I’ve taken a several-month hiatus from blogging, but with good reason. In December, I welcomed this little guy to my family.
Look at those cheeks!
The fatigue of late pregnancy and the early newborn weeks – combined with a busy work schedule, my two older boys and husband, and a host of other “real-life” obligations – left me little time for blogging over the past several months. But I’m ready to re-enter the blogosphere. And, since I’m living with a newborn and will be teaching physical therapy students about infant development later this spring, it makes perfect sense to create a series of posts on newborn development. Today’s post is on primitive reflexes.
Primary standing & stepping
When most people think about reflexes, they think about sitting on the table in the doctor’s office getting hit on the knee with a rubber hammer. Those types of reflexes are called deep tendon reflexes and are completely different than the primitive reflexes I’m writing about today.
Primitive reflexes are a set of involuntary movements that are typically seen in the newborn infant. These reflexes originate in the lower, more primitive parts of the central nervous system (hence the name primitive reflexes). Parents are often surprised and sometimes even entertained when I show them primitive reflexes in their baby – because they are involuntary, they can be elicited in a newborn baby almost any time and are often times quite strong. But primitive reflexes are more than cool newborn party tricks (Look, Grandma! I’m 2 weeks old and I can stand!). They give healthcare providers important information about a baby’s neurological function.
Asymmetrical tonic neck reflex
When a baby is born, the higher centers of the central nervous system – areas that allow for voluntary movement – are not fully developed. This means that lower areas of the brain are in control and primitive reflexes dominate movement. In the first few months of life, the presence of primitive reflexes tells us that the lower portions of the central nervous system are functioning as they should. If primitive reflexes are absent or otherwise abnormal (weak or asymmetrical), we may suspect neurological injury or dysfunction in these lower areas of the central nervous system.
By 6-12 months of age, the higher, more sophisticated areas of the brain mature and voluntary movements dominate. In older babies, we expect primitive reflexes to integrate or “disappear” as more purposeful movements emerge. If we continue to see primitive reflexes in the older infant, we suspect that the higher centers of the brain may not be developing normally. Persistence of primitive reflexes can inhibit future development, making it difficult for the baby to learn to roll over, creep and crawl, reach and grasp, stand, and walk. Of course, primitive reflexes never really disappear – they continue to “live” in the lower brain and spinal cord and are simply masked by more mature brain function. This is why primitive reflexes may also be assessed in an older child or adult with neurological disease or injury – the reappearance of primitive reflexes may indicate damage to higher centers of the brain.
The following primitive reflexes are frequently tested by physicians, nurses, and physical and occupational therapists as part of a newborn neurological exam:
- Asymmetrical tonic neck reflex (also known as the “fencing” reflex) – When baby’s head is turned to the side, he assumes a “fencing” posture by extending one arm in front of his face and bending the other arm behind his head.
- Rooting/sucking – When the skin next to baby’s lips is stroked, she turns her head to find the stimulus and attempts to “latch” on and suck.
- Palmar and plantar grasp – Pressing into the palm of the hand or ball of the foot causes the baby to grasp with his fingers/toes.
- Primary standing and stepping – When held in a supported standing position, the newborn “stands” and even takes some steps.
- Galant reflex – Stroking along the side of the baby’s spine causes the spine to curve toward that side.
- Moro reflex – When the baby’s head is dropped backward, it elicits a “startle” (he quickly extends both arms), recovery (arms back to midline), and a cry.
For more information or to see primitive reflexes in action, check out the video:
Yesterday, the medical journal Neurology published a study suggesting that professional football players are 4 times more likely to die from the Alzheimer’s disease and ALS (Lou Gehrig’s disease) than the general population. This is just the most recent addition to a growing body of evidence linking football to neurodegenerative disease.
As a pediatric health care provider, this body of research continues to be alarming and thought-provoking. As a mother of two boys* (and another on the way), it is terrifying. And complicated.
