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Why Isn’t My Baby Walking?

The walking stage is a huge milestone for every child. It’s an exciting new time when your baby officially becomes a toddler. Most babies learn to walk between 12 and 15 months. A baby isBlog-Walking-Main-Landscape considered delayed in walking once they turn 18 months old. When a child is delayed in a certain gross motor skill, parents are always curious why this delay is happening.

Here are some reasons that your baby may be delayed in walking:

  • Muscle weakness and/or low muscle tone. This is the most common reason. A child who has weakness or low tone in their core and hip muscles may have difficulty with walking. Sometimes this weakness affects the earlier milestones such as crawling, pulling up to stand, and cruising. If your baby had difficulty learning early milestones, they are more likely to have difficulty with walking. A physical therapist can do exercises with your child to strengthen their muscles and help them learn to walk.
  • Orthopedic concerns. This involves the bones and joints in a child’s legs and how they are aligned. An example is hip dysplasia. These concerns are diagnosed by an orthopedic surgeon and are treated in a variety of ways.
  • Neurological concerns. This involves the nerves, muscle fibers, and nervous system of the body. An example is diplegic cerebral palsy. These types of concerns are diagnosed by a neurologist.

Orthopedic and neurologic concerns can be very scary to parents. It is important to understand that a delay in walking does not automatically mean that your child has an orthopedic or neurological disability. If you think your child is delayed in walking, speak to your pediatrician. A pediatric physical therapist can evaluate red flags for causes of delayed walking, as well as help your child to learn this skill.

NSPT offers services in Bucktown, Evanston, Highland Park, Lincolnwood, Glenview, Lake Bluff, Des Plaines, Hinsdale and Milwaukee! If you have questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140.

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Why Isn’t My Child Walking Yet?

As a follow up to last week’s blog, Signs that My Child Will Walk Soon, I present the next topic in my walking series, Why Isn’t My Child Walking?. As first birthdays come around, many anxious parents wonder, “why hasn’t my child taken his first steps?” First off, let me dispel the myth that babies will begin taking their first steps by their first birthday. The normal range for independent walking is 10-18 months, however most children begin walking around 14-15 months. Delayed walking skills may be due to decreased muscle strength, decreased confidence, or impaired balance. Read below for a description of signs of each and tips to help improve them.

 Reasons Your Child May Not Be Walking Yet:

  • Decreased Muscle Strength: Walking is a major milestone for children and requires a lot of lower extremitywhen will my child walk strength. This is why there are so many important precursors to walking, such as cruising and creeping on hands and knees. Children typically spend 1-4 months in each of these precursory milestones in order to build the strength necessary for walking. Encouraging your child to spend time in these gravity dependent positions will help build lower extremity strength.
  • Decreased Confidence: Often times children who have been cruising for significant periods of time without making the transition to independent stepping may have decreased confidence in their walking skills. Employing a towel or blanket that is held as a link between parent and child, can help build their confidence.
  • Impaired Balance: A child who shows difficulty with independent standing may have impaired balance and proprioception. Using heavier shoes that help give feet to the child that let them know where they are in space.
  • Other Medical Reasons: There may be an underlying medical condition preventing your achieving his gross motor milestones in an appropriate time frame If your child is not demonstrating signs that he will walk soon by 12 months of age, please contact your physician or come into North Shore Pediatric Therapy for a free physical therapy screen.

NSPT offers services in BucktownEvanstonHighland ParkLincolnwoodGlenview and Des Plaines. If you have questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140 and speak to one of our Family Child Advocates today!

signs my child will walk soon

When Will My Child Start Walking? 5 Signs That Your Child Will Be Walking Soon

All children develop and grow and their own rates. Current research gives a range where typically developing children achieve their gross motor milestones. But when the baby books and Pediatricians tell you that your baby will probably be walking independently somewhere between 10-15 months, with some children even walking at 18 months and still falling within normal ranges, parents want more answers. A great way to see if your child is on the right track is to check for these 5 signs that walking may be in their imminent future.

5 signs your child will be walking soon:

  1. Pull to Stand – When a child begins pulling up into standing using hands or stablesigns my child will walk furniture, he is strengthening his legs to prepare them for walking. The mature form of pulling to stand is to perform through a half-kneeling position.
  2. Cruising – Cruising is defined as walking while holding onto furniture. Cruising allows your child to practice weight shifting and forward progression in a safe environment.
  3. Crawling onto and over Furniture – As a child becomes stronger throughout his core and extremities, you may find him starting to climb onto furniture or crawl over obstacles. These are all signs that your child is developing the muscle strength and balance needed to walk independently.
  4. Walks with Push-Toy/Handheld Assistance – The added stability of walking while holding onto a push-toy or a parent’s hands helps children develop the confidence needed to take those first independent steps. Some children may use this as a crutch, so be sure to provide as little support as needed (2 handheld assistance>1 handheld assistance> holding onto sleeve of shirt>holding blanket between child and parent).
  5. Standing Independently – Children begin to let go of objects while standing when they feel confident and stable. The longer the child is able to stand, the greater his confidence is.  Bonus if the child is able to get into or out-of this position with control by himself.

