Monthly Archives: January 2015

Why is W-Sitting Such a Big Deal?

 

Does your child sit on the floor with their legs rotated out to the sides, feet pointing in front of them?  Is this their preferred pattern of sitting on the floor?  Is it, in fact, the only position your really ever see them use on the floor?  Well then, you have yourself a W-sitter.  And it might not be the death knell to development that you may have been led to believe.  But here is why it can affect your child’s walking and sitting, and here are some easy ways to address this issue.

“W” sitting is not an abnormal sitting pattern.  Let me repeat and refine that: it is not abnormal for young children to sit in that position at times throughout the day.  It is a very stable position that allows them to reach forward for toys placed directly in front of them.  If your child uses a variety of sitting patterns, and you have no indication from anyone that they have issues with strength or stability, relax.

Therapists get concerned when three things happen: your child uses only this position when floor sitting, she isn’t comfortable or stable in any other position so that even if you help her sit another way, she pops out of it and reverts to “W” sitting or falls over, and she also has either low muscle tone or weakness in her hip and trunk muscles.  I am not going to delve into the difference between muscle tone and muscle strength, and kids who “W” sit can absolutely have issues with both.  But if your child has that triple play (preference, instability/discomfort, and tone/strength issues) then you should take action to reduce “W”-sitting.

Here is the reason why:  This position will create an imbalance in hip muscle strength, bias your child’s movement patterns in ways that actually weaken their core musculature, and over-stretch the non-elastic ligaments that support the spine and hip.  “W” sitting is a self-fulfilling prophecy.  The more this pattern is used, the less control your child has for strong, dynamic and balanced trunk and hip control.  Therapy can do a great job of helping your child build the strength and control to use a wider range of sitting and movement patterns.  This is what you can do:

  • Pay attention to how they sit, and offer alternatives.  Sitting on a bench or chair that is well-proportioned for them is a good alternative.  This means that you have to offer a young child a table and a chair that allows them to place their entire foot flat on the floor while sitting, and reach objects on a table with ease.  Big-box stores do not sell sets that fit children under 3 unless your child is at the top of the height curve.  Look around for wooden sets that you can make shorter, take a look at the sites that sell Montessori sets or school supply sets.  Don’t let the price tags frighten you: these things sell fast on ebay or craigslist.  When your child is 4 or 5, go out and buy the bigger set.
  • Try not sitting.  Have them stand at a table, and easel, or use toys that stick to the wall or another vertical surface for play.  A child can lie on their stomach or even try hands-and knees play.  Use high kneeling at a table ( child kneels on knees but hips aren’t touching their bottom, their upper body is straight up). Your PT will thank me.
  • This is an extra credit question:  Why would you ask them to lie on their back and play?  Answer:  They engage their core more fully, and their legs are likely to either be planted flat on the floor or raised up in the air in play.  Kick/catch a balloon or something equally silly.
  •  Children love to be seen as more mature.  Tell them that since they are growing up,these new positions are for big kids and grown-ups, and since babies aren’t strong, that is why they prefer to “W” sit.  That should motivate them to give these a try!

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Toddler “Jeopardy”: Why we Phrase Directions in the Form of Questions

“Would you please clean up this toy so we can get our next one?”  When my toddler client shakes her head and smiles, I have to smile too.   What was I thinking?  I gave her a choice to clean up or not, and she chose, as they say in the Indiana Jones movies, wisely.   I wouldn’t choose to clean up if I were 2 years old.    Why did I make it sound like her participation was optional?

I forgot at that moment that she is not a little adult, not even a young child.  She is a toddler.  When we speak to an adult or older child, we often use this kind of complex but indirect request.  They know that you are really telling them to do something if they want a certain outcome.  You aren’t asking whether or not they would consider doing it.  Toddlers are the most literal people on the planet.  They hear your question as “Would you like to clean this up?  We are going to get the next toy.”  Then they consider your apparent request on it’s merits.

If you subsequently change your question into to a firm instruction, they will be highly offended that you seemed to change the rules.  It would be like being asked whether or not you would like to pay your taxes, and then being sent the bill.  So be very careful when you phrase a directive or a contingency to a toddler.  Peaceful coexistence with them requires understanding how they hear what we say to them.  Unlike the game show, your response should not be stated in the form of a question.

Swaddle With a Blanket or a Swaddle Garment? How to Decide What is Right for Your Family

You have decided to swaddle your baby, and you read the book/watched the DVD/had a private consultation with me.  You know why swaddling helps your infant calm down, fall asleep, and stay asleep.  But what do you actually use for swaddling?  Two choices appear: the blanket or the manufactured garment.  Swaddle blankets can be muslin, microfleece, synthetic, natural or organic, and come in a fairly standard size.  Manufactured swaddle garments can be made from the same materials, usually have velcro closures, and are sized newborn-large.  Some are convertible from arms-in to arms-out.  So how do you choose?

