As my youngest son is just starting to stand on his own, cruise along the coffee table, and walk with a push toy on his own, I have been reminded once again how amazing and significant learning to walk really is.
As a physical therapist, one of the most common questions parents ask me is, “When will my child walk?” Walking is a developmental milestone that is extremely meaningful for children and families. For children, walking leads to independence, exploration and learning, as well as improved ability to socialize and participate in home and community life. For families, walking is a very visible sign that their child is developing and healthy, and relieves the physical burden of having to carry or wheel their child everywhere.
Although there are many different “normal” variations of learning to walk, walking is a very visible skill and it is hard for parents NOT to compare their child to others they see. It is even harder to avoid listening to well-meaning friends, family, and even strangers ask questions and offer advice about walking, particularly if your child is a late walker (Is he walking yet? No? Well you just need to get him some hard-soled shoes!). I’m here to set the record straight with a few fun facts about walking.
1. 90% of healthy, typically developing children will take their first steps sometime between 9 and 15 months of age. On average, a child will take his first steps right before his first birthday, but this can vary widely from child to child. This does not mean that something is wrong if you child doesn’t walk by 15 months. I have seen many typically-developing children walk at 15-18 months or later, and late walking is rarely a sign that anything is wrong. However, in rare cases, late walking can be associated with neurological or genetic conditions, so it is a good idea to talk to your pediatrician if your baby isn’t walking by 15-18 months of age.
2. Learning to walk involves multiple body systems. In order to take his first steps, a child must have sufficient strength to hold his body up and the ability to move his legs in a walking pattern. The brain must be able to send signals to the body to activate the correct muscles in the correct order, the sensory systems must send information back to the brain about how the environment looks and feels, and the child must be motivated to walk. Even body shape/size plays a role – infants have a very large head relative to the body and one of the most challenging aspects of walking is overcoming that top-heaviness and controlling the head over the body. Children who are smaller or shorter may walk earlier than children who are larger or taller or have relatively large heads. The bottom line is this – no matter how “strong” or “smart” or “determined” your child is, he won’t take his first steps until all of his body systems are ready.
3. The best way to help a child learn to walk is: TUMMY TIME! It may seem counter-intuitive, but the best way to teach your baby to walk is to lay him on the floor on his tummy and let him learn to play, move, and explore. When babies are born, they have been packaged in the womb for 9 months and their bodies are sort of stuck in a flexed or fetal position. They have little to no ability to hold up their head, neck, and trunk. In the first few months, tummy time is critical to help babies stretch out the muscles on the front of their bodies and strengthen the neck and upper back. By the middle of the first year, babies begin to push up on their arms and come to hands and knees, strengthening their lower back, pelvis, hips and legs. All of these things are critical for learning to pull to stand, step, and walk.
4. Barefoot and soft-soled shoes are best for new and emerging walkers. See my previous post for more information on this.
5. Baby walkers are bad for development of walking. Apart from serious safety concerns (the American Academy of Pediatrics has called for a ban on baby walkers in the US and they have been banned in Canada for many years), baby walkers don’t help babies learn to walk. In fact, research shows that children who spend time in baby walkers actually tend to walk later than their peers who do not. Baby walkers put babies in an unnatural standing position, take away the ability to see the legs and feet during stepping, and deny opportunities for crawling and pulling up. For parents who need to keep their baby contained for a few minutes, a playard or a gated baby-proofed room are much better solutions. And for learning to take first steps, a push toy allows baby to see his legs and feet and practice standing and stepping in a much more natural way. There are commercial push toys available, but most families have ordinary objects around the house that will work just fine – a play grocery cart or doll stroller, empty laundry basket, or large box are all perfect for holding on and pushing around the house.
6. Walking posture changes significantly in the first 3-4 years. Flat feet, walking on toes, or walking “bow-legged,” “knock-kneed,” or “pigeon-toed” can all be normal in the first few years of life. Walking typically looks adult-like by age 6-7. If you’re concerned about your child’s leg or foot posture during walking, you should talk to your pediatrician or physical therapist to find out if your child needs to see an orthopedic specialist or is a candidate for foot orthotics. But, as long as what you are seeing looks the same on both sides and isn’t causing any pain or problems with function, there is a good chance that what you are seeing is one of the many variations of “normal.”
