Is Your Baby Missing Milestones?

Having a baby is one of the happiest times in a parent’s life. You welcome this beautiful bundle of joy home and prepare to experience a life of many firsts. The first smile. The first time rolling over. The first giggle. The first time reaching for a toy, getting up on her hands and knees, crawling, walking, and especially the first time she sleeps through the night. The first year of your child’s life is full of change, growth, laughs and cries, sleepless nights and many, many questions for parents. When some of these “firsts” do not occur when expected, you may start to question if your baby is developing appropriately. Is she meeting important milestones? Is he progressing adequately? Is there something wrong?

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What are Developmental Milestones?

Developmental milestones are markers that help determine whether a child is progressing through important stages of growth and development. They are ultimately the determining factors for potential future problems. Often the first few months of milestones are met without noticeable delay. If there are developmental delays, it is not until the infant gets to more complex milestones between 6-9 months of age that deficiencies are noted, and questions or concerns start to emerge. (Poinsett, 2020)

At 2-6 months your baby will progress from smiling, cooing, turning his head toward sounds, to babbling, reaching for a toy with one hand, and rolling over and kicking his feet. These are all very basic social, cognitive, and motor skills that are starting to appear. After 6 months of age, however, your baby should continue to progress these skills to a more complex level requiring the use of both sides of the body, improved trunk control to allow for sitting without support, and expressing her own needs with more vocal cues. (Pathways, 2020) Instead of grabbing a toy with one hand she may start bringing the toy to her mouth or transferring the toy from one hand to the other. He may start to sit up on his own and push up onto his hands and knees and even rock back and forth, sometimes crawling backward or forward. He may even pull to stand. Fine motor skills will start to allow him to pick up things like cereal between the thumb and index finger. (Pathways, 2020)

If your child is missing these more complex milestones, you may begin to question if there is something wrong. Of course, there are some infants who have slower development as not every child will hit each stage according to its projections. Some may completely bypass certain stages. Every child is different. There is usually no need to panic if a milestone is missed. However, catching problems early is imperative for your baby’s future development.

Milestone Red Flags

There are some missed milestone red flags that could allude to larger complications. (Poinsett, 2020) These should not be ignored. Below are some examples of red flags at each stage that should be discussed with your health care provider.

Six Months:

  1. Inability to roll at least side to side if not front to back or back to front.
  2. Lack of emotional expressions such as a big smile or joyful response to a parent
  3. Inability to hold head up during tummy time due to decreased head, shoulder, and trunk control.
  4. No assistance with upper extremities especially when being pulled from lying to sitting position by a care giver.
  5. Appearing visually interested in objects, but unable to reach for them or grasp them.
  6. Struggling to maintain head and trunk control when sitting up.
  7. Does not initiate weight bearing with legs when placed in supported standing position.
  8. Using only one arm to reach for items. Does not transfer toys to the opposite hand. Or one arm is always held close to the body.

Nine Months:

  1. No mimicking of sounds, smiles or other facial expressions with a parent.
  2. Inability to roll over from back to front or front to back.
  3. Inability to push up on hands and knees when lying on tummy.
  4. Inability to move independently from lying down to sitting up.

Twelve Months:

  1. Inability to stand due to stiff legs and/or pointed toes.
  2. Leaning to only one side when sitting or needing some help to maintain trunk stability while sitting.
  3. Only using arms to pull to standing rather than pushing with legs as well.
  4. Poor head control.
  5. Rigid arms either in flexed or extended position.

Missing important milestones or identifying with any of these red flags can indicate many different things. It is important to remember that they are not always bad as every child progresses at a different rate. However, when these gross motor delays are due to a medical problem, it can have several different causes. The most common cause of motor disability in children is Cerebral palsy (CP), which affects movement, balance, and posture. (CDC, 2020) It is caused by abnormal brain development or damage to the brain. This can occur in utero or during birth (Congenital CP) or after birth (Acquired CP). In many cases, the specific cause is not known.

Risk Factors for Cerebral Palsy

The majority of CP is congenital (85-90%). (CDC, 2020) . While having one of the following risk factors does not mean that the child will automatically have CP, most children diagnosed with CP in fact had one or more risk factors. Some of the risk factors for congenital CP include low birth weight, prematurity (the more premature the higher the risk), multiple births (twins, triplets, etc.), the use of infertility treatments, infections during pregnancy (such as chicken pox, cytomegalovirus, measles, and pelvic infections), infant jaundice, and certain maternal medical conditions – such as thyroid disorders, seizure disorders or intellectual disabilities. (Glader, 2019) Additionally, birth complications such as placenta previa, placenta detachment, umbilical cord problems, and medical errors can also lead to infant oxygen deprivation that can in turn cause CP. (CDC, 2020)

Acquired CP usually results from infection or head injury that occurs sometime after birth. Risk factors for acquired CP are infections of the brain such as meningitis, brain injury from child abuse or motor vehicle crash or some other type of trauma, problems with blood flow to the brain such as with blood clotting disorders, heart defects, sickle cell disease, and a stroke or bleeding on the brain. (CDC, 2020)

Communicating with Your Health Care Provider

If you are concerned about your baby’s development, it is important for you to discuss it with your baby’s doctor. You MUST be your child’s advocate. Afterall, you are with your child most and know your child better than anyone. You are seeing her growth as it occurs minute by minute, day by day. You will likely notice subtle problems that others may not – including the pediatrician/baby doctor. (Jochman, 2021) The pediatrician will perform regular developmental evaluations screening for milestones at each well child visit that are meant to detect developmental delays. Make sure you are attending these regularly scheduled well child visits. If delays are detected, it may be necessary for a referral to be made to a specialist such as pediatric neurologist or pediatric physical medicine including occupational therapist or physical therapist. There may be additional tests needed such as brain imaging, electroencephalogram (EEG), genetic testing, or metabolic testing. Diagnosing CP at an early age is important not only for the child, but also for parents and families. Ultimately, “it is important to communicate with the doctors and follow your gut until you get your answers”. (Jochman, 2021) The key to any good patient care is communication. The key to good pediatric care is communication and listening. If you do not feel your concerns are being heard, it is ok to seek out other medical opinions until your concerns are put at ease or validated.

This article should not be used to diagnose your child.  Rather it should be used as a resource to help you understand how to detect abnormal developmental progressions that may warrant further examination by your child’s health care provider.  Although CP may be a potential cause for your child’s missed milestones, there are many other causes – some that may be overcome in time.  Amy Puls, NP is a practicing Family Medicine Nurse Practitioner and has worked with the pediatric population for over twenty years.  She can be reached at apuls@globalnurseconsulting.com. 

References 

CDC. (2020, December 31). Cerebral Palsy. Retrieved from CDC Centers for Disease Control and Prevention: https://www.cdc.gov/ncbddd/cp/diagnosis.html

Glader, L. M. (2019, October 24). UpToDate. Retrieved from https://www.uptodate.com/contents/cerebral-palsy-evaluation-and-diagnosis?search=cerebral%20palsy%20milestones&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 

Jochman, S. (2021, February 13). Raising a Child WIth Cerebral Palsy. (N. Amy Puls, Interviewer) 

Pathways. (2020). Retrieved from Pathways.org: https://pathways.org/growth-development/4-6-months/milestones/

Poinsett, P. M. (2020, July 19). Perinatal Stroke and Cerebral Palsy. Retrieved from https://www.cerebralpalsyguidance.com/cerebral-palsy/causes/perinatal-stroke/#:~:text=Perinatal%20stroke%20is%20a%20common,them%20also%20had%20cerebral%20palsy

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