Hi Reader

Dad Joke: How do you make an octopus laugh? With ten-tickles!

A mum said something to me recently that I suspect every paediatric practitioner has heard hundreds of times.

“He’s fine though, isn’t he?”

Her three-month-old was lying happily on my beanbag baby chair, smiling up at us. He was feeding well, gaining weight, sleeping reasonably, interacting beautifully and there was nothing particularly worrying in his history. If you bumped into this family in shops you wouldn’t be thinking there was anything “wrong” with this baby.

And she was right. He was fine. The problem was…the assessment wasn’t.

I had been working through our three-month observations that we teach on Connected Paediatrics and there were a few things that weren’t organising quite as well as I would have liked. Nothing dramatic. No big flashy red lights or anything. Just a couple of asymmetries and movement strategies that made me stop and look twice.

And that made me think…what do we do with information like this…when the child, is to all other intents and purposes fine, but the function is shaky?

Because we have two basic options. We can turn every small finding into a problem, frighten the absolute daylights out of the parents and start predicting all sorts of things that may never happen…Or we can shrug our shoulders, say “he seems happy enough” and wait until something becomes obvious enough that they come back in again.

I don’t particularly like either option…and I don’t think you would either. But what if there is a third option...a sneaky choice behind door number three?

What about: “The absence of a problem is not necessarily the same thing as the presence of good function”. That sounds a bit pedantic, but I think it matters in paediatric practice.

A child can be pain-free, happy, growing and hitting milestones while still showing little clues and tid-bits about how they are organising themselves. One side might be doing more work. Rotation might be easier in one direction. They might be able to get into the position we are looking for, but using a slightly strange, suboptimal strategy to get there.

None of this means we have found a diagnosis. Nor does it mean he is on some inevitable path towards one. It is just information…a marker. I think we sometimes underestimate how useful that middle ground can be. We are used to thinking in absolute terms. Problem or no problem. Normal or abnormal. Treat or discharge. But development is much messier than that I think.

Imagine taking a reasonably good young swimmer to a swimming coach. She can swim. She’s not drowning hazard and she can get from one end of the pool to the other, it may look a bit funky but hey, a length is a length. The coach doesn’t stand at the side of the pool and say, “Well, you’re making it to the other end, so there is nothing for me to do.” They break it down, they look at the stroke. They look at how her shoulder enters the water, how the trunk rotates, how well she catches the water, what the kick is doing and whether one side is working harder than the other.

Why does he do this, she’s fine…right?

Because the goal isn’t just to prove that she can swim. It is to get the best possible function out of her system. Coach isn’t waiting around until she starts coming stone last in her races before he becomes interested in her form!!!

That is the bit I think we can borrow in paediatrics. My little three-month-old wasn’t losing a race...yet. But I had the chance to look at his “stroke form”. How was he organising against gravity? Was one side doing more of the work? Did he have enough movement options? Was he using an efficient strategy or finding a workaround that happens to get the job done?

And markers here don’t make him broken any more than correcting a swimmer’s stroke means the swimmer couldn’t swim. It means I was interested in his function, not only his failure. And maybe that is where we need to change our thinking as paediatric practitioners. Maybe we have become a little bit too comfortable waiting for the symptom, the delay, the obvious asymmetry or eventually the diagnosis before we feel justified in becoming interested.

But a coach works further upstream than that. They look at what the athlete is doing now and ask whether the strategy is giving them the best options for what they are going to ask of that body next. Development gives us the same opportunity.

The demands on this three-month-old are about to change enormously. Rolling, loading through the arms, sitting, transitions and eventually standing are all coming. The small marker we see today might disappear as those new skills emerge. Fantastic. Or perhaps, when the next developmental demand arrives, we see that same strategy again. Now we have learned something. Not because we predicted a diagnosis. Not because the child was secretly unwell. But because we watched the form as the task became harder.

And perhaps that is a better way of explaining what we are doing to that mum. Her baby is fine. But I am not waiting for him to “lose the race” before I become interested. For now I am just watching how he is swimming.

Chat soon

Mike

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Connected Paediatrics – Dr Mike Marinus is a registered paediatric chiropractor treating babies and children and helping chiropractors learn effective paediatric techniques that they can use in their practice