Locomotor milestones and babywalkers: cross sectional study
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7352.1494 (Published 22 June 2002) Cite this as: BMJ 2002;324:1494
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EDITOR – In entering the discussion on baby walkers, I would concur
with the reservations of Garrett et al(1) about their use, particularly in
respect of the delayed acquisition of motor milestones. In making an
informed choice about baby walker use, parents need not only evidence for
the occurrence of locomotor delay, but also an explanation of why it
should happen. None of your correspondents to date has addressed this
question. I should like to propose the following hypothesis:-
Fundamental to the achievement of motor milestones in any child is
the development of postural mechanisms of balance. This involves
important trunkal and pelvic stability mechanisms which baby walkers do
not promote. In a ‘stand-in’ baby walker the baby achieves movement by
merely leaning in the direction he/she wants to go while the lower limbs
follow(2). In addition, the baby is held in the upright position, and
therefore prevented from exploring the floor, a further natural step in
infant development.
When taken with the reports indicating an increased risk of
injury(3,4), this means that in my paediatric practice I actively
discourage parents from using a baby walker for their infant. While I am
more ambivalent about the use of baby bouncers which possibly do encourage
weight bearing through the feet, I strongly recommend the ‘push along
truck’ type of baby walker which, with a hand rail at the correct height,
actively encourages trunk control.
Ros Jefferson
Specialist Registrar in Paediatrics
Wexham Park Hospital, Slough SL2 4HL
1. Garrett M, McElroy AM, Staines A. Locommotor milestones and
babywalkers: cross-sectional study. BMJ 2002;324:1494(22 June).
2. Sonksen P, Stiff B. Show me what my friends can see. A developmental
guide for parents of babies with severely impaired sight and their
professional advisors. Institute of Child Health 1991.
3. Coats TJ, Allen M. Baby walker related injuries – a continuing
problem. Arch Emerg Med. 1991;8:52-55
4. Mayr J, Gaisl M, Purtscher K, Noeres H, Schimpl G, Fasching G. Baby
walkers – an underestimated hazard for our children? Eur.J. Pediatr
1994;153:531-4.
Competing interests: No competing interests
We thank those who took the trouble to comment on our report for
their interest. We have two fundamental reservations about baby walker
use. The first is the danger of injury, which is real and substantial (1-
4). The second is our confirmation of the findings of some smaller
studies (5-7), that babywalker use is associated with delayed acquisition
of motor milestones. We should emphasise that there is some evidence to
support the assertion that babies who use walkers have abnormal patterns
of motor development (7,8).
The most important comment concerns the relationship between age at
rolling over and age at standing alone and crawling. Turton, Grueger and
Powls correctly draw attention to this. Due to severe space constraints we
were unable to address this in the published report, however extensive
modelling work was done, and this supports our interpretation of the data.
There is no association at all between age at rolling over and the other
milestones. Specifically, including age at rolling over in our models
strengthens or does not affect the relationship between walker use and the
other developmental outcomes (data not shown).
Gardner and Phillips both ask about confounders. We did not measure
these in our project for reasons of logistics and resources. However there
is little evidence of substantial variation in baby-walker usage by social
class (9).
Misra has slightly misunderstood our results – the delay is almost 4
weeks, not four days. We believe that this is likely to be clinically
significant, although there is no information on the longer term effects
of baby walker usage.
While we agree with Shilkin that baby-walkers can be useful for
babies with severe reflux, this is a relatively rare condition.
Warren’s point about developmental delay is well taken, and we do not
suggest that there is any global developmental delay in these children,
however there is evidence of significant delay in the acquisition of gross
motor skills. We certainly hope that Warren and Sager are right to suggest
that there will be no long-term impact, but no-one knows the long-term
effects.
The issue of parental choice raised by Philips and Warren is
important – we believe that many parents are misinformed about the effect
of babywalker use, and we argue that they should receive accurate
information, and then make a choice. Babies, rather obviously, are not
able to judge risks. Their parents must act as a proxy for them. Parents,
as Davies observes, will be influenced by the fun their child has (10),
but they need to know the downside. The observations of Kumar Patnaik,
Alexander and Davies show the danger of relying on anecdotal experience to
guide hazard assessments. Babies would undoubtedly vote for babywalkers
(11,12). This doesn’t justify using them.
References
1) Kavanagh CA, Bano L. The infant walker. A previously unrecognised
health hazard. Am. J. Dis. Chi. 1982; 136:205-206.
2) Fazen LE, Felizberto PI. Baby Walker Injuries. Pediatrics
1982;70:106-109.
3) Chiaviello CT, Christoph RA, Randall Bond GR. Infant walker-
related injuries: a prospective study of severity and incidence.
Pediatrics 1994;93:974-976.
