How To Hellp Infants And Children Develop Their Gross Motor Skills Practical Suggestions For The Home Daycare Provider Short Version

"How to Help Infants Attain Gross Motor Skills: Practical Ideas for the Home Daycare Provider" Julie Wattenberg, PT, MPT, DPT Adventist Paulson Pediatric Rehabilitation Center Independent Provider, Early Intervention Pediatric Physical Therapist January 20, 2009

Goals of today’s lecture
You will review the gross motor milestones of infants from 0-12 months of age
You will learn some easy exercises to help facilitate gross motor milestone attainment for infants at different ages/stages of development

Typical Development In the First Year

Reminder
In the following developmental progression, months are used to detail what an infant should be doing at each month.
However, please think of these as stages in development. If an infant is not demonstrating gross motor skills at the age reported, then please adjust accordingly and use the exercise suggestions for a bit longer than the “age” expected

First Month
First Month
Your baby is just learning how to lift and turn her head when she is on her stomach. She is lengthening out of the physiologic flexion that she had when she was born. She is unable to hold her head in the middle when she is on her back and has difficulties holding her head up.

Second Month
Two Months
He is starting to feel a bit floppy. This is because he has lost all of the physiologic flexion tone. When he is on his back, he is moving his head side to side and seems to be very limp. When on his tummy, he is not able to hold his head in the middle. At this age, he is learning how to activate his muscles on one side or the other, but has trouble activating them on both sides of a joint at the same time.

Three Months
Three Months
Your baby has learned how to activate their muscles and now is starting to learn how to activate them together, on either side of the joint. This means that the baby is more stable when it comes to head control. Your baby really likes to be in the middle. By three months your baby should be able to hold his head in the middle when on his back, show a nice chin tuck when on his stomach and have independent head control when held.

Exercises to facilitate Developmental 0-3 months
Positioning Suggestions
Large boppy pillow for midline orientation of hands
Small boppy or rolled towel for prone
Carrying/Pick Up Suggestions
Carry in supine, facilitate flexion, not extension
Prone carry to improve tummy time – this should be used with caution and should not be used with kids who like to extend all the time
Rotation to sitting every time you pick up a baby
Exercise Suggestions
Sitting on ball – holding at upper trunk
Prone on the ball - maintaining elbows under shoulders
Bicycles and Abdominal Massage for Gas
Lower trunk stretch in supine
Supine in lap with facilitation of hand to hand and hand to mouth
Side-lying play – elongation of posterior muscles

Positioning Suggestions 0-3 months
Supine (on back) on large boppy pillow or on your lap to facilitate midline orientation of hands
Use rings to bring toys close to baby’s chest to facilitate downward gaze and swatting of toys
Prone with small boppy or rolled towel under chest
This shifts the baby’s weight posterior (toward bottom) so that she can more effectively lift and turn her head.
You can help by placing your hand on her bottom. This will also bring the weight backward
Babies should start being on their tummy from DAY 1 for at least 30 minutes per day

Carrying Suggestions 0-3 months
When you carry a baby, you should always be sure that you are preventing any arching
Carry the baby in a flexed position, do not allow the head to extend
Flex up and hold one leg so that the baby cannot extend.
This will prevent abnormal muscle activation and movement patterns that so many infants are demonstrating now
You can carry a baby in prone and when they are little this is a great position as they can get that feeling of comfort when being in prone.
However, if you have a child who likes to arch and extend all the time, this is not a good option for this child as they get older as they are demonstrating unbalanced extension

Pick Up Suggestions 0-3 months
Every time you pick a baby up you should rotate him to sitting.
This helps to strengthen the muscles on the side of the body and the rotational muscles that are important for smooth dissociated movement

Exercises 0 – 3 months
Sitting on ball – holding at upper trunk
The higher you hold a baby at his/her trunk, the less she has to work. Therefore, since a baby from 0-3 months is not very strong in their head, you will have to hold them higher on their trunk
Prone on the ball - maintaining elbows under shoulders
The ball is a GREAT place to work on prone skills for babies who have trouble tolerating prone positioning
You can move the ball forward and back to increase or decrease the work.
Be sure you are providing support at the arms so that the baby learns how to push through the surface and is not using unbalanced extension
You can use this trick on the floor to in facilitate the baby learning to push through the surface

Exercises 0-3 months
Bicycles
Bicycles help with gas as well with improving rotation of the pelvis
Abdominal Massage
Abdominal massage also helps with gas. Be sure you are moving the gas from the baby’s right to her left
Strokes include: I love you, waterfall and knees to chest

