Infant Development in Supine: Difference between revisions

No edit summary
No edit summary
 
(24 intermediate revisions by 2 users not shown)
Line 1: Line 1:
<div class="noeditbox">
This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! ({{REVISIONDAY}}/{{REVISIONMONTH}}/{{REVISIONYEAR}})
</div>
<div class="editorbox">
<div class="editorbox">
'''Original Editor '''- [[User:Pam Versfeld|Pam Versfeld]]
'''Original Editor '''- [[User:Pam Versfeld|Pam Versfeld]]
Line 9: Line 5:
</div>  
</div>  
== Introduction ==
== Introduction ==
Time lying supine on a firm flat surface is important because it is the first position that allows infants to independently interact with their environment and learn how to stabilise head and trunk which in turn allows them to use their vision, hands and feet to explore their social and physical environment.  
Time lying supine on a firm, flat surface is important because it is the first position that allows infants to independently interact with their environment and learn how to stabilise their head and trunk. This, in turn, enables them to use their vision, hands and feet to explore their social and physical environment. Treatment interventions and management should focus on encouraging infants with developmental delays to thrive during the early years of their life, as this period is critical for maximising their potential.<ref>Smythe T, Zuurmond M, Tann CJ, Gladstone M, Kuper H. [http://academic.oup.com/inthealth/article/13/3/222/5891235 Early intervention for children with developmental disabilities in low and middle-income countries–the case for action]. International health. 2021 May;13(3):222-31.</ref>  
 
Over the first six to eight months of life, the typically developing infant will learn how to:
 
# Move the head in all directions to scan the environment
# Maintain the head and trunk steady when moving the limbs for reaching and kicking    
# Use the hands to explore their own bodies, clothing and support surfaces
# Reach with hands and feet in increasingly differentiated movement patterns
# Reach to grasp and hold toys
# Anticipate being picked up
# Learn to roll from supine into both sidelying and prone, and back into supine
 
Treatment interventions and management should focus on encouraging infants with developmental delays to thrive during their early years of life, as this period is critical for maximising their potenitial.<ref>Smythe T, Zuurmond M, Tann CJ, Gladstone M, Kuper H. [http://academic.oup.com/inthealth/article/13/3/222/5891235 Early intervention for children with developmental disabilities in low and middle-income countries–the case for action]. International health. 2021 May;13(3):222-31.</ref><blockquote>Important definitions:


* '''Alert and active state''': infants engage in bouts of vigorous spontaneous movements of the limbs
This article describes infant motor development when lying supine on a firm, flat surface. In this article, development in supine is divided into four periods: (1) newborn infant, (2) infant from 1-2 months, (3) infant from 3-4 months and (4) infant from 5-6 months.  
* '''Alert and quiet state''': movement is minimal. The alert but quiet state is often associated with visual attention to the infant's own hand or the face of a social partner and other interesting visual stimuli in the environment.
* '''Writhing movements''': “In the period from birth at term age up to 6–9 weeks of postmenstrual age, general movements are called writhing movements.”<ref name=":1">Doroniewicz I, Ledwoń DJ, Affanasowicz A, Kieszczyńska K, Latos D, Matyja M, Mitas AW, Myśliwiec A. [http://www.mdpi.com/1424-8220/20/21/5986/pdf Writhing movement detection in newborns on the second and third day of life using pose-based feature machine learning classification]. Sensors. 2020 Oct 22;20(21):5986.</ref>
* '''Fidgety movements''': “small movements of moderate speed with variable acceleration of the neck, trunk, and limbs in all directions”<ref>Einspieler C, Peharz R, Marschik PB. Fidgety movements–tiny in appearance, but huge in impact. Jornal de Pediatria. 2016 May;92:64-70.</ref>  in expected development of the infant, "writhing movements are replaced by fidgety movements. These are general, circular movements of small amplitude and variable acceleration throughout the body. They are present continuously in an awake infant” <ref name=":1" />
</blockquote>This article describes infant motor development when lying supine on a firm flat surface. In the article development in supine is divided into 4 periods: (1) newborn infant, (2) infant from 1-2 months, (3) infant from 3-4 months and (4) infant from 5-6 months.  


== Supine Development in the Newborn Infant: 0-4 weeks ==
== Supine Development in the Newborn Infant: 0-4 weeks ==
During the newborn period infants are adapting to the new social and physical environment.  The sensorimotor abilities they acquired while in the buoyant fluid intrauterine environment are harnessed and adapted to the new constraints on movement imposed by gravity and the surfaces they encounter.   
During the newborn period, infants are adapting to their new social and physical environment. The sensorimotor abilities they acquired while in the buoyant, fluid, intrauterine environment are harnessed and adapted to the new constraints on movement imposed by gravity and the surfaces they encounter.   


* weight and movement of the limbs produce reactive forces and momentum which need to be factored into the control of their movements
* Their limbs have weight, and limb movement produces reactive forces and momentum - these need to be factored into the control of their movements
* when awake and alert on a firm surface can respond to visual and auditory events in the environment and actively produce spontaneous movements of the limbs
* When awake and alert on a firm surface, they can respond to visual and auditory events in the environment and actively produce spontaneous movements of the limbs
* observation of and interaction with their surroundings create perception-action loops need to shift from spontaneous exploratory movements to intentional, goal directed actions
* Observation of and interaction with their surroundings create perception-action loops that are the basis for making the shift from spontaneous exploratory movements to intentional, goal-directed actions


=== Limb Movement Synergies at Birth ===
=== Limb Movement Synergies at Birth ===
* lower extremity synergy is characterised by intra-limb coupling of hip and knee flexion or extension  
* The lower extremity synergy is characterised by intra-limb coupling of hip and knee flexion or extension
* upper limb synergy combines shoulder and elbow extension with extension of the fingers and wrist
* The upper limb synergy combines shoulder and elbow extension with extension of the fingers and wrist
 
Over the next few months, as the infant explores different ways of interacting with the environment and the frontal motor areas of their brain become more active, the strong intra-limb coupling lessens. Movement is adapted to allow for effective interaction with the environment.<ref name=":3">Von Hofsten C. Developmental Changes in the Organization of Pre-reaching Movements. Developmental Psychology. 1984;20(3):378-88.</ref>


Intra-limb coupling lessens as the frontal motor areas of the brain become more active with environmental exploration and experimentation.<ref>von Hofsten, C.  (1984). Developmental Changes in the Organization of Pre-reaching Movements. Developmental Psychology 20(3), 378–388.</ref>
=== Behavioural States and General Movements ===
When awake, infants shift between several different states. These states affect the organisation of their spontaneous movements.  


