So, today, we are talking about hypotonia. So, starting off, what is hypotonia? So, we all know that all of our muscles have a baseline resistance to passive movement. So, a lot of times, you'll hear us talk about tone, and a lot of times, we're saying tone as in high tone, but we all have some appropriate level of tone. So, that's really that spectrum. So, when we're passively ranging muscles, we can experience high tone, or we can experience low tone. So, hypotonia is that they do not have that baseline resistance to passive movement. This is not related to strength, so this is different, but there are not clear diagnostic criteria. So, when you look in the literature, there's some surveys that have been done looking at different experts who deal with this, trying to define what exactly hypotonia is, and what the criteria should be to diagnose hypotonia in a patient. This survey here was sent to 1,000 PTOTs about the criteria for hypotonia. They got 268 responses, and the top three were hypermobile joints, increased flexibility, and decreased strength. So, what's clear here is that it's pretty difficult to distinguish what's ligamentous laxity, what's weakness, and what's hypotonia. So, kind of talking about that a little bit more. So, there's a lot of overlap between these three. So, even though they're not the same, when you survey experts, and there were other studies done as well, a lot of times, weakness and ligament laxity, or flexibility, are what they define as criteria for hypotonia, even though hypotonia is kind of something different. So, like we just talked about, so hypotonia is just simply that resistance to passive stretch on muscles, whereas weakness, we're really talking about force, power generation. And then laxity is more focused on the joints, so focused on those ligaments, and how much we can stretch them. So, the Baton scale, which we'll touch on later, is something that measures ligament laxity specifically. But we know that there is overlap here, and when you think about certain diseases, you know, a classic cause of hypotonia in infants is SMA. We know that kids with SMA have weakness. We know that their alpha motor neurons are dying. They have weakness, but they're also hypotonic. So, there's a lot of overlap here, which makes a lot of the research pretty difficult. So, we've all heard of the floppy baby that we see in the neonatal ICU. So, this happens to about one to 4% of kids will have hypotonia. It's usually central. So, we talk about central and peripheral, which we'll talk more about in a moment. Central is a more common cause of hypotonia for late preterm and term babies. Sometimes you'll see arthrogryposis in these kids too, just because since they weren't maybe moving around as much when they were in the womb, they got stuck in certain positions, or they might have higher risk of things like torticollis because they're just stuck in positions and not kind of fighting and moving around. And so, we're kind of in a new era, you know, in the past 10 or so years with how readily available genetic testing is to us, which is great. So, for these babies, over half who have genetic testing immediately sent in the NICU will have a diagnosis identified. So, just thinking what the most common genetic cause of central hypotonia is, which is where a lot of our research ends up coming from, is these patients. So, our most common cause is Down syndrome, big cause of hypotonia. And then the second most common cause is Prader-Willi syndrome. So, those kids are also known to have pretty severe hypotonia. So, talking about the causes of hypotonia and related diagnoses. So, we have the central and peripheral that we tend to break it up into. So, central, a very big cause is HIE. So, we'll see this in our premature patients if they've had a bleed. And then it can also be associated, central, we tend to associate more with arousal, other cognitive findings. We also know that a lot of kids who might end up with spastic cerebral palsy eventually are at first hypotonic. So, sometimes we see that hypotonia and then that higher tone develops as the months go on and they get a little bit older. Genetic causes, any intracranial hemorrhage, metabolic, brain anomalies, infections, those congenital torch infections, acquired infections, drug effects. So, if the babies are on a lot of benzodiazepines or other medications for whatever reason, sometimes that can cause hypotonia. And then we have the peripheral causes, which are a little less common. So, thinking about the spinal cord. So, the spinal cord itself, you can have myelopathy or cerebral myelia. Like you had the alpha motor neuron in the spinal cord. SMA is a very common cause of hypotonia in kids. The nerve itself, so various neuropathies, all the CMTs, then moving down to the neuromuscular junction. So, little kids who come in with a new hypotonia, we're always trying to rule out botulism. So, that is a big cause of neuromuscular junction. You can also have congenital myasthenia gravis. And then the muscle itself, of course, we have all of our myopathies, our myotonic dystrophies, our muscular dystrophies, Pompe disease, other connective tissue diseases. But then there's this other classification. So, for these kids who