My baby feels like a slippery little noodle!!

I always found this term strange when they were explaining low muscle tone to us at uni - but after 15 years of experience as a paediatric physio, I think I can safely say it’s often quite true. For the most part, I can tell if a baby has low muscle tone (or hypotonia) the minute I pick them up. They seriously do feel like a little wet slippery noodle!

They’re the babies that make you feel like you need to have ‘octopus arms’ to hold them upright. The ones that feel like they could slip through your fingers. Does that sound familiar? Is your baby a bit spaghetti-ish? It might be why you’re reading this blog?

When we refer to muscle tone, we are referring to the amount of resting tension (or resistance to movement) in muscles. In my head, I like to think of it as to how ‘alert’ a muscle is - how ‘ready’ it is to spring into action.

Low muscle tone (or hypotonia) may be caused by problems with the nerves or the muscles. Sometimes it is caused by a combination of the two. Sometimes the low muscle tone is a ‘symptom’ of another condition. Often the low muscle tone is idiopathic, which means the cause is unknown.

Hypotonic muscles take longer to ‘fire up’. I describe them as ‘sleepy’ muscles sometimes. They’re often referred to as ‘floppy muscles’. Children with hypotonic muscles need to generate more effort to get their muscles to spring into action, and hence have more difficulty not only with propulsive activities such as running and jumping, but also just simply with maintaining an upright posture when sitting or standing.

Hypotonic muscles have the ability to get stronger with training

True ‘hypotonic’ kids are often your floppy, kinda tired-looking kids in the classroom. The ones that wrap their legs around the chair legs to help keep themselves upright.

But make no mistake.

Low muscle tone is not the same as muscle weakness

(though the low muscle tone can potentially cause a muscle to become weaker over time, a hypotonic muscle still has the ability to get stronger with training, it might just take a little longer to get there than the average muscle.)

And most importantly, if a child has low muscle tone they are certainly not ‘lazy’

These kids are literally unable to generate the force through their muscles as quickly as a child with typical muscle tone. This makes some movements and postures quite difficult for them. So they sink into ‘resting’ positions more often than usual. Like wrapping their legs around chair legs. Or playing while laying on their side on the floor….which might get mistaken for being lazy….

In a baby hypotonia might present as:

Difficulty holding or carrying them i.e ‘the wet noodle’ effect mentioned above
Difficulty with sucking and swallowing and hence feeding
Difficulty tolerating tummy time
A head lag that persists after 4 months of age
Skipping the crawling phase and moving to bottom shuffling or very splayed hips and an arched or ‘sway’ back when attempting to crawl.
A delay in gross motor milestones such as rolling, sitting, pulling to stand and walking

In an older children it might present as:

Frequent w-sitting or even frequently wanting to lie down on their side on the floor to play
Clumsy or uncoordinated walking or running
‘Slapping’ feet or very ‘loud and stompy’ walking. (‘You can hear her coming a mile away’ is something I hear often).
Frequent trips and falls
Poor endurance with walking, or physical activity in general
Difficulty (and delays) with more propulsive activities such as jumping, hopping, skipping etc
Difficulty with activities requiring upper body strength such as monkey bars or gymnastics
Fatigue in maintaining upright postures in sitting and standing (particularly evident in a classroom setting)
Difficulty with concentration in a classroom setting due to above

As always, it is important to look at the wider pattern of development in a child before we jump to conclusions on the emphasis we put on a child’s muscle tone.

Hypotonia is a term that gets thrown around a lot in the paediatric physio world. I think sometimes a little too loosely. It kinda gets all the blame for many a child’s delayed development. And for sure, it can be a culprit. But there is a spectrum of hypotonia, just as there is with most paediatric conditions.

Your child who displays any of the above symptoms may lie anywhere from what we refer to as “low-normal tone”, to “low-abnormal tone”. The spectrum goes further than this too: there are also babies with boring old “normal tone”, “high-normal tone” and “high-abnormal tone”.

Confused? I’ll try and explain this a little better.