=== Behavioural States and Movement ===
* '''Alert but quiet state''': minimal movement. The alert but quiet state is often associated with the infant's visual attention being focused on their hand, the face of a social partner or other interesting visual stimuli in the environment
When awake infants shift between several different states which affect the organisation of their spontaneous movements.
* '''Alert and active state''': bouts of vigorous, spontaneous limb movements
* '''Distressed state''': movements are ongoing and very vigorous; limb jitters and trembling may be present


* Alert but quiet state: movement is minimal and is often associated with visual attention to own hand, the face of a social partner or other interesting environmental visual stimuli
Einspieler et al.<ref name=":1" /> describe the characteristics of the complex movements that involve the entire body observed in infants from 0-2 months as follows:<blockquote>These writhing general movements "are characterised by a variable sequence of neck, arm, trunk, and leg movements. They wax and wane, varying in intensity, speed, and range of motion, and have a gradual onset and end. Rotations along the axis of the limbs and slight changes in the direction of movement make them appear fluent and elegant and create the impression of complexity and variability.” - Einspieler et al., 2008<ref name=":1">Einspieler C, Marschik PB, Prechtl HFR. Human motor behavior prenatal origin and early postnatal development. Journal of Psychology. 2008;216(3) 148-54. </ref></blockquote>
* Alert and active state: bouts of vigorous spontaneous limb movements
* Distressed state: movements are ongoing and very vigorous, limb jitters and trembling may be present


==== Newborn Head Posture and Movements ====
==== Newborn Head Posture and Movements ====


* generally keeps head turned to one in supine<ref name=":0">Bly L. (1994) Motor Skills Acquisition in the First Year.  </ref>, tends to have a preferred side (typically to the right)<ref>Rönnqvist L, Hopkins B. (1998) Head position preference in the human newborn: a new look. Child Dev. 69(1):13-23. </ref>
* Generally, newborns keep their head rotated to one side in supine,<ref name=":0">Bly L. Motor Skills Acquisition in the First Year, 1994.  </ref> and tend to have a preferred side (typically to the right)<ref>Rönnqvist L, Hopkins B. Head position preference in the human newborn: a new look. Child Dev. 1998;69(1):13-23. </ref>
* neck rotation continues to be associated with neck extension and lateral (external) rotation<ref name=":0" />
* Neck rotation continues to be associated with neck extension and lateral flexion to the contralateral side<ref name=":0" />
* head turning may be associated with an asymmetrical tonic neck reflex (ATNR) posturing
* Can turn the head to the midline and briefly sustain this position:
* can turn the head to midline and briefly sustain the position  
** with visual attention to an interesting person, object or event
** with visual attention to an interesting person, object or event  
** when actively moving limbs or distressed<ref>Cornwell KS, Fitzgerald HE, Harris LJ. On the state‐dependent nature of infant head orientation. Infant Mental Health Journal. 1985;6(3):137-144.</ref>
** when actively moving limbs or distressed <ref>Cornwell, K. S., Fitzgerald, H. E., & Harris, L. J. (1985). On the state‐dependent nature of infant head orientation. Infant Mental Health Journal, 6(3), 137-144.</ref>
* Over the next few weeks, they develop the bilateral, antigravity neck muscle strength and the control needed to counteract the force of gravity and maintain their head in midline for longer periods
** over the next few weeks develop bilateral antigravity neck muscle strength and control needed to counteract the force of gravity and maintain the head in midline for longer periods of time


===== Visual Attention =====
===== Visual Attention =====


* Infants pay attention to interesting objects that come into their field of vision
* From the first few weeks, infants pay attention to interesting objects that come into their field of vision:
** when the head is supported ''in midline'', will look at the face of a caregiver for extended periods of time and will turn the head away when they need a break  
** when their head is supported ''in the midline'', they will look at the face of a caregiver for extended periods; they will turn their head away when they need a break
** when the head is supported, can move the head to bring the social partner's face into the centre of their visual field, and can mirror facial expressions  
** when their head is supported, they can move their head to bring their social partner's face into the centre of their visual field and can mirror facial expressions
* Visual attention is usually associated with cessation of limb movements
* Visual attention is usually associated with the cessation of limb movements
* Engage in sustained visual regard of their own hands tend to pay close attention to the hands of a caregiver
* Infants engage in sustained visual regard of their own hands and tend to pay close attention to the hands of a caregiver
 
==== Newborn Rolling ====
In newborn infants with typical limb stiffness (muscle tone), head turning may initiate partial rolling to the side.  This response may be due to the neonatal neck righting reflex<ref name=":0" /> but may also be because turning of the neck shifts the infant’s weight  laterally which destabilizes the trunk and the infant "'topples"  over to side lying.
 
=== General Movements ===
Extensive research has described the characteristics of the complex movements that involve the entire body observed in infants from 0-2 months. “These movement, referred to a writhing general movements, are characterised by a variable sequence of neck, arm, trunk, and leg movements. They wax and wane, varying in intensity, speed, and range of motion, and have a gradual onset and end. Rotations along the axis of the limbs and slight changes in the direction of movement make them appear fluent and elegant and create the impression of complexity and variability.”<ref>Einspieler, C., Marschik, P. B., & Prechtl, H. F. R. (2008). Human Motor Behavior Prenatal Origin and Early Postnatal Development. Journal of Psychology, 216(3) 148–154. </ref>


=== Lower Limb Posture, Range of Motion and Kicking Actions ===
===== Newborn Rolling =====
In infants born at term range of movement (ROM) of the hips and knees is limited by muscle tightness and increased muscle tone (stiffness) in the lower limb flexor muscles that result from the flexed posture in the restricted space in the uterus in the last weeks of intrauterine life.  The restriction in hip extension is referred to as neonatal hip flexion contracture.  
Typical limb stiffness (muscle tone) in newborns allows head turning to initiate partial rolling into side-lying. This response may be due to the '''neonatal neck righting reflex'''.<ref name=":0" /> It may also be because turning the neck shifts the infant’s weight laterally, which destabilises the trunk, "toppling" them over into side-lying.  


During periods of relative quietening of movement, the hips are flexed, abducted and laterally rotated and the infant lies with the feet lifted up off the supporting surface.  The knees cannot be fully extended and when passively extended they recoil back to a more flexed position.
=== Upper Extremity Posture and Movements ===


Newborn kicking actions are characterized by a decrease in the range of hip flexion, along with some extension of the knee. The ankle remains in dorsiflexion with the toes in flexion. This relative extension of the hip and knee is followed by a return to the more flexed resting position.
* During periods of relative quietening of movement:
** upper arms rest on the supporting surface close to the body, with the shoulders in slight external rotation, the elbows in flexion and the hands slightly open<ref name=":0" />
* Spontaneous movements of the upper limbs: 
** bring the infant's hand into their visual field, and a period of quiet may ensue as the infant pays attention to their hand
** bring the infant's hands into contact with their face and / or hand-to-mouth


=== Upper Limb Posture and Movements ===
* Hand and finger movements:
Bly (1994) states that when the newborn infant is lying quietly, the upper arms rest on the supporting surface close to the body, with the shoulders in slight external rotation, the elbows in flexion and with the hands slightly open.<ref name=":0" />  
** large range of motion (ROM) of the shoulder and elbows is seen, with the fingers opening when the elbow is extended and the fingers flexing with elbow flexion<ref>Von Hofsten C, Rönnqvist L. The structuring of neonatal arm movements. Child Dev. 1993;64(4):1046-57.</ref>
** spontaneous movements of the fingers include (1) grasping and hand opening, (2) pointing with the forefinger, (3) thumb to forefinger, and (4) simultaneous flexion of the forefinger and middle finger, and the ring and little finger
** infants are able to imitate a demonstration of one-, two- and three-finger extension patterns<ref>Nagy E, Pal A, Orvos H. Learning to imitate individual finger movements by the human neonate. Dev Sci. 2014;17(6):841-57.</ref>
** '''palmer grasp reflex (response)''': when gentle pressure is applied to an infant's palm, the infant's fingers flex to hold the examiner's finger. The pressure applied to the palm produces traction on the tendons of the fingers, which encourages the infant to cling to the examiner's finger. The infant's thumb is not affected by this reflex.<ref>Anekar AA, Bordoni B. [https://www.ncbi.nlm.nih.gov/books/NBK553133/#:~:text=The%20response%20to%20this%20stimulus,leading%20to%20the%20clinging%20action. Palmar Grasp Reflex]. 2020.</ref>