Lower trunk stretch
This helps to lengthen the muscles of the lower back and upper back, especially for babies who are prone to extension postures
This also helps to facilitate activation of the abdominals.
Place your hand under the low back and maintain this position. Place toys on baby’s feet to attract attention to her feet

Supine on lap with facilitation of hand to hand and hand to mouth
Hand to hand and hand to mouth are very important skills for a baby to have
It helps a baby learn to self calm and is foundational for later skills

Side-lying play
Side-lying play is good for babies who are prone to extension.
This position lengthens the muscles in the back of their body
This position also allows the baby to active their arms and legs without significant gravity implications
You may use massage in this position and bring your hand from the middle of the back towards the wrist as well as the middle of the bottom toward the ankle. This will help to facilitate elongation of the posterior muscles (back muscles)

Three Months
Three Months
Your baby has learned how to activate their muscles and now is starting to learn how to activate them together, on either side of the joint. This means that the baby is more stable when it comes to head control. Your baby really likes to be in the middle. By three months your baby should be able to hold his head in the middle when on his back, show a nice chin tuck when on his stomach and have independent head control when held.

Four Months
Fourth Month
Your baby is getting really strong into flexion off the surface. This is not because they have spent so much time on their back that they are getting better at flexor strength, it is because they have spent so much time on their belly that they gained strength in their flexor muscles. When your baby is on her back, she is able to bring her arms off the surface and her feet off the surface and often is able to tough her knees. Sometimes, it is hard for her to stay here, though, and she falls to her side. When she falls to her side, she is just learning how to activate her muscles on the side of her neck, so she might lift her head off the surface when on her side. Your baby should feel really confident on her tummy now and should be able to tolerate it without fuss for at least 3-5 minutes at a time.

Five Months
Five Months
Your infant is really starting to move. On his back, he has gained more strength in his belly to bring his pelvis off the floor and reach for his feet. This helps to lengthen the hamstrings and strengthen the abdominal muscles to prepare him to sit. On his tummy, your baby is doing a great job pushing up on his hands and in sitting, your baby is able to prop sit. All of this pushing and reaching for his feet, teaches your baby how to use his triceps, the muscle on the back of his arm. This means that when on his back, your baby is becoming really good at reaching for toys.

Sixth Month
Six Months
Your baby is starting to move around, time to be cautious!! Your baby is now starting to roll from his back to his tummy. He is also sitting independently. Also, your baby really likes his tummy and likes to play on his tummy for a long time.

Exercises to facilitate Development 3-6 months
Supine with large boppy pillow under bottom to facilitate abdominal activaiton and hands to knees/feet
Prone positioning continues for at least 30 minutes per day
Supine on a large boppy pillow to facilitate reaching and bringing the arms forward if baby is having difficulties with this still
Bumbo seats may be used for a limited time
Do not use exersaucers, johnny jump ups or walkers
Carry in supine, facilitate flexion, not extension
Prone carry to improve tummy time – this should be used with caution and should not be used with kids who like to extend all the time
Rotation to sitting every time you pick up a baby
Sitting on the ball – progressing to lower on the trunk – side to side weight shifts
Prone on the ball – progressing to side to side weight shifts
Prone on hands off your lap
Rotation to sitting on your lap
Facilitation of rolling
Sitting practice with/without boppy pillow
Sitting balance on daycare provider’s lap with weight shift
Hand to feet in supine – rolling side to side

Supine (on back) with large boppy pillow under bottom.
Place toys on a play gym on rings to bring them close to baby’s feet so that he kicks the toys independently
This will help to strengthen his belly muscles
Supine with boppy pillow under shoulders
This will bring arms towards the toys.
Use rings to bring the toys down closer to the baby so accidental movements will result in batting of the toys
Decrease use of the boppy when baby is able to reach for toys independently when in supine (usually around 5 months)
Prone positioning
At least 30 minutes per day
Baby should be able to tolerate prone positioning without the blanket roll
Baby’s tolerance for prone should be increasing

When you carry a baby, you should always be sure that you are preventing any arching
Carry the baby in a flexed position, do not allow the head to extend
Flex up and hold one leg so that the baby cannot extend.
This will prevent abnormal muscle activation and movement patterns that so many infants are demonstrating now
You can carry a baby in prone and when they are little this is a great position as they can get that feeling of comfort when being in prone.
However, if you have a child who likes to arch and extend all the time, this is not a good option for this child as they get older as they are demonstrating unbalanced extension

