Developmental Milestones

This chapter is my least favorite chapter in this book, but it is one of the real reasons I wrote the book. Development has never been one of the things that have really interested me in my career. I have always liked respiratory problems and infectious disease the most, but this is the one area where most parenting books do the most harm. I have scared parents come to my office all the time because the book they read said their baby was supposed to be doing something by now and they are not. They all want to know, “Is something wrong with my baby?” The problem with development is that most skills happen in a range, meaning it can happen between a certain span of ages. For some skills this is a small range, like smiling, for others it could be a large range, like walking. The problem with most parenting books is that they only publish the fiftieth percentile, meaning the point at which 50 percent of children have actually achieved the skill by this time. As a result, when they state your child should be able to do a skill by this age, half the parents feel good about where their baby is in their development and the other half are scared to death. It is true some of those babies might truly be delayed, but the vast majorities are completely normal. This chapter is going to try to explain in general terms when the milestones most parents are worried about should happen, and what we should do, or look for, if they do not.

Tracking eye movements:

Eye tracking is the skill acquired by babies allowing their eyes to work together and follow something moving around the room. When a baby is about two months old they can follow an object for a few seconds. By three to four months your baby should be able to follow you moving around the room although it would not be abnormal for their head to move as they followed the object. After four months if your baby’s eyes are crossing, or they are not able to follow things as they move, then it is time to evaluate their eyes. At this point we would worry about the muscles of the eye not working right or the baby’s vision.

Smile:

A baby’s smile is the most anticipated developmental milestone in the first six months. We all want to see their first smile and we want the first one to be directed toward us. I hear stories of when a baby first smiles and to be honest they are all right…. to a point. Babies can reflexively smile when they are born and will often smile as they are sleeping, passing gas or just wiggling around. The real question is when the baby smiles deliberately. Most of the books will say about two months, which is a good average with the normal range being from about six weeks to three months. Could some babies smile on purpose by a month of age? Of course they could and some will, but the same number of babies will not smile on purpose until five months of age. So how do you tell the difference between a reflexive smile and a social smile? A reflexive smile you will see only in the mouth. A social smile you will see in the baby’s eyes, cheeks and body language. So what does it mean if your baby is not a smiley, social baby? Nothing! Babies who are not very smiley as little tykes might be a regular comedian at a later age and the little barrel of smiles baby could end up being a sour old codger, as they get older. There are no referrals in your future for a non-smiling baby.

Laugh:

As much as a parent looks forward to their little baby giving them a huge toothless grin, they look forward to their baby’s first big old belly laugh even more. Many parents have counted funny sounding burping, gasps and choking sounds as their first laugh. A good rule of thumb for counting their first laugh is when it is accompanied by a real smile. The age range normally quoted for laughing would be two to four months of age. It will happen after your baby has learned to smile. What happens if they do not laugh? Nothing! Again, I have never done a referral to a developmental specialist for a baby who does not laugh on time. Some babies laugh more than others, but it does not mean anything other than those parents get to see their baby laugh more.

Hold their head up:

Your pediatrician is going to ask you this question and you probably won’t know how to answer him/her. The reason is the question is not specific enough. A baby can hold its head up if it is lying on its stomach and you pick it up from birth. By two to three months a baby can start to lift their head off your shoulder for a few moments and turn from side to side. By five to six months the baby should be able to hold their head up on their own for extended periods of time and look around at whatever they want to. I am not even sure which one of these questions your pediatrician is asking, so be sure to ask him/her. The truth is there is a six-month time line for them holding their head up on their own. If your baby cannot hold its head up by this time it is time to talk to your doctor and have a thorough evaluation for a cause.

Rolling over:

Rolling over is going to be your baby’s first major motor skill development. Many people will tell you their baby rolled over by two months of age. This may be true, but in all likelihood it was not on purpose. Babies kick and wiggle around and if all things work together just right they will flip themselves over. This is completely different from a baby wanting to roll over and knowing how to get it done. Most babies will roll over from front to back first and then from back to front. It does not necessarily need to happen in this order, but it is easier for most babies to use their arms to help push themselves up and then over. Most babies will learn to roll over after they have learned to hold their head up well and just a little before they learn to sit up. The average age for this to happen is around four to six months of age. Babies that have broader shoulders and weigh more tend to roll a little slower than the skinny babies. Babies who have spent more time on their bellies learn how to roll over faster just because they have been building up more muscles in their arms and neck as well as having more opportunities. There are babies that skip rolling over and go on to sitting up and crawling but will eventually learn to roll over. By itself not learning this skill at a particular time is no cause for alarm. In combination with other motor skills being delayed, further evaluation might be needed to assess delays. A physical therapist or a neurologist might perform this further evaluation.

