Europeanlournal of Paediatric Neurology 1999; 3: 273-275

CASE STUDY

hfluence of infant-walkers on motor development:

Mimicking spastic diplegia?
RAOUL H H ENGELBERT,’ RON VAN EMPELEN,’ NIENKE D SCHEURER,2 PAUL J M HELDERS,’
ONNO VAN NIEUWENHUIZEN2
‘Department of Paediatric Physical Therapy, 2Department of Paediatric Neurology, University Hospital for Children and
Youth, ‘Wilhelmina Children’s Hospital’, Utrecht, The Netherlands

We discuss two patients, who used an infant walker during the period in which they learned to walk. The influence
on qualitative and quantitative motor development is illustrated in this report. A disharmonic and delayed motor
development, contractures of the calf-muscles and motor development mimicking spastic diplegia are considered to
be caused by the early use of infant walkers. As illustrated by the literature, infant walkers do not have any positive
effect on improving motor development. Vulnerability of infants with regards to accidents is increased. In our
opinion, the use of infant-walkers should be discouraged.

Keywords: Motor development. Spastic diplegia. Infant-walkers.

Introduction Case presentations

There is a wide age range in which healthy young Patient one
children achieve normal motor-milestones; 90% of
Dutch children stand with support between 8.1 and Patient one, an ll-month-old boy was referred
16 months of age. Independent walking is observed because of persistent toe-walking and contractures
between 10.7 and 17.6 m0nths.r An infant-walker is of the calf muscles (Fig. 1). Familial predisposition
frequently used in order to stimulate early walking for habitual toe-walking was not present. Preg-
and parents often report the use of infant-walkers nancy was uneventful. At term a caesarean section
as a pleasant, safe and comfortable way to was performed because of fetal malposition.
stimulate walking and the influence of transient Psychomotor development was normal. At the
motor signs induced by the environment has been age of 6 months, when the patient was able to sit
described.2 Infant-walkers have been used since the independently, he was mobilized with an infant
seventeenth century, but after an initial increase in walker for several hours a day. Parents reported
use of infant-walkers in the 197Os, their use is now that he was able to stand on his flat feet at the age
becoming less popular, as in the literature and lay they started using an infant walker. At the age of 8
press an increased risk of injuries such as fractures months, he was able to walk with support on his
of the skull and the upper extremity, burns, and toes after being placed in a standing position.
neurological deficits have been reported.3f4 This At assessment, anthropometrical values were
case report discusses two children, who were within the normal range. We observed an alert
mobilized early by means of infant-walkers and boy with a discrepancy in quality of movement
presented with delayed motor development and between the upper and lower extremities. In
motor development imitating spastic diplegia. the arms and trunk, age-appropriate quality of

Received 27.11.98. Revised 1.4.99. Accepted 7.7.99.

Correspondence: Dr RHH Engelbert, Department of Paediatric Physical Therapy, University Hospital for Chtldren and Youth, ‘Wilhelmina Children’s
Hospital’, PO Box 18009, 3501 CA Utrecht, The Netherlands
email: r.engelbert@wkz.aru.nl