we don't find a diagnosis. So, this is an older term that I have actually never used in clinical practice until I was really looking up more about this talk. So, this is benign congenital hypotonia. So, kind of thing is hypotonia, a syndrome in itself, or is it always a symptom of something else? So, this term came around in the 1960s. And initially it just described hypotonia that wasn't SMA type one or Worden-Eckhoffman's disease. So, this ought to be a diagnosis of exclusion, including the criteria listed there. So, impaired mobility, delay in development, generalized hypotonia. It was also thought that it mostly improved, but not always fully. So, a lot of these benign congenital hypotonia were thought to be in these buckets. They have a typical normal development, but some of them don't. So, there's this pathologic and benign. And a lot of, now that we kind of investigate a little bit more, some recommend that this not really be used as a specific entity in itself. So, this is a great review that came out recently in 2022. It's really more focusing on neonatal hypotonia, but just talking about what we should do for these kids in the NICU. So, when you see a hypotonic infant, it's recommended now to just go ahead and get that genetic testing right away, especially rapid genetic testing, if it's available, and then kind of figure out what this phenotype is. So, look at their brain, look at their eyes, look at their heart. Are there other associated comorbidities going on? And then if we do find a diagnosis over here on the green side, so we want to evaluate for targeted treatment options. For example, SMA has targeted treatment. There's some enzyme replacements for things like Pompe disease, provide prognostic indication. Here, I think this is really important and something that we can help from as a rehab standpoint when we're not quite focusing on making the decisions of how we're going to treat these diseases molecularly, but we can really help with connecting families to disease-specific groups and providing that support. And then of course, the families may want to get genetic counseling for future family planning. I think if a molecular diagnosis is identified, there should also be a referral at an early intervention. So, I added a blank back for that, especially for kids who do have a diagnosis, they might automatically qualify for early intervention. So, a lot of times you need at least a 20% delay to qualify for early intervention, but if we're already have a named diagnosis or have cerebral palsy, a lot of times that's a qualifier to automatically be able to be enrolled in early intervention. And then on the red side, if we don't figure out a diagnosis, basically keep looking, maybe do more invasive things like muscle biopsy, which used to be a much higher line issue, but now that genetics is actually less invasive, we can do that first. But another thing I highlighted that's something that I refer to patients in clinic a lot is a re-analysis of their genomic data. I've usually said every four to five years, but this review article actually says every two to three years. So, we're just finding out so much more about genetics. So, a lot of times I'll have a new patient and say, oh yeah, we have genetic testing in the NICU, it was normal, but this kid's seven now. So, I try to refer them back to genetics to have a re-analysis of that data because there might be something that we're able to pick up now that we've identified since then. So, why do we care about hypotonia? So, I made this slide and then I added back onto it benign and relignant because I think that is kind of the summary of this slide. So, we don't know, it might be benign, they might develop perfectly fine, or it could be an indication of something really, really serious. And it's pretty hard to know. So, we do know that laxity is associated with gross motor delay, but then other studies have shown that in healthy cohorts of kids, hypotonia is not correlated to motor development. One study in a NICU follow-up clinic showed that the presence of hypotonia was correlated with weakness on that subset of the Bailey scale. In that same study, they also showed that the presence of hypotonia was not correlated with a CP diagnosis. Hypotonia also, like we said, can be a marker for genetic disorders. It's been shown to be a marker for autism spectrum disease. So, kids with hypotonia actually will be diagnosed with autism one to 1.5 years earlier than peers without hypotonia who end up with an autism diagnosis. There's an association with developmental coordination disorder, which we'll talk about next. And then of course, the comorbidity screening, which is part of why we push early detection for CP as well. We wanna make sure we're looking at all of the potential associated issues so that we can intervene on them appropriately. That review that I talked about in the last section had a really nice supplemental table where they actually took the kids that they looked at and talked about how getting a definitive diagnosis affected things. So, this was for getting the actual genetic diagnosis, not just hypotonia. But in some cases, it helped the family decide that they're gonna switch to comfort-focused care. In some