This helps to strengthen the muscles on the side of the body and the rotational muscles that are important for smooth dissociated movement
By four months, baby should start to lift head laterally when you pick her up

Sitting on the ball
Progressing to lower on the trunk with side to side weight shifts shifts
By four months old your baby is just starting to develop her side to side control of her trunk and head. You can help facilitate this by moving her on the ball.
Shapes on the ball, move your baby’s bottom in circles, stars, square etc.
Prone on the ball – lateral and anterior/posterior weight shifts

Prone over legs with hands on the floor
To increase activation of the arms, lift your back leg (the leg farthest from the head of the baby)
This will facilitate triceps activation, teaches the baby how to push through their hands and works to open up the baby’s hands

Rotation to sitting on your lap
This exercise is very similar to rotating the baby up to sitting.
When you are holding a baby after they have been weight bearing through the ground on their hands, facilitate them up to sitting on your lap. This will strengthen their oblique muscles and lateral neck and trunk muscles

Facilitation of Rolling
Rolling from back to front is a really important skill
It is the first skill where infants become independent with their mobility
The important thing when helping a baby roll is to WAIT for them to activate their lateral neck muscles
It is very important to facilitate over both sides

Sitting practice
Tripod sitting (sitting with upper extremity support starts at the same time that your baby pushes on her hands on her tummy
Sitting with 1-2 boppy pillows
Sitting balance on daycare provider’s lap
When you are sitting with a baby on your lap, feel free to move your legs up and down, while holding the baby at her trunk slowly to let the baby practice reacting the balance challenges

Hand to feet in supine – rolling side to side
Facilitate hands to feet when in supine (on back)
This also helps to lengthen the hamstrings, activate the abdominal muscles, and lengthen the muscles in the back of the body
Place toys on baby’s feet to encourage her to get her feet
Encourage her to eat her toes as this helps to activate the abdominals more and deepen the stretch

Sixth Month
Six Months
Your baby is starting to move around, time to be cautious!! Your baby is now starting to roll from his back to his tummy. He is also sitting independently. Also, your baby really likes his tummy and likes to play on his tummy for a long time.

Seventh Month
Seven Months
Your baby is starting to explore positions where her belly is off the surface. These positions include laying on her side while one hand/arm is supporting and the other is playing. She also is starting to enjoy rocking on her hands and knees with her belly off the surface. She may even be trying to do a pike position where she straightens her legs and brings her bottom toward the ceiling. What a strong little girl! She loves to sit and play and is starting to explore the space to the side of her where she may be just starting to transition to four point independently.

Eighth Month
Eight Months
Your baby is getting very strong. He prefers to play in prone and sitting, and rarely plays on his back anymore. Your baby may be getting well by transitioning from sitting to four point and may even be starting to transition from the floor to sitting on her own. She may be crawling on her belly to get around. This is ok for a short period of time, but soon we want to see her get to her hands and knees to crawl. As your baby becomes more mobile, she will want to explore things that are higher than the floor. This drives her to transition from sitting to her knees at higher surfaces.

Ninth Month
Nine Months
Your baby should be a pro at getting around on her hands and knees and travels this way for long distances. She is loving exploring the world, especially higher surfaces. This drives her to want to climb higher and higher . . . even up the stairs. She may even be pulling to stand at low couches, but she prefers to use her arms more than her legs at this stage. You better get those gates! Your baby is not only sitting in the ring position, but has enough trunk strength that she can sit in a variety of sitting positions including on her heels, side sitting, on a small bench and long sitting.

Sitting independently, place toys laterally (at side) instead of in front of baby to stimulate lateral movement
Prone – your baby should love to be in prone and not like supine much anymore
Carry upright – encourage baby to hold onto you more as you carry him if he tolerates this
Rotation to sitting every time you pick up your baby
Ball – sitting on ball progressing to holding at pelvis due to improved trunk control and demanding more activation
Ball – prone on ball – progressing to more demanding positions where your baby has to lift her head against gravity as she comes closer to the ground and reaches for a toy
Walking on hands off lap or with a foam roller
Side sitting with upper extremity weight bearing
Transitioning to four point
Four point positioning

Position toys laterally
This facilitates lateral movement and transitioning from sitting to prone and/or sitting to four point
Prone
Your baby should love to be in prone now and prefers sitting and prone over supine

Carry upright
Encourage baby to hold onto you more as you carry him if he tolerates this now

