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Wednesday 9 March 2016

Helping baby crawl and walk

My first child, Thomas, is now almost 3 and my second child, Ella, is now 6 months old.  We're not planning to have another child for a while, at least, so my thoughts are no longer so centred on preparing for birth, but on raising children! I am still interested in birth very much and delight in talking about it to anyone who will listen (and definitely overwhelm them with all my opinions), but for this post, let's think a bit about what to do with baby when he/she arrives!

In the next couple of posts, I hope to bring together a few themes that have been spinning round my head the last few weeks - fostering neurological development and independence in babies and children and how that intersects with parent behaviour (and public health). In this post, I'll focus on motor skills development.

Neuroscience and Education

I've been thinking about neurological development because I came across this website (http://www.celinealvarez.org/).  Celine Alvarez is a French woman who studied neuroscience and wanted to apply her knowledge in that field to education, as she felt that schools were completely going against basic principles of child development and therefore not only neglecting golden opportunities for learning but actually damaging young minds.  She set out to become a kindergarten teacher so as to put her theory into practice in an "underprivileged" school in France.  She was very inspired by the work of Maria Montessori, but didn't stick to her work rigidly.  Her experimental class was very successful.  Her students started with numerous delays and ended up surpassing the average in all areas, to the surprise of parents and colleagues.  The national education system eventually decided to shut her class down, but she wanted to share her experience with the world, entirely for free, so that all could benefit and further advances can be made.

So far, she has made at least 18 training videos to describe her method.  The first four are about basic neuroscience in children. These concepts are being talked about by many scientists and educators, I just found Celine Alvarez's descriptions helpful.

One of the first concepts she explores is neuroplasticity and critical periods.  She explains that babies begin learning even before birth and continue to learn as they grow up, but most intensively in the first five years or so.  At that time, the brain is especially plastic - that is, the brain is in a period of change and flux whereby children absorb everything around them without making much of an effort, the "absorbent mind", as Montessori calls it. However, there are certain caveats - firstly, though the brain is hardwired for learning, it must be sufficiently stimulated in order to make those connections.  For example, though we are all built to learn language, real life examples show that if a child is not spoken to, they will not learn language.  Conversely, if a child grows up in a multilingual environment, they can learn multiple languages with ease.  Secondly, there are critical periods in which that stimulation should occur in order to allow learning to take place properly.  If a critical period is missed, the learning will be much harder, and most of these lie within very specific months of early childhood. There is another window of plasticity that opens up at adolescence, but the level of plasticity is less.  Beyond that, though the brain continues to be a little plastic, the adult brain is more in a mode of performing expertly the skills it has learnt rather than acquiring new ones. This is why the environment of children should be as rich as possible to stimulate learning experiences.

The third caveat concerns synaptic pruning.  Basically, though a child has the capacity to learn any and every human skill, those practiced infrequently will be eliminated in the process of helping the brain become an expert at what it does.  The process takes place rapidly in early childhood, therefore, we should keep in mind that it is not the best or nicest experiences that the child retains, but the ones that are most frequent.

These concepts have amazing implications for how we treat babies and children.

In the next few blog posts,  I'd like to look at neuroscience and what it suggests about infant care and the education of young children.   In this post, I'd like to take a closer look at the development of motor skills, such as crawling and walking.



Motor Skill Development and General Development

It seems to me, though I'm no expert, that the motor skills of crawling and walking would be very important in a child's development.  It's not only the fact that these skills are vital in themselves, but importantly, in that they allow the child to begin exploring the world independently.  You'll notice a baby who begins to crawl has very little spatial awareness - it's only through the process of banging into things, getting stuck under and between furniture, do they realize how space works.  Crawling also enables them to access their hands - to pick up small objects on the ground, put them in their mouth (which helps them understand their shape), and experiment with them by banging them and so forth, all of which is really a scientific exploration of their environment which results in amazing learning. In the process of learning to crawl and crawling itself, the child is also developing skills of coordination (especially in bilateral crawling) and developing muscles in the upper back, arms, wrists and fingers which will be useful (nay essential) in later life.