  • Preemies may or may not fit the small sizes, and some babies are large for their age.  Swaddling success depends on a firm wrap that doesn’t leave any fabric covering your baby’s mouth or nose, and is large enough to prevent accidental unraveling.  For a firm custom fit with the tiniest or the largest babies, you can’t do better than a blanket.
  • A few generously-sized blankets may be all you need for the entire period you use swaddling.  Once your garment needs to be washed, and overflow diapers and spit-ups do occur, you will need at least 2 of each size.
  •  Effective swaddling is a skill that you learn, and not everyone is good at the origami-like wrapping right away.  Are you good at wrapping a package, or does the mere thought of tape and ribbon send you over to the gift bag section? This a moving package and it could be fussy!   I think anyone can learn to swaddle, but not everyone wants to.  If you want something that is easy to get right, then you might want the garments.  You should know that it is possible to use them incorrectly.  If you ignore the signs that a child has grown out of their first one or you bought a larger garment than you needed, you will find that they either fuss more or they get their arms out and wake up.   And just like blankets, there should be plenty of room for both legs to move. Swaddling never involves limiting leg movement.   If your baby cannot stretch those legs out straight and out to the sides, you need a bigger garment right away.
  • Some daycare centers will not use a blanket but will allow you to provide a garment.  Why?  I am not sure, but I suspect it is because unless all the employees really know how to swaddle correctly, they are aware that loose fabric over a child’s airway (that no one notices) is a danger.  Even if your swaddle garment is wrapped too loosely to be effective, the velcro usually holds and doesn’t come fully undone and cover the airway. You probably won’t be able to challenge rules like that, so if you need daycare while you are using a swaddle strategy, you should check their policy closely.
  • As your baby transitions out of swaddling, many parents go to the one-arm swaddle.  Either the blanket or the garment will allow you to swaddle with one arm out, but again, the garments make it very easy to get that right.  Just check that it is still a firm swaddle, and that you are using all the other great steps to keep your baby calm and sleeping (white noise and sucking can still be very effective as they transition out of swaddling).

If you need more assistance with your decision, or want more support as you use swaddling or any of the other 5 S’s from The Happiest Baby with your little one,  visit my website: tranquilbabies.com, and purchase a phone/video support session.  You can get answers to all your questions and feel more confident in minutes!

Baby Wearing for Premature Babies

As a nationally certified Happiest Baby on the Block educator, I think that baby wearing is a great way to nurture your preemie, and I approach this topic as I do all the Happiest Baby training: parents need to know why wearing their baby is helpful and why correct technique matters so much.  The government’s Consumer Product Safety Commission has a short list of safety recommendations for baby wearing, but they do not explain why they should be followed nor do they explain the benefits of using wraps or slings for any baby.  There are many websites that either explain all the benefits, sell you products, or help you find a trained educator in your area.  But none seem to take a look at the special needs population.  My guess is that in this litigious age they don’t want to take responsibility for accidental misuse with the most vulnerable population.  Neither do I, but as a professional, it seemed an important topic to cover.  So let me say up front that I am not instructing you on how to wrap your baby or which carrier to use, but I will highlight specific considerations for the parent of a special needs child that wants to use baby wearing safely after they have been cleared by their pediatrician to do so.

The reasons to consider baby wearing are numerous.  The deep emotional connection between adult and baby (dads and caregivers can and probably should try wearing babies), the movement stimulation for balance and self-soothing, and the support for nursing are fairly obvious benefits.  Baby wearing can even help your little one sleep better Baby Wearing For Better Infant SleepThere is substantial research that babies need the stimulation received when moving inside a progressively tighter womb, and even passing through the birth canal.  These experiences are huge sources of tactile, vestibular, and propriocpetive input (touch, movement and pressure) to the sensory system.  Premature birth with a C-section delivery deprives a growing brain of that information.  Preemies have no alternative but to gain more learning outside the womb after birth.  I think baby wearing a preemie correctly and frequently is possibly the most powerful thing that you could do to give them this missing sensory input.

An important but less obvious benefit is that the baby who is worn correctly is one more baby that isn’t resting his head flat on a mat or strapped into a carrier for more than 30 minutes.   As an occupational therapist, I have treated too many toddlers whose infant siblings have been wedged in carriers for my whole session.  Every session.  And they are probably in there much longer and more frequently than those 45 minutes.  When I am the occupational therapist treating a child, the physical therapist and I often struggle to figure out how to get special needs children into safe and dynamic  positions that do not put them at risk for positional plagiocephaly (flat head caused by positioning).  You just cannot do tummy time all day.