If your child has not begun demonstrating the above skills by 12 months of age, he may benefit from a physical therapy evaluation.

NSPT offers services in BucktownEvanstonHighland ParkLincolnwoodGlenview and Des Plaines. If you have questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140 and speak to one of our Family Child Advocates today!

boy learning to walk

Gait Development In Children

A majority of my clientele are babies just learning to walk, toddlers who are delayed in their walking, or preschoolers who are showing an abnormal gait pattern. Years ago, when I worked in the rehabilitation and hospital settings, most of my patients were trying to regain their ambulatory abilities after an injury. Needless to say, walking is an important part of growth and locomotion. It is a complex task that requires musculoskeletal and neurological system maturation and cohesion.

Development of Gait:

The components of typical adult walking include 1) stability in stance, 2) sufficient foot clearance, 3) appropriate positioning of foot for initial contact of the next step, 4) adequate step length, and 5) energy conservation. Depending on the age or type of injury, a person’s walking ability might be impaired in any of these factors. Physical therapists work to address each component to encourage efficient and safe walking.

At age 1, children are just learning to walk and are still working on their standing stability. When they first start walking, their arms are held up high in protective guard, and they walk really fast so as not to lose their balance.  They rely on a wide base of support to maintain their stability. They often put their feet down flat on the ground and they do not spend as much time on each leg when clearing their feet for the next step.

About 6 months later, children will often start walking with a more natural gait, with arms down in a reciprocal swing, and with heels hitting the ground first.  Because of the structure of toddlers’ bones and joints, they still stand with a wider base of support than adults do, but are in the process of narrowing their stance.

In preparation for running efficiency and coordination, children who are two years old will have better ability to stand on one leg while clearing the other foot, and they are better at lifting their legs up and forward during walking. Base of support will continue to narrow during this stage.

By three years of age, children have gained the strength, upright posture, and limb coordination to walk similarly to adults. They might still stand and walk with different joint motions than adults, but this is more due to structural differences than anything else.  As their muscles and bones mature, children’s ambulatory abilities will improve as the forces of gravity and daily activity slowly elongate and strengthen the structures needed to perform adult walking. Of course someone who is seven years old cannot walk with the same speed and step length that an adult can, but they come pretty close.

The orthopedic and neurological changes that occur in a baby to enable him or her to walk are complicated.  It takes years and lots of practice for a mature walking pattern to develop in a child. Parents often ask whether or not their child is walking “normally.” That analysis depends on the child’s age, medical history, and family history. Studies have shown that adult gait is present in children by 7-8 years of age. A child can come into physical therapy with a variety of deviations (from flat feet, in-toeing, to toe-walking, to frequent falling). It is only through careful observation and assessment of their gait cycles that physical therapists can help these children achieve the optimal pattern.

Reference:

Stout, JL. Gait: Development and Analysis. In: Campbell SK, eds 3. Physical Therapy for Children. Philadelphia, Pa: WB Saunders Co,2004 :161-167.

Keen M. Early development and attainment of normal mature gait. Journal of Prosthetics and Orthotics 1993; Vol 5, Num 2, p 35. Available from: http://www.oandp.org/jpo/library/1993_02_035.asp; 2014 [accessed 31 March 2014]







World Health Organization Development Study Results: Gross Motor Milestones In the First Year

 

The line between typical and atypical development can be a hazy one. There are standards that pediatricians, physical therapists, and developmental experts use to monitor growth and deviations from the norm, which allow us to recommend interventions when appropriate.  In 2006, the World Health Organization (WHO) released a whole new set of standards for evaluating and assessing the development of children from birth to 5 years.

What makes this new standard a great tool to monitor the change and growth of infants? This standard is based on data collected from healthy children, over multiple years, in six diverse geographic regions including Southeast and Southwest Asia, Europe, West Africa, North and South America. What is exciting about the new evaluation tool is that now, pediatric specialists have more than just reference curves for physical growth, but curves for motor development as well.

