Talking Torticollis, Hip Dysplasia, Tummy time, and more with a DPT!

Originally a 'The Birth Lounge Podcast' Interview with Kara Masse, DPT. 

I'm really excited about this because I think these are things that you're going to want to know before your baby gets here, but nobody tells you.

Today we are sharing an interview with Kara Masse, who graduated with her doctorate in physical therapy in 2013, from Simmons college. She's been a pediatric physical therapist for seven years now. And she started her career in early intervention, just like me. She's a certified early interventionists and now she actually works in outpatient setting for Mass General in Boston. It seems like we all kind of know bits and pieces babies, but nobody knows the nitty gritty about their physical development. And that is what Kara is going to share with us today.

What is it that you do with infants every day as a pediatric PT? If you know, if somebody is out there listening and they've never heard about that, what would someone come to you for?

So a lot of times, we will get referrals for delays in motor development like abnormal tone. So just the way that their muscles are moving or if they don't seem to be following their normal development. With infants we do see some common muscular skeletal problems, such as hip dysplasia, club foot, or a very common diagnosis called Torticollis.  Torticollis is tightening of the neck muscles, which can lead to Plagiocephaly- commonly observed as flattening of the head. 

And about what age are these children? Are you talking about newborns because there are some babies that, during birth they actually experienced and get hip dysplasia. Would they come to you as a newborn? 

It depends on the severity of it. it depends on sort of what the treatment protocol is for the different diagnoses.  For hip dysplasia, it depends if they end up needing bracing for example.  For Torticollis, I do see a lot of newborns. I will get referrals around two to four months of age usually. We do recommend the earlier the better, so you can get ahead of any sort of abnormal neck movements or tightness that's there. 

If your pediatrician doesn't give you a referral, can parents self-refer to you or where would parents go if they were concerned?

Most of the time you're not able to self refer to physical therapy in the outpatient setting. If your pediatrician is hesitant about referring, and you have concerns as a parent, I would push for it and just say, 'you know, I'd rather get it checked out now'. If you are noticing some flattening of the head or you really feel like your child has trouble turning to one side, or they always look in one direction you want to get referred for Torticollis.  I don't find too many pediatricians are reluctant to refer, but if they are, for some reason early intervention would be the way you could self refer.  They would evaluate your child and determine eligibility. 

Let's dive into Torticollis because I think there's so many parents out there that are listening thinking, 'Oh my gosh, what is Torticollis? Does my child have it? How do I fix it? What do we do? Where do we go? Who do I talk to?' So can you explain to us what Torticollis is, how it happens, and what can we do probably starting at birth so that we don't get to two months and start seeing signs of Torticollis. Is that possible? 

So most parents end up noticing the plagiocephaly, the flattening on one side of the head, first. A lot of times parents won't realize until a little bit later, 'Oh yes, my child doesn't turn their head to both sides easily'. What they will notice is that when they pick their child up, the head might look a little flat on one side and that's because they're spending more time on one side of the head than the other. Most of the time with plagiocephaly it's caused because one of the muscles in the neck, the sternocleidomastoid, which is the muscle in that's involved with Torticollis, that muscle is tight. This tightness causes the head to turn to one side and they kind of get stuck there. So typically they say that this happens because of the position that they were in the womb where they weren't moving as much and then they get kind of 'stuck' in a position.

This diagnosis is considered a congenital diagnosis, so it's something they're born with. It's not always preventable. The biggest thing is in the first few weeks to a month, you want to start noticing, are they doing visual tracking and are they able to follow you to both sides and move their head to both sides easily? A lot of parents also notice that when their child is sleeping, they may only have their head looking to one side when they sleep. There's been a huge uptick in plagiocephaly ever since the 'back to sleep' campaign in the early 2000s, because of the way they're positioned to sleep. The 'back to sleep' campaign has done so much more for other issues like SIDS and things like that, but it can make them more prone to neck preferences.  