The developing brain and body are truly remarkable, and the journey to walking is different for every child. My own sons are a perfect example of this. My oldest didn’t take a step until he was over 13 months old and didn’t walk well until he was nearly 15 months. It took him several more months to be comfortable walking on uneven terrain such as grass and gravel. My middle son took his first steps at 11 months and never looked back. By his first birthday, he was practically running everywhere – in the house, across the yard, and at the park. My youngest is now 9 months old and is already beginning to stand on his own. I suspect he’ll take his first steps within the next few weeks. All three of my boys developed their walking skills completely differently and on their own timetables. But you know what? They’re all absolutely typical and equally awesome!
Walk on, my little friends!
The APTA House of Delegates kicked off its 2013 session tonight in Salt Lake City, Utah. Tonight’s House activities consisted primarily of introductory remarks, elections, and some logistical/procedural items to get us ready to dig into House business first thing tomorrow morning. Here’s a quick recap and a few things you need to know:
All 2013 motions with their original language are published in Packet I on the House Community and on the APTA HOD 2013 website. If you’re interested in the business of the House, Packet I is a good place to start. However, there’s a LOT of collaboration and discussion that goes on before and during the House as Delegates work together to edit motions, compromise, and come to a consensus on language. This collaboration is a good thing, and the fact that it happens OFF the House floor is important and necessary. However, it makes it challenging at times to stay up-to-date on the most current motion language. Packet II has already been posted with updated language on the following motions: RC 2, RC 7, RC 8, RC 16, RC 22, RC 27, and RC 29. More changes are coming, and Packet III with more updates will undoubtedly be available soon. Updated packets can be found in the “Onsite Packets” section of the HOD Community.
The main event today was Board of Directors & Nominating Committee elections (click here to learn more about the 2013 Slate of Candidates). I’m embarrassed to say that – before I became a Delegate – I had no idea how APTA officers were elected. So here’s the drill. Prior to the HOD, candidates prepare a number of materials that are posted online. Once at the HOD, they participate in candidate interviews, where they spend a morning rotating through rooms full of Delegates, answering questions from different Chapters and Sections. After a brief lunch break, the candidates participate in a “meet and greet” session where they have an opportunity to meet Delegates in a more informal, personal environment. A few hours later, the first order of business of the HOD is to hold elections. Here are tonight’s election results:
Secretary – Laurita Hack
Vice Speaker – Stuart Platt
Director (3) – Roger Herr, Susan Whitney, Carolyn Oddo
Nominating Committee (2) – Cecilia Graham, Peggy Newman
Did I mention that these people VOLUNTEER their time and – if elected – spend more than 40 days per year away from their friends and families? Major kudos to all candidates and congratulations to the winners!
The HOD will be back in session at 8:30 tomorrow morning (local time). Want to follow along? Check out the APTA HOD livestream, follow @APTAtweets and the #APTAHOD hash tag on Twitter (you can also follow me @KendraPedPT), and check the APTA HOD 2013 website and/or House Community for updates.
During the spring semester, I get to introduce second-year DPT students to “normal” motor development as part of their Control of Human Movement course. I created this 5-minute video (starring my three boys: Max, Charlie, and Bobby) for my students as a quick review of motor milestones in the first year.
As I note in the video, motor development is a complex and individual process influenced by individual differences, environment, and even culture. What I present here is meant to be a quick review, and is certainly based on the study of motor development in WEIRD cultures. Do you know any children who developed differently than what is presented in the video? Or who may have even skipped one (or more) of the milestones discussed?
Created using The Keep Calm-o-matic: https://www.keepcalm-o-matic.co.uk/p/keep-calm-and-swaddle-on-3/
As many new parents will tell you, swaddling can mean the difference between a happy, rested baby and cranky, sleepless nights. In fact, one of my favorite parenting books – The Happiest Baby on the Block by Dr. Harvey Karp – lists swaddling as one of the “5 S’s” to help babies keep babies calm and help parents survive the the first 12 weeks of infancy – the so-called fourth trimester. But why?
