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Children’s Community Physiotherapy

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Child development

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Positioning

Placing a new born baby in a variety of positions is essential for their physical development. Most of a baby’s day should be spent where they can explore and play on their tummy and their back. This way they will strengthen their muscles, discover their bodies, develop their response to sensations and reactions, and learn to move by themselves with your support for their safety.

Long periods in buggies and car seats should be avoided.

Tummy time

On their tummies, babies will develop their ability to hold their head up, and strengthen the muscles needed for sitting, rolling and crawling. Often babies don’t like this position as it is hard for them to lift their head initially, and they often can’t see you when flat on the floor. Here are some ideas about how to introduce tummy time.

Why lying on your tummy /prone is important:

  • Strengthen neck, back and shoulder muscles
  • Improve head control
  • Progresses to learning to 4 point kneel and crawl

What to check for:

  • Nose and mouth are clear so breathing is not interrupted
  • Head is turned to one side if not able to lift
  • Surface is soft in case head drops suddenly
  • Arms are not trapped under body and are in position ready for forearm prop
  • Hips are apart without crossing of the legs
  • Bottom is relaxed and resting down on the floor

What you may need:

  • A rolled up towel under the upper chest may help with lifting the head
  • Have suitable toys in front to stimulate lifting the head and reaching

Rolling (around six months)

Being able to roll over is often a baby’s first experience of being able to move towards a toy by themselves. Babies usually learn to roll from their front to their back before they learn to roll from their back to their front.

If your baby is having difficulty learning to roll over, you can help them.

Sitting (around six months)

Babies enjoy sitting up to play with toys, and look at their world from a different view instead of being flat on the floor. Babies are often held sitting on parents and carers laps, and as they get older and stronger giving them less and less support when you are holding them will help them to develop their ability to do this by themselves.

But be careful! Babies don’t develop their ability to save themselves with their hands, when falling to the side when sitting (saving reactions) until after they have learnt to sit independently.

Find out more about what you can do to support your baby’s sitting.

Why your sitting position is important:

  • Children need to learn how to sit symmetrically
  • Sitting develops strength of antigravity muscles of the head and trunk
  • Children learn to develop balance by being placed in sitting
  • To see the world from an upright position

What to check for:

  •  Symmetry or at least being able to return to a symmetrical position – once you can be symmetrical then a child learns how to be asymmetrical
  • Avoid w sitting or legs rolling inwards
  • Understand what positon your physiotherapist would like you to use and what to avoid
  •  Offer support where and when needed

Different sitting positions:

  • Long sitting – legs out straight in front. This is good for maintaining the length of the hamstrings muscles but often children cannot tolerate for long periods of time
  • Cross legged sitting – hips apart and legs crossed at ankles
  • Side sitting – check which side your physiotherapist suggests

How to progress:

  • Reaching in all directions
  • Pivoting
  • Moving from sitting to four-point kneel

Moving from lying to sitting

You move your baby frequently throughout the day from lying to a sitting position every time you change their nappy, or pick them up from the floor. For a baby to be able to move from lying to sitting, they will develop good muscle strength in their tummy, back and shoulder muscles, which they need to crawl and walk. As a baby develops their head control and sitting ability, they should start to join in with you, for example every nappy change you can practice.

Babies learn to sit up in 2 different ways

  • On their tummies (usually first)
  • On their backs

Find out more about how to help your baby learn to sit up from lying down.

Crawling (often around nine months)

A baby needs to be happy on their tummy and pushing themselves up on their hands and knees before they can start to crawl.  Sometimes babies commando crawl on their elbows with their legs on the floor, before crawling.