My husband and I both grew up in small towns where football was a huge part of the community. I was a member of the high school pep band and attended every single home high school football game. I loved those Friday nights when it seemed that everyone in town had come to the football field to cheer on the local team. My husband was a player for his team and has fond memories of the physical challenges of the sport as well as the camaraderie he developed with his teammates. We both continue to enjoy the game, and watch our Mizzou Tigers faithfully during football season. If – when we were expecting our first son in 2006 – you would have asked us if we thought football was too unsafe to allow our son to play, we both would have laughed. But a lot has changed since then, and there is now strong evidence (most released just within the last few years) that the repetitive trauma experienced in football is linked to depression, memory loss, suicide, and neurdegenerative disease. My husband and I have had many thoughtful conversations about this issue, and we are both unsure we can ever let our sons play. We agree that we will encourage other sports and interests and will be perfectly content if our sons never want to play. And we certainly won’t sign them up to participate in local youth football leagues, where – at least in our community – children as young as 8 years old practice up to 6 hours a week in full pads. But we haven’t decided what we will do if one of our boys asks us to play in junior high school. Luckily we have at least 7 years to make that decision.
Many have argued that the study published yesterday applies only to professional football players, elite athletes who take much harder hits for many more years than your average youth football player. That may be true in this case and, of course, research and statistics are tricky things. You can’t make decisions based on one study, and – at the end of the day – statistics are good at telling you what will happen to a group of 100 people, but not necessarily good at telling you what will happen to an individual. But isn’t about just one study or one group or one individual. Boston University’s Center for the Study of Traumatic Encephalopathy has an entire list of published studies on the effects of concussion and repetitive head trauma on young athletes. They are just one of the research teams finding that in football players – particularly those in “speed positions” who experience the hardest hits and are at greatest risk for concussions and repetitive head injuries – brain structure and function are altered. It is hard to ignore heart-wrenching stories (like this one) of boys who have died because their brains were damaged from the repetitive head trauma experienced in football. And consensus is growing among the medical community that football is bad for kids – it seems that every time I turn around, a pediatrician or orthopedic physician has written a blog post outlining why she won’t let her own children play football (see this one by Wendy Sue Swanson, MD).
Many supporters of youth football concede that the risks of neurological damage are increased, but argue that they are still small. They say that kids can get hurt doing a lot of things, that their child enjoys the sport. They cite the benefits of football – the exercise and physical activity, learning to be a part of a team, to be disciplined, to push themselves – and they choose to let their son play. I don’t think those parents are necessarily wrong. Parenting (and life, really), is about weighing benefits and risks and making informed – and often difficult – decisions. But I would argue that kids can get all those things – exercise, team building, discipline – from other activities that don’t carry the risk of head injury (I would also argue that – given the Greg Williams “Bountygate” and recent events at Penn State – the culture of football seems to be a lot more about winning games than caring about the mental and physical health of children and players, but that’s a post for another day).
I don’t judge the parent whose child plays youth football, but I do think he would be remiss if he didn’t educate himself and thoughtfully consider the risks and benefits associated with the sport. Taking an “I played and I turned out just fine” attitude doesn’t cut it – we have to set aside the fond memories and emotions we associate with the game and take a real look at the science and evidence before us. We have a lot more information than we did 10 years ago, and we are fortunate we can use that information to make better decisions for our children. And in our family, I think the decision is no football…for now.
*I in no way intend to be sexist or offensive by only referencing boys in this post. I know that girls do play football and I encourage parents of female football players to also seriously consider the evidence before letting their child play. But because that is a very rare occurrence – and because all research referenced in this post was done on boys – I chose to male pronouns throughout this post.
Approximately 4 million Bumbo Baby Seats have been recalled by the Consumer Product Safety Commission in response to reports of injuries – including skull fractures – in babies who wiggle out of the popular (and controversial) infant seat. The recall provides Bumbo seat owners with a free repair kit including a restraint belt, a new warning sticker, and updated safe use instructions. All new Bumbo seats will be equipped with the restraint belt.