Spontaneous movements of the upper limbs often bring the hand into the infant's visual field and a period of quiet may ensue as the infant pays attention to the hand.  
=== Lower Extremity Posture, Range of Motion and Kicking Actions ===
[[File:Neonatal hip flexion contracture .jpg|thumb|Cramped intrauterine environment causing neonatal hip flexion contracture]]
In infants born at full-term, hip and knee ROM is limited by lower extremity flexor muscle tightness and increased muscle tone, which results from the flexed posture assumed in the last weeks of intrauterine life. This hip extension restriction is referred to as '''neonatal hip flexion contracture'''.  


“To test whether newborn babies have voluntary control over their limbs, spontaneous arm-waving movements were measured in the dark while the baby lay supine with its head turned to one side. A narrow beam of light was shone over the baby's nose or chest in such a way that the arm the baby was facing was only visible when the hand encountered the, otherwise, invisible beam of light. The results showed the babies were capable of precisely controlling the position, velocity, and deceleration of their arms so as to keep the hand visible in the light. The findings indicate that newborns can purposely control their arm movements to meet external demands and that the development of visual control of arm movement is underway soon after birth.” <ref>Van der Meer, a L. (1997). Keeping the arm in the limelight: advanced visual control of arm movements in neonates. European Journal of Paediatric Neurology : EJPN : Official Journal of the European Paediatric Neurology Society, 1(4), 103–8. </ref>
* During periods of relative quietening of movement:
** hips are flexed, abducted and laterally (externally) rotated, and feet are lifted off the supporting surface 
** knees cannot be fully extended; when passively extended, they recoil back to a more flexed position


Spontaneous movement of the upper limbs also brings the infant's hands into contact with the face. This is a familiar experience for the infant as hand-to-mouth is a common intrauterine movement pattern.
* Newborn kicking actions are characterised by the following:  
 
** decrease in hip flexion ROM and some knee extension
Large range movements of the shoulder and elbows are seen, with opening of the fingers when the elbow is extended and flexion of the fingers seen with elbow flexion.<ref>von Hofsten C, Rönnqvist L.(1993) The structuring of neonatal arm movements. Child Dev. ;64(4):1046-57</ref>
** ankle remains in dorsiflexion with toes in flexion
 
** after kicking, the infant returns to the more flexed resting position
Spontaneous movements of the fingers are initially mainly grasping and hand opening, but including with increasing frequency a variety of hand postures, including pointing with the forefinger, thumb to forefinger, simultaneous flexion of the forefinger and middle finger, as well as ring and little finger.  
 
Not only do infants move their fingers individually, but a study by Nagy et al (2014) demonstrated that newborn infants are able to imitate a demonstration of one, two and three finger extension patterns.<ref>Nagy E, Pal A, Orvos H. (2014) Learning to imitate individual finger movements by the human neonate. Dev Sci. 17(6):841-57.</ref>
 
Strong finger flexion occurs when the hand is stimulated especially on the ulnar side – known as the palmer grasp response. When traction is applied to the arm, the fingers flex synergistically with the elbow and shoulder.  


== Supine Development in the 1-2 Month Period ==
== Supine Development in the 1-2 Month Period ==
During the 1-2 month period the infant is awake and alert for longer periods of time, increasingly responds to sounds and sights from the environment and gains more control of movements of the head and limbs
During the 1-2 month period, the infant is awake and alert for longer periods, increasingly responds to environmental sounds and sights, and gains more control of head and limb movements.


=== General and fidgety movements ===
=== General and Fidgety Movements ===
General movements continue to be characterized by writhing movements that involve the head, trunk and extremities in the 1-2 month period. However, towards the end of this period fidgety movements (FMs) are increasingly present (Einspieler 2016)
General movements continue to be characterised by writhing movements that involve the head, trunk and extremities, but fidgety movements become increasingly present towards the end of this period.<ref name=":2">Einspieler C, Peharz R, Marschik PB. Fidgety movements–tiny in appearance, but huge in impact. Jornal de Pediatria. 2016 May;92:64-70.</ref>


Einspieler C, Peharz R, Marschik PB. Fidgety movements - tiny in appearance, but huge in impact. J Pediatr (Rio J). 2016 May-Jun;92(3 Suppl 1):S64-70.  
* '''Writhing movements''' are complex and involve the entire body in variable sequences
* '''Fidgety movements''' are "general, circular movements of small amplitude".<ref>Doroniewicz I, Ledwoń DJ, Affanasowicz A, Kieszczyńska K, Latos D, Matyja M, Mitas AW, Myśliwiec A. [https://www.mdpi.com/1424-8220/20/21/5986 Writhing movement detection in newborns on the second and third day of life using pose-based feature machine learning classification]. Sensors. 2020 Oct 22;20(21):5986.</ref> They are moderate speed with variable acceleration of the neck, trunk, and limbs in all directions:
** they may appear as early as six weeks after term, but usually occur from around 9 weeks until 16–20 weeks
** they fade when antigravity and intentional movements begin to dominate
** the presence and character of fidgety movements are good indicators of the integrity of the infant's nervous system<ref name=":2" />


Writhing general movements in a healthy full term infant are described as complex and involve the entire body, notably arm, leg, neck, and trunk movements in variable sequences. They wax and wane, varying in intensity, speed, and range of motion, and have a gradual onset and end.
=== Head Control and Neck Movements ===
[[File:Asymmetrical tonic neck reflex.jpg|thumb|Asymmetrical tonic neck reflex: extension of the arm and leg on the side toward which the infant has turned their head, and flexion of the arm and leg on the opposite side]]
At the beginning of this period, infants still tend to lie in supine:


Rotations around the limb axes and slight changes in the direction of movement create the impression of fluency and elegance.
* they lie with their head turned to one or the other side
* head rotation continues to be associated with some neck extension and lateral rotation
* head turning may also be associated with an [[Asymmetrical Tonic Neck Reflex|'''asymmetrical tonic neck reflex''']] (ATNR) posture


FMs are small movements of moderate speed with variable acceleration of the neck, trunk, and limbs in all directions. They may appear as early as six weeks after term, but usually occur from around 9 weeks until 16–20 weeks, occasionally even a few weeks longer. They fade out when antigravity and intentional movements start to dominate.
By the end of the 1-2 month period:


The presence and character of fidgety movements are good indicators of the integrity of the infant's nervous system (Einspieler 2016).
* infants are more inclined to hold their head in the midline
* they easily turn their head to scan and observe the environment and are able to combine neck rotation with extension of the head to look upwards


Einspieler C, Peharz R, Marschik PB. Fidgety movements - tiny in appearance, but huge in impact. J Pediatr (Rio J). 2016 May-Jun;92(3 Suppl 1):S64-70.
Infants tend to lie with their upper limbs abducted and extended, a position that helps to stabilise the trunk and provide a stable base for head movements and kicking.<ref name=":0" />


=== Head control and neck movements ===
Infants can visually follow an object from the side to the midline and follow an object moving in a downward direction.  
At the beginning of the 1-2 month period the infant still tends to lie supine with the head turned to one or the other side. Head rotation continues to be associated with some neck extension and lateral rotation.