Sitting up:

Sitting up is a skill you start working on with your baby at a very early age, the funny thing is you will not even realize you are doing it. Every time you sit them on your lap to burp them, feed them or just hold them, they build up the muscles they need to eventually sit up on their own. By the time a baby is six months of age they should be able to sit with support. This means they will be able to sit by themselves if they are crammed into the corner of a couch or partially supported by pillows. By nine months most babies will be able to sit by themselves and even get themselves into a sitting position. Just like many of the motor skills, not doing this skill on time does not mean much unless it is seen by a delay in other motor milestones. Just like most motor milestones, if a delay is found a referral to physical therapy is made to assess their muscle strength and develop a plan to accomplish the skill. Again if many skills are being delayed, your pediatrician should make a search for the cause.

Crawling:

Crawling is one of the big motor skills we look forward to as parents, wait impatiently for it to happen, and then wonder why we were in such a hurry. The babies are so proud of learning this method of transportation and relish their newfound independence. For the parent, crawling marks the end of peace and calm and the beginning of new messes and danger. The midway point for learning to crawl is often quoted as being around nine months of age. The normal range is between six months and one year of age. There is no advantage to a baby learning to crawl early, nor is it a disadvantage for them to learn to crawl late. Babies often begin rolling over to get to things, start scooting on their bellies in what is called commando crawling, progress to getting up on their hands and knees and rocking back and forth, and finally take off like a bullet. The whole process could take a few days to several months. There are babies who develop a scooting process on their bottoms instead of crawling and some skip crawling completely and go to walking. We would only worry about a baby if they did not have enough strength to push up into a crawling position by the time they were about 9-12 months of age.

Walking:

For most parents—and I was no exception—walking is the high mark in their baby’s development. Those first steps are the stage most looked forward to and the one most cherished by parents. If everything is missed before and after, this is the “step” everyone wants to catch on film or tape and immortalize. It is also the one developmental step everyone turns into bragging rights and wants their child to do earlier than everyone else’s child. Most babies will start off standing while holding on to their parent’s hands as early as six months. Developmentally this skill just means their legs are strong enough to hold up their body weight since the parent is doing the balancing for them by holding their hands. Although this will help build up the strength in their legs needed for walking, this does not necessarily mean they soon will be walking. I commonly quote to parents that a baby will normally walk on their own somewhere between nine and 18 months. About half of the babies will walk by the time they are a year old. If they are 18 months and are not making any progress toward walking, pediatricians start to get worried about a developmental delay. The normal progression toward walking on their own will start with them pulling up against a couch or table. The next step is cruising, where they walk along a piece of furniture while holding on for dear life. They then will start letting go and standing on their own and will even stand up in the middle of the floor without holding on to anything. The next step is a few tottering steps which is then quickly followed by them running a hundred yard dash. I tell parents it is usually about one month from the time they start cruising until they are walking on their own. This is not a hard and fast rule, since some babies seem to be braver than others and some are more cautious and content to just hang on. If your baby is cruising well they probably have all the skills they need to walk on their own, they just lack the courage or desire. They will get there soon enough and then you will want to increase your anxiety medicine.

Going up and down stairs:

It is hard to put a timeline on these skills, as they will vary considerably depending on the age your baby learns to crawl and walk. It also makes sense the baby will want to get flat surfaces figured out first. What will surprise you is how fast your baby will go from first learning to walk to climbing the stairs and trying to kill itself. Babies will first learn to crawl and walk up stairs well before they learn to go downstairs. (I have always thought this area is the one where the developmental order is backwards (for the well-being of the baby). This will of course lead to some dangers, since what goes up must come down. Gravity is sometimes a very hard and painful lesson for your little toddler. Given most babies will walk by themselves by 18 months, most babies are going to be going up stairs by this time as well. They will first need to hold a hand and then will progress to using the wall or handrail. It is not a concern if your baby cannot go upstairs by the age of two without holding on to something. To going downstairs they will start by scooting on their bottoms and then progress to dangerously tottering down by foot. Going downstairs will usually trail going upstairs by two or more months. It is completely fine, and probably a good idea, if your baby has never gone down a flight of stairs by themselves by the time they are two.

