By: Elizabeth Yanow PT, DPT
In February 2022, the Centers for Disease Control and Prevention (CDC) released its updated developmental milestones and tips to support early childhood development. This is the first update in nearly 20 years. The panel of professionals that were consulted for the update included developmental-behavioral pediatricians, neurodevelopmental pediatricians, general pediatricians, child, and developmental psychologists, professors of special education and early intervention, developers of developmental screening tools, Editor of Bright Futures: Guidelines for Health Supervision…, and Authors of AAP’s 2020 clinical report Promoting Optimal Development. However, one group of professionals that were not consulted are Allied Health professionals. These are Speech, Occupational and Physical Therapists. These professionals are the ones who see your children for treatment when delayed milestones are identified.
Developmental milestones refer to tasks or skills like sitting, crawling, walking, talking, using fingers to pick up food, using utensils, and so much more. These are skills that a child will develop in the first 1-5 years of life with most skills developing within the first year. A delay in milestones could be an indicator of an underlying issue or cause a delay in other areas of development or difficulty with certain skills when starting school.
In previous years, many pediatricians have taken a conservative approach to developmental milestone achievement. The “wait and see” approach has delayed referrals to specialists such as physical therapists, occupational therapists, speech therapists, developmental pediatricians, and neurologists. The goal was to give the child as much time as possible to develop before seeking out specialty services and running up a medical bill. This may cause many children to be referred later than necessary for therapy services and may delay milestone achievement even further, leaving kids well below average compared to their age-matched peers, and requiring more treatment time to get them caught up than if they had been referred sooner.
The CDC states that the goal of the new recommendations is to discourage the “wait and see approach.” To develop these new recommendations, statistical analysis was collected to establish the age at which “most children” are performing a certain skill. The recommendations were then adjusted to reflect the age at which 75% of children, or “most” children, were achieving a given skill. This is increased from traditional standards in which 50% of children were achieving a given skill. Generally speaking, the standards were increased to provide a larger population of comparison. This allows a child more time than previously to achieve a skill. How is this different from the “wait and see approach?” How does this prompt earlier referrals and interventions?
For example, let’s look at sitting independently (without support from a pillow, person, or own hands). On average, research and physical therapy standardized assessments support that 50% of children are likely to sit independently between 6 and 7 months. There may be children who sit sooner and there may be children who sit later and still fall within a typical range. But, typically speaking 6-7 months is when the “average” population of children are capable of sitting on their own. The CDC now reports that children should be sitting independently at 9 months. The development of the new standards discussed in the previous paragraph indicates that 75% of children are sitting independently at 9 months. This is 2-3 months later than the original recommendation. Instead of being referred to physical therapy for concerns of not sitting at their 6-month well child check, the child may not be referred until their 9-month well child check. The child may not be seen by PT until they are 10 months due to our current medical model and insurance system thus delaying subsequent milestone development. This only allows for a larger span of physical delay.
In these examples above, an evaluation to physical therapy at 6 months, for not demonstrating independent sitting, can be valuable for many reasons. The physical therapist can identify if the prerequisite skills for sitting have been developed. The child may be close but not quite there, thus indicating no need for skilled physical therapy services. Essentially, no delay, the best-case scenario. Or, the therapist may identify some mild to moderate, underlying asymmetries that are getting in the way of achieving independent sitting. Therefore, a course of physical therapy services can be initiated. Attacking the developmental delay early can set the child up to overcome what is holding them back. By targeting the problem from this proactive stance, the course of physical therapy could be shortened compared to the latter “wait and see” approach.
Additional significant changes include the removal of the crawling milestone and changes to the walking milestone. We have learned a great deal over the years regarding the benefits of crawling. Some benefits of crawling include:
- Improved grip strength and development of the arches of the hand
- Better visual tracking while reading
- Enhanced body awareness
- Increased bilateral coordination (connects the right and left brain)
- Stronger trunk and shoulder girdle which is responsible for posture, handwriting, balance, and more.
If your child demonstrates poor sitting at 6 months, the inability to transition in and out of sitting at 8 months or prefers the “w” sitting position, these are red flags to delayed development of crawling and subsequent gross motor development. There are many reasons a baby might not crawl and this should be evaluated by a physical therapist. All of that said, the absence of crawling from the CDC developmental milestone guide may make it difficult for pediatricians in providing adequate recommendations to parents. Keep this in mind, and know that crawling is important to your child’s development!
The CDC now recommends a child demonstrate the ability to walk holding onto furniture at 12 months, walk “a few” independent steps at 15 months, and walk independently at 18 months. From a physical therapist's perspective, these recommendations allow a higher probability of a delayed referral. Traditionally, walking is a milestone with a wide range of acceptability. This is because the body requires new strength, balance, and coordination to move from a quadruped, crawling position, to being upright for the first time in life. Therefore, physical therapists typically break up walking into a few phases. Walking is defined as independent steps from one location to another (i.e. from one couch to another in the living room). Early walkers begin walking at 9-12 months, on-time walkers at 12-14 months, mild delay at 14-16 months, and delayed walkers at 16+ months. That being said, it is prudent to refer a child to PT for an evaluation by 15 months (at their 15-month well child check) if they are unable to stand independently and walk forward at least 3-5 feet independently to assess reasons for delayed walking.
Now, there are some good things to be said about the CDC’s newest release. The document includes updated recommendations to “Help Your Child Learn and Grow” for each developmental stage. These suggestions are fantastic and cover positioning for infants, feeding, speech, and growing a strong, valuable, connection with your child.
So, what do you do with all this information? Consider these questions:
- Was your child born prematurely or did they spend time in the NICU?
- Does your child show a preference for one side of the body more than the other? (i.e. look to the right more than the left or crawl with one leg up and one leg down?)
- Does your child (0-6 months) tolerate a minimum of 60 minutes, total, on their belly per day?
- Does your child feel rigid or tight? Or, floppy like they might fall through your hands when you pick them up?
If you answered yes to any of these questions, consider requesting a referral for a physical therapy evaluation from your pediatrician. And remember, in the state of Georgia, you may seek a PT evaluation without a referral. A prescription for your pediatrician will be required within 30 days of the evaluation so that treatment, should it be needed, can begin.
You know your child best! Follow your gut! Ask questions!
By: Elizabeth Yanow PT, DPT
Resources:
CDC