Your baby should really be helping with this transition now and will be pushing with her arm as she gets up.
You will also start to see her activate the side of her trunk muscles and her head

Sitting on the ball
As your baby gets bigger, she is getting a lot stronger in the trunk and the head
Hold your baby at her pelvis to demand more trunk activation when sitting on the ball
Prone on the ball
Your baby is getting really strong now when in prone, start to challenge her more by bringing her closer to the ground and asking her to pick up toys from the ground

Walking on hands off lap or with a foam roller
This exercise will teach your baby how to move their arms forward which will prepare them for forward motion as they learn to crawl
This exercise also strengthens the shoulder girdle and trunk
In the first picture, your baby is learning how to accept weight on her hands when gently moved forward at an increased speed (protective extension).
In the second pictures, your baby is learning how to shift her weight and reach for a toy, and/or move forward a few steps with her hands

Transitioning to four point
Your baby needs to feel comfortable placing weight on one arm and slightly lifting her bottom off the floor to reach for a toy before she can go all the way to four point, so practice this first
As your baby becomes more confident with this, you can facilitate her to go all the way from sitting to four point
Place your hand on her belly during the transition to help her to remember to activate her belly
It is absolutely ok to go from sitting to prone, in fact encouraged during this stage, your baby does not have to stop at four point

Four point positioning
You may use a foam roll or your leg to keep your baby in a four point position
When you get her into this position, you may rock her front to back
Only do what she tolerates

Transition side sitting to tall kneeling
This is an important transition as it allows your baby to gain strength of the side of her hip muscles necessary for independent crawling
You can do this on a roll, your leg or on the side of a couch or a stair

Why creeping is important
Hands and knees crawling is the preferred way for babies to get around.
It takes a lot more strength for a baby to creep on his/her hands and knees than it does to crawl on his belly or scoot on her bottom.
Typically if a baby is scooting on her bottom to get around or crawling on her belly there is a reason that she is demonstrating this pattern.

Ways to facilitate hands and knees crawling
Pushing a small item – while on knees (e.g. stool, phone book)
Facilitation of creep on hands and knees
Place your baby on hands and knees. Shift weight posteriorly (backward) so that her belly is on her knees. This decreases the need for increased strength of the upper extremities and provides increased support for the lower extremities and belly
Move one arm forward and then the opposite leg. Continue to progress
If your baby likes to extend her legs out, you will need to keep a bit of pressure back with her bottom on her heels to prevent her from extending
Wheelbarrow walking when moving off your lap (see next)
Place toys laterally to your baby to facilitate him to transition to the side to get the toys - versus being in front of her

Ninth Month
Nine Months
Your baby should be a pro at getting around on her hands and knees and travels this way for long distances. She is loving exploring the world, especially higher surfaces. This drives her to want to climb higher and higher . . . even up the stairs. She may even be pulling to stand at low couches, but she prefers to use her arms more than her legs at this stage. You better get those gates! Your baby is not only sitting in the ring position, but has enough trunk strength that she can sit in a variety of sitting positions including on her heels, side sitting, on a small bench and long sitting.

Tenth Month
Ten Months
Your baby is really wanting to be upright in standing a lot and he is transitioning to standing using his legs more than his arms. He often chooses to stand via ½ kneel. Your baby now able to lower himself to the floor independently from standing, instead of falling to the floor like he did last month! He is even starting to squat down to pick up a toy from the floor and returning to standing on his own. He is doing a lot of playing in standing, often with his belly off the surface. He is doing a lot of looking from side to side and weight shifting in preparation for cruising next month.

Eleventh Month
Eleven Months
Your baby is starting to cruise along furniture. This is getting exciting! She is becoming very strong with her legs and trunk, such that she is able to occasionally stand without her belly on the surface for a few seconds. She may even start to cruise between objects that are really close.

Twelfth Month
Twelve Months
Your baby is really getting big. You are marvel at her progress as she is standing from the floor independently from the middle of the room and starting to take some steps. She seems clumsy at first as she tries to take a few steps between objects that are a bit further apart, but she is going to very soon become a proficient walker.