Head turning may be associated with an asymmetrical tonic neck reflex (ATNR) posture, but this is not obligatory.  
=== Upper Extremity Posture and Movements ===
[[File:Fencing position.jpg|thumb|Note the upper extremities in this photo demonstrate the "fencing position."]]
During periods of relative quiet, the one-month-old infant adopts a variety of postures of the upper limbs:


By the end of the 1-2 month period the infant is more inclined to hold the head in the midline and easily turns the head to look at interesting objects and events in the environment.
* abduction of shoulders with upper arms resting on the support surface:
** allows the upper extremities to stabilise the trunk against movements of the head and lower extremities
** this strategy decreases towards the end of this period as infants begin to bring their hands into the midline<ref name=":3" />


At  this age infants tend to lie with the upper limbs abducted and extended, a position that helps to stabilize the trunk and provide a stable base for head movements and kicking (Bly 1994).
Head rotation may be associated with the '''fencing position''' (extension of the elbow on the side to which the infant has turned their head, and flexion of the elbow on the opposite side).  


The infant is also able to combine neck rotation with extension of the head to look upwards.
At the beginning of this period:


However, control of the exact position of the head is clearly still developing, as rotation is usually associated with some neck extension and lateral flexion. This combination of movements suggests that the movement is brought about by contraction of the sternocleidomastoid muscles, with limited action in the deep neck stabilizers (Bly 1994).
* infants produce large-range swiping movements of the upper extremities in supine, which are associated with elbow extension and finger extension
** during these movements, the hand comes close to the object but rarely makes contact


The 1-2 month old infant is able to visually follow an object from the side to the midline, as well as follow an object moved in a downwards direction.  
* over the coming weeks, the infant gains more control over reaching movements - they start to reach towards objects within easy reach with greater success<ref name=":3" />
** they bring their hand close to the toy and use small-range movements of the shoulder and elbow to explore different ways of touching and grasping the toy


=== Upper limb actions in the 1-2 month period ===
By the end of this period:
During periods of relative quiet the one-month-old infant adopts a variety of postures of the upper limbs.  Abduction of the shoulders with the upper arms resting on the support surface is often observed – in this position the upper limbs serve as outriggers and help to stabilize the trunk when moving the head and lower extremities.  Interestingly this co-opting of the upper limbs for a postural function during this period is associated with a decrease in the occurrence of swiping actions  towards objects within reach (von Hofsten 1993).


von Hofsten C, Rönnqvist L. (1993) The structuring of neonatal arm movements. Child Dev. 64(4):1046-57
* infants are better able to steady their head and trunk while reaching with the upper extremities
* they can bring their hand into contact with a toy and explore with their fingers
** this marks the beginning of the ability to stabilise their hand position in space while using independent finger movements to gather information about objects
** visual attention also improves and provides additional information about objects


Head rotation may be associated with the fencing position (extension of the face elbow with flexion of the skull elbow). However this association decreases over the 1-2 month period, and importantly, is never obligatory.  
===== Postural Sway and Stability =====
Exploratory movements allow the postural system to gather the sensory information needed to estimate the position of the body as a whole and explore the most effective strategies to maintain a stable posture.<ref>Dusing SC, Harbourne RT. Variability in postural control during infancy: implications for development, assessment, and intervention. Physical Therapy. 2010;90(12):1838–49.</ref>


The tendency to abduct the shoulders and use the upper limbs as outriggers decreases towards the end of this period when infants start to bring their hands into the midline.  
=== Lower Extremity Posture and Movements ===


At the beginning of the 1-2 month period infants produce large range swiping movements of the upper extremities.  These swiping movements are associated with elbow extension and extension of the fingers. The hand comes close to the object, but mostly does not make contact.
* Supine posture during relative periods of calm: feet rest on the support surface with varying amounts of hip and knee flexion
* Infants at this stage still engage in extended periods of kicking: movement patterns include repeated single-leg kicking with alternate leg kicking and bilateral hip and knee flexion and extension
* Hip and knee movements are still coupled:
** ankles remain in dorsiflexion with intermittent flexion and extension of the toes
** plantar flexion ROM has increased


Over the coming weeks the infant gain more control over reaching movements and starts to reach towards objects within easy reach with greater success.  The extension of the fingers seen in the one month old infant become less pronounced (von Hofsten 1984).
===== Lower Extremity Bridging =====


von Hofsten, C.  (1984). Developmental Changes in the Organization of Pre-reaching Movements. Developmental Psychology 20(3), 378–388.
* From time to time, the infant pushes one or both feet down on the support surface
* Pushing down with one foot is associated with head and trunk extension and lateral weight shift


The infant brings the hand into the proximity of the toy and then uses small range movements of the shoulder and elbow to explore different ways of touching and grasping the toy.  
===== Pull-to-Sit   =====
The infant's response to the pull-to-sit manoeuvre is often used as a test when [[Neonatal Physiotherapy Assessment|assessing motor development]]. It provides a good measure of the infant's neck muscle strength and the development of effective anticipatory postural responses.


Towards the end of this period (10-12 weeks), as the infant's ability to steady the head and trunk when moving the upper limbs becomes more reliable they gain more control of reaching towards toys.  They are able to bring the hand into contact with the toy and start to use the fingers to explore it.  
By the end of the 1-2 month period, infants have learned to anticipate being lifted and will participate in the pull-to-sit manoeuvre by engaging their neck and trunk flexor muscles, stiffening their upper limbs and flexing their hips. The head is held in line with the trunk as the shoulders are lifted.  


This is the start of the ability to stabilise the position of the hand in space and at the same time use independent finger movements to gather information about the texture, structure and behaviour of objects. Visual attention to the toy and the hand provides further information that starts to link what is felt and what is seen.  
Once in the upright position, the head is held erect, and the infant can lift their face to look at the examiner.


=== Exploratory hand movements in the 1-2 month period ===
== Supine Development in the 3-4 Month Period ==
During this period infants continue to use their hands to gather information about the surfaces they encounter.  Contact with a surface is often associated with exploratory movements of the hand across the surface, or repeated flexion and extension of the fingers.