cases, it helped them decide that they were ready to proceed with a tracheostomy or other times they wanted to do ophthalmology screening and EKG for cardiac screening. Sometimes it opened up a new treatment that might be available. So, I think even though there is this term of benign congenital hypotonia, I think especially the way that our minds work as physiatrists, we are always wanting to intervene. And I think we don't really think of things as benign. We think of them as how can this impact function and how can we make sure that it doesn't impact function in a negative way. So, I did also briefly wanna talk about the association with developmental coordination disorder. So, this is actually a DSM-5 diagnosis. It's under neurodevelopmental disorder. It used to be under learning disorder and then it switched from DSM-4 to 5. And basically the definition is that it is a disease with impaired acquisition and execution of motor skills. It shows that this issue with coordination interferes with ADLs and participation. There's an onset during the early developmental period and it's not explained by something else. So, some studies show that almost up to half of kids with developmental coordination disorder have joint hypermobility. Another big study in Dutch kids showed that in the general population, hypermobility didn't correlate with poor motor performance, but in the population that had a DCD diagnosis, the presence of hypermobility did correlate with poor motor performance. So, some suggestions that maybe in our more invulnerable kids that hypotonia or hypermobility does have more impacts on poor motor performance. This is a study that I really liked because I think it helped, this kind of makes sense to me of how it affects kids. So, like a lot of the research that we have, this isn't just looking at kids with idiopathic hypotonia, it is looking at kids with Down syndrome. So, that's kind of a limitation with expanding it to all kids with hypotonia. They had 20 kids totals. They had 10 kids that were typically developing and 10 that had this hypotonia from Down syndrome. They looked at them as new walkers. So, one month of walking and three months of walking. So, these new walkers, they had them walk along and then they had a barrier in the way. So, they had like a really long pole or something. So, the new walkers were likely to keep walking, try to keep walking. They were more likely to fail and fall or have an error as they called it. Then they looked at these kids who had hypotonia and they found that these kids were more likely to see this barrier and just go straight to a more stable mobility mode like crawling. So, they would see it, not even try, just go to crawling and stay crawling to stay safer. They saw that both groups did things like slow down, decrease their step length. But these hypotonic kids also would increase their step width. So, it would have wider width to have better balance. And then they also found that when their width did equal those of typically developing. So, when they weren't walking with a wider base of support, they were more likely to fall. So, they really needed that wide base of support to stay stable. And then they looked at them again when they were walking for three months now. And these typically developing kids continue to be more confident and more likely to try to walk. And they were more likely to be successful. So, they were usually able to step over it, avoid it appropriately, not lose their balance. But the patients with hypotonia still switched to that stable mobility. So, I really liked this because I think it kind of shows how this hypotonia probably affects their stability, maybe their proprioception, their balance, and then how that can lead to a gross motor delay. We also know that one of the things that we see are these hypotonic faces or hypotonic dysarthria. So, we know that having that upper airway tone and lower mouth tone can affect things like causing obstruction like OSA, having poor articulation resulting in dysphagia or poor secretion management. So, that's another thing that we have to think about with these kids. So, how do we find hypotonia? So, we talked about the definition, but how do we actually diagnose it? So, this first study was a group of 268 therapists. They asked them how they diagnose it. And if you see the most, the tool they use the most is just simply observation. This was a group of pretty experienced therapists. So, they might just be better at not needing to use a formal tool, but it did show that most therapists are not using a formal assessment tool to diagnose hypotonia. This was another survey-based study. Lower amount of people asked, just 11 pediatric experts. And they asked which tests and methods should be used when they're assessing 24 different characteristics of hypotonia. And these are the characteristics that they chose. So, things like pronated feet, their postural alignment. And so, for only of eight of these 24 characteristics did more than 70% agree on what method should be used to define or identify that issue. This is a study that looked at muscle tone assessments in kids. And they really ended up coming up with that we don't really have a current assessment that solely measures