The family of a special needs infant can still use baby wearing and foster all those wonderful experiences.  But please consider the following issues and get professional advice if possible:

  • Position your baby tightly, so that she doesn’t slide around as you move.  Recheck and re-position after nursing.  Many wrapping fabrics stretch, so that must be considered.  But tight doesn’t mean compressed.  If your child has a history of respiratory problems, difficulty expanding their ribcage or filling their lungs when lying flat, you really need to clear any tight wrapping with your pediatrician first.
  • Make sure you can see your baby’s face and your baby can see you.  You would never cover her face with a cloth in any other position, and so make sure that the wrap/carrier never covers her face.
  • Preemies and low-birthweight newborns may be too small for the structured front-facing carriers, or take a while to develop the necessary head control.  Use a wrap for a more custom fit, and one that fits both of you well.  Never use a back carrier for a medically fragile infant.
  • Only use the upright or vertical position with their chin up; the cradled or horizontal hold puts a medically fragile or very young child at greater risk for struggling to clear their airway.  A word about seeing your child struggle to breathe: they can be getting less air but not gasping at all!  Compression of their ribcage or airway can be just enough that they slowly become unresponsive.  This means that you watch their face, their color, their respiratory rate, and their activity level.  If you are really tuning into them, you know what “bad” color looks like, and what is normal for them.
  • Baby wrap advocates often recommend the warmth of wrapping, but just like swaddling, you want to match the fabric, your activity level and the length of time you wrap with the environment.  Medically fragile babies lose heat rapidly but they also cannot get rid of excess heat, and sleeping too warm is a risk for SIDS (sudden infant death syndrome). Choose your wrapping based on logic.
  • Think before you move.  Even with a well-wrapped infant, bend from your knees and be very aware of your movements and anything else you carry.  But that is not where movement concerns end with NICU graduates.  Special needs infants can sometimes become overwhelmed with the normal movement of a busy parent, or the common noises of daily life.  Sensory sensitivity doest just disappear once they are out of the NICU.  Some babies just can’t handle being that close to the blender to make your smoothie or listen to lost of talking.  A child who can’t handle the typical stimulation from an all-day wear deserves respect.  Watch for signs that he is shutting out stimulation or becoming fussy after lots of movement or location changes.  Your baby will still get the benefits of baby wearing for shorter or quieter periods, and his tolerance should increase over time.  And don’t fear swaddling, even though some baby wearing sites will show an awful swaddle with the legs jammed together.  A correct swaddle doesn’t restrict any leg movement and is approved by the American Pediatric Association.  Again, if you understand the swaddle and use it correctly, it is as safe as well-planned baby wearing.
  • If you are exceptionally concerned about using baby wearing techniques, ask either your pediatrician or an occupational or physical therapist that works with your child for some advice that pertains to your baby before beginning to use a wrap.

The Easy Way to Buy American-Made Products for Your Baby And Our Economy

I know that this is not the whole answer to raise all economic boats.  But I also know you will be shopping anyway, so I thought it would be nice for you to know that some of your favorite manufacturers (and some smaller guys too) are creating American jobs and make great toys, clothing, and equipment for kids.  Consumer Reports ran a short piece in their recent Shop Smart publication.  Their magazine is my grocery store indulgence, as I learn tons from their articles and love the experience of leafing through a magazine without being assaulted by ads.  There are none!

Here’s a short list of companies that manufacture right here:

  • Land’s End
  • L.L. Bean
  • Crayola
  • Little Tikes
  • Tinkertoy
  • Vermont Teddy Bear
  • Kowalli (baby wearing covers and baby clothing)
  • American Apparel
  • Ladybug Baby Organics

Toilet Training Strategies for Children With Autism and Sensory Processing Issues

These strategies have worked for a wide range of children on the spectrum and/or those with sensory processing issues.  Every child is different, but the following techniques are the best I know for most families:

