They are given to us on handouts from the pediatrician.
They are documented on every mother’s news feed.
They are somewhat ambiguous, yet constantly in the back of all of our minds as our little ones grow.
They are developmental milestones.
When asking for suggestions for my next PT blog post on Facebook & Instagram, “milestones” & “red flags” were mentioned a few times. So here we go!
Just like everything, milestones can be taken too seriously or too lightly. Missed or atypical milestones can be a symptom of an underlying issue, so we should be aware of when our children reach them or skip them so they can be addressed quickly. On the other hand, gaining skills toward the end of the normal timeframe should not cause you to panic. If you have concerns, it never hurts to have your child evaluated by a PT!
PSA: In most states a medical doctor’s script is required to see a PT. It is your right as a parent & a patient to request a referral to PT (or any other legitimate service). Just as medical doctors are experts in the field of medicine, physical therapists (many of which also have doctorate degrees) are experts in the field of body systems & processes related to movement. Use your motherly intuition & worthy resources along with your pediatrician to make decisions regarding your concerns. Some things that may help when talking to your pediatrician about a referral are to write down your questions & concerns, take photos & videos if possible, & track when major milestones have been reached!
Here are some statements that you should question:
- It is ok & normal to skip crawling & go straight to standing.
- Toe-walking is not concerning & they will grow out of it.
- It isn’t concerning that your child isn’t walking until they turn two.
- Let’s try surgery before physical therapy.
So let’s start at the very beginning, as Maria would say!
Head control when held in an upright position should be well controlled by 3-4 months. This is why we are advised to avoid jogging strollers & out-facing carriers until this time.
Rolling emerges between 3 & 4 months & should be well controlled by 5 months. Notice their quality & symmetry of rolling. Do they roll to both the right & left? Do they roll tummy to back & back to tummy? Do they extend their bodies & push through their feet (atypical) or flex their legs toward their tummy & reach their arms across to initiate rolling (typical)? If they are not rolling symmetrically or if they use an extension pattern, they may need some assistance to coordinate & strengthen their anti-gravity movement. Here is baby J rolling for the first time at 14 weeks!
Belly crawling happens around 6 months. Many parents are concerned that their child crawls backwards to get where they want to go, but this is actually perfectly normal!
Crawling on hands & knees should begin by 8 months. Since we maxed out Baby J’s gross motor skills, my lovely little sister agreed to act as a model!
If your child skipped crawling altogether, we still recommend using this important skill during play because it provides specific benefits that they will need in the future.
Why do babies need to crawl?
- Weight bearing through the knees helps the hip joint, a structurally shallow & unstable joint, to deepen & develop properly.
- Weight bearing through hands strengthens the muscles needed for grasping & handwriting later on.
- This motion helps the vestibular system acclimate to forward movement used during walking.
- Depth perception is developed through crawling.
- Some think crawling in quadruped (on hands & knees) can prevent shoulder & hip replacements in the future!
This is why we disagree when our parents are told that it’s of no concern that their little ones didn’t crawl. It’s actually very important for them to crawl for the right amount of time & in the right way.
Some children crawl, but not in quadruped. Here are some atypical types of crawling:
- Hitching: both hands, one knee, & one foot are in contact with the ground. Children choose to hitch when they have core weakness that causes them to seek extra stability.
- Scooting: sitting on their bottom & scooting forward or backward with both hands & feet placed on the ground. Children scoot when they have difficulty transitioning into quadruped (hands & knees) due to muscle tightness or weakness.
- Bunny hopping: arms move forward together followed by legs scooting forward together. You will most likely see their legs straighten when their head is down & bend when their head is up. Children bunny hop due to a reflex called the symmetric tonic neck reflex that should be present in early infancy, but should go away around 8 months, which is when quadruped crawling should emerge.
Why isn’t my child crawling yet? or Why does my child prefer to stand rather than crawl?
- Your child may have core weakness. Try getting on hands & knees, then lifting one extremity at a time. Now try lifting an arm & the opposite leg. It’s difficult! Their coordination is still developing & they do not have the emotional regulation to overcome obstacles like underlying core weakness like we do when we are in the gym learning a new exercise. Their brains are so smart & they find the most efficient way to do things. But this can lead to lifelong issues if it is not addressed.