muscle tone. So, we do have the modified Ashworth scale, we have TARDU, but that's really looking at spasticity. So, just looking at what can measure our tone from that range of low tone to normal tone to high tone, we really don't have something like that. They did come up with this list of some assessments that certainly include tone and that they felt like they could support use in some way. But right now, we don't have something to look at tone exactly. They also, in that same study, broke things up into resting tone and active tone, which is a nice way to think about things. So, they felt like resting tone was more things like just looking at the posture, their range of motion. So, that just that resistance to the passive stretch while they're attempting to maintain a relaxed state of muscle activity, whereas active tone is their ability or readiness to respond to environmental demand. So, things like pull to sit when you're changing gravity and you want their tone to respond to that appropriately. So, a lot of work is going into this right now so that we can better define hypotonia once we're better able to define it and we know we're talking about the same phenomenon, then hopefully we can study it more and study the interventions that help it the most. So, this was a proposed clinical algorithm. This was a working group with 59 experts. And this is nice because it does provide a checklist. So, they talk about just this clinical assessment and they go through these different items. And it also has a checklist for posture here, which I think can be useful to think about. But it doesn't look like this is really a quantitative measure for us to use severity. There is some work to my knowledge going on looking at a modified HINE, which we'll talk about for hypotonia with Vinny Palig. So, I believe that that is being studied. So, hopefully we'll have something that we can start using soon. But I think that our lack of a true assessment for tone is a big problem in this patient population. So we'll just go a little bit more into some things that we look at to identify tone. So observation, so just looking at the quality and quantity of movements, things like the general motor assessment is something that we can use for that. Looking for anti-gravity movements, which is really looking at weakness, but also just seeing if they have that presence of anti-gravity movements. Frog-legged positioning is something that we see a lot in kids with low tone. So they'll be in the NICU and they just have this resting position with their hips flexed and abducted. W-sitters is another thing that we see sometimes in low tone, especially in older kids. So this is what we're talking about when we refer to W-sitting. So significant internal rotation. And the other thing that that's doing for them is that's a wide base of support. So if they have some hypotonic, if they have a trunk that's hypotonic, this is giving them a wider base of support. Maybe they just have hips and that's how hip dysplasia, or they just have a preference toward internal rotation and that's just how they're made, but it also could be providing them a wide base of support. So that's something to think about too, making sure that this isn't actually the way that they're compensating for a weak trunk. And then of course, joint alignment. So looking at their feet and seeing if they are, have a lot of pronation in their legs. So posture and tone. So these videos are great from pathways.org. They're available on YouTube and they compare typically developing kids and atypically developing kids. So this is one of the horizontal suspension that we do. So we want to see the babies respond to this, kick their legs up, kick their, start to bring their neck extended. And here you see a hypotonic baby who's just kind of staying in that upside down U shape. Shoulders slip through or essentially vertical suspension. So this is when we pick the kids up and then their tone is low. So they kind of just slip right through your arms. They're not able to keep their shoulders down and strong. And then pull to sit is another one that we use a lot. So we want to see these kids starting to tuck that chin. So the HINE or the Hammersmith Infant Neuro Exam. So this is a standardized examination that we can use for kids who are two to 24 months of age. One thing that's really nice about this one is it also gives us some prognostic value. It's very sensitive. It's found to have good inner observer reliability. It's split up into 26 items in five different domains as shown here. And then you score them zero to three for a final score. And that will show you if it's a suboptimal score or grossly atypical score. This is a little bit newer. This came out in 1999. But not all of these maneuvers are looking at hypotonia either. So that's like I said, we don't have something that only looks at tone. But I think that a lot of these checklist items are certainly related to low tone. So we look at these range of motion for the lower and the upper extremities. So things here looking at low tone, having excessive dorsiflexion, having excessive popliteal angles, and then also looking at some of those postural controls. So things like ventral suspension and pull to sit like