Independent movements of the fingers are also frequently seen, especially when the infant  is socially engaged or is paying attention to an object within reaching distance.  
* Infants at this stage spend more time in an alert, awake state, which allows for more time to observe, explore and interact with the social and physical environment  
* They become aware of their ability to engage caregivers, are learning how to attract their attention, and engage in social interaction using smiles, facial mirroring (imitation) and vocalisation<ref name=":4">Brazelton TB. Touchpoints Birth to Three, 2006.</ref>
* They are better able to self-regulate their levels of arousal as they learn to self-soothe and turn away from visual events that they find unpleasant
* Fidgety movements can still be observed<ref name=":2" />


=== Postural sway and postural stability ===
=== Head Control and Neck Movements ===
Observing an infant during periods of quiet supine lying allows one to observe the postural sway present in the trunk. These exploratory movements allow the postural system to gather the sensory information needed for estimating the position of the body as a whole and explore the most effective strategies to maintain a stable posture (Dusing 2010).


Dusing, S. C., & Harbourne, R. T. (2010). Variability in Postural Control During Infancy: Implications for Development, Assessment, and Intervention. Physical Therapy, 90(12), 1838–1849.
* An infant's ability to maintain their head in the midline becomes fully established, which allows them to visually focus on people and toys presented in the midline
* Infants now easily turn their head through full range of motion, and can keep their head in flexion without associated side flexion. Rotation of the neck does not affect the position of the extremities
* They are also able to rotate and extend their neck to look at an object to the side and above their head
* Flexion of the head on the neck also allows the infant to look down to bring objects that they are holding into the centre of their field of vision for detailed inspection (foveal vision)


=== Lower extremity movements ===
===== Visual Convergence and Tracking =====
The 1-2 month old infant engages in periods of relative calm when the feet rest on the support surface with varying amounts of flexion of the hips and knees.  


The range of ankle plantar flexion has also increased.
* Infants are now able to track an object moved from one side to the other across the midline
* Tracking upwards is also present, but tracking downward is less consistent


The 1-2  month old still engages in extended periods of kicking. Movement patterns include repeated single leg kicking with alternate leg kicking and bilateral hip and knee flexion and extension.
===== Being Lifted =====
Infants increasingly anticipate being lifted when they see their caregiver preparing to pick them up. The caregivers's intention is signalled by their hands moving towards the infant's chest who in turn starts to recruit their neck and trunk muscles in anticipation of being lifted.<ref>Reddy V, Markova G, Wallot S. Anticipatory adjustments to being picked up in infancy. PLoS ONE. 2013;8(6):e65289.</ref>


At this age hip and knee movements are still coupled. The ankles remain in dorsiflexion with intermittent flexion and extension of the toes.
* As the infant's neck strength increases, caregivers provide less neck support while lifting the infant
* Infants tend to have improved control of neck lateral flexion and extension than flexion against gravity
* Turning infants as they are lifted allows them to maintain control of the position of their head


=== Lower limb bridging during the 1-2 month period ===
===== Pull-to-Sit =====
From time to time one or both feet push down on the support surface. Pushing down with one foot is associated with head and trunk extension and lateral weight shift.


=== Pull-to-sit   ===
* Infants increasingly anticipate being lifted from supine into sitting when the caregiver grasps and pulls on their hands: 
The infant's response to the pull-to-sit (PTS) manoeuvre is often used as a test when assessing motor development. It provides a good measure of the infant's neck muscle strength as well as the development of effective anticipatory postural responses.
** infants flex their neck and trunk, recruit their upper extremity muscles in response to the traction on their hands, and lift the lower extremities off the support surface
* When tipped backwards from sitting, infants can flex their neck to control the position of their head as their torso is lowered to the support surface


By the end of the 1-2 month period, infants have learned to anticipate being lifted and will participate in the PTS manoeuvre by engaging the neck and trunk flexor muscles, stiffening the upper limbs and flexing the hips.  
===== Postural Stability =====
When supine on a firm, flat surface, infants are very active, with repeated bouts of kicking, reaching for toys within easy reach, and actively using their hands and feet to explore the surrounding surfaces and their bodies. They are very curious and turn their heads to look at interesting and novel events in the environment.  


The head is held in line with the trunk as the shoulders are lifted.
* This activity is important for strengthening the trunk and limb muscles. Moreover, infants with high activity levels of the upper extremities, as measured by full-day wearable sensors, have been shown to have higher cognitive, language and motor scores<ref>Shida-Tokeshi J, Lane CJ, Trujillo-Priego IA, Deng W, Vanderbilt DL, Loeb GE, Smith BA. Relationships between full-day arm movement characteristics and developmental status in infants with typical development as they learn to reach: An observational study. Gates open research. 2018;2:17. </ref>
* This period also sees an increasing ability to stabilise the trunk when moving the extremities, which allows the infant more control to engage in intentional and goal-directed reaching and exploratory movements of the hands and feet


Once in the upright position the head is held erect, and the infant is able to lift the face to look at the person who has pulled him into sitting.
=== Upper Extremity Posture and Movements ===
During periods of relative quiet, 3-4-month-old infants adopt a variety of postures of the upper limbs, sometimes with their shoulders in abduction and their extremity held away from the torso, but frequently with the hands together in the midline.  


== Supine during the 3-4 month period (12-21 weeks) ==
Hands together in midline:
During the 3-4 month period infants spend more time in an alert awake state than before, allowing for more time to observe, explore and interact with the social and physical environment  


Socially they are becoming aware of their ability to engage parents and other family members, are learning how to attract their attention and keep the social interaction going using smiles, facial mirroring (imitation) and vocalization.
* infants will visually inspect their hands for long periods
* this visual attention is aided by the infant's ability to flex their head on their neck and, at the same time, look downwards to bring their hands into the centre of their field of vision for a clearer view
* reaching towards a toy presented in the midline is bilateral, with one hand usually making contact before the other


Their innate curiosity coupled with the ability to see clearly over longer distance draws them to paying attention to people and events in the environment. (Brazelton2006).  
=== Lower Extremity Posture and Movements ===
3-4-month-old infants have acquired the ability to move their lower extremities in a variety of ways due to their ability to flex and extend their hips and knees in different combinations.


Brazelton TB (2006) Touchpoints Birth to Three
In supine, during periods of relative quiet:


The 3-4 month old infant’s ability to self-regulate their levels of arousal is improving as they learn to self-soothe and turn away from visual events that they find unpleasant.  When used, they start to  retrieve a pacifier and return it to the mouth.  
* infants may lie with their hips and knees flexed, with their feet lifted off the support surface - this is associated with posterior pelvic tilt
* hip flexion and extension are associated with some hip abduction


== General and fidgety movements in the 3-4 month peiod ==
By the end of this period:
At this age fidgety movements (FMs) can still be observed. FMs are small movements of moderate speed with variable acceleration of the neck, trunk, and limbs in all directions They may appear as early as six weeks after term, but usually occur from around 9 weeks until 16–20 weeks, occasionally even a few weeks longer. They fade out when antigravity and intentional movements start to dominate. (Einspieler  2016)  


Einspieler C, Peharz R, Marschik PB. Fidgety movements - tiny in appearance, but huge in impact. J Pediatr (Rio J). 2016 May-Jun;92(3 Suppl 1):S64-70.
* hip extension ROM increases 
* hip abduction ROM in extension decreases
* crossing legs at the feet is frequently seen