A child may display some signs of hypotonia (e.g splayed hips and a sway back when crawling) but is able to ‘overcome’ this lower tone and still manages be in the typical age-range for their gross motor development.

They are still hitting their milestones as we would expect (perhaps on the end of normal age range, but they’re doing fine developmentally in a broader sense). This child would then be referred to as having “low-normal” muscle tone. These guys just need to be monitored over time.

If this same child was really struggling with other aspects of their development such as playing with age appropriate toys, had feeding or swallowing difficulties, was not in the typical age range for crawling, rolling etc etc, (i.e they were not able to overcome their hypotonia) then they would be considered to have “low-abnormal” muscle tone.

To make it even more confusing, children can be affected in different areas of their body more than others. Babies and toddlers with low oro-facial tone (low tone in the face and mouth muscles) can present with difficulties with latching, sucking, feeding, drooling and even speech and language delay. But they might be doing okay in the gross motor department. Or they may need some help in that department too. Every child with hypotonia presents so differently.

If you are concerned about your child's muscle tone or movement, it is important you see your local paediatric physio, maternal and child health nurse or GP.

You may be referred to a paediatrician, who will examine and investigate for any possible underlying causes of the low muscle tone. And an occupational therapist, physiotherapist or speech and language pathologist may also become involved, to advise on treatment and activities to help improve your child's movement patterns, strength, fine motor tasks, feeding or speech.

Here are some of my favourite physio tricks to help a child with hypotonia:

Upright games such as jumping are great exercises for children with hypotonia to help wake up their muscles

Get them UPRIGHT first.

Standing games (and even climbing or jumping or running around for an older child), before a seated or fine motor activity is so important for children with hypotonia. It fires the muscles up. It’s an excellent activity to do before starting a therapy session, or even before going into the classroom.
Got maths coming up? Go and climb on the playground for 5 minutes first! (It’s one of the many reasons why it’s so important that children are active during their break times at school).
Getting a child under 12 months to stand before practicing crawling and sitting activities (something I would not normally do with a typically developing baby)
For a baby with hypotonia, just getting them to sit on a parents knee while they’re rocked side to side and singing some action songs can help marvellously in getting the trunk active and ‘preparing’ the body for the next movement pattern.

Footwear

I know I always bang on about ‘bare feet is best’, and for the most part this is true, but I must stress the importance of good footwear for kids with hypotonia, and especially so for children with combined joint hypermobilty. Core stability is the core of what we do, but our feet are our foundation. And children with hypotonia and hypermobility need a good solid foundation.
There are loads of orthopaedic footwear options around, but as always, its best to get assessed by a paediatric physiotherapists or podiatrist first, before you go spending the big bucks.

Specific exercise

We physios are pretty great at prescribing exercises specific to a condition. Children with ‘low-abnormal’ muscle tone need a targeted approach to assist with muscle activation, strengthening and endurance.
My entire 10-step program My Strong Little Body is perfect for a baby diagnosed with hypotonia. It is these babies I had in mind when I was writing it.
And as for the older kids….a good start would be to check out my recent blog post on ’10 simple ways to improve your child’s core strength’. Because core stability is the core of everything we physios do. (Get it?).

A true diagnosis of hypotonia is one that needs to be taken seriously, especially if it is a symptom of another diagnosed condition. But the low muscle tone itself is just a small part of the puzzle.

Movement and the development of ‘learning to move’, is so multi-layered. Movement (and gross motor development) involves the brain, the muscles, and a child’s ability to know where their body is in space. It involves such a complex network of systems (including kid’s personalities!) that we can’t possibly narrow a child’s difficulties down to this one element of ‘low muscle tone’.

If your baby gets a diagnosis of ‘hypotonia’ , try not to get too worried. Check in with your local paediatric physio and let them guide you through it.

The good news is, that regardless of the reason why a child has gross motor delays, thankfully, there are so many strategies to assist these kids to live very normal lives.

Love Alana xxx

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hypotonia. The slippery noodle phenomenon.