The Bumbo seat has been the topic of heated discussion among the pediatric physical therapy community for some time now. For every PT who likes the Bumbo and uses the seat in practice, there is a PT who despises the seat. I posted my own thoughts on the Bumbo a few months ago. I own a Bumbo and have used the seat with my own children, as well as some of the infants and toddlers in my physical therapy practice. I still believe that – for typically developing children – the Bumbo (and similar seats such as the Bebepod) isn’t any more helpful or harmful than most other infant equipment. For children with special needs, the seat can have some benefit when used with the right child at the right time. But I’m also thankful for the recall, not only because a restraint belt on the Bumbo is long overdue, but also because it serves as a good reminder of things parents and healthcare providers should consider when placing their baby in (or recommending) ANY piece of infant equipment.
- Infant equipment should be used properly. The majority of reported Bumbo injuries occurred when the seat was placed on a raised surface, even though the seat is clearly marked with a warning to NEVER use it on a raised surface. Parents need to remember to always use infant equipment properly, and never place a baby on a raised surface in any piece of equipment (Bumbo, “bouncy” seat, car seat carrier, etc). For that matter, a baby shouldn’t ever be placed on a raised surface even when they aren’t in a piece of equipment and aren’t mobile yet. You never know how they might wiggle or when they might decide to try a new trick. How many of you have heard a friend tell the story of the time their baby rolled for the very first time…right off the couch? Remember also that the Bumbo is simply a device to facilitate supported sitting, and you should never place a baby in supported sitting on a hard surface (without carpet, blankets, and/or pillows to break inevitable falls).
- Infant equipment should be used at the correct developmental stage. Although this is not indicated in the recall, I suspect that many babies who wiggled out of the Bumbo seat were already sitting alone or were mobile (scooting or crawling). Most infant equipment is only appropriate during a certain stage of development – the Bumbo, for example, should only be used from the time infants are able to hold their head up until they can sit unattended (the 3-7 month range for a typically-developing baby). Once a baby can sit up alone and is mobile, the Bumbo, bouncy seat, bassinet, and even some infant swings are no longer safe or appropriate. Placing an older, mobile baby in this type of equipment greatly increases their risk of injury as they try to use their new found mobility skills to “escape.”
- Babies should not be left unsupervised in infant equipment. As the mother of young children myself, I completely understand the need to put your baby in a safe place so you can walk away and start dinner, answer the phone, or simply go to the bathroom. For a newborn who is not yet mobile, a blanket on the floor is a safe, simple option. Once babies become mobile, the floor is still a great place (with good baby-proofing and baby gates, of course). A playard (what used to be called a “play pen”) works well, too, and allows baby to practice moving, sitting, pulling to stand, and playing with toys in a very contained and safe environment.
- Infant equipment should be used rarely. This is the most important point of all. The truth is – although clever marketing makes parents believe that it takes hundreds of dollars worth of equipment to properly raise a baby – none of it is really necessary. The absolute best thing for a baby’s development is floor play, plain and simple. There is mounting evidence that increased use of baby “containers” has led to increased instances of torticollis and plagiocephaly, as well as mild delays in the attainment of motor skills in typically-developing children. The best way to combat that is tummy time, tummy time, tummy time! And the only piece of equipment you need for that is a good old-fashioned blanket.
Overall, I hope the Bumbo recall will make the seats much safer for parents who choose to use them, and I also hope it will spark continued discussion about proper use of ALL infant equipment.
As the school year winds down, many kids’ activity levels (thankfully) start to ramp up. With end-of-the-year field days and the beginning of summer ball, my Facebook news feed is exploding with comments and articles expressing a similar sentiment:
Remember when there were actually winners and losers? When everybody didn’t get a medal?
Sort of has a “good old days” (or “kids these days“) ring to it, doesn’t it?
As a parent myself, I don’t neatly fall into any of the media-hyped parenting categories (who does?), but I do tend toward being a bit free range. I believe that the world isn’t nearly as scary of a place as most people think it is, and that the best way for my children to learn to be citizens of the world is to live in it, without me hovering over them at all times. I know my kids need to try (and fail) before they learn to do something themselves. They won’t always be the best at everything, and I want them to know that (and also know that it’s okay). I understand that winning and losing is part of life, and that learning to be gracious in victory and defeat – although difficult – builds character. So you might think I would oppose the everybody-gets-a-medal-just-for-trying philosophy. But I don’t.