=== Head control and neck movements ===
===== Bridging =====
During the 3-4 month period the infant's ability to maintain the head in the midline becomes fully established. This allows them to visually focus on people and toys presented in the midline.
The infant will often put one or both feet flat on the support surface with their knees flexed:


The infant has learned to flex the head on the neck as the deep neck stabilizer muscles become more active and are able to balance the activity of the sternocleidomastoid muscles (which tends to extend the neck with bilateral activation).
* pushing down on the support surface with both feet does not yet result in lifting the buttocks up (bridging)
* pushing down with one foot leads to extension of the ipsilateral hip with forward rotation of the pelvis; this action may initiate rolling to the side


Flexion of the head on the neck also allows the infant to look down to bring objects that are held in the hands into the centre of the field of vision for detailed inspection (foveal vision).
===== Kicking =====


The infant now easily turns the head through full range of motion, keeping the head in flexion, without associated side flexion seen at an earlier age. Rotation of the neck does not affect the position of the extremities.
* Periods of repeated unilateral and reciprocal kicking continue at this stage
* the trunk is held steady and is symmetrical during periods of active kicking


The infant is also able to rotate and extend the neck to look at an object to the side and above the head.
===== Foot Movements =====


=== Being lifted ===
* Infants bring their feet together and engage in exploratory ankle movement
During the 3-4 month period infants increasingly anticipate being lifted when they see the caregiver preparing to pick them up. This caregivers's intention is signalled by their hands moving towards the infant's chest who in turn starts to recruit the neck and trunk muscles in anticipation of being lifted (Reddy 2013)..
* Isolated ankle dorsiflexion and plantar flexion movements are frequently seen


Reddy, V., Markova, G., & Wallot, S. (2013). Anticipatory Adjustments to Being Picked Up in Infancy. PLoS ONE, 8(6), e65289
===== Rolling =====


As the infant's neck strength increases,  caregivers provide less support for the neck when they lift the infant. The infant tends to have better control of neck lateral flexion and extension than flexion against gravity. Turning infants as they are lifted allows them to maintain control of the position of the head.      
* Rolling from supine to side-lying becomes more frequent
* Infants use a variety of patterns to initiate rolling


=== Pull-to-sit ===
== Supine Development in the 5-6 Month Period ==
Increasingly infants anticipate being lifted from supine into sitting when the caregiver grasps and pulls on their hands.  (This pull-to-sit manoeuvre is often used to assess head control.) The infant flexes the neck and trunk, recruits the upper limb muscles in response to the traction on hands, and lifts the lower limbs up off the support surface.


When tipped backwards from sitting the infant is able to flex the neck  to control the position of the head as the torso is lowered.
* At this stage, an infant's behaviour and actions become more intentional and goal-oriented (e.g. using hands and feet to explore objects and surfaces)
* Infants become increasingly aware of their ability to initiate social encounters and know how to attract and maintain the attention of social partners<ref name=":4" />
* Infants are increasingly able to adapt postural alignment, stability and movements to achieve a desired goal
* Infants become more mobile as they learn to roll from supine to prone and start to use this mobility to move around on a supportive surface


=== Looking, visual convergence and tracking ===
===== Emerging Abilities During this Period =====
The infant is now able to track an object moved from one side to the other across the midline.  Tracking a moving upwards is also present, with downward tracking being less consistent.
* Improved ability to steady the trunk when the limbs are moving
* Increasing hip and trunk flexor muscle strength, which allows the infant to lift both feet off the support surface in a sustained manner
* Posterior pelvic tilt is associated with bilateral hip flexion, which allows the infant to reach for their feet and bring one foot to their mouth
* Uncoupling of hip and knee flexion allows for increased ability to perform isolated movements of the lower extremity joints
* Increased control while reaching for objects
* Increasing ability to hold an object with one hand and explore its properties with the other
* Emerging tendency to bang and shake toys and pass them from one hand to the other
* Prominence of exploratory movements of the hands and feet
* Ability to actively initiate and control rolling from supine to side-lying and prone


=== Kicking and reaching in supine contribute to head and trunk stability ===
=== Head and Trunk Stability ===
When placed in supine on a firm flat surface healthy typically developing infants are very active, with repeated bouts of kicking, reaching for toys within easy reach and actively using the hands and feet to explore the surrounding surfaces and their own bodies. They are very curious and eager to know what is going on around them turns their heads to look at interesting and novel events in the environment.


This activity is important for strengthening trunk and limb muscles. Infants with high activity levels of the upper limbss as measured by full-day wearable sensors have been shown to have higher  cognitive, language and motor scores (Shida-Tokeshi, 2018).
* At this stage, infants have full neck rotation ROM
* They can visually follow a moving object in all directions, including from one side to the other and across the midline


Shida-Tokeshi, J., Lane, C. J., Trujillo-Priego, I. A., Deng, W., Vanderbilt, D. L., Loeb, G. E., & Smith, B. A. (2018). Relationships between full-day arm movement characteristics and developmental status in infants with typical development as they learn to reach: An observational study. Gates open research, 2, 17.
* Head-on-neck flexion is well established and allows the infant to watch their hands while reaching for or manually inspecting a toy held in midline above the chest
* They are able to keep their head and trunk steady when moving the extremities, which allows for more control of intentional upper extremity movements and holding


This period also sees an increasing ability to stabilise the trunk when moving the extremities allows the infant more control over their increasing tendency to engage in intentional and goal directed reaching and exploratory movements of the hands and feet.  
=== Lower Extremity Posture and Movements ===
In supine, during periods of relative quiet:


=== Upper extremity and hand actions ===
* infants lie with their feet resting on the support surface, particularly when engaged with a toy or observing the environment
During moments of relative quiet 3-4 month old infants assume a variety of upper limb postures, sometimes with the shoulders in abduction and the extremity held away from the torso but frequently with the hands together in the midline.  
* they often lie with both hips flexed, commonly with knee flexion. Hip flexion ROM increases with improving trunk muscle strength and control of posterior pelvic tilt
* they start to reach for and grab their feet


The tendency to bring the hands together in the midline is particularly prominent at the beginning of the 3-4 month period.  Infants will visually inspect them for long periods of time.  This visual attention is aided by the infant's ability to flex the head on the neck and at the same time look downwards to bring the hands into the centre of the field of vision for a clearer view.
===== Kicking =====


Reaching towards a toy presented in the midline is bilateral, with one hand usually making contact before the other.
* Infants continue to move their lower limbs vigorously, using a variety of patterns, including (1) reciprocal kicking movements, (2) bilateral hip and knee flexion, and (3) bilateral hip and knee extension


=== Lower limb actions ===
===== Bridging =====
The 3-4 month old infant has acquired the ability to move the lower limbs in a variety of ways that reflect the ability to flex and extend the hips and knees in different combinations. This ability to disassociate hip and knee movements differs from the tendency for the strong intra-limb association in 1-2 month old infant.


==== LE posture during periods of relative quiet ====
* With both feet on the support surface, infants begin to lift their buttocks off the support surface (into a bridge)
During periods of relative quiet the 3-4 month old infant may lie with the hips and knees flexed, with the feet lifted up off the support surface (SS). This is associated with posterior pelvic tilt.  At this time hip flexion and extension are associated with some hip abduction.