  • Time potty time about 20-30 minutes after meals and snacks.  The act of digestion and drinking should stimulate urination and bowel movements, and you might get results whether or not your child can respond to subtle sensations.  You can then work backward, and help your child connect the event with the sensation.
  • Know your toddler.  Most parents can easily identify when their child is ready to have a bowel movement by their expression or posture.  Some children duck behind the couch or stand in a corner.  Signs of urination are often more subtle, but wiggling while sitting or standing is a common one.  That’s the time to announce a trip to the bathroom!
  • What goes in on schedule will come out on schedule!   Avoid constant drinking throughout the day while training, and switch to only drinking at meals and during scheduled “drink breaks” through the day.  The goal is for you to be able to anticipate when his bladder will be full, and then have him use the toilet successfully 20-30 minutes later.  Connecting the sensation of having a full bladder and the experience of urination is easier this way.   This may be a big change for the child who carries around a covered cup and sips all day long, but once he is trained, you can go back to the “sippy life” if you wish.
  • Make sure that you have a plan, whatever it is, and know why you are doing it that way.  If you have a nanny or daycare provider, make sure that they know your plan and your rationale for it.  Children do best when they sense your confidence and support.  That doesn’t mean you cannot adjust things, but if you are just tossing new ideas out there every few days, it can be very hard for a sensitive child or one with limited modulation to handle all that change.
  • If your older toddler really struggles with control issues, and you suspect that they are resisting toilet training to establish their control rather than just struggling to learn a skill, then you need to address this first.  Establishing limits and building communication skills so that you are teaching more than begging is almost essential.  I suggest the Happiest Toddler methods to develop a strong alliance with you, based on mutual respect and cooperation.
  • Do not underestimate good positioning.  Toddlers that seek movement constantly, fear falling, or  those with a lack of stability all need to get their feet steady on either a stool or on the floor.  Some children with sensory issues can use the little rings over a standard potty, but it is more common for children with SPD to need more support.  They may not tell you they need it, they may just want to get off, not want you to leave them, or refuse to even hop up there.
  • If your toddler is often overexcitable or under-responsive to sensory input, he may have poor state modulation.  Your occupational therapist should be able to tell you if that is an issue for your child.  A nervous system that is idling too slowly isn’t registering the sensations of a full bladder.  The children that are overexcited will be paying attention to just about anything else.  Either way, use the techniques that work to create a more modulated state.  The Wilbarger Protocol, the How Does Your Engine Run activities, and more can help your child regulate their sensory arousal so that they can accurately perceive what is happening.

Remember:  independent toileting is a skill, and your child will develop this skill.  Think of all the skills they have acquired in the past few years.  This is the next one!

Sensory Processing Issues And Toilet Training Your Toddler: The Overview

Toilet training is never fun.  At it’s best, a sweetly cooperative child quickly connects urges with actions, and parents deal with an occasional accident.  In a few short weeks or months, you feel free to go anywhere without extra clothes, creme, wipes and diapers. Not when a child has difficulty processing sensory information.  Sensory processing difficulties do not prevent toilet training; they just make the training process much more complex.  The solution is to know what the typical toilet training strategies are, identify where your child needs more support, and create an environment that supports your unique toddler. Sound familiar?  If you have a child with SPD (Sensory Processing Disorder) or who has sensory processing issues related to developmental delays such as Down syndrome or Autistic Spectrum Disorder, your life is a series of these compromises and adjustments.

First things first:  know what the typical learning pattern looks like, so that your expectations can be reasonable.  “The Baby Whisperer Solves All Your Problems ” is my best resource book for a road map of toilet training through the whole toddler period.  I don’t know too many young toddlers with SPD that have finished training as early as her target age period, but it is helpful to know what she thinks signals readiness.  She also gives excellent studies of training gone wrong, with solutions, so that you feel that both of you can follow any mistakes with eventual success.

Secondly, you need to understand how your child’s sensory issues impact his learning.  Children with poor discrimination and relative insensitivity simply will not register the subtle physical sensations inside their bladder or the wetness in their diaper as strongly as other children.  They truthfully tell you they don’t have (any awareness of the need) to go.  Children who are very sensitive to touch may be very upset at being soiled and could find soggy or loose training pants very unsettling.  They may withhold just to avoid that sensation ever again.  Toddlers with poor postural control may be scared or even actually be unsafe on a loose seat placed over a standard toilet.  How could an adult  “let it go” after climbing up to a 4 foot high seat without no foot support and nothing but a removable ring to grip?  Poor modulators can get overwhelmed with the excitement of success, and poor auditory processing renders encouragement as confusing and stimulating but not instructive. Use all the techniques that have helped your child in the past.  Routines that create calmness, familiarity, and comfort, deep pressure or vestibular activities to stay alert and focused, and techniques that increase their general body awareness will help.  Develop a vocabulary around toileting so that they can explain their experience and can understand what your goals are. And timing.  Toddlers that are tired, agitated, or hungry are your worst students.  Toddlers that have had major scheduling or caregiver changes are stressed already.  Life is complex; you may have to create a calmer and more focused period to start training.

Next Blog Entry:  Specific Toilet Training Strategies for the Toddler with Autism and/or Sensory Issues