I think it goes back to the first (and only) season I ran track in school. I was in 8th grade. I had always been okay at sports, but I had recently gone through puberty and – once my body starting changing – I became slower, weaker, clumsier, and much less confident in my physical skills. I had never been interested in track and I’m not sure why I decided to join the team that year. I wasn’t fast and couldn’t really jump or throw, but – to my and my coach’s surprise – I was a decent distance runner. So my coach put me on the 800-meter relay team with 3 other girls. At our first track meet, I was the third leg of the race and our team was in second place as I waited for the hand-off. I took the baton and started running, overtook the girl in front of me, and finished my leg of the race with our team in first place. It felt good, until I realized that the next member of my team wasn’t there to take the baton, the ref (a coach from the home team) was in my face yelling about something I didn’t understand, and my coach was grabbing me and pulling me off the track. Apparently, I had my foot on the line of the handoff zone when I grabbed the baton, and I had disqualified my team. Looking back, I realize that this was at least partially my coach’s fault – she had not thoroughly gone over handoffs with us, and I didn’t know about the handoff zone or the rules surrounding it. I also know now that the ref who was screaming and yelling at me about how I was disqualified was totally over-the-top about the whole thing. But I didn’t get any of that at the time. I was a kid. A kid who had failed not only herself, but her team. I was mortified and embarrassed and sorry I had ever even gone out for the track team. I finished that track season (my parents made me), but my heart wasn’t in it. I never came close to running the 800 in the time I had run it in that first track meet, and I begged to come off the relay team for the rest of the season.
That was the beginning of the end of competitive sports for me. I stopped playing softball and basketball, deciding to get an after-school job to earn some money instead. The only high school sport I played was golf (a much more individual and somewhat less active sport), and I became a chubby teenager who didn’t get nearly enough physical activity.
I think the idea that participation medals are bogus and that it builds character for kids to lose rests on the assumption that all kids are competitive, and that losing a competition will drive kids to to better and work harder next time. But there is another side to that coin, and 13-year-old Kendra is a perfect example. For some kids, the competition itself will be enough to drive them away – they’ll never be brave enough to join the team or enter the contest. And those who muster up the courage to participate once, like me, may never come back once they feel that first sting of defeat. Those are usually the kids who need that physical activity the most – the kids who are clumsy or overweight, who have an intellectual or learning disability that makes it harder for them to understand the game, or who don’t have a parent who models physical activity or works with them on playing catch in the back yard.
Don’t get me wrong – I certainly think there is a time and place for competition. That includes junior high and high school sports, and I’m sure I deserved to be disqualified from that race. But I wonder if it would have been handled differently – if our team could have finished, if they would have quietly talked to me and explained what I did wrong and how I could do better next time, if there would been a little less emphasis on winning and losing – if I would have kept up with track and been a healthier teen. I wasn’t a competitive kid and I’m still not competitive as an adult, so I wonder if I would have thrived in a program like Girls on the Run (that promotes self-esteem and healthy activity rather than competition) instead of a competitive track team. I wonder if the parents and coaches who scream the loudest about how “kids need to learn that there are winners and losers” really care much about the kids at all, or if they are just somehow trying to relive their days of competitive sports. Do they assume that, because they are driven by competition, that all kids must also have that same competitive drive? Frankly, I suspect many of them aren’t all that interested in their own kid learning about losing, but are convinced their kid will end up in the winner’s circle so others can learn the lesson.
There is a time and place for competition, but 7-year-olds don’t need to play tackle football. Nine-year-olds don’t need to throw 100 pitches a day 10 months out of the year. 3-year-olds don’t need to run soccer drills. And a chunky 13-year-old who makes a mistake running her first track meet doesn’t need to be dragged off the track and disqualified in front of all her teammates in dramatic fashion. Activity should be fun, and should be part of everyone’s daily life.
