My Child is not walking at 18 months: Is this Normal?!
Welcome back to yet another blog on a very common child neurology question which I get asked frequently from parents. For starters, not every child is alike and they all do stuff at their own time and pace. Secondly, the last time I checked babies do not read child neurology books, therefore they don’t follow what’s written in them too!!
Having said that, when a baby does not walk by 18 months of age, it raises concern as it is classified as a motor delay. So to understand what motor delay is, one must know a few basic aspects of normal motor development in babies and toddlers.
Babies usually start sitting by 8-9 months of age, crawling around 9-10 months, pulling up to stand by 12 months, and independently walking by 18 months. If a baby is not walking by a year-and-a-half it is delayed walking and warrants a pediatric neurologist’s input. Children who have motor skills delay can also have delays in other modalities like fine motor skills, speech, and language, cognition, etc, but for the purposes of the blog, I will stick with delay in walking alone.
What are the common causes of delay in walking?
The possible causes of delayed walking in childhood is as long as my arm (and I am seriously tall!), so I will not go into the rare causes but focus on the common ones. Moreover, the purpose of this write-up is to raise awareness amongst parents to bring their child to the attention of doctors if the baby is not walking by 18 months, and not to make them pediatric neurologists!!
So, the baby could be late in walking if someone in the family or one of the parents walked late, also called “Familial delay”. In my experience, the baby’s other milestones in this case are usually age appropriate. Some babies might “bum shuffle” for a long time before they start taking their first independent steps. Some babies “appear” to walk late because they have born prematurely and yet not reached the “corrected age” of walking. These are the less and not worrying common reasons and I usually just reassure the families and keep a close watch over them with regular follow-ups.
Now let’s have a look at some of the other reasons that the baby may walk late which need urgent attention.
- Motor Coordination Disorder: Or Developmental co-ordination disorder(DCD), also used to be known as dyspraxia, is a condition affecting physical co-ordination. In this disorder the children are described as “clumsy” and it affects boys more commonly than girls. It may run in families and the children usually have fine motor difficulties as well e.g. hand writing, drawing skills, etc.
- Cerebral Palsy: CP is a disorder in which quite a significant proportion of children walk late. I wrote a blog about Cerebral Palsy in children earlier for parents explaining what it means in simple terms. Children with CP need a regular multidisciplinary approach with Pediatric Neurologist, Physiotherapist, Occupational therapist and the cumulative work helps them to achieve motor skills depending on the degree of severity of Cerebral Palsy.
- Duchenne Muscular Dystrophy: DMD is a genetic muscular disorder which is seen in boys (girls can be affected carriers rarely) which needs to be diagnosed as soon as possible. The boys usually walk late in this disorder and on occasions walk on tip-toes. If you are interested in reading about tip-toe walking in children and its causes, feel free. DMD also needs a multi disciplinary approach and the good news is that for certain genetic mutations in DMD, FDA has recently approved medication for treatment.
- Other causes: Sometimes low thyroid levels (hypothyroidism), chromosomal disorders and genetic disorders can also cause delayed walking amongst other causes.
What does a Pediatric Neurologist do in such a situation?
Well like all other times, I have to take a detailed history and carry out a complete neurological examination which gives clues to the reasons for delayed walking in children. Once we have done that the child may need investigations like blood tests, particularly the muscle enzyme CK, and on occasions more extensive tests like MRI scan of the brain and spinal cord. The child may also undergo highly specialized tests like Nerve Conduction Study and Needle EMG to look at the function of nerves and muscle. This should ideally be done by a pediatric neurologist who is trained specifically to do these tests. If the history is conclusive of a genetic or hereditary disorder, I also carry out blood tests to look for genetic conditions.
How do you manage delayed walking in children?
Children with delay in walking need Multi-disciplinary approach with multiple teams working towards set goals which keep moving once the child achieves a set goal. The physiotherapists play an important role in this and wherever possible the child should be seen by a specialized pediatric physiotherapist. The children may also needs splints to the feet to help them to ambulate and some children may need extra support like a walker.
If the child has a condition which can be treated or helped with medications, then the child may need hospital admission to undergo the treatment to improve his/her muscle tightness, e.g Botox injections to the muscles.
The children need regular follow ups to ensure that the hard work put in my parents and medical team is constantly under review to avoid any fallbacks.
If you have or know a child who is not walking as age appropriate, please feel free to drop a line at firstname.lastname@example.org