So it kind of goes back to balancing that back sleep with enough tummy time throughout the day. So that that head gets that balance and they're not always laying on the back on their head?

Exactly. So the whole push for tummy time and pediatricians talking about doing that, that tummy time is actually there to counteract the back to sleep and to allow for more gross motor development. Most children develop those gross motor skills- lifting their head and all that head control through being on their stomach. They're now getting less of that when they sleep, so they need to balance that throughout the day during tummy time. So they recommend at least an hour of tummy time throughout the day. That can be broken up into 5 minutes chunks if needed, but to have accumulated hour throughout the day where they are on their tummy and working on those gross motor skills. 

That is amazing. So I personally love tummy time. I know a lot of children don't like it. You can totally make tummy time fun and engaging and like where your baby likes it. Remember your baby's going to have a learning curve. Everybody fights back on new things. So just to give them the space to learn to love tummy time, because it will eventually get to a point where they have independence there. They can lay on their tummy, they can reach things, they can bring it to their mouth. I have one last question about Torticollis. If your child is tight, let's say they're looking to the left and they are favoring the left the most. Does that tell us that the neck on the left or the right is tight? Is it the same side that they favor or the opposite side? 

So that is a tricky question.  There are a few different types of Torticollis.  Depending on how they are presenting and which muscles are really involved. With classic Torticollis if your child favors the left, as in is looking to the left, then most likely it's actually the right side that's tight. The muscle involved does opposite actions where it tilts the head to one side, but turns to the other. So their head would be tilted to the right, but turn to the left. Occasionally, there are certain instances where a kid may be tight on the same side. We actually see that a lot in kids who have reflux. There is relationship between Torticollis and reflux. It's more of a posturing effect that infants do to help relieve the pressure or the heartburn from reflux. Hence, they are both favoring and tight on the same side.

Isn't that so interesting that their body kind of knows how to cope with that reflux or that heartburn. Of course. I mean, I guess it's at the expense of their neck, but wow. At their body's intuition, I think I'm just kind of blown away by that. That is that's amazing. 

Right. So I think it's something if you feel like the child, if their head is sort of a little off center or they have trouble turning to one side and they either have reflux or you're just noticing that they're not moving it while it's great to have someone take a look to see if there's anything going on there. 

So what are some things that we can do at home if you do notice this and you're like, 'Oh yeah, this is totally my child. They're describing my child a hundred percent.' What are some things that we can do at home that maybe from the beginning?  What other simple things that parents can do?

Right. So, the biggest thing that we worry about first with Torticollis is the repositioning techniques for the plagiocephaly. So being able to reposition them and the flattening is not getting worse. So turning them on opposite directions in the crib when you put them to bed so they're not always facing the same way.  Tummy time again is just the best thing to do because they're off their back. But also tummy time is great for torticollis because in that position the muscle that is tight actually gets canceled out by the neck extensors when they lift their head. They're able to move side to side easier than when they're on their back.

So I think with tummy time really varying different positions of doing it- doing it over the boppy, doing it on your chest- that all counts as tummy time. Trying to make it successful for them. When they're early on in that newborn stage having them at an incline just makes it so much easier for them. When you want to work on sort of some of the strengthening for Torticollis, just trying to get them to track to both sides and also working in side lying.   Having them on their side and playing there will also relieve some pressure on the flat side of the head. So putting them on the opposite side that's flat. 

Amazing. Thank you so much for those tips. I'd like to circle back to hip dysplasia as well. If a child does have a need to have a brace after birth because of hip dysplasia, can you step us through that? What is that going to look like visually kind of on your baby and then what limitations do you have at home in those first few weeks with that brace? 