4) Smith GA, Bowman MJ, Luria JW, Shields BJ. Babywalker-related
injuries continue despite warning labels and public education. Pediatrics
1997:100:E1
5) Crouchman M. The effects of babywalkers on early locomotor
development. Dev Med Child Neurol 1986;28:757-761.
6) Siegel A, Burton R. Effects of babywalkers on early locomotor
development in human infants. Dev. Behav. Pediatr. 1999;20:355-361.
7) Kauffmann I, Ridenour M. Influence of an infant walker on onset
and quality of walking pattern of locomotion: an electromyographic
investigation. Percept Motor Skills 1987;45:1323-1329.
8) Engelbert RHH, van Empelen R, Scheurer ND, Helders PJM, van
Nieuwenhuizen O. Influence of infant-walkers on motor development:
Mimicking spastic diplegia. Eur. J. Paed. Neurol. 1999;3:273-275.
9) Kendrick D, Marsh P Babywalkers: prevalence of use and
relationship with other safety practices. Inj. Prev. 1998;4:295-298.
10) Laffoy M, Fitzpatrick P, Jordan M, Dowdall D. Attitudes to and
use of baby-walkers in Dublin. Inj. Prev. 1995;1:109-111.
11) Gustafson GE. Effects of the ability to locomote on infant’s
social and exploratory behavious: An experimental study. Dev. Psychol.
1984; 20:397-405.
12) Kermoian R, Campso JJ. Locomotor experience: A facilitator of
spatial cognitive development. Chi. Dev. 1988; 59:980-917.
Competing interests: No competing interests
Stairs and babywalkers dont match, but neither do stairs and
crawling/walking baby. Babies need to be supervised anyway.
What about mental effects? Babywalkers give early experience of joy
and fun. It is a good way to pacify an irritated baby. It also is good way
to let a mother take couple of steps back and let the baby take care of
amusement. Why to ban all these positive effects?
Competing interests: No competing interests
Garrett, Mc Elroy and Staines carefully document delayed milestones
in
children who use babywalkers(1). They also note that babywalkers are
known
to increase the risk of injuries in infancy. They go on to conclude that
the use of babywalkers should be discouraged. In doing so they seem to
make
assumptions that are hard to justify. Firstly, they imply that these
delayed milestones actually make a long term difference to the child's
outcome. I would question this. Secondly, they fail to acknowledge that
day to day risk management is a balancing act between a variety of risks,
rather than an isolated consideration of a single risk. (2) They need to
consider the wider picture.
I would draw on my n=2 completely unscientific study of two infant
subjects
using a baby walker. The babywalker gave an 8 month and a 6 month old
child
a level of mobility long before they would have achieved this by crawling
or
walking. I believe that the stimulus they gained from this, for several
months, far outweighs the few weeks delay in the milestones cited. In
terms of risk, babywalkers and stairs are
undoubtedly a perilous mix. I understand that Canada banned babywalkers,
after too many injuries from tumbling down unguarded stairs to
concrete-floored basements(3). As with any other activity, children need
an
appropriate level of parental supervision. However, some risks are
reduced.
The defence of a babywalker has meant that our younger child has often
been
far less vulnerable to the malevolent intentions of her older brother and
the household cat!
In summary, I would challenge Garrett et al's conclusion. I believe
that
the use of babywalkers with appropriate supervision has greatly enhanced
our
childrens' infancies, without detriment to their overall development.
References
(1) Garrett M, McElroy AM & Staines A. Locomotor milestones and
babywalkers: cross sectional study. BMJ 2002; 1494 (22nd June)
(2) Adams J. Do we have enough 'injidents'? British Journal of
General
Practice, 2002, 52, 454-458
(3) Trout G. Personal communication
Competing interests: No competing interests
In their article "Locomotor milestones and babywalkers: cross
sectional study" The authors conclude that locomotor milestones are
delayed in normal term babies who use babywalkers. In their article they
dismiss, without further discussion, the fact that the one locomotor
milestone "rolling over" was also delayed in this group. Their reasoning
being that this milestone overlapped with the introduction of babywalker
use.
Methodologically it is wrong to dismiss such a pre-trial difference
as the authors have chosen to do, especially where this difference (in an
early locomotor milestone) is closely related to their later outcome
measures (later locomotor milestones)
Surely this difference indicates that, far from being a comparable
group to the non-users of babywalkers, babies who subsequently used
babywalkers were already showing evidence of slower locomotor development
before the introduction of babywalkers.
The groups of babies in this study were not randomly assigned to the
use or non-use of a babywalker. It is perfectly plausible that parents may
conciously, or subconciously, be more likely to use a babywalker if they
perceive early milestones to be delayed. They may derive pleasure from
seeing the baby appear to be in a more mature posture like their more
rapidly developing peers.
This difference between the two groups casts doubt on the authors
conclusions that the use of babywalkers delays developmental milestones in
normal term infants. I would suggest that the authors require to perform
a regression analysis using both babywalker use and the age of acheiving
locomotor milestones prior to babywalker use as independant variables.