The six gross motor milestones WHO examined in babies were the following:

1.    Sitting without support
2.    Standing with assistance
3.    Hands-and-knees crawling
4.    Walking with assistance
5.    Standing alone
6.    Walking alone

The “windows of milestone achievement” were organized into percentile rankings which pediatricians and physical therapists can use, much like a growth chart.

Without delving too deep into statistics and calculations, the typical age range (in months) for each milestone is listed below:

1.    Sitting without support: 3.8 – 9.2 months
2.    Standing with assistance: 4.8 – 11.4 months
3.    Hands-and-knees crawling: 5.2 – 13.5 months
4.    Walking with assistance: 5.9 – 13.7 months
5.    Standing alone: 6.9 – 16.9 months
6.    Walking alone: 8.2 – 17.6 months

The average (mean) age for healthy children achieving each milestones is as follows:

1.    Sitting without support: 6 months (with 1.1 month standard deviation, SD)
2.    Standing with assistance: 7.6 months (with 1.4 month SD)
3.    Hands-and-knees crawling: 8.5 months (with 1.7 month SD)
4.    Walking with assistance: 9.2 months (with 1.5 month SD)
5.    Standing alone: 11 months (with 1.9 month SD)
6.    Walking alone: 12.1 months (with 1.8 month standard deviation)

(Click here to view this information in chart form from WHO.)

What is most interesting is that about 90% of the children studied met their milestones in a common sequence, and only 4% of the children skipped hands-and-knees crawling.  (Read here about the importance of crawling.)

As you read over these standards and timelines, remember that every baby develops differently from another. If you see your baby fall behind on any of the 6 gross motor milestones above, mention it to his pediatrician, and she will most likely recommend a physical therapist to help him along.



Reference:
WHO Multicentre Growth Reference Study Group.  WHO Motor Development Study: Windows of achievement for six gross motor development milestones. Acta Paediatrica, 2006; Suppl 450: 86-95.

How to Encourage Baby’s First Steps

As a physical therapist who works primarily with the 5 and under crowd, I have had the pleasure of witnessing many babies’ very first steps. Some of the proudest moments I’ve experienced on the job have involved children meeting their milestones for the first time.  Watching a child develop the confidence in his abilities to venture onto unfamiliar terrain on his own makes the months leading up to that moment so worthwhile.

I am sure that I do not have to talk about the importance of walking as part of typical development. What parents don’t realize are the components of human ambulation and the importance of each step.   For many new parents, I often reiterate the fact that weight-bearing through their feet is a great way for babies to learn. They learn how their bodies move, strengthen their muscles and bones, and receive the appropriate feedback from their environment to perform more and more challenging tasks, such as jumping, and running, and stairs.

Often, first time parents are unsure how to best encourage their child to take those first steps. So how do we facilitate and not hamper their exploration?

How best to help out a toddler learning to walk:

  1. Cruise is first: About a month after a baby first learns to pull to stand, he will start cruising along furniture.  At this time, he still relies on his hands a lot for standing and doesn’t yet have the full grasp of shifting his weight from foot to foot. Help him cruise along by placing toys just out of reach and he will slowly become more and more stable when all his weight is on one side. Cruising long distances increases baby’s standing stamina and strengthens those important hip and thigh muscles. Place toys on a low surface off to the side and behind him, and he will learn to let go with one hand and rotate in his trunk. Trunk rotation is an essential component of reciprocal walking later on. Click here to read more about cruising.
  2. Where to support: Contrary to popular practice, the best place to support a baby just learning to walk is actually at his trunk.  If you take an early walker (say, 9-10 months old) by both hands and try to lead him, he is most likely going to tilt his body forward and step really quickly to try to catch up with his center of gravity. This will not help him place weight throughout his whole feet. Instead, he may rise up on his toes. Weight-bearing through the heels during early walking is important. That impact from the ground helps build muscles and bones up the chain so babies’ thigh bones and hip joints can become strong and stable enough to support their growth. When assisting babies to walk, stay with them and let them lead, however slow each step may be. For more info about best ways to support a toddler learning to walk, click here.
  3. Slow them down: Children usually start to take steps on their own after they feel safe during independent standing. With each new step, babies will keep their feet wide apart so they can feel balanced.  Many parents I know like to give their babies a push-toy such as a doll stroller or shopping cart so they can speed walk around the house. While these toys may seem like a great way to get babies moving on their feet, if given to a baby in the early stages of walking, they also encourage poor postures and improper weight shifts.  If you have to use push-toys, weigh them down. When a baby takes each step slowly, he can experience the way his center of mass transfers over the entire surface of his feet. His foot muscles and his ankle joints need to experience the hard work required by each step in order to properly respond and develop the balance strategies he needs for later.
  4. No shoes or socks:  While I tell parents from early on that babies should experience their environment with only a diaper on, many parents think shoes are a necessary part of early walking.  Many pediatric therapists will tell you how important it is for babies to learn to walk barefoot. Why? Because babies rely on the feedback they feel from the ground to adjust their standing balance as needed. Standing and learning to walk on plush carpet, grassy terrain, or hardwood floor are all so different and our joints, muscles, and posture have to adjust accordingly. Taking that proprioceptive feedback away from babies just learning to walk by giving them shoes will make them unaware of the differences between surfaces.  Read here for information about the best footwear for babies.
  5. Importance of squatting: Squatting is a key play position for babies. Starting as early as 9-10 months, babies can lower themselves slowly from a standing position while holding onto furniture. So place some toys at his feet and try to get him to pick them up. That up and down motion, supported or unsupported, is great for strengthening hip and thigh muscles. Learning to safely transfer their weight during standing tasks will help them with walking skills. Eventually, around 15 months, a toddler is able to stand unsupported, pick up a toy from the floor, stand back up, and keep walking, all without any help from us. Now that is one independent baby on the move!