Does it matter when a child develops these skills?   I wonder whether there are more optimum periods of plasticity for these skills and whether waiting a few months could actually be significant. After all, a couple of months in the lifespan of a baby is a huge proportion of this critical, ultra-plastic period of life.  But, can we control when a child reaches these milestones?  Don't they just do it when they're ready?

Well, yes and no.  There is nature - what the child is genetically programmed to be able to do, but there is also nurture.  In terms of nature, there is surely great variation between individuals, but on the other hand, those neural pathways need to be stimulated in order for the skills to be developed and so a child's development could be delayed by lack of proper stimulation.

Back-Sleeping

There was a campaign in the 1990's to get parents to stop putting their babies to sleep on their stomachs (which was the previous recommendation) and to start putting them on their backs in order to try to combat SIDS.  Though this isn't the purpose of this post, I personally think that SIDS is due to an internal abnormality (perhaps one of many possible abnormalities) that is aggravated by external factors, such as the presence of cigarette smoke, formula feeding, and stomach sleeping. That does not mean that stomach sleeping is the cause.  For many babies, it is harmless (as evidenced by the fact that before the Back to sleep campaign, the SIDS rate was still actually a tiny percentage of babies), but for some babies who have some unknown abnormality, they are more vulnerable in this prone position.  Possibly because of more Slow Wave Sleep and more trouble arousing naturally. A truly healthy baby in a safe environment (i.e. no dangerous gases around, no overheating and no suffocation risks), should be able to sleep on his/her stomach and be able to arouse safely.  However, since no one really knows what kind of baby they have (any baby could have hidden abnormalities which science needs to discover), it's safest to put baby to sleep on their back.



Back-Sleeping and Developmental Delays

Although this campaign was quite successful in getting people to change their habits, an unintended consequence of this campaign that is getting more attention nowadays is developmental delays as compared to the prone sleepers out there! Notably motor development, but also social and cognitive development. This information from Wikipedia on their "Tummy Time" page is enlightening:

"Since 1998 there have been several studies published which report that infants placed to sleep in the supine position lag in motor skills, social skills, and cognitive ability development when compared to infants who sleep in the prone position.[4][5] In a 1998 article entitled "Effects of Sleep Position on Infant Motor Development" by Davis, Moon, Sachs, and Ottolini, the authors state "We found that sleep position significantly impacts early motor development." The prone (stomach) sleeping infants in this study slept an average of 225.2 hours (8.3%) more in their first 6 months of life than the supine (back) sleeping infants.[5]

In the 1998 article entitled "Does the Supine Sleeping Position Have Any Adverse Effects on the Child? II. Development in the First 18 Months"[6] by Dewey, Fleming, Golding, and the ALSPAC Study Team the objective of the study was "To assess whether the recommendations that infants sleep supine could have adverse consequences on their motor and mental development." They used the Denver Developmental Screening Test (DDST) and studied infants at 6 and 18 months. According to the study, at 6 months of age, the infants who were placed to sleep in the prone position had statistically significant higher social skills scores, gross motor scores, and total development scores than those infants who were put to sleep in the supine position. In the 2005 article entitled "Influence of supine sleep positioning on early motor milestone acquisition"[4] by Majnemer and Barr they used the Alberta Infant Motor Scale Scores (AIMS Scores) to analyze the impact of infant sleep position. They reported that "Typically developing infants who were sleep-positioned in supine had delayed motor development by age 6 months, and this was significantly associated with limited exposure to awake prone positioning." But, the authors also note that awake prone (stomach) positioning is associated with prone (stomach) sleeping. No studies have been conducted which compare supine sleeping infants who have regular awake prone positioning to prone sleeping infants who have regular awake prone positioning.

Placing infants on their stomachs while they are awake has been recommended to offset the motor skills delays associated with the back sleep position[4] but positioning the infant on their stomach while awake will not impact the amount of slow wave sleep[7][8][9][10][11] since tummy time only occurs when an infant is awake."
https://en.wikipedia.org/wiki/Tummy_time

The developmental delays are mostly attributed to simply less time spent on the stomach (prone) engaging in "anti-gravitational activities" which encourage them to lift up their head, lift up their chest, roll in both directions, crawl, sit up, pull to standing and finally walk.  If a child is delayed in any of these milestones, the others seem to be pushed back and they are also missing out on the opportunities they could be getting to explore and interact with their environment, which are so crucial to stimulating those neural connections. One other possibility for delays is actually the amount and quality of sleep between the two groups, with prone sleepers getting more sleep and more slow wave sleep.