Crawling is excellent for developing muscles and sometimes older children who never learnt to crawl continue to have some weakness in their muscles. Babies need a surface with grip to learn to crawl, such as carpet or a large rug, so they can push themselves without slipping. Sometimes babies who have laminate and wooden flooring at home tend to bottom shuffle instead of crawl which can delay walking.  Once a baby has learnt to crawl, crawling up stairs is a good way of helping babies learn to push up on their feet to get into standing and walking (but always need close supervision for their safety)

 Why crawling is important:

  • Independence and confidence
  • Strengthening muscles
  • Building blocks for improved gross motor skills
  • Develops balance
  • Allows a child to explore their surroundings which gives them the opportunity to learn

What to check for:

  • Head in line with body and looking ahead
  • Body straight and shoulders level
  • Hands under shoulders, with elbows straight fingers open and pointing roughly forwards
  • Knees under hips, and legs parallel

Once your child starts moving it is important that you ‘child proof’ their surroundings, removing articles that may cause them harm.

Ways to progress and challenge:

  • Give them cushions and other soft safe items to crawl over.
  • Give them items to crawl through, under or round to develop their balance and spatial awareness.
  • Help them crawl up or down stairs – ensure they are closely supervised for safely.

Moving to standing

Moving into standing requires babies to be able to sit, move into kneeling, and then pulling up into standing. Being able to complete this movement by themselves is important for babies to be able to then walk. Allowing your baby to pull up on your fingers when sitting (without moving through kneeling) won’t help your baby to be able to complete the movement for themselves.

Why getting up to standing is important:

  • Strengths muscles and bones, and helps the hips develop properly
  • Independence and confidence
  • Building blocks for improved gross motor skills
  • Develops balance
  • Allows a child to explore their surroundings which gives them the opportunity to learn

What to check for:

  • Head upright and in line with body and looking ahead
  • Body straight and shoulders level
  • Knees straight
  • Feet flat on the floor – when babies start to stand, they may spend time up on tiptoes but this should decrease over time.

Once your child starts moving it is important that you ‘child proof’ their surroundings, removing articles that they can reach that may cause them harm.

Ways to progress and challenge:

  • Place toys on the sofa for your baby to reach for and play with
  • Move the toy away from the baby slightly, so that they have to cruise (side step) along the sofa to reach it – make sure you do this in both directions.

Walking

Is the last of the big milestones a baby will achieve, usually within their first 12-18 months, and a much anticipated day by parents. Babies will first cruise around the furniture, walk with push a long walkers, or hands held before taking their first steps.

Why walking is important:

  • Independence and confidence
  • Strengthening muscles
  • Building blocks for improved gross motor skills
  • Develops balance
  • Allows a child to explore their surroundings which gives them the opportunity to learn
  • Strengthen antigravity muscles
  • View the world from an upright position

How to promote walking:

  • Encourage your child to stand at a surface and walk sideways (cruise) to another adjacent surface. You can progressively increase the gap between these surfaces to challenge them further.
  • Encourage the use of a push along walker or brick trolley. We do not advise the ‘sit in’ baby walkers.

What to check for:

  • Symmetry
  • Posture
  • Weight through both legs
  • Hips straight and apart
  • Knees straight
  • Heels down

How to progress:

  • Walk carrying a toy
  • Uneven surfaces
  • Steps and stairs
  • Running
  • Kicking a ball

Baby equipment

Parents often feel the need to buy lots of equipment for a baby, but the following should be avoided or their use kept to very short periods as they do not help a baby to develop physically:

  • Bumbo style seats don’t allow babies to sit by themselves or use their muscles to encourage independent sitting, or then develop their ability to move in and out of sitting.
  • Door bouncers and standing/jumping baby gyms encourage babies to stand on tip toe and arch their backs. Your baby may then find it difficult to learn to sit and be still, and walk with flat feet.
  • Baby walkers allow babies to walk abnormally (often on tip toes), and do not strengthen the muscles needed for sitting, crawling or independent walking.

It is much more important to give a baby a safe space on the floor to roll, crawl and pull themselves up into standing.

Find out more about baby walkers.