Talking:

Parents are always in a hurry for their baby to talk, unless they have other children, and then they realize silence is golden and should last as long as possible. There is a huge range in the normal acquisition of language and I will try to touch on some of this. First, we will go through the normal development of language, then the normal ages each happens, what can cause variations in language development and when we get worried speech is not developing appropriately.

The first speech a baby makes is in the form of a cry and is going to happen soon after their first breath. You will soon become attuned to this form of speaking and realize all cries are not created equal. You will find your baby has a different cry for hunger, pain, sleepiness, fear, and to get your attention. I wish I could teach you this language, but it varies greatly from baby to baby. Thank goodness for the maternal or paternal instincts we were born with. The next stage of language will be gurgling noises the baby makes with its tongue, lips, and nose. Sounds then progress to oohs and goos that sound like they are practicing their vowel sounds. The next step is the addition of consonant sounds combined with the vowels, which is when you will start to hear things like words. These words will be the dada, ma-ma, ba-ba variety and will be accompanied by some excited and competitive parents. The last stage will be where actual words with meaning start to appear. During this last stage babies will add words to their vocabulary and start to experiment with different sounds of the words to mean demands, statements or questions. As this stage progresses the baby starts to combine words to give them even more meaning and truly begins to speak.

The age ranges for the acquisition of language are only estimations. This estimation disclaimer is something commonly left out of parenting books. There are very few absolutes in childhood development and I will mention them as they pertain to language. Babies should start to cry after birth. This is an absolute and if they are not crying the pediatrician needs to find out why. The reasons could vary from not breathing to a condition affecting the vocal cords, and this is something the doctor will find out at a rapid rate of speed. The variations in the sound of crying are often heard soon after birth although you will find your instinctive interpretation may lag behind. Gurgling sounds start around the time a baby learns to smile and laugh, or around six to 12 weeks of age. The vowels follow with most babies cooing in the range of two to four months. The consonant sounds show up from five to nine months and so too are the claims the baby has spoken its first word. By the time a baby is one year of age they will usually have at least two to three words that are real words and have distinct meanings. The 15 month old toddler will usually have between five and 10 words. The 18-month child will have between 10 to 20 words. Most babies really take off between 18 and 24 months and will have up to several hundred words they will link together in two and three word sentences by their second birthday. There are always variations to the norm and these variations can range from normal things that can be easily explained and addressed to problems needing to be pinpointed and taken care of by an appropriate means.

There are some normal variations we see happen all the time. We find girls tend to talk earlier than boys. First-born children acquire words faster than subsequent children. Babies exposed to other babies and children tend to talk earlier than children who stay at home and are not around other children. Twins also tend to talk a little slower, at least in a language their parents can understand, but this is thought to be because they invent their own language to communicate between themselves. Some of the problems can cause delays in speech and include the following: problems in hearing, which could be caused by deafness or temporary problems like ear infections; severe illnesses which lead to prolonged hospitalizations, such as premature babies or illnesses or injuries leading to prolonged intubation or sedation; and Pervasive Developmental Delay, commonly known as autism which can lead to other problems.

With all the above being said, when is your pediatrician going to get worried? We get worried if the baby does not cry after birth. This would not be normal and is something we would want to find a cause of. Some of the things we would check for if this happened would be to make sure the baby was breathing and not acutely ill. We would make sure the vocal cords were working properly; something we would suspect if the baby was acting like they were crying, but no sound was coming out. Finally we would worry something might not be right in the baby’s brain so we would order some tests to look at the brain such as a CT. The next time your pediatrician would worry about speech development is around four to six months if a baby was not making vowel sounds or had stopped making vowel sounds. This could indicate your baby is not hearing well and would prompt them to do a hearing evaluation. The next stage that may cause your pediatrician to worry is when they are two years old and make no attempt to put words together or are not acquiring new words at a rapid rate. This is the time a speech evaluation would be ordered by a speech therapist. This is also one of the times more questions would be asked to evaluate for autism.