we talked about on the last slide. So I think that this is something, I forgot I had boxes there. So this is something that you could use formally and totally and do the full exam and get your score. Or you can also just think through this exam. So when I was a trainee, I really liked the HINE, especially because it just gave me a framework of how to do a neuro exam on these little kids and what I should be thinking through. So even now in clinic, if I'm not doing a formal HINE, at least it helps me kind of go through that checklist of what to think about. And this is the exam that there is some research going on right now to try to find a way to scale it for just these hypotonic items so that we could get a quantitative measure of hypotonia, which I think would be really exciting. This is an exam that I have not used, but it did come up a lot looking at different research of hypotonia. So this one's a bit older. So I think that this used to be used to identify hypotonia a little bit more. So similar age range, zero to 18 months. They looked at 20 items split up into these five domains, and then that could help identify hypotonia. I also want to talk about the Baton score. So the Baton score looks at ligament laxity. So really just looking at those joints and how flexible those joints are. So this looks at five items. So it ends up being scored out of nine as four of these items are bilateral. And so you can see they're looking at the range of motion of different items. So, and then seeing if you can touch the floor with your knees extended. So this is a nice way to identify ligamentous laxity as well. You know, I think trying to differentiate between hypotonia and ligament laxity, I think, you know, when I talk to a lot of my mentors who are more experienced, they just say like, you know, you really get the feel of it. You can just feel a kid and know if it's coming more from the muscle or coming more from the ligaments. You know, I will say as time has gone on it, I would say I've had some kids who do have a lot of ligament laxity and you can feel that looseness. It does feel different. So I think just kind of speaks to the importance of continuing to get your hands on kids and examine them on your own and get that feeling of normal and not normal so that you could identify these as you go on. But hopefully we will also have a more defined scale eventually for everyone to use. So what do we do about hypotonia? So what is the management of this? So this is a great systematic review that came out with Jay Palig, who I mentioned before, who's doing a lot of research in the hypotonia domain. You know, one thing with all of this hypotonia research and even just trying to research things on my own doing a lit search for hypotonia is that you come up with all these different disorders because it's a symptom of so many disorders. So you try to search hypotonia and X, and it comes up with all of these different genetic disorders. So it's hard to just study hypotonia on its own and not in relation to the given genetic disorder. She did this beautiful review looking at the current evidence for our interventions for central hypotonia. And this is actually from, so this is the review that she did. This chart is actually from the AACPDM. So the AACPDM has some clinical pathways and they have a clinical pathway for central hypotonia, which is a great resource that I recommend. And then in the review, she did like a green, yellow, red light intervention for how well things were recommended. So one of the, there weren't that many green light items, but one was massage. So using massage on infants to help improve their muscle tone, their use of their vision and their gross motor skills. And then the other green light item, I don't know where my circles went off base, are for treadmill training. So that was really looking at kids with Down syndrome in particular, but using treadmill training to accelerate the onset of walking and improve their gait parameters. So a lot of these kids will come into clinic and you see they have that overpronation. You can look at the lateral border of their foot, especially for the really little kids, because we know that smaller kids sometimes are a little bit looser. But if you see that lateral border of the foot going off the ground, that's a good sign that it's a little pathologic. So sometimes I'll have these kids come into clinic and have to decide what to do with these flat feet. So I think the first is putting them into a clinic So I think the first is putting them into which flat feet bucket they are. So are they typically developing and they have normal tone? Are they typically developing, but they just have low tone? Or are they atypically developing with low tone? Because I think that really changes what you want to do. We know that the arch doesn't develop until around four years. Sometimes the foot arch doesn't have full shape until up to 10 years. And 10% of the population has a flexible flat foot. So you always want to make sure that it's not a rigid flat foot. And the way that you can do that is by having patients go up on their toes, and then you can see the arch form, which most of the time they edit will be a flexible flat foot, especially for the