Over the next weeks the range of hip extension increases and hip abduction in extension decreases. Crossing of the feet is frequently seen.
===== Rolling =====
The 3-4 month infant will often put one of both feet flat on the support surface with the knees flexed.  Pushing down on the support surface with both feet does not yet result in lifting the buttocks up (bridging).
* Infants become progressively more adept at rolling from supine to prone
Pushing down with one foot leads to extension of the ipsilateral hip with forwards rotation of the pelvis.  This action may initiate rolling to the side.
* They explore different options for initiating rolling


Periods of repeated unilateral and reciprocal kicking are still seen. The trunk is held steady and is symmetrical during periods of active kicking.  
== Atypical Development and Developmental Delay ==
Typical infant development occurs via an interaction between the development of the nervous system and various organ systems and stimulation from the infant's social and physical environment.<ref>Brown KA, Parikh S, Patel DR. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082247/ Understanding basic concepts of developmental diagnosis in children]. Translational pediatrics. 2020 Feb;9(Suppl 1):S9.</ref> Infants who demonstrate atypical or developmental delay tend to be (1) less physically active, and (2) lack movement repetition. Therefore, they miss opportunities for motor learning and sensory integration.


=== Foot movements ===
To learn more about paediatric diagnoses which can cause developmental delays, please review the following Physiopedia Pages:
The 3-4 month infant also brings the feet together and engages in exploratory ankle movement. Isolated ankle dorsi- and plantar flexion movements are frequently seen.  


=== Rolling ===
* [[Low Functioning Cerebral Palsy Physiotherapy Assessment and Intervention|Cerebral Palsy]]
Rolling from supine to lying on the side is becoming more frequent.  The infant uses a variety of patterns to initiate rolling. In the sequence of frames below you see Will initiating rolling  by reaching across the body to reach a toy. As he brings his arm forwards he extends his neck and trunk. At the same time he pushes away with his right foot which helps to shift his weight to the left.
* [[Down Syndrome Developmental Milestones and Physical Activity|Down Syndrome]]
* [[Muscular Dystrophy]]
* [[Prematurity and High-Risk Infants|Preterm Birth]]


== Supine in the 5-6 month period (20-28 weeks ==
The management and treatment of developmental delay should be an interdisciplinary team effort. The team should include primary care providers, neurologists, developmental and behavioural paediatricians, speech and language therapists (pathologists), occupational therapists, physiotherapists, and nutritionists. Treatment strategies are usually multi-modal<ref>Khan I, Leventhal BL. [https://europepmc.org/books/nbk562231 Developmental delay]. 2020.</ref> and often require input from multiple medical and rehabilitation disciplines, with strong family support.
During the 5-6 month period infants' behaviour and actions are becoming more intentional and goal oriented. They become increasingly aware of their ability to initiate social encounters and know how to attract and maintain the attention of social partners ( Brazelton 2006)


Brazelton TB (2006) Touchpoints Birth to Three
== Resources  ==
 
The use of their hands and feet to explore surfaces and objects becomes more focused and intentional.
 
The 5-6 month period is characterized by an increasing ability adapt their postural alignment and stability, and their movements to achieve a desired goal.  
 
During this period the infant also becomes more mobile as they learn to roll from supine to prone and start to use this mobility to move around in the cot and on the floor.
 
=== Emerging abilities during this period ===
 
* Improved ability to steady the trunk when the limbs are moved.
* Increasing strength in the hip and trunk flexor muscles which allows the infant to lift both feet up off the support surface in a sustained manner.
* Posterior pelvic tilt is associated with bilateral hip flexion which allows the infant to reach for the feet and bring one foot to the mouth.
* Increasing ability to perform isolated movements of the lower limb joints, with uncoupling of hip and knee flexion.
* Increasing control of reaching for objects and the ability to hold an object with one hand and explore its properties with the other hand.
* Emerging tendency to bang and shake toys and pass them from one hand to the other.
* Prominence of exploratory movements of the hands and feet - also reflecting the ability to adapt movement of the limbs to suit the task and the ability to more isolated movements of the distal segments.
* Ability to actively initiate and control rolling from supine to side lying and prone.
 
=== Head and trunk stability ===
The 5-6 month infant has full range of neck rotation and can visually follow a moving object in all directions, including from one side to the other, and across the midline.
 
Head-on-neck flexion is well established and allows the infant to watch the hands when reaching for, or manually inspecting, a toy in held in the midline above the chest.
 
The 5-6 month infant is able to keep the head and trunk steady when moving the limbs. This allows for more control of intentional upper limb reaching movements towards an object, as well as holding and manipulating objects.
 
=== Lower limb actions in supine ===
Active 5-6 month infants continue to move the lower limbs vigorously, using a variety of patterns, including reciprocal kicking movements, bilateral hip and knee flexion, and bilateral hip and knee extension.
 
Some of the time the infant lies with the feet resting on the support surface, particularly when engaged with a toy or when watching what is happening in the environment.


At other times, when the general level of arousal is higher, the legs cycle through a variety of postures with the feet lifted up off the support surface. These kicking actions are associated with trunk muscle activity to stabilise the trunk.
==== Optional Additional Reading: ====
 
With both feet on the support surface the infant is starting to lift the buttocks up off the surface (bridge).
 
Another pattern frequently seen is bilateral flexion of the hips, in most instances associated with knee flexion, but sometimes with knee extension. The range of hip flexion increases with increasing trunk muscle strength and control of posterior pelvic tilt.
 
Infants start to reach for, and grab their feet.
 
=== Rolling ===
During the 5-6 month period infants become progressively more adept at rolling from supine to prone. They explore different options for initiating rolling. Lifting the lower limbs and toppling over is one option.
 
The difficult part of rolling is lifting the head and trunk to free the arm that is trapped under the torso as the body moves through side lying into prone.
 
This is achieved by initiating side flexion of the head and trunk against gravity, lifting the torso and freeing the upper limb to move forwards as the infant moves from through side lying into prone.
 
== Resources  ==
*bulleted list
*x
or


#numbered list
* Dusing SC, Thacker LR, Stergiou N, Galloway JC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3496827/ Early complexity supports development of motor behaviors in the first months of life.] Developmental psychobiology. 2013 May;55(4):404-14.
#x
* Einspieler C, Peharz R, Marschik PB. [https://scholar.google.com/scholar?output=instlink&q=info:x-oP6ceMmdkJ:scholar.google.com/&hl=en&as_sdt=0,44&scillfp=17226233611725422657&oi=lle Fidgety movements–tiny in appearance, but huge in impact]. Jornal de Pediatria. 2016 May;92:64-70.


== References  ==
== References  ==


<references />
<references />
[[Category:ReLAB-HS Course Page]]
[[Category:Paediatrics]]
[[Category:Course Pages]]
[[Category:Rehabilitation]]

Latest revision as of 10:05, 12 February 2024

Original Editor - Pam Versfeld

Top Contributors - Stacy Schiurring and Jess Bell  

Introduction[edit | edit source]

Time lying supine on a firm, flat surface is important because it is the first position that allows infants to independently interact with their environment and learn how to stabilise their head and trunk. This, in turn, enables them to use their vision, hands and feet to explore their social and physical environment. Treatment interventions and management should focus on encouraging infants with developmental delays to thrive during the early years of their life, as this period is critical for maximising their potential.[1]

This article describes infant motor development when lying supine on a firm, flat surface. In this article, development in supine is divided into four periods: (1) newborn infant, (2) infant from 1-2 months, (3) infant from 3-4 months and (4) infant from 5-6 months.