During pregnancy, the baby is contained in an environment (the womb) where she is constantly being held. She is contained from almost every direction, and – particularly during the final weeks of pregnancy when things get pretty tight in there – is unable to move without experiencing some resistance. After birth, the baby is (quite literally) pushed into an environment where she isn’t contained all the time and where her limbs can move freely. While this freedom of movement is important for developing the muscles for rolling, sitting, crawling, and walking, it can be unnerving for baby. Free movement of the limbs can give the baby the sensation that she is falling, triggering the Moro (startle) reflex (see this post for more info on newborn reflexes). A generation ago, when babies were typically placed on their tummies to sleep, the problem of flailing arms and legs wasn’t a big problem. Gravity pressed the arms, legs, head, and body against the mattress, provided womb-like resistance to movement and a sense of comfort for baby. However, in the early 90’s, we learned that it was much safer for babies be placed on their “Back to Sleep” (for more on what is now known as “Safe to Sleep,” click here). While back sleeping is an important recommendation and has had a significant effect on reducing the risk of sudden infant death syndrome (SIDS), gravity works against the baby in this position. Instead of pressing the limbs against the mattress and their little bodies, gravity pulls the limbs away from the body which results in flailing motions and startling. Babies simply feel less secure in this position and most don’t sleep well without their arms and legs contained. That’s why most babies need a way to transition from the comfort of sleeping in a cozy womb to learn to sleep while fighting against pesky out-of-womb issues like gravity and moving limbs. That’s also why many frustrated (and tired) parents find that the “only way” their baby will sleep is if they’re being held (and grandparents often aren’t much help – they didn’t put babies on their backs to sleep and so many didn’t swaddle). With back-sleeping, you have to trick the baby into thinking she’s being held. Enter swaddling.
From a developmental perspective, swaddling is absolutely safe (and can even be helpful), but there are some things to consider before you swaddle. Because the arms are generally considered the “trigger” for the startle reflex, the arms and upper body should really be the focus of the swaddle. In fact, care should be taken NOT to bind the baby’s legs tightly together when swaddling. Newborns have shallow hip sockets, which means their hips can dislocate much more easily than an older child’s or adult’s. Keeping the legs apart is a stable position for the hip (this is also a consideration in baby wearing – I’ll cover this in a future post). Forcing the legs together is a more unstable position and increases the risk of hip dislocation. So care should be taken when swaddling to keep the legs wrapped loosely while tightly wrapping the arms and trunk. This can be tricky (especially for a wiggly older baby), which is why I love fool-proof products such as the SwaddleMe blanket or the Woombie that firmly contain the arms while leaving the legs in a loose pouch. However, you don’t need a special product for the perfect swaddle – all you need is a good-sized blanket with just a little bit of stretch (I love Aiden & Anais Swaddle blankets and have also had good luck with basic waffle-weave receiving blankets). These blankets should provide plenty of warmth without overheating baby, but – if you think your baby may be a bit warm – you may want to undress her down to a t-shirt or onesie before swaddling.
First, lay the blanket on the floor or bed and fold the top corner down.
Next, lay the baby on the blanket with his shoulders at the top of – or just slightly below – the fold.
Fold one side over the baby’s trunk, going over the arm on the same side and UNDER the arm on the opposite side. Tuck the blanket firmly under baby and give the loose end of the blanket a tug to keep everything tight.
Take the bottom corner of the blanket and bring it over the uncovered arm/shoulder. Tuck it under the shoulder/upper arm, creating a nice loose pouch for the legs to move. Make sure both arms and shoulder are contained – the whole point is to make sure the baby can’t work his arms out of the swaddle. I also like to make a small fold over the top of the remaining “tail.”
Take the remaining tail of the blanket and wrap it tightly around the baby’s arms, bringing it back around the front. Give it a good, firm pull. Don’t be afraid to make it nice and snug around the arms!
Tuck the loose end in to complete the swaddle.
And there you have it!
So how long should you swaddle? Swaddling is most helpful during the first 3-4 months of life, but some babies continue to need swaddling for a few more months (which is perfectly safe as long as they are still unable to roll over while swaddled). Once babies begin to gain more control of their movement, they are usually able to get into their own preferred position of comfort while sleeping and are less likely to startle, so the swaddle is not longer needed. I was effective in weaning both of my older sons from the swaddle at 4-5 months by swaddling with one arm out, then the other arm out, then getting rid of the swaddle completely.
Of course, swaddling should only be used for calming a fussy baby and during sleeping. When baby is awake, he should be unwrapped so he learns how to move and control his limbs on his own. Laying down on an old-fashioned blanket on the floor during play time should give plenty of opportunity for movement and exploration, and all young babies should practice “tummy time” several times a day while awake with supervision.
A swaddled newborn is a happy newborn!
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.