Motor Monday: Baby Sit-ups

Tonight's post is going to be quick and "off the cuff" because I had another post written and then realized I was missing a key video!  So I'm whipping this up before heading to bed.  Just like us, babies should be doing sit ups as part of their regular exercise routine.  Baby sit ups are a great way to work on head control and abdominal strength.  Here's a video of Avery doing baby sit-ups, or pull to sit, at about three and a half months.

In this second video, she has already done 3 or 4 reps of baby sit ups and you can see the muscle fatigue set in.  One tip for doing baby sit ups is to try to get your baby to look at your face before you start (making silly faces, talking, and singing can help).  Most babies will be motivated to keep that eye contact and will work harder to lift their head so they can keep seeing mom or dad.  Avery wasn't cooperating with that for this video.  She was too busy looking around which didn't help with her head control!

If your baby isn't ready for this version of baby sit ups, you can start with a modified version where you support your baby behind her shoulders rather than grasping her hands/arms.  If your baby's head is dropping back like Avery's in the second video right from the start, try the modified version.  If it seems like your baby is having trouble getting started, you can start at the top and slowly lower baby down to the floor/bed/changing table.  Just like grown up sit ups, babies are working both on the way up and on the way down so take your time both directions. You may notice that at first the baby will be able to hold her head until just before reaching the bed and then it will flop back.  You can keep your fingers positioned just an inch or two behind baby's head when doing this so you can "catch" her head if it flops.  A more advanced version is to hold just the baby's hands rather than her whole forearm as I do in this video.

Baby sit ups are super easy to integrate into daily routines, which is one thing I love about them.  Our babies do them almost every time they get up from the changing table or floor.  You can also do the reverse sit up every time you put them on the changing table for a diaper change for double duty.  Just doing these at diaper changes means they're doing a minimum of eight sit ups over the course of a day, and as we can attest, often many more times than that!  If you want to work on endurance you can do multiple sit ups in a row until your baby shows signs of fatigue.

Did you know that a study was published in 2012 showing an association between head lag (where the babies head lolls backward) during pull to sit and autism spectrum disorders in high risk infants (siblings of children with ASD)?  They showed an association, which is very different than causality, so this does NOT mean that all infants with head lag at 6 months will have autism, but head lag at 6 months may be indicative of some type of neurodevelopmental problem.  Pull to sit is only one indication of the development of postural control, but if your baby is struggling with it at 6 months of age, it is worth bringing up with your pediatrician!  

Motor Monday: Look Both Ways

If you read my first Motor Monday post you might remember me talking about how one issue for babies in the NICU is that they often turn their heads to the right?  Well side preferences don't just happen with preemies and in fact I just got a question today from a friend with a newborn who prefers to look to the left.  She said "He pretty much is always looking that way.  We have tried noise and visual stimulus to get him to turn and stay on the non-preferred side.  Do you have any more suggestions?"

So although I had another post started, I figured this was a perfect Motor Monday topic and wanted to get suggestions to my friends sooner rather than later!  At my request they sent me pictures of the back and top of his head and said I could share them here.

In the picture from the top you can see a VERY mild flattening on the left side (really, the right just looks a little rounder/fuller in the back).  On the picture of the back can you see how his right ear is tilted down towards his right shoulder?  Having never met this little guy I certainly can't and would never diagnose him, but I wouldn't be at all surprised, based on the pictures and his moms' descriptions of him, if he had a mild torticollis, or tight neck muscle on the right side of his neck.  When this happens, kiddos prefer to look to the left and tilt their head to the right.  So, what can his moms do to help him?  Here are a few tips for any parents who notice that their baby has a favorite side.  I'm going to write this for our friends' kiddo who looks left, but if your kiddo prefers to look right, just flip the sides!

1. Everything interesting is on his right!  This little guy is only a couple weeks old so his moms are probably the most interesting thing to him right now but lights, noise, other people might also work.  The big thing is just to be mindful of his positioning throughout his day.  Place him in the crib so that he would have to look to the right to see you when you come to pick him up after naptime.  This goes for the changing table too.  It might feel awkward for you to have to switch to using the other side but do it for your baby!  Same thing applies to being on the floor or in a bouncy seat...everything cool is to the right.  It's even better if you or the toys can be just a bit behind to encourage the baby to look up and right because that stretches out the tight neck muscle even more.

2. The side carry stretch.  This was apparently the best way to calm me down as an infant and it works like a charm for our little hothead Avery too.  Have the baby face away from you on his side with his right ear on your right arm.  Place your left arm between the baby's legs to support his body.  The idea here is to gently stretch his right ear away from his right shoulder. (i.e. moving his left ear closer to his left shoulder)

Here's an example of a version of the side carry with Avery

3. Tummy time.  Our friends are already working on this (I know this because I've seen adorable pics on Facebook!) but their little man, who keep in mind is only two week old, manages to turn his head back to his favorite left side when they put him down facing right. In this case, You could try tummy time on mom's chest with his head gently blocked from turning left by mom's head or hand.