- Your child may have retained primitive reflexes. They govern the movement of babies before they have any conscious thought or movement. Some emerge while they are still in the womb like sucking when their hand touches their face or wiggling when it’s time to move through the birth canal. Others show up after birth to help them move against the newly discovered force of gravity. As our babies develop awareness & anti-gravity strength, the reflexes should go away, or integrate, leaving them with intentional movement instead of reflexive movement. If primitive reflexes are retained & not integrated, they will influence their intentional movement, leading to abnormal patterns & possibly delaying gross motor milestones.
Prop Sitting occurs between 4 & 5 months. This is when babies can maintain sitting when momma puts them there with their hands propping them up in front of their body. It’s still a little early for Baby J, but we decided to try prop sitting anyway. I think it’s safe to say he isn’t quite ready yet!
Babies usually sit independently at 6-7 months, meaning they can get in this position without your hands on them. They may not be able to do a lot in sitting yet & their balance is still not great. At this age they may be ring sitting, tailor sitting (criss-cross applesauce), long, or straddle sitting.
At 8 months, they should be able to play with toys in sitting. They should also be able to catch themselves when falling forward in sitting & possibly to the side.
By 12 months, babies should have really good sitting balance & should be able to sit in a child-sized chair & side sit, along with the other typical types of sitting mentioned above.
There are also atypical types of sitting, including:
- W sitting: because of low muscle tone or weakness, children will unconsciously increase their base of support by W sitting. (remember, their brains are very smart!) This places the hips in medial rotation, stretching their hip joint capsule, ligaments, & muscles, as well as putting them at risk for hip subluxation because their entire body weight is pressing down into this rotational position. W sitting can also cause in-toeing, or “pigeon-toed” position. In the clinic, we teach parents how to not only discourage this sitting position, but introduce new ones through strengthening & problem solving in the home in order to protect their hips.
- Propping: some children need to place a hand or a foot on the floor, or constantly lean against something, when sitting because their anti-gravity muscles have impaired strength & low endurance.
- Sacral sitting: many children learn this pattern because they learned to sit in Bumbo seats or other artificial positioners. Others sacral sit for the same reasons as propping.
Why does my child prefer to stand rather than sit?
- If your little one is the child that stands to watch tv, puts their toys on the coffee table instead of the floor, or skipped sitting altogether & went straight to standing, they most likely have some strength deficits. They have learned that they feel unstable when sitting or they find it takes too much work – who wants to work hard just to sit?? – so they find that standing is actually easier. That may not make sense at first since standing is a later skill, but when we stand, we can “lock” out all of our joints, balance our center of mass over our base of support & literally hang with very little muscle activation. Compare this to sitting, when our hips are flexed & we are relying on our core & postural muscles to work constantly & in perfect coordination so that we can stay upright, turn our head, & reach with our arms. It’s hard to passively sit. It’s much easier to passively stand.
10 months brings pulling to stand followed closely by cruising.
Walking happens within a wide range, most acceptably between 10 & 17 months, at which time it is considered delayed. Regardless of what advice you get – because we all get lots of advice that is anecdotal or just outdated – we encourage parents to seek a physical therapy evaluation if your child is approaching 15 months & is not taking independent steps. It never hurts! We love telling parents that they are age appropriate & there is nothing to worry about. We also love being there to support those kids who need a little extra care.
Since the range for typical walking is so wide, a safe way to gauge your child’s progress is to see where they are after walking for about 6 months. At that point, they should have their arms out of high guard, feet should be shoulder-width apart, they should fall less often, & be able to squat to pick up a toy without losing their balance.
At 2 years old we should see:
- Pre-running. More of a fast walk without a flight phase while keeping their balance.
- Walking upstairs by placing both feet on each step.
- Jumping up from a flat surface with both feet.
At 3 years old they should be:
- Walking up & down stairs placing both feet on each step.
- Walking backwards.
At 4 years old you may see:
- Running with flight phase.
- Walking up & down stairs with one foot on each step.
- Hopping on one foot.
- Riding a tricycle.
While it is beneficial to know what is “normal,” it is also important not to rush our babies to the next milestone! The journey is teaching them just as much as the destination when it comes to gross motor development. Any questions about gross motor milestones? You can contact me here!
Expert consult: pediatric physical therapist, private practice owner, & also my mother, Sabra.