ones that we're seeing. And if it's not, then they should go to orthopedic. I do think that it's important for us to know, so Choosing Wisely is a campaign about not using excess resources in medicine. So they have a lot of recommendations for things like if a CT scan is warranted for X, Y, or Z. And it is a recommendation from Choosing Wisely to not use shoe inserts for symmetric flat feet or high arches in patients without symptoms. So I think one thing that's important is this is for patients without symptoms, including pain. So if they have pain, then that's a totally different bucket. But they've showed that it doesn't help develop an arch. So they actually don't recommend this for kids who are, sometimes I will have kids who are typically developing and just come in with a flat foot. And so sometimes I won't tell them to get a shoe insert. So do we brace or do we not brace for hypotonia? So this is a big question of what we should do for these kids who have a hypotonic flat foot or high foot eversion. So there's kind of a spectrum of how much support we can provide. So we have the foot orthotics, which is really just helping out the arch. And then we have something called a UCBL, which gives a little bit of this heel cup. So it gives a little more support than just a shoe insert. And that can add a little bit of coronal, plain, medial, lateral stability for these patients. So some studies have shown that using these can improve motor capabilities, help children meet age equivalent norms. One study showed that it did improve the arch index, even though Susan Wisely says it doesn't. So maybe for hypotonic kids, it's a little bit different. And then moving to the next level of support is the SMOs. So this is supramalleolar orthosis. So it comes above the medial and lateral malleal line. And so now that you're really capturing that, you get a lot more medial lateral plain stability, so that coronal plain. So they're not gonna be wiggling back and forth or collapsing into hind foot eversion. And that can also really help their gait mechanics. So we know that it improves stability, but there are some concerns that just using this much bracing on these kids constrain their ability to explore different movements. And then lastly is our AFO. So our ankle foot orthosis. So this is when we're getting a little bit higher, so going up the calf. And that adds on a sagittal plain stability. So that prevents us from excess plantar flexion or dorsiflexion. Recently, I've had some patients who go into plantar flexion and junior rector bottom, not because they have tone, which is often when we think of kids going into that alignment, but just because they're so hypotonic that they kind of just collapse and hyperextend their knee, because I think it's just the most efficient way for them to stand instead of really activating their muscles. So I have given AFOs at times for these kids to practice being in standing with the hope that preventing from that plantar flexion will prevent that junior rector bottom, which will then hopefully have proximal effects to help them get into kind of a posterior pelvic tilt to activate that lower core. But with these kids, one of the things I also say is don't use this all of the time. So that's one of the things that we really don't know. When do we use it? How much do we use it? So there's some differing opinions out there. If I go back to this slide, this systemic review by Weber is really great looking at orthotics for hypotonia. So I highly recommend it. There's a general agreement that there is benefit to using AFO after these kids are walking if they still have a lot of hypotonia, but probably we don't want to start using it full time before walking. So some people say that we don't think we should use them until after they're ambulating independently. Some people say that we should use them before, but probably not using full time before is at least a good happy medium. Something that we can also help with as physiatrists are the prognosis. So we might kind of understand the big picture of where this kid is going. And if they're always gonna need a brace, then we're gonna be less concerned about adding on a brace. Another thing to think about is their risk versus benefit. So we know that having mobility and the ability to explore one's environment is super important for cognition. So if we can help them move around, even if it means providing a little bit of extra support, that might be really important for developing their cognition. And then again, dosing. So should we use this half of the time? Should we use this just in therapy? Should we use them just outside of therapy? So a lot of questions with that. A lot of times I will have the therapist kind of make that decision as well, since they're the ones who are working with the patient and they see them more often than me. So sometimes I'll talk to the families. You know, I'll say, I don't think that they need this all the time, but talk to the therapist about when they should be using it. So moving on to trunks. So we all see a lot of weak hypotonic trunks, sometimes even in kids who have spastic cerebral palsy who are tight in their extremities, but then their trunks are loose. And then we're stuck in