1090-3798/99/03/0273+3 $18.00 0 1999 European Paediatric Neurology Society

274
Fig. 1. Patient one, an 11 -month-old boy, with persistent
toe-walking, structural contractures of the calf muscles and
a discrepancy in quality of movement between upper and
lower extremities, mimicking spastic diplegia, considered
to be caused by the early use of an infant-walker.
Reproduced with the parents’ permission.
movement was observed, whereas in the lower
extremity pathological movement patterns were
seen in adduction and extension of hip- and knee
joint and equinus position of the feet. In the toes we
observed isolated movements and in the feet an
equinus position was found, which remained
present in the relaxed state and during sleep.
Standing on flat feet was therefore impossible.
Muscle tone according to Amiel-Tison was normal
in the arms and increased in the legs.5 Tendon
reflexes of the calf and knee, anal reflex and
sensation appeared to be normal. Radiography of
the feet, ankle joint and tibiae revealed no
abnormalities. Motor development according to
Bayley was age-appropriate, except for a discrep-
ancy between motor skills. He was able to roll over
from prone to supine and back, and also came from
supine to a sitting position, in which buttock
shuffling was observed. He was unable to come
to a standing position, but after being placed in a
standing position, he walked with support. Parents
were advised to withdraw the infant-walker and to
Case study: R H H Engelbert et al.
prevent him from standing and walking with
support. Physical therapy was started, aiming at
correction of the discrepancy in motor skills and
restoration of range of joint motion of the ankle
joint. An ankle-foot orthosis was indicated during
the night.
At the age of 2 years motor development was
normal with age-appropriate quality of movement,
muscle tone and range of motion.
Patient two
Patient two, a 19-month-old boy was referred to
the Department of Paediatric Neurology because of
delayed motor development, abnormal, asymme-
trical crawling and intermittent hypertonia in the
right leg.
Pregnancy and delivery were normal and the
neonatal period was without complications. Famil-
ial predisposition for habitual toe-walking was not
present. Motor development was normal until the
age of 12 months, when he was able to come to a
standing position independently. At this age,
standing with support and side-stepping was
present. He was subsequently mobilized by
means of an infant walker. At examination,
anthropometrical values were within the normal
range and motor assessment revealed an asymme-
try in crawling and buttock-scooting. In the lower
extremities the following abnormal movement
patterns were observed. The hip joint was mainly
placed in adduction and extension with extension
of the knee and equinus position of the feet (right
more than left). Isolated movements in the toes
were observed. ln the upper extremity age-
appropriate quality of movement was observed.
Muscle tone according to Amiel-Tison was
normal in the arms and trunk and increased in
the lower extremity (right more than left, distal
more than proximal). Tendon reflexes of the calf
and knee, anal reflex and sensation appeared to be
normal. The range of joint motion in hip- and knee
joint appeared to be normal and in the feet an
equinus position was found which remained
present in the relaxed state and during sleep.
Standing on flat feet was just possible. Motor
development deviated more than two standard
deviations from the normal population, indicating
a severe retardation. Parents were advised to
withdraw the infant-walker.
At the age of 2 years, motor development was
age-appropriate. Running was possible without
asymmetrical quality of movement. Muscle tone,
muscle strength and range of joint motion were
normal.
Case study: Infant walkers and motor development
Discussion
A delay in motor development may occur when
infant walkers are used more than 1 hour a day.
Thein et al. reported an abnormal or questionable
motor development, with a delay mainly in gross
motor development in 12 of 167 (10.8%) children
who used infant walkers.‘j Crouchman observed a
delay in the development of prone locomotion and
independent sitting in normal babies who spend
more than 2 hours a day in infant walkers and
suggested that excessive use of infant walkers
might alter the pathway of normal locomotor
development.3 Kauffman and Ridenour documen-
ted the influence on quality of walking, using data
from cinematography and electromyography.
was shown that the use of the walker enables an
infant to commit substantial mechanical errors yet
succeed in bipedal locomotion. The infants placed
in walkers had a stiff-legged gait, a leaning forward
of the trunk due to hip flexion, and a decreased
stride length. The infant walker prevented the
infant from practising equilibrium reactions and
protective responses that should be developing
during the first 2 years of life.7 Holm et al. reported
that the gait pattern in children using infant
walkers was similar to spastic diplegia. He also
indicated that the use of infant walkers in children
with cerebral palsy may lead to an increase
abnormal movement patterns in the legs, with
delayed integration of primitive reflexes and
delayed development of equilibrium reactions.*
Besides kinesiological problems in motor devel-
opment, children who frequently use infant
walkers have an increased risk of accidents. In
the USA, infant walkers are used in 70% of the
children between 5 and 12 months of age, of which
3040% had a physical trauma.9 Petridou et al.
reported a peak incidence for accidents between
the 9th and 10th month of age. Falls from the stairs
were the most frequent cause of baby walker
related injuries. lo Besides the occurrence of bruises
and fractures of skull and extremities, children
using infant walkers are also at risk for contracting
burns or scalds.ll As described above, children
who learned to walk with infant walkers seem to
have a propensity for developing contra&u-es,
increased muscle tone, and abnormal posturing of
275
the legs. A neurological course should be ruled out,
as the abnormalities found in children using an
infant walker (hip adduction and extension of the
legs with tiptoeing) may resemble a central motor
neuron dysfunction. A full neurological examina-
tion including the cranial nerves and assessment of
the upper and lower extremities should be carried
out. Special attention should be paid to the
examination of the integrity of spinal functions, to
rule out spinal cord abnormalities such as tethered
cord.
Based on the acquired delay in motor develop-
ment, the aberrations in qualitative motor
performance and the vulnerability to accidents,
the use of infant-walkers should be discouraged in
our opinion.
It
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