Baby and child development

This article was published in Australian Doctor, www.australiandoctor.com.au on 29 January 2015 by Dr James Best.

Parental anxiety over their offspring’s progress is a common presentation. 

Because GPs see babies and small children so frequently, we are in a terrific position to monitor their developmental progress, and I am passionate this should remain a core role of the GP.

Parents can be guided by us on important developmental milestones, how they can foster healthy development, and importantly, what not to be worried about.

Gross motor development

Monitoring gross motor development is relatively easy. The neurological control of the infant’s body travels from the top down and from the inside out. It is analogous to a flag unfolding.

If you are in an art class drawing an adult, you will draw the hips at the halfway point, the nipple line a quarter of the way down, and the patellae three-quarters of the way down. If you divide the first 12 months of a child’s life into quarters, you will quite conveniently find that gross motor development roughly corresponds to these points.

That is, at three months a baby should have control of their chest; at six months their hips (sitting usually happens at 7-8 months old); at nine months their knees (eg, crawling, bum-shuffling or commando crawling); and at one year their feet (standing holding on, but not necessarily walking).

Beyond 12 months, children will expand this neurological connection into increasingly complex activities (see box: Gross motor skills to encourage).

As well as providing a monitoring role, GPs can encourage parents to foster their child’s gross motor development by actively providing opportunities for their children to work on these skills (see table 1). The whole world seems to be telling parents to cocoon children for safety, but development is fostered through opportunity, and safe exposure should be encouraged.

Something parents occasionally get wrong is to not provide enough tummy time (“He/she doesn’t like it!”). Once children are sitting, hard surfaces are fine — they won’t hurt their back. Hard surfaces are also fine to crawl on.

Spring-loaded jumping devices used prior to achieving walking do not foster motor development, and may lead to toe-pointing once walking occurs (ie, tight Achilles). Walking chairs (‘walkers’) will not help an infant’s motor development and are downright dangerous around stairwells. There is no benefit of shoes prior to standing.

Baby gates tend to come off too late. Once a child is developmentally ready to access an area safely (eg, stairs), parents should let them do it.

Another parental worry is that the child will fall when beginning to walk — but this is to be expected: one study showed children on average fell around 17 times an hour when learning to walk.

GROSS MOTOR SKILLS TO ENCOURAGE

(12 months to 6 years)

  • 2.5 years: jumping
  • 2 years: Walking up stairs holding onto an adult hand, and possibly attempting alternating feet with each stair
  • 3 years: starting to try to use a tricycle
  • 5-6 years: weaning the trainer wheels off the bike
  • 6 years: skipping

Fine motor development

Fine motor development mimics that of gross motor, with a steady progression down the body, then an ‘unfolding’ pattern of control of movement, with extension and opening out of joints (particularly hands and fingers), followed by increasing complexity of movements.

An easy way to remember the principles of fine motor development is to think of the first nine months in terms of whole-hand activity, and the second nine months (9-18 months) as individual digit activity (see box: Fine motor skills).2

Encourage parents to provide age-appropriate opportunities for their children to develop these skills. In a similar fashion to gross motor skills, parental anxiety regarding fine motor skills often surrounds worry about exposing them to activities they perceive as potentially unsafe.

Examples of this include not letting a child use pencils or other markers because of lead toxicity (even though there is no lead!), unfounded concerns about choking risks in older children, and in particular, doing things for their child (eg, cutting up food, doing up a zipper) before the child has an opportunity to have a go at it themselves.

FINE MOTOR SKILLS

Whole-hand activities (0-9 months)

  • 3-6 months: Include grasping objects passed to them, looking at objects they are holding (‘object regard’) and possibly banging objects onto a surface, such as a tray in a high chair.
  • 6-9 months: Banging objects together. By nine months, babies should be doing hand-to-hand transfers and purposefully releasing objects.
Individual finger activities (9-18 months)

  • Pinching (pulp-to-pulp), pincing (tip-to-tip with curled fingers) and pointing, all of which can emerge progressively.
  • Pointing is an important milestone. It is often present by 12 months and should be present by 18 months. Prior to a child developing their own point, they will reach out towards things, straightening out fingers while they reach. This action will be followed by the index finger being straightened in isolation while the other fingers are curled. We start in the first year of life by ‘following a point’; that is, looking at an object when someone says: “Look at the …”  As well as following a point, a child will often be pointing themselves by 12 months. A young child points for several different reasons. Sometimes it is to share something interesting with another person, sometimes it is to get something they want, and sometimes it is to find out what something is called.

Social development

The first major challenge parents face with their child’s social development is with infant crying. The normal pattern is for crying to start increasing about two weeks of age, peak around two months, and then settle down about 3-4 months, perhaps five.

Parents, however, often feel that their baby’s crying is way beyond anything they were expecting. Through the prism of parental sleep deprivation, infant crying (which can frequently be up to five hours a day) can be overwhelming. A useful resource for parents on infant crying, produced by developmental paediatricians, is the Purple Program on the National Center on Shaken Baby Syndrome website.

Of course, a crying baby should be assessed for other causes of perceived prolonged crying, such as urinary tract and other infections, hernias and milk protein intolerance. Feeding, growth and developmental domains should be reviewed.

Parental conditions, such as postnatal depression should also be considered. If the GP is confident that this is ‘normal’ infant crying, they should offer necessary support, including reassuring parents that they are not doing anything wrong. There are emerging paediatric nurses in the community as well who can help.

Around six months old, babies frequently develop separation anxiety, often resulting in subsequent parental anxiety.

Separation anxiety is a normal developmental phenomenon, which occurs when an infant becomes more aware of ‘object permanence’ (something existing when it is out of sight). Parents, particularly mothers, may worry about causing distress through separation (eg, leaving the baby in the cot to self-settle), but this is something that we want a child to learn to handle.