The typically developing baby learns to walk around 11-15 months. He might not look stable and he may fall after a few steps, but he is doing what he should. He is trying. Every child is different in how and when he chooses to take that first independent step. Our job is to provide a safe and motivating environment for him.  If your baby is not making any attempts to stand by 12 months, or has been standing for a few months and seems to drag one side and trips often, or still has not walked by 16-18 months, it is a good time to bring up your concerns with your pediatrician and contact a physical therapist for an evaluation.

The 411 on Infant Rolling

Around the 4th or 5th month of a baby’s development, he will roll over from being on his tummy to his back. This is often purely accidental; he does not have the ability to control his weight-shifting on his tummy and often tips over as a result.  Around the 5th or 6th month, a baby will have the abdominal strength to lift up his feet and roll over from his back to his tummy. Many of the kids I see are infants and toddlers who somehow missed this important step, or who didn’t start rolling until after the 9th month.  Many of the parents I talk to didn’t give this a second thought until they noticed delays in other skills later on in their children’s growth.

Why is rolling so important?

A healthy, typically developing infant is constantly moving. Like the rest of his body, his musculoskeletal and nervous systems are constantly maturing. As he gains strength in all his big muscle groups, he is also learning how to control his limbs. Motor control is an important aspect of a baby’s neuromuscular growth. Rolling encourages postural muscle recruitment (including the back extensors, hip flexor/extensors, the obliques, and the abdominals). The muscles need to be strong before a baby can learn to crawl, stand, or walk.

The segmental volitional rolling that babies learn to do also encourages trunk dissociation. Through rolling, they learn to separate the movement of their limbs from the movement of their head and trunk. Through these transitional positions, they learn to balance the muscles on the front of their body with the muscles on the back and sides. When they roll to one side of their body, they are elongating that side and contracting the other. It is through this unilateral segmented use that children develop their sequential motor skills – crawling, walking, and most other locomotion skills require the ability to separate one side from the other and separate limb movements from trunk movements.

How can parents help encourage rolling?

  1. Start early. This is similar advice I give to parents about increasing infant tummy time: get down on the floor and play with him. Encourage him and motivate him with toys, sounds, lights, and faces. Start as early as you can. Babies have certain built-in reflexes that help them roll to their side if they just turn their head (the neck-righting reflex).
  2. Ease in.  The more a baby rolls, the more input he receives from his environment to his big muscle groups. Our job is to introduce him to his environment and help him tolerate each new position. His own maturation process will take it from there. Play with him when he is on his tummy or back, then help him to his side and play with him there.
  3. Engage your child, step-by step. With your baby on his back, place a toy just out of reach. Help lift one of his legs and bend his hip to 90 degrees or higher. Slowly cross his leg over the other hip. Wait for him to turn his upper body and kick in his trunk muscles. Your pressure across his hips should be firm, but gentle.
  4. Practice. Practice. Practice. And repeat.

When should I seek a pediatric physical therapy evaluation?

What I often look for is initiation.  The lack of initiation by 6 months is a good indicator that your baby may need a little push from a pediatric physical therapist.  If your baby is not picking up his feet and rolling easily from side to side while on his back by 6 months, bring him in for an evaluation.

Does my child need an Orthotic?

Orthotics are custom foot support devices that may be as simple as an insert worn in your child’s shoe, to a full-leg brace. Some orthoticsorthotics are worn during the day and during all regular activities. Other orthotic devices are designed to be worn only during the night.

The type of orthotic your child needs, and when and how they will wear it will depend on your child’s orthopedic condition and developmental abilities. Because children grow rapidly, orthotics may need to be replaced at least twice a year.

