Overcoming Hypotonia in Down Syndrome

There are numerous factors that causes gross motor delay in Down Syndrome. Hypotonia and ligamentous laxity due to the abnormal collagen content causes movement to be effortful, resulting in delay in achievement of a motor skill. Attached is the power point presentation done for Down Syndrome Association Singapore to empower parents on what can be done and treatments available to help these children to maximise their gross motor potential.


Categories: Down Syndrome

How to choose backpack for your child

  1. How does carrying heavy bags hurt children’s backs? What are some common complaints? Are children more susceptible to back injuries?

Carrying heavy bags can cause shoulder and back pain in children. A heavy backpack, when used incorrectly, can pull the child backwards. The child will have to use compensatory strategies of either sticking the neck forward with a rounded shoulder and/or tightening the back muscles to maintain his/her balance.

Overtime, this poor posture can cause tightening of the shoulder and chest muscles, weakening of essential neck and shoulder stabilizer muscles and tightening of the lower back. This uneven development of the shoulder and chest muscles results in what medically known as the upper cross syndrome. In addition, prolong carrying of heavy backpack, especially those with tight and narrow strap, causes reduction in blood circulation, which can lead to numbness, tingling sensation and weakness of the arms and hands.

The muscle imbalances make it difficult to self-correct the poor posture, causing excessive strain of the shoulder and neck, leading to pain. This condition is not exclusive to children. Adults get it too, mainly due to prolong sitting due to a deskbound job.

Shoulder aches and low back pain are 2 common complaints in children as a result of poor posture.
Children are actually less susceptible to back injuries compared to adults, as children are more flexible and it takes a longer period for muscles and joints to ‘stiffen up’ compared to adults. However, as children weigh less, it is easier to overload their body with a relatively light backpack. For instance, a 3kg backpack may be acceptable to a child who weighs 30kg but may be too heavy to a child who weighs 25kg.

2. Do heavy backpacks stunt children’s growth?

There is no evidence to show that heavy backpacks can stunt children’s growth.

3. Does carrying ergonomic bags help? Would you recommend it? What are some guidelines for children to ensure that back stays injury-free?

Carry ergonomic bags do help, if used correctly. Ergonomic bag helps to distribute the weight of the backpack evenly onto the shoulders and back, hence reducing a focal point of pressure buildup. As the load is more evenly distributed over the shoulder and pelvis, the child need not bend forward and hence is able to maintain a good posture.

General guidelines on backpack:

  • Accordingly to American Academy of Pediatrics, loaded backpack should not exceed 10-20% of body weight. Hence, purchase a backpack made of light and durable material. Carry essential materials required for the day and not the whole week’s worth.
  • The back should be padded so items such as pens will not poke out of the bag, which may injure the child if he/she falls. Padded back also increase the comfort.
  • Use both straps of the backpack instead of just using one. Using one strap may look ‘cool’ but it can put too much weight on one side of the body, resulting in uneven strain on the shoulder and back.
  • The straps should be wide in order to distribute the backpack’s weight over a bigger area
  • The straps should be well padded so that it does not impede blood circulation around the shoulders and arms.
  • It should preferably come with a waist belt to help distribute the backpack weight to the pelvis, off loading the shoulders.
  • Backpack should come in multiple compartments, to help distribute load evenly. Pack heavier items near the centre of the back.
  • Pick up the backpack by bending at the knees, and not at the waist.
  • A trolley bag may help children off load their shoulder; however, it may not be practical. Lugging the trolley bag up and down staircase and kerbs pose as a fall hazard to the child and others around him.
Disclaimer: The information and advice contained in or made available through this website is for educational purposes only and is not intended to replace the services of a health professional or to be a substitute for medical advice of physicians.

Red Flags in Gross Motor development from 0-5 years old

Red Flags in Gross Motor development from 0-5 years

Development of gross motor skills in children follows a similar pattern. For instance, a child should be able to roll by 6 months and walk independently by 18 months. If parents notice that their child is still not reaching the appropriate milestone, it is a warning sign, or red flag, and the child should be brought to medical attention. The delay in milestone may signify something ominous and bringing the child to medical attention early ensures no child gets left behind.

Early intervention for children is essential once a condition is suspected or diagnosed. The child’s brain is still developing hence it is the best time to teach a skill or to change a behavior. Late diagnosis or parents’ denial in a condition may result in late intervention, which will prevent the child from reaching his/her maximum potential due to a smaller window to teach skills or create changes.

The table below shows the red flags, or warning signs of delayed gross motor development, with reference to the Queensland Government Early Intervention Referral Guide for Children 0-5 Years. If your child shows any signs of delayed stated in the table, it is highly recommended to bring your child to medical attention or to paediatric physiotherapist where a full gross motor developmental assessment can be carry out.

Age Red Flags Red Flags at any age
6 months
  • Not rolling
  • Not holding head and shoulders up when on their tummy
  • Not achieving indicated developmental milestones
  • Strong parental concerns
  • Significant loss of skills
  • Lack of response to sound or visual stimuli
  • Poor interaction with adults or other children
  • Difference between right and left sides of body in strength, movement or tone
  • Loose and floppy movements (low tone) or stiff and tense (high tone)


9 months
  • Not sitting without support
  • Not moving eg creeping or crawling motion
  • Does not take weight well on legs when held by an adult
12 months
  • Not crawling or bottom shuffling
  • Not pulling to stand
  • Not standing holding on to furniture
18 months
  • Not attempting to walk without support
  • Not standing alone
2 years
  • Unable to run
  • Unable to use stair holding on
  • Unable to throw a ball
3 years
  • Not running well
  • Cannot walk up and down stairs
  • Cannot kick a ball
  • Cannot jump with 2 feet together
4 years
  • Cannot pedal a tricycle
  • Cannot catch, throw or kick a ball
  • Cannot balance well standing on 1 leg
5 years
  • Awkward when walking, running, climbing stairs
  • Ball skills are very different from peers
  • Unable to hop 5 times on each foot
Disclaimer: The information and advice contained in or made available through this website is for educational purposes only and is not intended to replace the services of a health professional or to be a substitute for medical advice of physicians.