I could move my hand up to his head if he started to turn
his head the other way.

4. Sidelying with a boppy. This is the same idea as the side carry, getting the right ear away from the right shoulder. Just like with the side carry, the focus for this stretch is on the tilt part versus the turn.  So you are stretching the right side of his neck by increasing the distance between his right shoulder and right ear. Here's a picture of Isaiah in this position.

Right shoulder away from right ear for a kiddo who prefers to turn left

5. Body Block!  Use your body to block the baby from turning his head to his favorite side.  You can do this having the baby's body facing you and head looking up when held in a cradle position or use your hand or head to block the preferred side when held at your shoulder.  Here's Michelle with Isaiah using her arm to block him from turning to the right.

I hope these tips are helpful for our friends and other babies who are favoring one side. Once babies start turning their heads both ways equally and moving more, their heads will gradually even out in most cases.  In the meantime, while he is awake I would hold him and wear him as much as possible and do lots of tummy time to avoid more time with pressure on the same spot on the head.  Your baby will be spending a lot of time on his back already just while he's sleeping so minimize time in equipment like the carseat, swing, etc and laying on his back on the floor.  When he is sleeping, if you have a sound sleeper, I'd recommend turning his head to the non-preferred side once he is asleep!  (That said, Isaiah used to consistently sleep with his head to one side and I was rarely willing to risk waking him up by turning his head so I understand the value of sleep!!)

Big thanks to our new mom friends in Boston for their question!  Do you have any motor development questions (about a certain age or disability) that have been rattling around in your brain?  If so, leave it in the comments and I'll add it to my list!

Motor Monday- Let's start at the very beginning

I wasn't sure what my first topic should be for Motor Monday, but then we got an email from someone at Geisinger asking us to answer some questions about our experience there in labor and delivery and the NICU. Answering those questions had us reflecting on our experience and me thinking about the NICU from a motor standpoint. I thought maybe we should "start from the very beginning" and talk a bit about the NICU and what the big deal is about being a preemie. (My apologies if you have the entire Sound of Music soundtrack stuck in your head now! I know I do!)  When we were in the NICU I was way too busy falling head over heels in love with our little trio and being nervous about their health (especially nutrition & breathing) to spend much time thinking or blogging about the NICU from a motor standpoint, so I might as well do it now.

Since most of you reading this blog probably aren't pediatric therapists or NICU nurses, I'll start with the basics.  What is the difference between preemies and term babies other than the obvious size difference? The general problem is that these tiny babies were born too early into a world they weren't quite ready for! Their nervous systems are not fully developed and for the most part they're so small that they haven't been squished in the uterus yet.  Because of this preemies look very different from term babies when they're laid down, either on their backs or their tummies.

Premature babies generally have low muscle tone, which means that they have less resting tension in their muscles and it takes more effort to essentially turn their muscles on.  I find that muscle tone is a challenging concept to explain to people.  In person, during my early intervention visits, I use my hands to explain the crossover of muscle fibers, but that's tricky to do in blog form, so let's try this metaphor.  First, imagine yourself sitting on a kitchen chair and think about the effort  required to stand up and start walking.  This is like "normal" muscle tone.  Now imagine yourself in lounge lizard or couch potato mode, sunken into a deep cushy La-Z-Boy recliner and the monumental effort it would require to walk to the kitchen for a beverage.  The second image is akin to having low muscle tone, or hypotonia.  It just takes more effort to get started because the muscles are starting out in a more "rested" state.  Babies with low tone are often described as "floppy babies" and feel squishier than babies with normal tone.  As they get older when you pick them up, it might feel like they're going to slip right through your hands and they may feel heavier than you expect because they don't hold their own weight.  People with low muscle tone also tend to be more flexible (hypermobile) and fatigue sooner (lower endurance).  I often have parents ask "can muscle tone change?" and generally my answer is no, but preemies can be an exception to that because their nervous system is still maturing similar to how it would in utero.  In my experience, not all preemies who are born with low tone present with hypotonia as kids.

Babies born full term are usually so big and so squished in mom's uterus for the last few months that when they are newborns they tend to rest in the aptly named "fetal position" with their hips and knees flexed (bent) and their arms in tight to their bodies, elbows flexed. In PT terms this is known as "physiological flexion."  Premature babies are born before they get big enough to be super squished for very long, if at all. As a result of this and their low muscle tone preemies don't naturally "ball up" like term babies and instead lie fairly flat. The classic preemie position is to have their legs in a frogged position out to the side and their arms flat out to their sides, often making the shape of a W. 

You can see how our babies are kind of "flattened out" when lying on their backs in their warming beds. And because they were triplets and a little more squished in there than single babies born at 34 weeks they're actually a little more flexed than some preemies.

"Gravity is rough guys!!!"

