Pediatrics foundational
Developmental milestones
The following developmental milestones are organized by the age at which they typically occur:
2 months
- Holds head up in prone to 45 degrees
- Does not accept weight on the lower extremities
- No head control during support sitting
4 months
- Rolls prone to side, supine to side
- Head control demonstrated in supported sitting
- Ulnar-palmar grasp
- No head lag when pulling up to sit
6 months
- Rolls supine to prone
- Independent sitting
- Prone on extended arms and weight shifting with extended arms
8-9 months
- Creeping
- Pull to stand via kneeling with furniture
- Can stand independently for 1-2 seconds
- Able to transfer objects between hands
- Independent with side-sitting
10-15 months
- Independently walking
- Creeps up/down steps
- Transfers floor to standing
20 months
- Ascends steps with step-to-step pattern while holding unilateral rail or hand
- Uncoordinated running pattern
- Able to jump from a 2-inch step independently
24 months
- Ascends steps with step-to-step pattern independently without holding unilateral rail or hand
- Uncoordinated running at increased speed
Primitive reflexes
The following are the primitive reflexes, along with the age at which each typically appears and integrates:
Rooting
- Definition: stroking the cheek to allow for locating the bottle nipple or breast for consuming milk
- Age: appears at birth, integrates by 3-4 months
Moro
- Definition: protective reflex activated by the sympathetic nervous system that occurs when a loud noise startles an infant
- Arms and legs extend with fanned out fingers
- Head extends
- Infant cries
- Infant quickly pulls arms/legs back into midline position
- Age: appears at birth, integrates by 4-6 months
Palmar grasp
- Definition: grasping of an object when placed in the palm
- Age: appears at birth, integrates by 5-6 months
Asymmetrical tonic neck reflex
- Definition: aids infant in developing muscle tone, hand-eye coordination, and motor skills
- Infant turns head; face-side arm/leg extends, while scalp-side arm/leg flexes
- Age: appears at birth, integrates by 6 months
Spinal galant
- Definition: stroking laterally to the spinal column causes lateral flexing to the ipsilateral side
- Age: appears at birth, integrates by 3-9 months
Tonic labyrinthine reflex
- Definition: aids the infant in learning how to control the head and neck
- Neck flexion causes arms/legs to flex
- Neck extension causes arms/legs to extend
- Age: appears in utero, integrates by 3.5 years
Symmetrical tonic neck reflex
- Definition: aids the infant in learning how to control the upper and lower body independently
- Infant head moves forward; arms flex and legs extend
- Infant head moves backward; arms extend and legs flex
- Age: appears at 6-9 months, integrates by 9-11 months
The reflexes above are easy to mix up because they all key off head or neck position but produce opposite limb responses. The table below lines them up side by side:
| Reflex | Stimulus | Limb response |
|---|---|---|
| Asymmetrical tonic neck reflex (ATNR) | Head is turned to one side | Face-side arm/leg extend; skull-side arm/leg flex |
| Symmetrical tonic neck reflex (STNR) | Neck flexion or neck extension | Flexion: arms flex, legs extend. Extension: arms extend, legs flex |
| Tonic labyrinthine reflex (TLR) | Neck flexion or neck extension | Flexion: arms/legs flex. Extension: arms/legs extend |
Landau
- Definition: aids infant in motor control and coordination
- Infant held horizontally in the air with head and back extended, forming an arch in the back
- Age: appears at 4-5 months, integrates by 12 months
Babinski
- Definition: involuntary movement that occurs when the foot is stroked
- The lateral edge of the foot is stroked, causing extension and fanning of the toes
- Age: appears at birth, integrates by 2 years
Flexor withdrawal and crossed extension
- Flexor withdrawal
- Definition: protective reflex that occurs when a sharp pressure is applied to the sole or the palm, causing withdrawal (flexion) of that same stimulated extremity
- Age: appears at birth; remains present throughout life
- Crossed extension
- Definition: protective reflex in which a noxious stimulus applied to the sole of one extended leg causes that leg to withdraw while the opposite leg flexes, adducts, and then extends - unlike flexor withdrawal, which only involves the stimulated limb
- Age: appears at birth, integrates by 1-2 months
Primary standing
- Definition: an infant, when placed in a standing position, will support some weight and extend lower extremities
- Age: appears at birth, integrates by 2 months
Primary walking
- Definition: when the infant is held upright with the soles of the feet touching a flat surface, a slight forward tilt of the trunk elicits reciprocal (alternating) stepping movements
- Age: appears at birth, integrates by 2 months
Plantar grasp
- Definition: pressure on the sole or lower foot causes the toes to curl
- Age: appears at birth, integrates by 9 months
Example: Recognizing a persistent reflex
During a treatment session, a PTA notices that a 10-month-old still shows a strong ATNR response - turning the head causes the face-side arm/leg to extend and the skull-side arm/leg to flex - well past the reflex’s expected integration age of 6 months.
Answer: The PTA documents the observation and reports it to the supervising PT rather than diagnosing the cause or independently changing the plan of care; the PT determines whether further evaluation or a change to the plan of care is warranted.
Newborn considerations
The normal gestational period is 40 weeks. Infants born before this time have an increased risk of developing congenital anomalies and developmental delays.
Infants are assessed at 1 minute and 5 minutes after birth (and every 5 minutes thereafter, up to 20 minutes, if the 5-minute score is below 7) via the APGAR scale. The APGAR scale assesses appearance (color), pulse, grimace (reflex irritability), activity, and respirations. Each is scored with a 0, 1, or 2, with the goal of the score being between 7-10. At every assessment, the expectation is that the score will go up. If scores decline below 7, this indicates the presence of pathology and possible complications.
Examination of the newborn also includes assessment of the musculoskeletal system, range of motion, posture, primitive reflexes as appropriate, and tone. Any abnormalities noted will be the rationale for performing specific outcome measures for assessment.
Outcome measures
Alberta infant motor scale (AIMS)
- Definition: gross motor skills assessment tool used to evaluate weight-bearing, posture, and antigravity movements in infants
- Age of use: 0-18 months
Peabody developmental motor scales (PDMS-2)
- Definition: assesses gross and fine motor development to include spontaneous, elicited reflexes, and automatic reactions used primarily for developmental delay
- More sensitive to change than the Bayley scales of infant development
- Age of use: 0-5 years (birth to 71 months)
Gross motor function measure (GMFM-88)
- Definition: measures gross motor function in the cerebral palsy population
- Focuses on voluntary movement in five phases - prone and supine, sitting, crawling and kneeling, standing, and walking and jumping
- Age of use: 5 months to 16 years
Bruininks-Oseretsky test of motor proficiency (BOT-2)
- Definition: developed to measure gross and fine motor skills for individuals with developmental delay
- Age of use: 4-21 years
Bayley scales of infant development
- Definition: developed to measure motor and mental scales for children with developmental delay
- Assesses 5 domains: cognitive, language, motor, social-emotional, adaptive
- Age of use: birth to 42 months
Functional independence measure for children (WeeFIM)
- Definition: assesses function in self-care, mobility, locomotion, and social cognition in children following an acute injury, such as spinal cord injury, traumatic brain injury, or multiple fractures
- Age of use: 6 months to 7 years