Delay In Walking

Most children are able to walk alone by 11 to 14 months but the the rate of development is very variable. Some children will fall outside the expected range and yet still be fine in the end.

Most developmental screening is done by health visitors but if they suspect a problem they will bring it to the GP. Hence even doctors who are not directly involved in developmental assessment must have knowledge of normal development. If a child has failed to reach a milestone at a given time but appears to be on the threshold of achieving it then a safe option is to review the child a month or so later to ascertain the progress made. If the child is nowhere near achievement of the milestone or there are other causes for concern then referral is required.

There are a number of essential questions to ask about any child suspected of developmental delay. Most of the answers should be in the health visitor's record.

• Was the child a full term normal delivery? Prematurity and problems suggesting possible intrapartum asphyxia should be noted. Only a minority of cerebral palsy is due to intrapartum asphyxia.¹ As babies of earlier gestation are surviving there is evidence that they are contributing more to the burden of cerebral palsy.²
• Were there any problems in pregnancy? Antepartum haemorrhage or hypertension in pregnancy may be relevant.
• Did the child feed well from the outset? A slow, floppy or irritable baby is of note.
• Was there deep jaundice? A degree of jaundice is normal but severe jaundice can lead to kernicterus.
• Has the child had any serious illnesses, such as meningitis?
• Are there any significant inherited conditions in the family? A family history of muscular dystrophy or some other neurological disorder may be significant.
• Has the mother been trying to get the baby to walk? An overprotective or immature mother may be treating the baby like a doll, just feeding, changing and keeping in the pram or cot? Has the baby had a chance to try to develop motor skills? Has the mother encouraged these? The mother may have untreated postnatal depression.
• Are there any other aspects of development that have been a cause for concern? This includes sitting, fine motor skills, speech and any other parameter.

• Does the child look well cared for? Neglect and emotional deprivation cause developmental delay.
• Does the child look normal? A syndrome like Down's syndrome mosaic may have been overlooked. Sometimes it is impossible to name a syndrome but the child looks strange.
• Does the child seem alert and attentive? Is he interested in this new stranger or unconcerned about his surroundings?
• What is the resting posture? Talipes or inversion of the foot suggest imbalance of muscle tone and neurological abnormality.
• How is muscle tone? Passively flex and extend the limbs and pick up the child to assess muscle tone and control. Is there any asymmetry between sides? Does the head flop on being lifted? Does tone and muscle control feel normal for a baby of this age? Cerebral palsy is associated with spasticity eventually but at an early stage flaccidity is present.
• Try to get the child to walk. Put the child down on his feet, at first keeping some control over the body. Does he bear weight or nearly do so or does he flop down? Can he stand with support but not unaided? Hold him standing, facing towards his mother and encourage him to walk a few steps to her. Make nice noises. Be reassuring and congratulatory. This is how mothers should behave but some may need teaching to do so. Note the mother/ child relationship.
• Test the plantar (Babinski) response. The plantar response is extensor at birth but by the time that the child is ready to walk the neural pathways should have become myelinated and the response should be flexor.
• Check that the crease of the buttocks looks normal. It is possible that congenital dislocation of the hip can be overlooked, especially if bilateral.

• A full developmental assessment is a very intricate and time consuming task.
• A GP should be able to do a few basic tests and should learn the "feel" of a normal or abnormal baby, but full assessment is best left to those with the skills, the training and the time.
• A multidisciplinary approach is often needed.

• Delay in walking may be simply variation of normal.
• Cerebral palsy is a common cause at about 2 to 2.5 per 1,000 live births.³
• Many other neurological or muscular abnormalities may be associated with delay. It is common to find a history of delayed walking in Duchenne muscular dystrophy but less so in Becker muscular dystrophy as it has a later onset.
• Most syndromes associated with learning difficulties have global delay.
• There may be non-specific brain damage and delay in walking is one feature.

• Management is rarely curative. Poor parenting may be corrected but the basis of management is supportive. Other aspects of delay need to be excluded or addressed. Community physiotherapy or occupational therapy staff may help parents give more intense attention to the child to make the most of the limited potential. The sooner intervention can take place the less will be any long term deficit.⁴
• If the child reached all other milestones normally and seems on the verge of achieving this one: review in one month and if the child can walk that is fine. If not, refer.
• If walking seems to be the only significant delay: referral to a community paediatrician may be in order for more detailed assessment but a paediatric physiotherapist or occupational therapist may be able to take a direct referral and offer appropriate management.
• If this seems to be part of global developmental delay: refer to a community or general paediatrician. The cause of delay may be brain damage or unknown.
• If this would appear to be part of a previously undiagnosed syndrome: refer to a paediatrician for full diagnosis or exclusion. If a diagnosis like Downs's syndrome or cerebral palsy has already been made then an explanation should be given that delayed milestones are to be expected. It may still be appropriate to involve other healthcare professionals to make the most of the limited potential.