But, that aside, the reason that back sleepers have trouble getting enough opportunities to develop "anti-gravitational" skills is nicely explained here:

"Prior to the Back to Sleep campaign, infants who slept in the prone position also tended to spend awake time in the prone position. When an infant awakes in prone and becomes fussy or bored, it naturally learns to push up on its forearms and lift its head to explore the environment. Pushing up against gravity also has the added benefit of strengthening the muscles used in other prone skills such as pushing up onto hands and knees, creeping, crawling, and rolling over. Infants who sleep in a supine position are not in the appropriate position upon awakening to achieve these skills spontaneously. Without adequate prone time, the antigravity motor patterns may be underdeveloped. When the infant is then placed in prone, it is an uncomfortable position and the infant will often fuss and cry. The parents' response is to then say that their infant does not like this position, and therefore they may not provide prone time during the day."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595182/

Tummy Time

So, to compensate for these factors, public health workers have tried to emphasize the importance of tummy time for awake play.  But, it's been difficult when people are so afraid of SIDS.

"Although “tummy time” is also included in the Back to Sleep educational materials, it is often forgotten. In addition, parents are often so fearful of SIDS that they are often reluctant to provide prone time, even when the infant is awake.  found a significant association between the knowledge of SIDS and fears connected with prone play positioning. In a self-administered questionnaire, 93% of the parents reported that their knowledge of SIDS influenced the sleep position they chose for their infants. Eighty-four percent of these parents reported that they never placed their infant in a prone position for sleep, and 26% reported never placing their infant in a prone position for play. These results demonstrated a significant association (p = 0.002) between the knowledge of SIDS and the avoidance of the prone position for play."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595182



There is actually a little evidence that tummy time may compensate for the advantage prone sleepers have, but only "partially" - see "The Flip-Side of Back to Sleep".  To my mind, this is because in practice, babies sleep a lot and so if a child sleeps prone, it's simply getting many more opportunities to be in a prone position every time it wakes up, even between sleep cycles to turn it's head or shift around.  It is very difficult to get a child who is used to being on their back to play on their stomach and it's simply a challenge to remember to keep trying with the tummy time.  I personally think there should be more research done to discriminate between those infants at risk of SIDS for whom sleeping prone really is dangerous.  However, since we still don't have that information, I can understand that the message still needs to be "back to sleep and prone to play."  There just needs to be a lot of effort and attention paid to that area and a bit less fear around just leaving baby on their tummies.

Is it okay to skip a milestone?

To add, some children are not only having delayed motor skills but to even skip certain stages altogether, and this is linked back to supine sleeping/not enough tummy time.  Here are some consequences of not learning to crawl:

"Crawling helps strengthen the hands, wrists, elbows, and shoulders because babies have to constantly activate them to support their body weight," says Felice Sklamberg, a pediatric occupational therapist at New York University's School of Medicine. "We're seeing that because non-crawlers aren't as strong, they have a harder time as older children pulling themselves out of a pool, climbing a jungle gym, or even picking themselves up from the floor."

Skipping this milestone can also affect a child's ability to hold silverware or a pencil down the road, since the weight-bearing experience of crawling helps develop arches and stretch out ligaments in the wrist and hand that are needed for fine motor skills. "During the crawling period, the large joint at the base of the thumb is expanded into its full range of motion, so non-crawlers may have messier handwriting, for example," explains Mary Benbow, an occupational therapist and a leading expert on pediatric hand development.

Crawling is a unique experience in other ways as well. "It's a real step up for coordination because it's the first opportunity to practice bilateral coordination  -- using the arms and legs in reciprocal movements," says Jane Case-Smith, director of the division of occupational therapy at Ohio State University's School of Allied Medical Professions in Columbus and an early-intervention specialist. "This skill is used in activities like getting dressed, self-feeding, and sports. A child who sidesteps crawling may have more of a struggle catching up."