Your baby learning to talk is going to be an enjoyable time. It will also be a very short period of enjoyment. It will not take long before they are asking “why?” about everything, answering “no!” to all your questions, and claiming everything is “mine!” This is when you will believe the old adage, “silence is golden”.

Know colors:

There is a good chance your child will know at least one color by the time they are two years old. They will know more by the time they are three, however they may call every color the same thing. Every child has a different color, Dalton’s was green. The funny thing is most of them when asked to go get a particular color will pick out the right one. This is one developmental milestone you can work on with your baby, but it means nothing if they do not know colors by the time they are two.

Know shapes:

This is another one of the developmental milestones you want to start working on with your baby after they are one year old, but they are not necessarily expected to learn them by the time they are two. There will be babies who know shapes by the time they are two, but there are also babies reading by the age of two. Do not worry about them being delayed, just keep practicing by repetition.

Stack blocks:

The question about block stacking is one that gets asked in office visits as a way to assess fine motor skills. The question itself will be, “How many blocks can your child stack on top of each other?” Your answer may depend on whether you have ever given your child blocks to play with. The age at which stacking blocks usually happens is as follows:

• 2 blocks by 15-21 months of age
• 4 blocks by 17-24 months of age
• 6 blocks by 18-36 months of age
• 8 blocks by 24-36 months of age

What happens if your child does not stack blocks? Then it is time to assess fine-motor skills other ways. Assessing how your child picks things up and if they can get objects out of a basket or put things in a box is a way of checking their fine-motor skills. If the baby is not developing fine-motor skills in an appropriate time then they may be referred to an occupational therapist. The therapist will then thoroughly evaluate your child to determine if a delay exists and then formulate a plan if needed to get your child’s development up to age-specific levels.

Learn patty cake:

I put this in here just to be obstinate. Your baby should not really know how to do the motions for the patty cake song in their first two years of life. The reason I have included this topic is so I can tell you a story. I have always thought the patty cake motions and song were silly, therefore I did not teach them to Dalton. One day at his daycare they were doing developmental assessments and we received a note saying he was delayed. I was surprised since I was a pediatrician and had not noticed any delays nor had his regular pediatrician. When we asked what area he was delayed in we learned it was his lack of ability to play patty cake. Sometimes children do not meet a certain milestone just because their parents have not taught them it.

Potty train:

I know you wish this was a normal developmental milestone in the first two years, but it is not. Some of you will be lucky, thanks to the alignment of the planets that your child will be potty trained before they are two years of age. You could buy some help books, punish your child, practice elimination communication or any other of the numerous voodoo ideas out there but most of you will still be waiting until after they are two for your child to be potty trained. If your beloved child happens to be a girl, you will be more likely to be in the lucky group as girls having an average age of potty training around the age of two. If you have a boy who is an early potty trainer before two years old you have been very good. The average age for a little boy to potty train is three years old. Regardless of the age of your child’s potty training the only thing it really means is you get to change more diapers and it’s a good measure of how stubborn your child is.

It is time to start potty training when your child can start to control how often they are peeing and pooping and they show an interest in the toilet or at least a disinterest in their diaper being messy. Girls are easier to potty train because they do not like to be dirty and they love to please their parents. Boys are harder to potty train because they care less if they are dirty and they have better things to do than make their parents happy. I often tell parents never force a little girl to sit on the potty because they are little women and it is only a good idea if it is their idea. When they think it is a good idea, relegate yourself to a cheerleading position and make the potty available and heap on the praise, they will do the rest. If you have a little boy, you almost need to potty train them by gunpoint (dear American Academy of Pediatrics, I did not mean that literally). In the case of a little boy you are just going to have to start taking them to the bathroom and have them try. You may be doing this a couple of times an hour. You will eventually get them there when they have to go. Cheer when it happens and keep it up. They will eventually get the hang of going to the bathroom (getting them to get it in the toilet is a whole different story). For both girls and boys, peeing in the toilet is going to come before the pooping in the toilet (yes I know, it would be nice if it was the other way around).