It depends. There are a couple of types of braces that they use. Most of the time if a child is at the point that they need that brace, they are wearing it mostly 24 hours a day. So it can be very challenging to have great sleep routines, to feed them, to change them.  Usually the hips are very outstretched kind of like a frogged out leg position. So it may also be challenging to do tummy time with them, because they're wearing this brace and they're in this position for 24 hours a day. So  a lot of it is finding seats, swings, or things that being able to prop them up that might be a little bit more comfortable for them. They might not be as comfortable just laying flat on the floor or trying to do tummy time with that. 

I think a lot of it would be trying to see if you could comfortably do tummy time at that point. You could try chest to chest to get some tummy time. You may also need to put a little bit of a blanket over yourself to make it a little bit comfortable. They aren't going to be able to lay flat so you need to prop them up or support them from underneath. 

I want to talk about tools and baby products and things that you can buy that are not the healthiest for your baby's hips. And if you are going to use them, you want to be mindful of how you use them. What do parents need to know about using those toys? Even the baby wearing- what do we need to know about our child's hip development when using carriers? 

So with those baby wearing and all the sort of baby carriers, there are certain carriers that really facilitate a better hip posture. What we ideally want to see is that their hips and their legs come out straight and that their knees come down at a 90 degree angle. So they kind of look like a frog leg almost. We don't want their legs hanging straight down because that's going to put pressure on the hip joints. So a lot of the baby carriers have really adapted to give more padding underneath and sort of look like they cover their whole thigh and all you see is their little knees hanging down. That's exactly what we want to see. 

When it comes to the exercisers and some of those other toys, we really want to wait on those until kids are a little bit older and they're closer to seven or eight months old. We want to wait until they have a little bit more head control and they have trunk control. As well, if you put them in, it's limiting how long they're in there- 10 or15 minutes at a time when you need to get something done and no more than an hour a day total.  

I wish you guys could see me because I'm like shaking my head, like a crazy person. Like, yes, yes, yes. The frog legs are key. You guys, you've got to protect your child's hips because it's going to impact their lower back and their knees and their ankles. We have to protect these, these newborns so that, you know, they crawl and they can walk and they can do whatever they want with their bodies, actually in the future, we just need to protect their little bodies. I love to hear you say, you can still use those things, those tools. It hurts my heart when I have people who recommend like, well, don't have them in your house at all. Okay. That doesn't work for all parents. So how can we give boundaries where it can be an healthy option. We don't want their hips to be hyperextended, they need to really have leg muscles to kind of stand up really in that exercise toy. Is that correct? 

Infants go through a few different stages of developing through standing. So a lot of parents will be like, 'Oh, at four months, they're really pushing their weight through their leg!',  but certain things that you have to kind of take notice when they're doing that- Are their hips behind their shoulders? Are they straight under their shoulders? When are they able to really have that full head control, trunk control and everything from their head to their toes or in a line? If they're sort of flexed forward at the hips a little bit and they're not able to balance their whole trunk over their legs, they're not going to have enough, support and strength to really push through and support their legs. 

The next thing I wanted to dive into is sitting. If your child is not sitting by 4-6 months- how can we support our child sitting up? 

So I think what parents don't realize in general about child development is that there is a huge window for child development for all of these different milestones.  Just because your child isn't hitting that early end of the range, as long as they're within that range, it really doesn't matter. So really for sitting it can go up to about eight months and for rolling as well.  Rolling really goes, technically the end of the range of normal is nine months and parents think, 'Wow, that's crazy. That's late.' I think one of the things that we really want to look at are: Are they hitting all those milestones and where are they getting stuck? What movements are they having trouble with? There are some kids that sit really early, but they aren't enrolling at all. 

So we really want to know are they able to get some of those rotational movements in- how are they using their core? Can they reach across the middle? Can they turn to their side? So if a kid is hitting all of them sort of in sequence, but every milestone is a little bit on the later side, but they're hitting all of them- I would not be worried at all. It's more about the quality of the movement and how they're getting in and getting out of these movements.  Can they get into sitting, can they get out of sitting if they're stuck? If they can only sit, what does that do for them? So also, how are they participating in their environment? 

