Hip Safe Baby Wearing aka How to Avoid Crotch Dangling

As a new mom I was excited to get a front carrier so I could tote my new bundle of joy around like a kangaroo and enjoy the many benefits of "baby wearing." However, as a physical therapist I was concerned about positioning in the carrier and the health of my baby's hips.  This post will detail how infants' hips develop, risks for and signs of hip dysplasia,  the benefits of baby wearing, how some carriers place baby's hips in an unhealthy position, and proper positioning and examples of carriers that are "hip healthy."

First a brief lesson on hip anatomy: The adult hip joint is a ball and socket joint where the head of the femur or thigh bone attaches to the pelvis at the acetabulum (socket). The head of the femur is held in place by strong ligaments and muscles. The nature of the hip joint allows the lower extremity to flex, extend, internally and externally rotate, abduct and adduct, and circumduct allowing us to sit, walk, run, jump and kick, among other things. 

Photo credit healthfavo.com

There are several important differences between an infant's and adult's. First, an infant hip joint is made of soft cartilage that slowly turns into hard bone during the first few years of life. An infant also has a shallow acetabulum meaning that the femoral head is less seated in the socket. Additionally, the angle of inclination or angle between the shaft of the femur and the neck of the femur is highest in infancy around 150 degrees and slowly lessens to 125 to 135 degrees in adults.  Another important difference is torsion, or the amount of rotation present in the femur. At birth, one has the largest of amount of rotation 30 to 40 degrees. By age 16 most people reach the adult value of 16 degrees.  Changes occur over time through muscle pull, bone growth and upright standing and walking to form the mature adult hip joint. 

Due to the state of infants' hips at birth approximately 1 in 5 babies will have or develop hip dysplasia or instability. Risk factory include:

• Family history of hip dysplasia
• Breech position in utero
• Other orthopedic concerns at birth including clubfoot, and other congenital conditions
• Female gender
• Positioning after birth (more on that later)

Signs of hip dysplasia include:

• Limitation or asymmetry in abduction, or moving the leg out to the side
• Difference in skin folds at the hip crease, noted when changing diapers
• One leg appearing longer than another
• Pistoning and positive Ortoloni and Barlow signs

Now, onto the fun part: "Baby wearing!" While this list is not scientific and is largely anecdotal, the benefits of carrying baby in a front carrier may include: Less crying (yay!), convenience, bonding, improved development, and helps to regulate infants physiologic responses.  I love the idea of having babies in carries as it is a great alternative to carrying them in a car seat or putting the car seat in the stroller. Babies spend a lot of time on their backs, which is important for sleeping, but can cause babies heads to flatten in the back. A carrier allows the baby to rest it's head against the caregiver or hold it up themselves as they advance. Also, a car seat is designed to fully support an infant in the event of a crash, so it is very passive for the baby and does not contribute the babies development. In a carrier the baby has to hold it's head up, at least partially, and respond to the walking, bending, reaching and other movements of the wearer. 

In utero, babies are in a position where there knees and hips are flexed, or bent: As in the fetal position. It takes several months for the legs to naturally stretch out. After birth the healthiest position for the hips is for the knees hand hips to be bent and for the knees to fall out to the side, like a frog-leg position. The opposite of this position is for the legs to be straight and held together. Being held this unhealthy position for long periods of time may increase the risk for hip dysplasia or dislocation.

Image credit Pinterest.com

The International Hip Institute has an image that demonstrates how being in a carrier effects a baby's hip joint. A carrier should have the following features in order to be "hip healthy:"

• The thigh should be supported from the hip to the knee
• It should allow the hips and knees to be bent so that the knees are at or above the hip
• The knees should be apart, wrapping around the caregiver
• Avoid the "crotch dangling" position

It is important to keep the above features in mind when choosing a baby carrier. I personally use the Ergobaby Original, and love it. My little guy feels snug and secure and seems comfortable during walks, errands and house work. He even falls asleep in it sometimes. There are other carriers that are also "hip healthy," including : Beco Gemini, Boba Air, and Tula Gossamer. This is by no means an exhaustive list or an endorsement for these products other than the hip positioning. When shopping for a carrier make sure that the above 4 criteria are met and you will be on your way to happy, "hip healthy," baby wearing!