A step-ladder approach (gently increasing a child’s exposure to separation, as they increase their skills to cope) will help. Separation anxiety often peaks around 14-18 months, and then decreases through preschool years.

Stranger anxiety — usually appearing around 7-9 months and reducing after 14 months — is similar to separation anxiety. It is also best managed through graduated exposure.

Tantrums, which are common between 18 months and three years, cause a lot of parental anxiety. Parents often don’t understand why they happen or what to do about them. There is a lot of misinformation about tantrums, frequently over-emphasising control rather than guidance.

Tantrums happen because a young child has no other mechanism for handling an emotionally challenging situation. Diverting a child from predictable tantrum triggers, ‘scaffolding’ (giving necessary support) to handle the event (eg, a five-minute warning), distraction, or active listening in the build-up to a tantrum, can be useful strategies to employ.

Once a child is mid-tantrum, any attempts at negotiation will be ineffective. Afterwards, an unemotional and calm response from the parent will tell the child that tantrums don’t work (although, of course, this can be difficult for a stressed parent).

Skill-building toddlers on how to handle emotionally challenging situations is best done either before or after. Rousing at a child is counter-productive — they are still learning to control their emotions, and this will just increase the risk of them becoming demoralised and losing self-esteem.

Speech and communication development

Once children start developing speech, parents tend to worry about vocal clarity and the number of words. Certainly, vocabulary and articulation issues are important.

A child’s vocabulary will often start to quickly expand around 18 months of age. Word combining, small sentences and increasingly reciprocal (back-and-forth) conversation expand markedly over the next 18 months. Articulation also improves over this time, with about 25% of articulation intelligible at 18 months, 50-75% intelligible at two years and 75-100% at three years. Other articulation issues, such as lisps and stutters, may require investigation and/or referral to a paediatric speech therapist.

In contrast, parents tend to underestimate the importance of receptive language development (understanding), sentence structure and grammar (semantics), and the social use of language (pragmatics). The last can be encouraged by involving children in prolonged reciprocal conversations (See box: Techniques to develop reciprocal conversations).

TECHNIQUES TO DEVELOP RECIPROCAL CONVERSATIONS

  • Observe, wait, and listen for the child’s language
  • Don’t interrupt
  • Follow the child’s lead
  • Balance questions and commands with comments
  • Use routines and structured activities that provide opportunity for language to emerge
  • Encourage the child to take turns in conversation (especially using pauses)
  • Label; repeat; expand on what the child says; extend the topic
  • Talk about topics the child is interested in

If GPs have an appreciation of normal development, this will enable them to effectively monitor for any concerns. Encouraging parents towards strategies that foster these skills, as well as educating them on common misconceptions that cause anxiety, will help the GP help their patients, both child and parent.

TABLE 1: MOTOR DEVELOPMENT SCREENING

Age

Expected motor developmental milestones

‘What to encourage’ discussion points

 

6 WEEKS
  • eyes mostly moving together
  • some head control, not flopping everywhere
  • symmetrical movements of limbs
• tummy time in small grabs of time
4 MONTHS
  • hands to midline and then to mouth
  • hand regard
  • lifts knees
  • tracks objects through 180 degrees
  • lifts head up 90 degrees when lying prone
  • grasps objects handed to them
  • tummy time in small grabs of time
  • point and look at objects with them
  • handing objects to them to grasp
  • objects over pram or lying flat that they can see and hit with hands
6 MONTHS
  • propped up sitting (independent sitting 7-8 months)
  • hands down in front of them, hands to feet
  • keeping head level with body when pulled to sitting position
  • rolling up on extended arm when placed in prone and creeping when placed in prone
  • possibly banging objects on a surface
  • pull apart or stretch toys
  • push-pull toys when sitting
  • handing objects to them to grasp or bang on a surface (and modelling this)
  • tummy time — 50% of time awake
12 MONTHS
  • takes weight on feet when feet placed on ground in standing position (parachute them) or standing holding onto furniture
  • transitions by moving in and out of positions
  • cruising (probably) and crawling
  • points and follows a point (possibly)
  • grasps with index and thumb
  • claps hands
  • opportunities to use their feet (eg, cruising)
  • opportunities to plan movement (eg, in boxes/cushions to crawl over/pull to stand, etc)
  • opportunities to rake, pinch or pincer objects (eg, berries, sultanas or cut-up snacks in high chair)
  • self-feeding opportunities
  • using an open cup and spoon
18 MONTHS
  • walks well and probably holding hands upstairs
  • climbing on and off everything
  • attempting a jump
  • isolated ‘tip to tip’ pincer
  • bilateral play — hands doing different things
  • eyes point, focus and track a moving object
  • posting objects into containers
  • supervision with stairs, but let them do it
  • if they fall, encourage them to get themselves up
  • holding and using crayons, paints and markers
  • picking up small objects (eg, in high chair)
  • provide opportunities such as toe threading/throwing and bilateral play
  • starting to manage dressing themselves and other self-care activities (give them a chance)
4 YEARS
  • moving towards learning to ride bike
  • catching a ball onto chest
  • catch a larger ball with their hands
  • throwing a ball overarm
  • hopping
  • wash and dry hands
  • doing puzzles independently
  • bike riding, climbing, swimming
  • catching, throwing, hitting (one and two hands) different-sized balls and types of bats
  • writing with a ‘kissing grip’ (thumb and index finger just touching), for as long as possible (to encourage grip endurance)
  • activities that encourage pinching dexterity and endurance (eg, using blocks, threading and colouring in)
  • supervised brushing of teeth

*Article produced with the assistance of Therapies for Kids, Annandale, NSW.