Last updated on Feb 8th, 2021 at 05:20 pm

If your child seems to trip over his own feet, slouches, leans or lies down while playing, he may have low muscle tone, also known as hypotonia. More severe cases are usually picked up by a paediatrician, if your child is not meeting certain milestones like sitting, crawling and walking, but less severe cases can go unnoticed and untreated. This can lead to discomfort and frustration for the child – especially when he struggles to sit at school for longer periods.

ALSO SEE: 9 essential baby milestones your little one should reach

Hypotonia defined

“Muscle tone is the readiness of a muscle to move,” explains Liz Senior, occupational therapist and founder of Clamber Club. “It is genetic and can’t be changed, so the muscle tone you are born with is what you will have for the rest of your life,” she explains.

“Muscle tone can be defined as the amount of continuous contraction of a muscle at rest,” explains Claire Malone, a physiotherapist working in the UK. “Muscles require a certain amount of contraction at all times in order to maintain structure and function. If there wasn’t a degree of contraction, our bodies would become floppy and distorted when we slept, due to gravity.”
She says it’s also important for parents to know there is a difference between muscle tone and strength. “Although the two are related, tone relates to resistance to passive movements and strength relates to the ability to perform active movements.”

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Understanding a diagnosis

In a paper published in African Journal of Disability, the author states: “Clinical assessment of hypotonia is challenging due to the subjective nature of the initial clinical evaluation,” and that “the presentation of hypotonia can be either a non-threatening or malevolent sign.”

“Hypotonia itself is an easily recognisable condition, but determining the disorder causing the low tone is often difficult,” explains Claire. Low muscle tone can’t be viewed in isolation as it is always caused by an underlying condition, which could range from hypermobility of the joint and treated through strength and stability exercises to more serious congenital and genetic disorders that will require medical intervention, such as cerebral palsy, meningitis, muscular dystrophy or spina bifida. A February 2012 memo from Johns Hopkins Medical Center urged paediatricians to screen all babies for vitamin D and calcium deficiencies and stated that this relatively easy issue to correct could be an underlying cause for the number of children presenting with low muscle tone, as vitamin D is involved in the absorption of calcium. “Much of our lifelong health is pre-programmed in childhood, and many adult diseases are rooted in exposures, lifestyle and diet during the first decade of life, experts say. Vitamin D, or lack of it, is a classic example,” wrote the authors.
“For differential diagnosis, your doctor may request further investigations such as an MRI, a CT scan, blood tests or genetic testing,” explains Claire.

ALSO SEE: What you need to know about vitamin D deficiency

Spotting the signs

“When my son was two years old, his nursery school teacher mentioned in our first parent/teacher conference that he has low tone. I was shocked by the suggestion, because our paediatrician and doctor hadn’t mentioned anything,” says Rebecca Todes, mom of Blaine (2).
“I was worried about what this meant for my child and had little understanding of the implications,”
says Rebecca. Blaine’s teacher was the first to pick up his low muscle tone, because he struggled to sit still during morning ring and often ended up slouching or lying down by the end of it. His speech was also slightly behind that of his peers and he would run in an awkward way – often from his hips – if he was overly excited.
“Once I started researching, things began to fall into place. Blaine did drool excessively when he was a baby and crawled slightly late at 10 months. We didn’t think anything of it because he started walking soon after at around 12 months.”

Liz says the implications of low tone can include your child avoiding socialising and playground activities that require physical strength, fearing he won’t be able to keep up. “Alternatively, a child may completely dominate situations in order to control them,” she says.

Claire explains that hypotonia ranges from mild to severe, so it’s important for parents not to panic if their child presents with a few of the symptoms, but to be vigilant as early diagnosis can go a long way in assisting the child.
“The underlying condition has not yet been found, but Blaine’s symptoms have improved through encouraging certain play activities, particularly jumping on a trampoline,”says Rebecca.

Signs of low muscle tone in babies

Claire says the tell-tale signs of low tone include a baby who:

  • Is noticeably “floppy”
  • Is emotionally or physically placid (often described as “good babies”)
  • Has poor head control for age.
  • Exhibits poor reflexes.
  • Has a weak sucking strength.
  • Is delayedin reaching milestones.
  • Becomes easily fatigued with reduced alertness.
  • Prefers to sit in a “ W” or “M” position (sitting on the bottom with knees bent, feet tucked under, and legs splayed out to each side).

Tips to try

  1. Encourage your child to spend time on his stomach and use visual and auditory stimuli to encourage your child to lift his head in this position, progressing to resting on his elbows.
  2. Encourage your child to spend time in four-point kneeling once he is more comfortable during tummy time. Provide support under your child’s abdomen using a rolled-up towel or blanket. Sway him forwards and backwards gently to encourage weight-bearing.
  3. Focus on development of milestones, including crawling.Crawling is a milestone that is occasionally skipped, but at the very least your child should spend a decent amount of time in four-point kneeling.
  4. Place toys on top of a low table and encouraging your child to push up onto his knees while playing to activate the gluteal muscles and weight-bearing through the hips.
  5. Play dough and drawing are excellent play activities.
  6. Discourage “W” or “M” sitting.

SIgns of low muscle tone in toddlers (one to four years)

  • Extreme flexibility of muscles.
  • Increased range of motion in joints, especially noticeable in hips, knees and elbows.
  • Slouched sitting posture.
  • Difficulty maintaining postures against gravity.
  • Constant fidgeting when trying to remain in upright positions.
  • Constant open-mouth posture.
  • Lack of postural alignment due to weak core.
  • Reduced physical activity tolerance.
  • Poor balance and coordination, with frequent falling and clumsiness.
  • Flat foot arches.
  • Speech problems (severe cases).
  • Difficulties with breathing and swallowing (severe cases).

Tips to try

  1. Same as for babies, where appropriate for age.
  2. Encourage activation of the core by gently bouncing your toddler on your leg or on a large exercise ball. Start with support around the shoulders, progressing to the rib cage and then the hips.
  3. Encourage active play. Ball games are great at this age as they assist with hand-eye coordination, strengthening of muscles, activation of core and balance.
  4. Let him climb stairs – even on hands and knees.