References

http://hipdysplasia.org/developmental-dysplasia-of-the-hip/causes-of-ddh/

http://pediatrics.aappublications.org/content/105/4/896

http://www.stanfordchildrens.org/en/topic/default?id=developmental-dysplasia-of-the-hip-ddh-90-P02755

Campbell, Susan. (2005) Meeting the Physical Therapy Needs of Children. Philadelphia, PA: F.A. Davis.

http://hipdysplasia.org/developmental-dysplasia-of-the-hip/prevention/baby-carriers-seats-and-other-equipment/

Motor Milestones....When to be concerned

As a pediatric physical therapist, one of the things I get asked the most is "When should my child walk (or sit, crawl, run, jump etc.)? I am often hesitant to answer this question as the answer can vary from child to child and there is always a range of what is considered normal. Some parents want a firm age and become concerned if their child hasn't reached every skill by that age. So, keep in mind that each child is different. If a child isn't walking by 14 months but is pulling to stand and cruising, I would not be concerned. If a child is 14 months and showing no interest in walking and not standing yet, I would be concerned.   In this post I will give an overview of what are considered typical ranges for motor milestone achievement, when to be concerned and a FREE developmental screening offered if you are concerned. 

New babies have limited head, trunk and extremity control. As most new parents can tell you babies often cut themselves with their sharp little nails because they have poor control of their arms. Control begins to develop within the first few months in a cephalocaudal direction: beginning with the head and trunk and then proceeding to the arms and finally the legs. Within the arms and legs control begins proximal and progresses distally. Meaning control starts at the shoulder and hip and progresses to the hand and foot. As children gain control of their bodies their skill acquisition generally proceeds in a predictable pattern: Sitting without support, standing with assistance, crawling (some children skip this), walking with help, standing alone, and walking alone. Once these skills have been attained children can progress to skills requiring increased coordination: Running, jumping, hopping, skipping etc. Below us a list of general ranges of when major milestones are usually attained, keeping in mind that each child is an individual and has unique abilities and circumstances.

• Rolls stomach to back:  4-6 months
• Rolls back to front:  5-7 months
• Sits without support when placed:  7-9 months
• Gets into sitting independently:  7-9 months
• Crawls:  7-10 months (Approximately 5% of babies never crawl. Some children bear crawl, army crawl of scoot on their bottom rather than traditional crawling.)
• Pulls to stand:  7-9 months
• Walks holding onto hands or furniture:  9-11 months
• Stands alone steadily:  10-14 months
• First Steps: 10-14 months
• Comes to stand in the middle of the floor: 12-14 months
• Walks steadily:  12-15 months
• Throws ball:  18-24 months
• Walks up steps holding railing placing both feet on each step:  22-24 months
• Runs in coordinated pattern:  24-36 months
• Walks down steps holding railing placing both feet on each step:  24-26 months
• Walks up steps holding railing alternating feet:  30-32 months
• Jumps:  28-30 months
• Climbs on playground equipment (ladders, slides): 30-36 months
• Walks up steps alternating feet with no rail: 3 years
• Pedals tricycle: 3 years
• Catches ball: 3 years
• Hops on 1 foot (2-3 times):  3-4 years
• Walks down stairs alternating feet holding rail:  3.5-5 years
• Skips:  4.5-6 years
• Pumps swing independently:  5 years

If your child has any of the red flags listed to the left  or is behind on any motor milestones, or you just have a feeling that something is not right, Kids in Action Physical Therapy offers FREE gross motor development screens to ease parents concerns and to identify those that may benefit from physical therapy intervention. It has been my experience that parents, especially mother's have great intuition when something is not right with their child.  The screen consists of completing a motor skill assessment which will give us the age a child is performing motor skills at.  Call today to set up an appointment: (720)421-7412.