Orthotics for a flat foot or in-toeing:

In cases of flat foot (poor development of the longitudinal arch) and in-toeing, children usually benefit from an orthotics evaluation. Some children who walk on their toes have tight calves and may benefit from night splints to stretch out their calves. It is typical for children to have flat feet. Children do not usually need custom orthotics until about the age of 6. If a child is still not developing a normal arch at that point, or if in-toeing persists, orthotics may be needed. This is particularly true when the child is involved in athletics and sports activities. In these cases, custom-made orthotic support for the arches can improve gait and running performance significantly. Biomechanical issues could lead to injury and pain.

There are many different brands of over-the-counter shoe insert orthotics available. Look for info in upcoming blog!

Incorporating Balance into Your Child’s Before-School Routine

boy balancing on floorBalance, like many things, will only get better with practice and through challenging the balance systems. However, it can be hard to find time after school to work on balance activities when kids already have mountains of homework to keep up with. It can also be difficult to make balance exercises fun and enjoyable for kids.

In order to work on balance skills while saving time and keeping it interesting, here is a list of 5 balance activities that can easily be incorporated into your child’s before-school routine:

  1. Put pants, shoes, and socks on while standing up-This will require your child to stand on one leg while using her arms to don the clothing.
  2. Sit in ‘tall kneeling’ (sitting on knees with hips straight and knees kept at a 90 degree angle) while packing up the backpack-Sitting in the tall kneeling position narrows your child’s base of support, making it harder for her to maintain her balance. This posture also helps to strengthen her hip muscles, which are an important part of keeping her stable in positions that are challenging for her balance.
  3. Sit on a pillow while having breakfast-The pillow serves as an unstable surface, so your child will have to work hard to balance while sitting on it. This is a great way to work on core strength as well.
  4. Walk heel-to-toe on the way to the bus stop-Narrowing the base of support by walking heel to toe will challenge your child’s balance  and help improve her balance when she performs dynamic movements such as running or walking.
  5. Brush teeth with eyes closed-Vision is a big component of balancing, and when you close your eyes you are no longer able to rely on that sense to balance. Your body instead will have to use its vestibular and proprioceptive systems to keep steady.

It is going to be important to supervise your child when beginning these balance activities, as they may be hard at first. If you have significant concerns about your child’s balance with daily activities or if you have balance-related safety concerns, you can contact an occupational or physical therapist at North Shore Pediatric Therapy. To find out more about the vestibular system read our blog To find out more about the proprioceptive system read our blog

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The Great Debate: What Should Babies Wear on Their Feet When Learning to Walk?

Parents frequently ask me what the best option is for their child when they are learning to walk: shoes or barefoot? This is a topic that baby walkinghas been controversial in the past. It was once suggested that new walkers should wear shoes with thick soles so that they are provided with additional support that is required for proper foot development; however, this is false. The new philosophy is quite the opposite; shoes can provide too much support and can possibly limit the child’s muscle and gait development. The bottom line is that a child should be barefoot as much as possible until he or she is about two years of age.

Below are some explanations and tips for new walker footwear:

  • A child’s foot muscles are very small and they will become stronger as the child learns to walk. With shoes that provide too much support, these muscles will not strengthen properly when the child is learns to walk.
  • Walking barefoot not only strengthens a child’s foot and ankle muscles, it also facilitates proper development of the arches and balance skills while encouraging a natural gait pattern.
  • It is important for a new walker to feel the ground beneath their feet and the differences between carpet, hard floors, grass, etc. This will not only foster good sensory development, but also facilitate development of their proprioception skills (where their foot is in reference to the rest of their body).
  • Walking barefoot is not always appropriate. In the winter, or when venturing outside, socks that include non-slip bottoms or shoes made of cloth or leather are the best options. These will provide protection and warmth while still giving the child freedom.
  • When choosing shoes for your toddler, the best shoes will be flat and will be made of cloth or leather. A flexible sole will minimize tripping. Cloth and leather will allow your child’s feet to breathe and decrease excessive sweating.
  • I recommend shoes like the Robeez. In addition to being completely adorable, these shoes have all of the features required to optimize development of a toddler’s foot when learning to walk.

As a parent, you always want to provide the best care for your child and do everything possible to foster development. When it comes to shoe wear, the choice is easy: the simpler, the better. Barefoot is best and if your child must wear something on their feet, use the tips above. Keep in mind that these suggestions are for children who are developing normally.  If you are unsure about what is best for your child with neurological or orthopedic conditions, be sure to consult your pediatrician or a physical therapist.

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