Ellie showing off the "W" arms I talked about--though fairly close
to her little body

even our "big boy" is struggling with the whole gravity thing

For comparison...here's wikipedia's example pic of a newborn
one hour after birth.  Notice how flexed the hips are and how
arms are in by the chest

Ideally, we don't let babies stay in this position for long, but instead try to mimic the "everything pulled in tight" positioning of term babies. The normal fetal position is calming for babies, which is super important for preemies in the NICU being bombarded with monitor noise, heel sticks, IVs, and other medical procedures.  It's also important to be mindful of positioning to support preemies' motor development.  If they aren't positioned well the typical preemie postures can lead to delays in meeting milestones like rolling and sitting.

an example of ineffective attempts at positioning...the rolls are there
but they aren't really doing much to support her

ah...peaceful, calm baby all tucked in tight
knees flexed up under her belly and arms in tight to her body

Ellie in a nice sidelying position. Snug as a bug
(all my positioning pics seem to be of Ellie!)

Isaiah all swaddled up to help keep his limbs in tight
(he was the first one in clothes and a swaddle because he was maintaing his temp)

An example of a much smaller baby being positioned in NICU
(granted I wish her legs were flexed more!)

      nice "hands together" positioning here  
(Thanks Heather for sharing the pics!)

One other NICU thing parents need to be aware of is that the way the workstations are set up, the babies are almost always approached from the right. This sets them up to get torticollis, or a tightening of the neck muscles on one side that can make it hard to turn all the way to the left. This is one thing I actually talked to the NICU docs about while we were there because I have had more than one kiddo on my caseload from that NICU with this issue.  (See, even in the midst of semi-crisis I can't totally turn off my PT brain!) Also, because gravity is a beast, preemies' heads often fall to one side or the other and they rarely face up.  Even if they aren't always turned to the right, this can cause a form of plagiocephaly (or flattened head), called scaphocephaly, where the babies' head is flattened on the sides and longer in the back like the sketch below from Hanger Orthotics.  This was already starting to happen to Ellie from her time in the NICU I think.  Her forehead was more prominent and her head was pretty narrow at first. (though not to this extreme)

Or if the baby's head is partially turned a lot of the time to the same side it can result in a flat spot just on the back corner leading to a head shape like this one.

you an see how the eyes and ears can
become assymetrical when this happens

The take home message is the NICU nurses and therapists play an important role in helping premature infants start from a better place when it comes to motor development!  The goal is to mimic typical newborn postures and to be very conscientious about the position of the babies' heads during their stay in the NICU.  Understandably, there are a lot of other things for nurses to pay attention to, but if parents are also aware of these vulnerabilities then they can be advocates for their babies!  Okay, time to wrap up the inaugural Motor Monday post that I am just sneaking in before heading to bed.  I need to work on getting these written up over the weekend so I can post them first thing, but, well, I have triplets you know, so that might not happen!  Let me know what you think about Motor Monday and if you have any topic suggestions!

Early Intervention update

As I was writing the last blog post with the health update, I realized that I told you that we'd scheduled the early intervention evaluation, but then never followed up on how it went. The eval itself went fine. Avery was the most cooperative, being in a nice quiet alert phase and really engaging with the examiner. By the time it was Ellie's turn she was getting pretty sleepy and fussy so she didn't tolerate much. And Isaiah had fallen asleep and woke back up for his eval, so again, probably didn't put his best foot forward. But overall the examiner was impressed with them and said she really didn't have any big concerns, but that if we had any concerns or questions she would support them getting early intervention (EI) services just because they were preemies.

So we decided to do an OT consult (check in) with an occupational therapist that I know has experience with oral motor skills (I did my research before the eval!) so we could ask her for suggestions to help the girls with eating better. We only had one visit and she gave us a few exercises to do with them (stimulating the muscles around their mouths) but said she thought they were coming along nicely and would just improve with growth.  The other service we asked for was infant massage. I've done some infant massage but am not certified so I thought it would be nice to have someone come in and teach all of us (Hope, the PSU student who lives with us joins the sessions too to take baby #3).  It has been nice and we've been doing massages after baths and sometimes before bed.  Infant massage has been shown to help with weight gain and sleeping so it's definitely worth a shot!  

And for Miss Ellie, who is just a little more of a low tone/floppy baby (meaning her muscles are just a little looser/ squishy) and a bit behind her siblings on her milestones, we are doing every other week PT. It seems more than a little silly to be doing PT since I am a pediatric PT and do things with her every day, but we figured it would be a good idea to have a pair of non-mommy eyes checking in just to make sure I'm not missing anything. (Though honestly I think I'm able to maintain pretty good objectivity about it all!).

It sometimes seems like a lot just to schedule the one or two visits we have in a week so I empathize with families I work with who have even more providers to schedule with! Scheduling visits to line up with awake times is also a bit tricky right now. And I can empathize with how hard it can be to remember or find time to do the recommended activities in a week!  That is why a key tenet of EI is to incorporate therapy activities into families' daily routines...

Ellie's tummy time on Mommy's chest

    

Tummy time for everyone after eating