References

http://www.who.int/childgrowth/standards/Windows.pdf?ua=1

http://www.cdc.gov/ncbddd/actearly/pdf/checklists/all_checklists.pdf

http://www.medschool.lsuhsc.edu/medical_education/undergraduate/spm/SPM_100/documents/MotorDevelopment.pdf

http://www.amazon.com/Normal-Development-Functional-Motor-Skills/dp/0761641874

http://www.amazon.com/By-Jan-Stephen-Tecklin-Pediatric/dp/B008UB5WWC

Disclaimer :The information in this blog are for general informational purposes only.  It is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician, physical therapist or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read on this website. Under no circumstances will Kids in Action Physical Therapy PLLC be held liable for any loss or damage caused by reliance upon information obtained through this website or blog. Any reliance upon information on this website and blog are at your own risk. Click here for full disclaimer.

Ten Reasons I Love Being a Home Health Pediatric Physical Therapist!

When I first decided to become a physical therapist I was sure I would work in a big clinic with athletes. I was an aide in a clinic before PT school and I enjoyed it. The first time I became aware of the possibility of becoming a pediatric physical therapist was when a patient came into the clinic for back pain and brought her son who had special needs. He and I would play while his mom did exercises.  My boss at the time said "you should go into pediatrics." Once I got into PT school I took every opportunity to explore pediatric physical therapy and I was hooked! I've been blessed to be able to work in a variety of pediatric settings in my career, my favorite being home therapy. Below is a list of 10 reasons I love working with kids in their homes:

1. The whole family can be included in physical therapy.  When a family has one child with special needs, often the siblings can feel jealous or feel left out. I love when I can include siblings in games and activities. It's also great to have the parents there to assist with activities such as walking or bicycle riding so that they can learn how to better assist their child outside of physical therapy. There is nothing more rewarding than the look on the parents and child's faces when they complete a new skill for the first time. 
2. We can work on functional activities in a natural setting. One of my favorite things to do is work at a playground with a child. This has so many benefits including strength, coordination, balance, sensory integration, social interaction and community mobility. We can also work on navigating a child's home environment safely, getting in and out of bed and on riding a bicycle all of which may not translate when worked on in a clinic environment. 
3. Everyday is different. My schedule often ends up looking totally different at the end of the day than I had planned on at the beginning. This flexibility of scheduling is great for me and for families. I have also worked in homes with baby goats inside wearing diapers, in a hotel, at daycare's, in filthy homes and in (mostly) lovely homes. You never know what each day will bring! Also, you do not need to vacuum or worry that your house is messy before I come over, the mere fact that you considered doing that means your house is probably lovely and be assured I have seen much, much worse. 
4. I get to be creative. I really enjoy having to problem solve and use my imagination to figure out the best way to achieve a patient's goals. I have used the squeaker out of dog toys for auditory feedback, can use a therapy ball to strengthen almost every muscle and incorporate a child's favorite toys into therapy sessions. Whatever works! 
5. My garage is filled with toys. I love a good toy store, my favorite is Dandelion Toys in Fort Collins. Neighbors and acquaintances often ask how many children we have when they see our garage because of all the toys. Until recently, the answer was none, those are all my toys. They do come in handy when my nieces come to visit!

6. Children are hopeful and resilient. I am honored and humbled to work with families and children who have overcome so much. Even when dealt really difficult circumstances children are still smiling and never give up...It's truly inspiring. 

7. My days are filled with laughter and smiles. Of course there are the occasional tears and tantrums as well, but they are far out numbered by laughing, smiling, playing, being goofy and having fun.

8 .Building long term relationships and watching kids grow up. Due to the nature of many childhood conditions, children may require prolonged physical therapy. While I wish that weren't the case, I do love the relationships that form and watching kids and families grow, progress and change over time. 

9. When the weather's nice I get to work outside. I'm a Colorado girl and love being outside. One of the reasons I became a PT is that I didn't want to sit at a desk all day. During the summer, I often have to put on sunscreen because I'm outside for a lot of the day. Not only is that fun for me it is a great way for children to explore their environment and improve community mobility.

10. It's fun! I rarely feel as though I'm working and spend most of the day playing. I truly am lucky.