Hi Reader
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Dad Joke: How many apples grow on a tree? All of them!
Every day is a school day! This week I saw a 5-month-old baby who reminded me how easy it is to fall into pattern recognition.
Mum explained that her baby liked to hold herself in an extended position and immediately, my brain went where many of ours probably would.
This is a dural tension/ fascial tension case. The next few minutes would really just be going through the motions. I started to line up my questions, mentally building the usual picture.
Deep front line involvement. Dural tension. Poor flexion patterns. Core organisation issues. Maybe feeding difficulties. Maybe reflux. Flattening through the skull somewhere. Poor tummy time tolerance. The classic extension-dominant baby picture we see so often.
And as soon as I began…the case started breaking the rules.
Tummy time was actually excellent. Feeding was largely fine. No reflux picture. No significant flattening of the skull. No obvious asymmetry. No real sense that this was the mechanically compressed / fascially dominant baby we so often associate with extension patterns.
After a few minutes of me swinging and missing, Mum said (I think out of pity at this stage) “let me just show you her party trick and then you can see for yourself”. And with that she hoisted her child out of the car seat and lifted her up into a vertical suspension position…
To say that this baby went into extension would be an understatement. And not just a little bit stiff either…I’m talking full surfboard. Head back, trunk extension, even the elbows locking out. Her whole body seemed to be captured by extension the moment she was lifted.
If we are not careful, once we see one visible pattern, we subconsciously fill in the rest of the neurological story ourselves. We see extension and assume we already know the mechanism behind it.
But babies do not read our seminar notes.
So, with the history not making sense and her exhibiting phenomenal tummy time, instead of staying attached to my first interpretation, I changed the question I was asking. Rather than asking what fascial or postural system was driving the extension, I started asking whether this looked more reflexive than mechanical.
So, I placed her into horizontal suspension and gently brought the head into flexion. The extension disappeared almost immediately and that changed the entire direction of the examination for me.
I went back and looked much more carefully at the spinal medullary reflexes. Grasp, Rooting, Sucking and Galant were all still very active. Not subtle. Not fading into the background. Very much present for a 5-month-old baby.
These early reflexes are brainstem-mediated, automatic responses that are expected to be present in early infancy and then become increasingly inhibited as cortical control and voluntary movement mature. So, when several of them are still very strongly present around 5 months, it gives us a useful clue that the extension pattern may be more about immature reflex organisation than simply a dural or fascial tension pattern.¹
At that point, the picture started making much more sense.
Instead of seeing her as a run of the mill “extensor baby” with a deep front line or dural tension pattern, I started seeing the extension as part of a broader immature reflex organisation picture. The TLR backwards response also became much clearer once I looked at it through that lens.
After working around the more primitive spinal reflex activity and reassessing her in ventral suspension, the extension response through the TLR pattern had already started to diminish. Not perfectly. Nowhere near completely integrated. But noticeably different.
And honestly, that was the real lesson from the case. Not all extensor babies are dural fascial tension babies. Don’t get me wrong…loads absolutely are. Many babies with strong extension dominance do present with flattening, feeding struggles, reflux patterns, poor flexion control and obvious signs of mechanical tension through the system. Those patterns are real and clinically useful.
But not every extension pattern comes from the same neurological pathway.
Sometimes the driver is more reflexive than mechanical. Sometimes the visible posture is simply the nervous system’s output rather than the primary issue itself.
I think one of the dangers in paediatrics is that once we learn a useful pattern, we start seeing that same pattern everywhere. “I have a hammer so…everything must a nail” syndrome. But…babies have a wonderful way of humbling us if we keep observing carefully enough.
This case was a good reminder for me that extension is not a diagnosis. It’s a strategy. And very different nervous systems can arrive at the same visible strategy through completely different routes.
Chat soon,
Mike
Reference
1. Modrell AK, Tadi P. Primitive Reflexes. StatPearls Publishing; 2023. Available from NCBI Bookshelf. NCBI Bookshelf – Primitive Reflexes