So if you do see this, is there something we can do as parents at home? Or is this something we should make a pediatrician appointment with? Is this something that we should call it early intervention? Where do we go from there? 

Yeah, I think a lot of it is giving different floor time opportunities.  Varying the play for them with different toys, putting him in different places, really allowing for as much tummy time as possible and letting them explore.  If they are doing well in sitting- can you get them to reach a little bit outside of their base to support where they're sitting to create more movement and see if they'll do some transitions? If you're getting to eight months and they're really not sitting well, or they're not rolling, that's when I would  contact your pediatrician to look into it. I would think you would start that discussion at the six month appointment, but you know, if they're kind of on their way and you're starting to see signs of it I would give it another month or two and follow up between 8-9 months. 

To define, 'not sitting very well'. What I imagine is a baby kind of slumped over not having a strong core, not being able to really engage with their environment.  What else should we know about, you know, kind of not great sitting, what are we looking for? 

Most infants will start sitting in what we call a prop sitting position, between four and five months. Where they'll be able to put their arms down in front of them and they can support their weight through their arms. When they're sitting between five and six months, we want to start seeing them sit upright more. They're not using their arms on the floor as much for support. They may put their arms on their legs for support, but by 7-8 months, we want to see them upright, with no arm support, and they can start reaching side to side for toys without too much falling to either side. 

Then after that, we are just looking for them what to be able to get out of that sit and probably crawl in and engage fully with their environment. Is that right? 

Exactly. We want them to be able to go from sitting to their stomach. To be able to crawl whether that's  an army crawling on their stomach or crawling on hands and knees, whichever they're starting to do. 

So let's dive in the army crawl, it freaks parents out. What do you say? Should we be worried about army crawl? 

No, definitely not. The army crawl is usually a phase. Most kids do army crawl. It's sort of that in-between where they don't have enough core strength to be on their hands and knees, but they're figuring out how to move and get themselves there. What we really look for with crawling is reciprocal motions. We want to see alternating arms and legs, because that coordination piece offers so much that it doesn't matter if they're doing it on their stomach or they're doing it on their hands and knees. 

And what about scooting? Some kids don't crawl because they learn that they can get around on their butt. Is this concerning? Should we be worried that they've chosen to scoot rather than beyond their belly? 

Most kids that learn how to scoot, have already sort of decided or have had difficulty with that tummy time. That's usually why it happens over the hands and knees crawling. It is something that it can be a little bit concerning. We want to develop some of that arm strength. We want them to be able to have that shoulder stability for later on. Also with crawling, those reciprocal movements- that coordination piece is huge. A lot of times when kids scoot, they use one side more than the other, and they're not getting that alternating piece. We do try if someone comes to physical therapy because they, were having trouble pulling up to stand or they are later walkers, and they scoot- we still try to encourage different techniques of being on their hands and knees and continue to promote that crawling. 

Kids with Torticollis will develop a scoot, or they may crawl on their hands and knees, but one of their legs is sort of up in this flex position. A lot of times it can either be on the same side or it can be the opposite side. Either due to some tightness that's throughout the rest of the body, because we do see some tightness down through the trunk as well as the hip, but the more dominant side may also be the one that is up when they're scooting because the opposite side is stronger. 

That makes a lot of sense. So now that our child is crawling or scooting, how long does that phase last and when should we expect our child to start walking in? What are those phases kind of look like? Plus when should we be worried if our child is not walking? 

Right. So the window is huge. People don't realize that the normal walking window is anywhere between 12 and 18 months. Yes. 18 months is normal. What are the opportunities for pulling up to stand and cruising. So still having that floor time where they can explore is important. The walker toys where the child sort of sits in the walker, that's not going to promote cruising and the weight bearing that they need for walking. Whereas the push toy walkers are great. Those model some of that forward walking that typical progression that we see. So, around 15 months, if they're really not pulling up to stand or cruising, I would start to look into maybe why aren't they, but I wouldn't be overly concerned. They're still normal. If they're starting to pull up to stand and cruise, they may start walking by 18 months. 