1. Queensland Health,  Queensland Government Early Intervention Referral Guide for Children 0-5 Years, http://www.health.qld.gov.au

Cycling for Kids

Cycling is a life skill that will not be forgotten once mastered. It is an advance motor skill that involves the integration of several motor skills, such as balance, left-right, hand-eye and leg-eye coordination. Repeated practice reinforces these skills to form a ‘cycling program’ which is stored in the brain, and to be retrieved when required. That is why some skill, such as swimming and cycling, will ‘never’ be forgotten.

A child can be introduced to his first bike as early as 2 years of age. This is the age where the child is perfecting basic motor skills and combining them together to accomplish complicated motor task. To learn cycling, this complex task is broken down into basic components during the initial stages, such as balancing, pedaling and steering. As the child gets better at the individual motor skill,  they are combined together. Through trial and error with repeated failure, adjustment and perfecting of motor skills, the child will finally be able to ride a bicycle on ‘auto-pilot’ mode.

Transition from a tricycle to a bicycle can be difficult. In fact, some people never achieve it. There are some suggestions to make transition easier from a tricycle to a bicycle. These include elevating the training wheels further from the ground such that the child will learn to balance on 2 wheels of the bike momentarily without tipping over. Another method, (in my opinion) which is more fun and successful, is to introduce the child to kids training bike as their very first bike. Kids training bike is a kid size bicycle without pedals. Some manufactures do have models of different levels of difficulty (from broader wheels with increased stability, to thin wheels which demands high level of balance skill). Below is a video on how these kids training bike works. The ‘fun’ factor of these training bikes is important on reinforcing practice. With the balance skill conquered, learning how to pedal is usually a breeze (wearing of safety gear applies when the child is on the training bike).





There are also toys in the market to help a child learn how to pedal. Stationary bike is a great tool to teach a child how to pedal, without the need for parent to manually guide the pedal and chasing after a moving bike at the same time (which can cause serious strain on the parent’s back!). It is especially great for child with coordination problem who need to learn the pedaling component and balance component separately. The stationary bike is also great for children who need to shed some weight, to improve cardiovascular health and fitness.





Cycling is a great life skill to master. With the aid of new products such as training bikes, learning how to cycle will be much easier for the parent and child.





Disclaimer: The information and advice contained in or made available through this website is for educational purposes only and is not intended to replace the services of a health professional or to be a substitute for medical advice of physicians.

Gross Motor Milestone (12-18months)

At 12 months

At 12 months, your child may take his very first independent step.  Independent walking is a very important milestone. It represents a new phase of the child’s development, being independent from caregiver and able to explore new things on his own that used to be out of reach. With the new found skill, he will be a more confident baby. He will be constantly challenging his walking and balance skills on different terrians and falling occasionally. It is definitely alright to fall, as no baby can learn how to walk without falling.

As walking balance improves, your child will be able to multitask. He will be able to walk and hold his favourite toy at the same time. He will also be learning to lower himself from standing into sitting position with increasing control.

At 18 months

Your child has been perfecting the basic gross motor skills for the past 18 months and is now ready for more advance skills. He will be able to climb up the staircase with assistance, a step at a time. He will be able to kick a ball in standing, although with a poor sense of direction. He will be able to walk fast, and attempting to run. This is the age that you can introduce your child to a tricycle, or a balance bike.

18 months is usually considered the cut off month for a child learning to walk independently. If your child is still not walking independently at this stage, you may want to seek an expert opinion on your child’s motor development.

  • Gross Motor Milestone Brochure

Disclaimer: The information and advice contained in or made available through this website is for educational purposes only and is not intended to replace the services of a health professional or to be a substitute for medical advice of physicians.

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Gross Motor Milestone (7-12 months)

7 months old

Sitting balance is improving. The child will be able to sit momentarily without arm support. In prone, the trunk extensors and upper limbs are strong enough to allow child to push his chest off the floor. He will be able to reach for objects with one hand, while supporting the weight of the upper body with the other.

9 months old

By 9 months old, the child will be able to sit independently on the floor for about 10 minutes or longer. Trunk control developed over months of practice enabled the child to reach for toys in sitting without toppling over. The baby will find transiting from lying to sitting a breeze. There will be repeated failed attempts to pull himself to standing. At this stage, the child may start to crawl, although some children do skip this milestone.

12 months old

Pulling furniture to standing and crawling are no longer a problem for a 12-month-old child. Other alternate ways to move around are by bottom shuffle or bear walk. The child will be perfecting his walking skills at this age. He will be able to walk with one handhold. The base of support may be large due to poor hip strength and balance. However, as the child practices, walking will be faster and steadier. This is the stage that parents will not want to miss as the child may initiate their first independent step at any moment.

– 7-12 months Gross motor milestone pamphlet

Disclaimer: The information and advice contained in or made available through this website is for educational purposes only and is not intended to replace the services of a health professional or to be a substitute for medical advice of physicians.
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