Kids are fatter and less active than ever. Of course kids need to learn about winning and losing, but – when it comes to physical activity- the main lesson kids need to learn is that it feels good and is fun to move! For some kids (usually the ones picked first for the team), competition is part of the fun, and those are the kids who should join competitive teams. But in some ways, competitive sports reward the kids who are more active, who are “better” at physical skills, while the kids who aren’t so good (and frankly need more practice and activity) get cut from the team and sit the bench. Competitive sports have their place, but they widen the gap between kids who are “athletic” and those who are not. Perhaps we should realize that there is value in sports (and in people), even if they’re not competitive. We need to reach out to the kids picked last for the team, and provide opportunities for healthy activity that doesn’t divide everyone into winners and losers. Physical education class, school field days, and local parks & recreation sports should be places where ALL kids can feel comfortable participating in sports without worrying about being labeled a failure or a loser.
There are plenty of opportunities in life to learn about winning and losing. But when it comes to physical activity, the consequences of failure – obesity, diabetes, heart disease, and premature death – are just too high.
I say keep the participant medals, and everyone wins.
[Creative-commons licensed photo by Flickr user Mike Saechang]
How much exercise do your kids get each day? The CDC recommends that all children participate in 60 minutes of physical activity each day, including aerobic exercise, muscle strengthening, and bone strengthening. Sixty minutes per day may seem like a lot, but it is important to remember that children aren’t simply small adults. Kids (especially young ones) can’t stick with any activity for an hour, and they certainly aren’t going to be excited about doing 20 push-ups or 2 miles on the treadmill. The key to get kids moving is to break up activity into several shorter sessions during the day (for example, six 10-minute bouts of activity) and – most importantly – to make exercise fun. As summer approaches and we enjoy warmer temperatures, outdoor play provides the perfect opportunity to have 60 minutes (or more) of fun with movement each day. Here are a few ideas for you and your kids to get outside and get moving:
- Take a “penny hike.” Walk to a crossing, then flip a coin to decide which way to go. Repeat until you make it back home or are just ready to go back.
- Go for a ride. Depending on your child’s age, a tricycle, bicycle, scooter, or roller skates are all great ways to get moving. Don’t forget the helmet!
- On a hot day, turn on the sprinkler. Kids can run, jump, and hop through the water.
- Have animal races. Pretend to be a bear (walking on hands and feet), dog (on hands and knees), elephant (one arm swinging like a trunk), kangaroo (jump), snake (slither), or crab (crab walk). Be creative and let your child choose his or her favorite animals.
- Get out the sidewalk chalk. Draw a hopscotch grid for practice jumping and hopping. Create an obstacle course where kids can practice walking on a line or running, jumping, hopping, or crawling to different shapes and letters.
- Climb, swing, and slide. Use the swing set in your back yard, or walk (don’t drive!) to your community park. Close supervision may be necessary, but let your child do the climbing, swinging, and sliding herself. It really is safer that way, and she’ll learn so much more.
- Go back to the basics. Teach your child how to jump rope or hula hoop. Grab a ball and play catch, kick ball, or dodge ball. These inexpensive, classic toys provide almost endless opportunities for movement and play.
- Just send them outside! If your kids are old enough and you are comfortable with the safety of the environment, turn them loose while you catch up on chores in the kitchen (stay within ear shot and check on them frequently, of course). If they’re younger or you live on a busy street, you may need to sit on the porch or patio and supervise. But the point is that kids need unstructured play, and lots of it, to learn and grow. Rolling in the grass, digging in the dirt, playing tag with siblings, or practice “tricks” like cartwheels and somersaults are important for children to learn about their bodies and the world around them. You can’t really teach a child that he’ll get dizzy when he spins around, or that he’ll fall down if he tries to walk down a hill too quickly. He needs to learn those lessons on his own terms.
Daily outdoor play is good for the whole family, and helps establish a life-long habit of regular recreational exercise for your child. Do your kids play outside every day? What are some of their favorite outdoor activities?