Sitting independently
Standing at a surface
Prone – your baby should prefer sitting and standing postures more than prone at this time
Carry upright – encourage baby to hold onto you more as you carry him if he tolerates this
Rotation to sitting every time you pick up your baby
Ball sitting and prone (see 6-9 months)
Facilitation of crawling up a surface (unstable surface and/or stairs)
Walking on hands
½ kneel to stand at a surface
Squat to stand at a surface
Four point standing (L shaped)
Pushing in a four point stand
Pushing weighted objects
90/90 sitting on bench or small ball
Sit to stand from a small bench
Facilitation of cruising
Facilitation of floor to stand via plantargrade

Carry upright
Encourage baby to hold onto you more as you carry him if he tolerates this now

Your baby is likely able to do this transition on her own now and will likely do it for you if your just place your hand on her pelvis or ask her to sit up.

Sitting on the ball
As your baby gets bigger, she is getting a lot stronger in the trunk and the head
Hold your baby at her pelvis to demand more trunk activation when sitting on the ball
Prone on the ball
Your baby is getting really strong now when in prone, start to challenge her more by bringing her closer to the ground and asking her to pick up toys from the ground

Facilitation of crawling/climbing
Allow your baby to practice crawling up the stairs
Place a bunch of pillows next to the couch and allow him to climb up the pillows
Place the ball next to the couch and help him climb up the ball and onto the couch
Walking on hands
As your baby wants to get off your lap, gently hold up her pelvis so that she can walk off your lap on her hands. This will strengthen her trunk, gluts and shoulder girdle

½ kneel to stand at a surface
Facilitate your baby to bring one leg up when holding onto a surface
As your baby becomes stronger at pulling to stand, she should no longer be pulling up with arms more than legs, help her up with one leg first
Be sure to switch legs
Squat to stand at a surface
While your baby is holding onto a surface, place a toy on the floor or a stool (which is higher and easier) and encourage her to get the toy
Help her bend her knees and support her bottom so that she gradually lowers and comes back up to standing
Four point standing
Four point standing is when a child is standing with their hands on a lower surface (such as a stool)
This position makes her really use her abdominal muscles
Pushing in four point standing
Encourage her to push an object in this position ( a small trunk, stool, milk crate, telephone book etc.)
Pushing weighted objects
Placing bags of rice or beans or heavy balls/weights concealed in push toys are a good way to provide increased resistance for pushing
This increased resistance provides increased abdominal strengthening and plantarflexor strengthening as well as shoulder girdle strengthening
If you are available to help, you resist the object as it is coming forward to provide added incentive for your baby

Bench sitting
Have your baby sit on a small bench or a small playground ball
Place toys slightly out of your baby’s reach so that she has to use her trunk to get the item

Sit to stand at a bench
When your baby is at the 11-12 month developmental level, she is ready to start working on sit to stand from a bench
You can provide a target, such as a basketball hoop and a small ball to help her get to standing
You do not have to facilitate at the arms. You may be able to get the baby to stand by gently tapping at her belly and her bottom as well as providing a good incentive for her to stand to
It will be more successful at first if you have her stand to a surface such as a couch and later have her stand independently

Facilitation of cruising
Your baby is getting very confident now when he is standing at a surface. You now are going to help him move side to side
Holding onto the pelvis, lift one hand up and press the opposite down
On the up side, the baby’s leg will lift off the ground and move out
Then swich hands the up goes down to weight the leg and the down goes up to bring the opposite leg to the standing leg
Repeat until you get to your destination
Facilitation of floor to stand via plantargrade
The best way to facilitate floor to stand is to pair it with a verbal command such as “1-2-THRE-eeeee”
Each time you facilitate floor to stand you say 1-2-3 (with an emphasis on the THR- EEEE) so that when you want your baby to stand independently and she is able to do it, you just say 1-2-3 and she stands
In order to faciliate standing, get your baby in hands and knees, her hands must stay on the floor
Bring one leg up and say 1, the other and say 2 then the bring her weight backwards and slightly up and say THRE-eeee as she stands up by herself . . . Very proud!

Reminders/Disclaimers
These exercises are only suggestions for how you can help babies that may be struggling with their developmental skills and how you can progress the strengths of those babies that are even on track
Please use caution when doing these exercises as you can harm a baby if you do anything too forcefully
If you suspect a baby is delayed in their development, please let the parents know so the family can receive a proper evaluation with proper and individualized exercise instruction from a qualified pediatric physical therapist
If you have any questions, please do not hesitate to contact me at [email_address]

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How To Hellp Infants And Children Develop Their Gross Motor Skills Practical Suggestions For The Home Daycare Provider Short Version

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How To Hellp Infants And Children Develop Their Gross Motor Skills Practical Suggestions For The Home Daycare Provider Short Version — Presentation Transcript