural divides separating them from the United States, some experts warn. Anyone wanting to sell Brazilians pediatric home care equipment, for example, might be hampered by the fact that children are considered a private matter for the family. Outsiders' wishes, even in the form of sensitive salesmanship, can be considered intrusive without a bond of family trust.

"Be prepared to commit long-term resources-both time and money-toward establishing strong relationships in Brazil," advise the authors of Kiss, Bow or Shake Hands: How to Do Business in 60 Countries. "Without such commitments, there is no point in attempting to do business there at all."

Many cultural differences can be quite unexpected to U.S. businesspeople. Pediatric products advertised on U.S. soil tend to have a toy-like appearance, at least in promotions. But this is not true in all countries, particularly in technologically advanced ones such as Japan, where children and their parents may want to see evidence of gizmos and gadgets.

Case in point: In the United States, Convaid advertises its Safari tilt chair by showing a winsome stuffed tiger peering out from the seat. The little tiger looks a lot like the tabby cat "Tama" from Japan, a fuzzy feline that also may be featured sitting in a wheelchair-but for a different reason. "Tama" actually is aimed at the elderly. It was developed by the Matsushita Corp. to monitor the home-based elderly for home care purposes. "Tama" is hard-wired for receiving and recording information that can be downloaded later by nurses or home care aides.

Creating a distinction between a stuffed tiger here and an orange tabby abroad might not be much of a problem, but what about those eye-catching strollers from Sunrise?

In some Asian cultures or countries, such as Taiwan, items in which the main color is black or blue are considered offensive, making navy blue a potentially unpopular color. Conversely, red, pink and other pastel colors are considered lucky and cheerful, according to the authors of Kiss, Bow or Shake Hands.

Not a problem, said Sunrise's Whelan. "We still have our traditional models available for those who want the standard equipment." HC