that situation where we wanna give them tone medications, but we don't wanna weaken their trunk more. So overall, it's thought that the compression garments probably outweigh, the benefits probably outweigh the disadvantages. So this big review that Jenny Paley did does conditionally recommend the use of hypotonic trunks, but there are pretty limited studies in this. Particularly, it seems like there's a lot more in the foot orthotic area than this. So it's conditionally recommended. Our hope is that it's providing support, but also providing kind of some proprioceptive feedback, tactile feedback to help them learn to activate their core. And so the goal is always that it's gonna carry over when that is removed. Another thing that I like to think about for these kids are sometimes they're working so hard to control their trunk, that they can't really focus on developing their fine motor skills. So sometimes I do like to give them that support so they can be up in a supported chair with a tray in front of them and explore using their hands and just have the energy to spend on their hands instead of just focusing and working so hard on their trunk. So just reviewing what some of our options are for trunk support. So some over-the-counter options. So Lycra vests are popular, which is something that Stio provides that you might hear of. There's also over-the-counter knit compression vests that you can just buy on Amazon that are pretty cheap. So this is an example of one by SmartKnit. Neoprene vests are really popular. So this is something that the Benick company makes. So a lot of times you'll hear of Benick vests. And Benick vests are nice because you can add panels and you can also add stays. So you can make them more supportive because you can add things into it, which is nice. Then there's custom Lycra vests. So one that's popular here is DMO. So I really like these. They're a lot more work to have. They're like very perfectly, very custom measured to these patients. They provide a lot of support. I trained in Boston. And when I was in Boston, I used these a lot because I think that they have a company they work with who can make DMOs. But now that I'm in a different institution, these are used a lot less, which just kind of goes to speak of the different geographical preferences of managing orthotics, which is kind of why it's a great, I think doing this lecture series to hear from people all over the place. So something that I was using before and now I just don't have as readily available. So I'm using other options more often. And then of course, much more supportive is just a full TLSO. So how else can we strengthen the core, which I think is a really important part of care for these kids. So one thing is limiting container use. So containers, meaning high chairs, exercisers, bouncers. So this is an example of a bouncer. So the kid's not really bearing weight. They're just jumping. And there are some studies showing that more equipment use is associated with lower motor development scores. There's other studies showing that for healthy kids, it might cause a transient delay, but then they catch up. But this is something that I almost always recommend to families. So I talked about, there's all these fancy things out there. You don't need it. You just need to put this kid on the floor and let him move around and let him have that environment. Another thing that comes up sometimes is crawling. So a lot of you probably know that the CDC removed crawling as a milestone at all recently. And we see a lot of kids who do perfectly fine without ever crawling. And so I tell parents that you don't have to crawl before you walk, but it can also be a sign that maybe their core is a little weak because crawling does help with core strength. So if they're scooting around instead of crawling, could it be related to some core weakness? So generally if a kid's not crawling, I will talk to another thing that can improve core strength and kind of be similar to crawling is climbing. So a lot of times if a kid's not crawling, I don't stress the parents out about it because I don't think it's a huge deal, but I do want them to create opportunities to strengthen the core. So I'll say to set up like couch pillows on the floor, to let them practice almost like climbing up the stairs on pillows so it's safer. And then, you know, increasing the motivation to move. So having the early intervention therapist work with the parent to try to help that kid want to move more. This is the hypotonia wheel. So this looks at different milestones and then gives you some activities to do with them, which I think is really cool. And so things like, oh, is this kid walking alone yet? If not, encourage more time in standing, consider a mobility device. They have a lot of emphasis on including the parents and caregivers, which I think is a huge point, especially in these really young kids with hypotonia. So making sure that we're doing that. So overall, just encouraging that movement as much as we can. And that is about all that I have. I think we still have a few minutes left. So if anyone has any questions, please let me know.

hypotonia

weakness

diagnostic criteria

genetic testing

NICU

management

massage

orthotics