Shoes

Babies feet are soft and pliable and if the wrong footwear is worn for long periods of time, it may cause damage and lead to problems later in life. Young children who are not yet walking do not usually need shoes, but you may wish to buy them soft shoes which help to protect the feet when crawling and keep your baby warm when you are outside.

Young children may often have bowing of legs, knock knees, in-toeing or pigeon toes, curly toes and flat feet. These are normal variations and will resolve naturally as the child grows. Children with these conditions need to develop their movement skills through outdoor play activities. Physiotherapy or leg splints/insoles will not alter their leg appearance.

A child can be referred to us if the condition has an impact on their development, functional skills or causes pain.
NOC leaflet – ?can use pics and reference

Flat Feet

 It is common for children to have flat feet: the inner arch in feet may not develop until five to six years. Frequent falls due to flat feet is common in children under four years and physiotherapy is not required. Walking on uneven surfaces (sand, wood chippings, grass, slopes), walking along balance beams and stepping stones help develop foot and ankle muscles needed for balance. See leaflet for more information.

Curly toes/over-riding toes and bunion toes

Physiotherapy or orthotics (insoles) will not help to correct this condition, but parents can stretch the curly toes regularly. This will not cure the condition but it will help to maintain flexibility.

If the condition is causing blisters, rubbing, pain, or muscle/tendon tightness, please seek a referral to the Nuffield Orthopaedic Centre in Oxford.

In-toeing/pigeon toes

This is a common in children, who may have in-toeing either in one or both legs. It is more noticeable between ages four and seven years, and will correct itself naturally as a child grows older. This may take up to 11 years, and physiotherapy will not help or speed up the natural correction.

In-toeing related tripping is common and physiotherapy treatment will not prevent it. ‘W’ sitting (bottom between heels) can make in-toeing worse, and so should be avoided in favour of cross legged sitting instead. See leaflet for more information.

Out-toeing

Out-toeing resolves spontaneously, and physiotherapy treatment will not change this. Your GP can rule out the following medical conditions: Perthes disease, slipped upper femoral epiphysis (SUFE) and developmental dysplasia (dislocation) of the hip (DDH).

Bow legs (Genu Varum)

A small gap between the child’s knees when standing with their feet together is common under two years old and will gradually improve over time.

Knock Knees (Genu Valgum)

A small gap between the child’s ankles (6 – 7 cms) when standing with their knees together is normal: no referral is required, and the conditino will resolve naturally around six years. Helath care practitioners should measure the gap before making any referrals to the Nuffield Orthopaedic Centre.

Toe walking

Children under three years tend to walk on their toes to gain stability. If your child squat down fully to the floor with their heels on the floor, and while standing momentarily, this does indicate they have full calf muscle length. If your child can’t do this, they may benefit from a referral.
  • Where can a child play: Everyday, children need spaces and different places to explore and help them develop their physical skills such as running and jumping. Activities such as soft play, swimming pools and parks provide great opportunities for children to be active and to challenge and develop new skills.
  • Being active: Encourage children to walk and be as active as possible. Playing computer games and watching TV promotes a sedentary lifestyle and should be restricted to short periods. Prolonged periods in car seats and push chairs should be avoided.

What you can do to help children’s physical development

  • Wheels
    Starting with a toddlers scoot a long toy, ride on toys, progressing to trikes, scooters and bikes are all excellent for developing balance, strength
  • Bounce
    Children love trampolines, bouncy castles and space hoppers, which are all great for developing strength and balance, and getting fit
  • Friends
    Children learn by watching and playing with others who are often older than them. Families taking part in activities together are really important in promoting a child’s development. Good opportunities for this include playing games with children in the garden or park.
  • Practice
    Children often need to do something again and again to help them get it right. They might need encouragement if they are getting stuck or reassurance to come back and try again later. It is very tempting to take over and do something for them as it’s quicker, but this won’t help them to learn how to do it next time.

For more ideas, see:

Last updated: 29 August, 2018