Melissa Kreft was a year old when her mother, Lisa, noticed that her daughter kept her legs stiff and her toes pointed. Her walking was delayed.
Kreft and her husband, David, who live in Maywood, had their daughter evaluated by a neurologist and physical therapist, who said there was “nothing wrong.” Nevertheless, Melissa began a program of physical therapy at Children’s Memorial Hospital in Chicago.
Melissa took her first steps–walking flat on her feet–on New Year’s Eve. She was 19 months old.
Yet Melissa’s twin brother, Michael, walked normally, without toe pointing, before he was a year old.
So what made Melissa point her toes? Kreft blames the equipment she placed her daughter into several times a day. Known as baby walkers or activity centers, the floor-mounted devices like the one Kreft used hold a baby’s pelvis in a vertical position, suspending the child upright in a cloth supporter above the floor. A tray table, equipped with toys, flashing lights and noise makers, is mounted in front of the child.
Melissa was “a more passive baby,” her mom said, and it was easier to put her into the equipment while Kreft was caring for Michael or her third child, who is a year older than the twins. Kreft, a physical therapist, estimated that Melissa spent about 40 minutes a day in the walker; Michael spent very little time in one.
“It’s the equipment that caused her delay. There’s no other explanation for it,” Kreft claimed.
A growing problem
Physical therapists and surgeons at Children’s Memorial and other hospitals in the Chicago area agree that more children are toe walking.
“We’re seeing many, many, many more problems with this than we used to,” said Mary Weck, a clinical specialist in physical therapy at Children’s Memorial.
Weck, who also thinks the walker devices are suspect, stressed that there has been no research proving that use of the equipment leads to toe walking; her opinion is based solely on her clinical experience.
A spokeswoman for Graco, the largest manufacturer of juvenile products in the United States and a maker of walkers, referred questions to the Juvenile Product Manufacturers Association, which sets industry safety standards. Rick Locker, general counsel for the association, said blaming the devices for toe walking is “highly speculative.”
He said, “There’s no evidence of children not learning to walk normally after they use walkers.”
Similarly, the federal Consumer Product Safety Commission has “no findings,” said spokesman Ken Giles. Children once suffered skull fractures and other serious injuries when the walkers tumbled down stairs, he noted, but manufacturers now make them so wide they cannot slip through a doorway, or they place a “gripper strip” on the underside.
“We don’t know anything about this toe walking, but we tend to look more at acute injuries where people are brought into emergency rooms,” Giles said.
Other physical therapists said it’s too early to draw a connection between toe walking and use of a walker.
Looking for other causes
Michelle Babcock, clinical educator at the Rehabilitation Institute of Chicago, said, “You can’t really draw a conclusion from A to B, because there are so many factors we don’t know about. Parenting is so individualistic. If a child develops toe walking, it’s hard to know what caused it.”
Still, Weck said, when parents bring children in for corrective therapy, she asks them if they have ever used such activity stations or walkers. “Ninety percent of the time they say, ‘Yes,’ ” Weck said. “The muscles that keep you aligned over your feet are just not going to be as strong if you use a walker.”
She said toe walking also has increased as parents are cautioned not to place their babies on their bellies to sleep as a way of preventing sudden infant death syndrome. Instead, they are urged by pediatricians and other child-care experts to place them on their sides or backs. Thousands of SIDS deaths have been prevented, Weck said.
“At the same time, the combination of walkers and not placing babies on their bellies means kids don’t develop the strength they need in their stomach muscles,” she said. “They end up practicing incorrect alignment.” For many, that means toe walking and arched backs.
Toe walking can invite teasing from playmates or draw stares from adults, but Weck said it’s a “serious situation. When you’re walking on your toes, the rest of your skeletal alignment is off, and you’re more susceptible to injuries.”
Apparently it’s a tough habit to break. Physical therapy alone is only rarely successful. Usually therapists find they need to place the child in casts that hold the feet in a flat position for as long as 12 weeks while using a brace and splints at night.
Some children require surgery.
Dr. Erik King, an osteopathic surgeon at Children’s Memorial Hospital, said the procedure involves lengthening the patient’s Achilles’ tendon. Following surgery, the child’s heel is placed in a cast for six months. “We remove the cast and then follow up with physical therapy,” King said.
He said most of his patients are 3 or 4 years old. “There’s a social stigma associated with toe walking,” King said. “Kids get teased that they’re walking like a ballerina, and the families don’t like to see it. They think the child will get picked on.”
Some habitual toe walkers learn to walk flat-footed by themselves, he said, when they enter school. “But those kids are rare,” King added.
King also noted that there has been no research that proves his opinion, but he added that “walkers that get children up prematurely can promote toe walking. I tell patients I’m not in favor of walkers, and I urge parents not to use them.”
He said he also encounters parents who believe the walkers will teach their kids to walk earlier. “I tell them, ‘No! God will get us up and walking when we are ready to walk.’ “
Delaying mobility
The American Academy of Pediatrics has said walkers actually will delay sitting, standing and walking, according to Dr. Gary Smith, a member of the academy and director of the Center for Injury Research and Policy at Columbus Children’s Hospital in Columbus, Ohio.
Those delays, he said, may be caused by the tray table, which hides the child’s feet from his eyes. “Eye-foot coordination is blocked. There’s a visual piece that is also important in walking,” Smith said.
But Smith quickly added that the delay is only “a transient effect. The delays disappear within months after the kids are able to walk.”
Nevertheless, Smith recommends against using walkers: “Good old-fashioned belly time on the floor is best. It helps ensure a normal progression, from sitting to standing to walking.”
Layman expressed sympathy for the busy parent who needs hands free while cleaning the kitchen, sorting laundry or caring for other children.
Locker, general counsel for the JPMA, agreed. He said walkers and activity centers perform “a useful function in providing a safe environment for a child to explore the world.”
But Weck said there are other ways of keeping a child safe without risking problems with toe walking. She recommended an old standby: the playpen.