What do we need to know about shoes? I've always heard and kind of recommended not to put your child in these big, huge, clunky that the thinner, the better you really kind want to you're, I'm a huge fan of barefoot. After six months, I really kind of just think having their feet on the ground is the best way to really give them, you know, the lay of the land, if you will. So thin shoes is kind of what I recommend. What do you recommend? And then also in the winter time, especially here in Boston, we can't do thin shoes. What do we do? How do you manage that? 

Right. So the thought behind shoes is really the best thing is for them to be barefoot as much as possible. So when they're home, wherever they are being barefoot is the best. Winter time, creates some issues where you know, thick enough socks that they can wear that to still allow them to be barefoot or if they really need that extra layer- thin shoes would be better. After they start walking, if it's not too cold or not cold in your house and you can keep them barefoot or wear socks, that's ideally the best. 

Even as they are outside of that 18 month window, and they're toddlers, you still want them to be barefoot because that's how they're going to build up their arch. Their arch doesn't fully develop until they're close to school age, around five. So we really need to strengthen all those muscles in their feet. You get that feedback by being barefoot. That's how they strengthen all those muscles. 

You are speaking to my country heart. So I don't know if you know this about me, that I grew up in Mississippi and on a farm. Okay. I do have one final question. What do we do as parents that hinder our child's development? And for example, what pops into my mind is hip carrying. What are some things that we might do unintentionally as parents that we could do better or differently that might benefit our child and their physical development from a PT standpoint? 

I think one of the biggest things is just allowing their own exploration. Kids innately really have motor plans built into them. Giving them the opportunity just to be on the floor and to explore and to also really change up their environment. As they're getting close to that sort of 5-6 months of age and they're really starting to try to move, we want them to be able to learn from trial and error.  They learn the best from trying and failing and then realizing, 'Oh, I have to do it differently because that didn't work that time.' So if they're always in the same place or with the same toys and it becomes routine, they don't know how to change their play.  They don't learn to change their movements or how to adapt them. 

I know I said that was my last question and it's not, it never is. What do we do about lazy baby? So if you change your baby's environment and they literally just lay there and they're like, look, I'm not doing tummy time here. I'm not doing tummy time there. I'm not doing tummy time anywhere. Like I'm not doing tummy time. Um, you know, you lay them on their back and they're like, okay, I'm just gonna hang out here. What can we do to kind of get these babies engaged?

Yeah. I think a lot of it is finding distraction techniques.  What do they laugh at? What do they squeal at? You know, is it music? Is it those baby mirrors? Kids will love looking at themselves in a mirror. What are the different tools that you can do to distract them and start from ground zero and build it up.  You know- 1 minute is a success, 2 minutes is a success. How can you build off of that? Work with your child and meet them where they're at. Every baby is different. 

I love that so much. I love to say baby steps for your baby. It is insane. And so just age inappropriate to expect your baby to perform at an older child or an adult level, right? Oh my gosh. This has been such a fun conversation. Thank you so much for joining me. If there were any listeners who were concerned about any of the things that we might have mentioned today what should their first steps be after they listened to this podcast?

Yeah, I think the first steps would be if there were any concerns, especially if it's young infants and you're worried about sort of the flattening or your baby's only looking to one side, have those open conversations with your pediatrician. Really, you know, express your concerns about it. Most of the time the pediatricians are more than happy to have second look if you feel that you want a referral to physical therapy at any point.  Or seeking out early intervention, as a second resource, since you can self refer to early intervention to kind of just have your baby looked at and find where they are developmentally. 

I love that. Thank you so much. That is really the most empowering thing that you can ever tell a parent is, take it into your own hands, look it up and, you know, take it into your own hands. Self-refer start talking to people. The best thing you can do as a parent is just action.