Babies who skip any kind of scooting or dragging miss out on the benefits of being on the floor as well. "Children learn through interaction with their hands. They don't get as much if they go straight to walking, because then they need to use their hands for balance," says Karen Hendricks-Muñoz, M.D., chief of neonatology and associate professor of pediatrics at New York University's School of Medicine. "Navigating on the ground also helps visual spatial skills and depth perception develop more quickly."
http://www.parenting.com/article/do-babies-need-to-crawl

Proponents of the back-to-sleep campaign, before it was even widely implemented, knew that supine sleeping could cause developmental delays, but argued that these were not significant, as children caught up to their peers eventually.  However, some have since questioned this, especially in the case where a child completely skips a milestone.  It looks to me like their development is affected beyond their infancy into early childhood and schooling and possibly further down the line.

Long-term Consequences

In an article entitled "Losing our grip: More students entering school without fine motor skills", it explains:

"...many therapists believe the Back to Sleep campaign...has delayed muscle development. The problem becomes more pronounced when parents skip wakeful tummy time because their kids don’t like it: toddlers might not be able to hold their bodies upright as well as their peers did years ago.

They might not be as adept at spreading their hands and using their arms to push themselves up, a fundamental base for good seated posture and proper shoulder support when writing. Their eyes also may wander, making focusing on detailed tasks difficult."

So, as I tried to explain initially, motor skills are important not only in themselves, but also in developing a whole host of other skills as they are the keys to exploring the environment and interacting socially with others.  And, it seems, that when a skill is delayed or skipped entirely, it can have flow-on effects into the future.

So, apart from providing plenty of tummy time, can anything else be done to assist motor skill development?

This "exersaucer" doesn't help a baby learn to walk. Au contraire...!


Beware of products that 'help' motor development

Sometimes parents (and manufacturers) think that they can allow a child to experience their environment more fully by buying products that 'support' the child in a more upright position (sitting or standing), such as walkers, jumpers, bouncers and seats of various kinds.  It makes sense, from a neuroscientific perspective to want to allow the child to get a better view of the world or be able to use their hands, but the way they go about that is misguided because those products actually slow down the child's ability to do those things themselves by reducing their tummy time and can in some cases be detrimental to development by, for example, encouraging the wrong muscle groups to be developed. I know that these devices can sometimes be necessary as a safe place to confine baby, or to make something like feeding solids easier. But, if you want to buy something to help your baby learn to crawl or walk, skip the jumper or exerciser that helps her stand, and buy a nice, comfy mat where you can both hang out as much as possible.

Here are some articles explaining why some popular baby devices are unhelpful:

Bumbo chair:
http://articles.chicagotribune.com/2012-03-15/health/ct-met-bumbo-posture-20120315_1_physical-therapists-developmental-benefits-babies

Jolly jumper:
http://www.coreonehealth.com/jolly-jumpers-and-infant-development

On the other hand, there are some 'devices' that seem okay to me, though I would like to know if I'm correct in saying this -

Carrying baby in a sling/baby carrier - if you are carrying baby this way, you are not forcing your baby to use muscles in an unnatural way, what you are doing is much the same as what happens when you hold bubba in your arms.  You are actually allowing them to develop head and neck muscles as they gradually learn to look around when supported in the sling. When baby is ready, carrying him/her on your back seems to me to mimic being on the floor on his/her tummy in some ways.  However, I have heard that carrying the child in a forward facing position puts them in an unnatural position that strains their back, and yours - http://www.boba.com/blog/nine-reasons-not-to-carry-your-baby-facing-out

Push-toy walkers - these are different from the other walkers mentioned above in that they do not force baby to stay in an upright position, but rather give the child something to hold onto when they need extra stability when starting to walk.  However, one chiropractor disagrees, saying that holding a push toy aggravates muscle weaknesses and imbalances, and is different from furniture surfing, which is okay.  Hmm... okay then, it seems that tummy time wins again!


Conclusion

Babies have amazing brain plasticity which allows them to learn an astonishing amount of information in a short span of time.  This time is precious, not stimulating him or her enough in critical windows can have long-lasting effects.  However, whether a few months delay would be akin to missing an optimum period of development or not is unclear.  Also, how to foster motor development precisely is still a subject of contention.  To me, it seems that allowing the child to develop as much as possible in a natural way (i.e. not allowing him/her to do what she cannot do unaided) and giving him/her plenty of tummy time, are both crucial.