Only if the use of babywalkers remains predictive of delays in later
milestones within this model will they be able to state their conclusions
with confidence
Competing interests: No competing interests
Had the study by Garrett et al focused on the average elapsed time
between a milestone they concede would not be influenced by the use of
baby walkers (i.e. rolling over) and a milestone which would occur after a
period of baby walker use (i.e. walking alone), they would have shown a
difference of just 0.12 weeks (less than 1 day). Hardly a significant
variation (0.32%) when the average elapsed time between these milestones,
according to the authors' figures is in excess of 37 weeks.
In addition, the contention that a greater amount of babywalker use
causes later walking is also invalid, as the authors appear to be
confusing a correlation with a causal link. A child using a baby walker
is likely to carry on doing so until s/he can walk unaided - hence a child
who walks alone late will be expected to accumulate more hours of use.
Whether this is cause or effect is not addressed by the study - it would
be equally valid to state that late walking causes increased baby walker
use. The authors would need to have looked at the amount of use per day
of use, rather than a total for their conclusions to have any validity.
Competing interests: No competing interests
Editors,
the conclusion - to disapprove the use of baby-walkers - seems not to
be valid for two reasons:
Firstly, there was a significant difference between the two groups
before the walkers were used (with the chidren who were to use walkers
rolling over later than the other group); while this pre-walker delay
corresponds to 13.6% of the life-time (2.86 days out of 21.07), the delay
for standing is only 6% of the life-time, and the delay of walking alone
7.7%.
Secondly, the motivation for parents to use or not to use walkers was
not clarified in these non-randomized groups.
Thus it could even be inferred that parents rightly used walkers if
they felt that their chidren did not develop certain motor skills on time,
and that this intervention improved the motor skills in the long run
(closing gap between the early-roll-overs and the late-roll-overs).
Albert Grueger (Neurologist and father of a 15-month-old ex-walker-
user)
Competing interests: No competing interests
From the table of results, it apparently takes a babywalker user an
average of 3-4 weeks longer to learn to stand alone or walk alone. Would
someone mind telling me why that means we should ban all babywalkers? Does
this sort of delay matter to a baby in the longer term? Does any harm come
to these babies who make these milestones a little later? I think not.
Competing interests: No competing interests
EDITOR- I read with interst the paper by Garrett et al which stated
that Babywalkers are detrimental to the development of young children. As
the parent of a 16-month old child who used a babywalker and has just
started to walk I was initially concerned. However, their results showed
only a 3 week delay in standing and walking.
Every Healthcare Professional who has been involved in the care of my
son has stressed how there is no benefit in comparing his development
against that of other children and that "Milstones" are not gold
standards. Why is it then that we should now place such emphasis on this 3
week difference and ban all Babywalkers?
I am sure that most people who have seen the enjoyment on children's
faces as they roll around the house will need a lot more convincing. I
would certainly allow any future child of mine to use a babywalker as much
as he liked.
Competing interests: No competing interests
Other factors deciding walker use
This response to the article is very late (by several years) but I
still wanted to write for parents who may be influenced by the findings.
Although I am now a stay at home mother with small children, previously I
worked in fields using my Psych degree and other post grad training, and
statistics training.
Both my children (now 2.5 yr and almost 1) have used a variation on
a walker - without wheels, but that they could move around. Its main
feature is that they can bounce it, but they could also push with their
feet to cross the room. I assume that it has less mobility than a walker,
as it does not continue to push after they have stopped - the wheels
don't encourage movement.
I have used it for only short periods each day - generally when I
have breakfast and get his/her breakfast, and when I have an evening
shower (I put it in the bathroom). Occasionally I have used it other
times. It has kept my babies happy so that I could get things done.
Note that I don't leave my baby in it for hours on end. It is a safe
place for him to be (while I can see him the whole time) so that things
can get done.
My older baby didn't start walking until well after her first
birthday, but now, one year later, she is running, skipping and dancing as
well as anyone. The almost one year old is getting quite mobile
already - a lot earlier.
I am very careful to keep all stairs blocked, electrical cords out of
the way, saucepan handles turned back, etc. My baby is actually safer in
the walker/bouncer, as he is less likely to start openning kitchen
drawers or to open an outside door, or to crawl into small, hard to get at
places. He also can't pick up small things off the floor that my toddler
has left there.
The benefits of this wheel-less walker far outweigh any hazards, for
someone who is careful. I don't know how I would have survived without
one for the past few years.
When this one temporarily broke, I looked for a replacement but
couldn't find the same bouncing mechanism. Is this because of the
current wave to ban anything resembling a walker? If so, this is to the
detrement of babies and their mums who have to survive in the real world.
I would certainly not encourage the ban of these products, but would
support education around using them, and safety modifications - even to
limit mobility entirely as long as the baby could bounce!
Competing interests:
None declared
Competing interests: No competing interests