Supine Development in the Newborn Infant: 0-4 weeks[edit | edit source]

During the newborn period, infants are adapting to their new social and physical environment. The sensorimotor abilities they acquired while in the buoyant, fluid, intrauterine environment are harnessed and adapted to the new constraints on movement imposed by gravity and the surfaces they encounter.

  • Their limbs have weight, and limb movement produces reactive forces and momentum - these need to be factored into the control of their movements
  • When awake and alert on a firm surface, they can respond to visual and auditory events in the environment and actively produce spontaneous movements of the limbs
  • Observation of and interaction with their surroundings create perception-action loops that are the basis for making the shift from spontaneous exploratory movements to intentional, goal-directed actions

Limb Movement Synergies at Birth[edit | edit source]

  • The lower extremity synergy is characterised by intra-limb coupling of hip and knee flexion or extension
  • The upper limb synergy combines shoulder and elbow extension with extension of the fingers and wrist

Over the next few months, as the infant explores different ways of interacting with the environment and the frontal motor areas of their brain become more active, the strong intra-limb coupling lessens. Movement is adapted to allow for effective interaction with the environment.[2]

Behavioural States and General Movements[edit | edit source]

When awake, infants shift between several different states. These states affect the organisation of their spontaneous movements.

  • Alert but quiet state: minimal movement. The alert but quiet state is often associated with the infant's visual attention being focused on their hand, the face of a social partner or other interesting visual stimuli in the environment
  • Alert and active state: bouts of vigorous, spontaneous limb movements
  • Distressed state: movements are ongoing and very vigorous; limb jitters and trembling may be present

Einspieler et al.[3] describe the characteristics of the complex movements that involve the entire body observed in infants from 0-2 months as follows:

These writhing general movements "are characterised by a variable sequence of neck, arm, trunk, and leg movements. They wax and wane, varying in intensity, speed, and range of motion, and have a gradual onset and end. Rotations along the axis of the limbs and slight changes in the direction of movement make them appear fluent and elegant and create the impression of complexity and variability.” - Einspieler et al., 2008[3]

Newborn Head Posture and Movements[edit | edit source]

  • Generally, newborns keep their head rotated to one side in supine,[4] and tend to have a preferred side (typically to the right)[5]
  • Neck rotation continues to be associated with neck extension and lateral flexion to the contralateral side[4]
  • Can turn the head to the midline and briefly sustain this position:
    • with visual attention to an interesting person, object or event
    • when actively moving limbs or distressed[6]
  • Over the next few weeks, they develop the bilateral, antigravity neck muscle strength and the control needed to counteract the force of gravity and maintain their head in midline for longer periods
Visual Attention[edit | edit source]
  • From the first few weeks, infants pay attention to interesting objects that come into their field of vision:
    • when their head is supported in the midline, they will look at the face of a caregiver for extended periods; they will turn their head away when they need a break
    • when their head is supported, they can move their head to bring their social partner's face into the centre of their visual field and can mirror facial expressions
  • Visual attention is usually associated with the cessation of limb movements
  • Infants engage in sustained visual regard of their own hands and tend to pay close attention to the hands of a caregiver
Newborn Rolling[edit | edit source]

Typical limb stiffness (muscle tone) in newborns allows head turning to initiate partial rolling into side-lying. This response may be due to the neonatal neck righting reflex.[4] It may also be because turning the neck shifts the infant’s weight laterally, which destabilises the trunk, "toppling" them over into side-lying.

Upper Extremity Posture and Movements[edit | edit source]

  • During periods of relative quietening of movement:
    • upper arms rest on the supporting surface close to the body, with the shoulders in slight external rotation, the elbows in flexion and the hands slightly open[4]
  • Spontaneous movements of the upper limbs:
    • bring the infant's hand into their visual field, and a period of quiet may ensue as the infant pays attention to their hand
    • bring the infant's hands into contact with their face and / or hand-to-mouth
  • Hand and finger movements:
    • large range of motion (ROM) of the shoulder and elbows is seen, with the fingers opening when the elbow is extended and the fingers flexing with elbow flexion[7]
    • spontaneous movements of the fingers include (1) grasping and hand opening, (2) pointing with the forefinger, (3) thumb to forefinger, and (4) simultaneous flexion of the forefinger and middle finger, and the ring and little finger
    • infants are able to imitate a demonstration of one-, two- and three-finger extension patterns[8]
    • palmer grasp reflex (response): when gentle pressure is applied to an infant's palm, the infant's fingers flex to hold the examiner's finger. The pressure applied to the palm produces traction on the tendons of the fingers, which encourages the infant to cling to the examiner's finger. The infant's thumb is not affected by this reflex.[9]

Lower Extremity Posture, Range of Motion and Kicking Actions[edit | edit source]

Cramped intrauterine environment causing neonatal hip flexion contracture

In infants born at full-term, hip and knee ROM is limited by lower extremity flexor muscle tightness and increased muscle tone, which results from the flexed posture assumed in the last weeks of intrauterine life. This hip extension restriction is referred to as neonatal hip flexion contracture.

  • During periods of relative quietening of movement:
    • hips are flexed, abducted and laterally (externally) rotated, and feet are lifted off the supporting surface 
    • knees cannot be fully extended; when passively extended, they recoil back to a more flexed position
  • Newborn kicking actions are characterised by the following:
    • decrease in hip flexion ROM and some knee extension
    • ankle remains in dorsiflexion with toes in flexion
    • after kicking, the infant returns to the more flexed resting position

Supine Development in the 1-2 Month Period[edit | edit source]

During the 1-2 month period, the infant is awake and alert for longer periods, increasingly responds to environmental sounds and sights, and gains more control of head and limb movements.

General and Fidgety Movements[edit | edit source]

General movements continue to be characterised by writhing movements that involve the head, trunk and extremities, but fidgety movements become increasingly present towards the end of this period.[10]

  • Writhing movements are complex and involve the entire body in variable sequences
  • Fidgety movements are "general, circular movements of small amplitude".[11] They are moderate speed with variable acceleration of the neck, trunk, and limbs in all directions:
    • they may appear as early as six weeks after term, but usually occur from around 9 weeks until 16–20 weeks
    • they fade when antigravity and intentional movements begin to dominate
    • the presence and character of fidgety movements are good indicators of the integrity of the infant's nervous system[10]

Head Control and Neck Movements[edit | edit source]

Asymmetrical tonic neck reflex: extension of the arm and leg on the side toward which the infant has turned their head, and flexion of the arm and leg on the opposite side

At the beginning of this period, infants still tend to lie in supine:

  • they lie with their head turned to one or the other side
  • head rotation continues to be associated with some neck extension and lateral rotation
  • head turning may also be associated with an asymmetrical tonic neck reflex (ATNR) posture

By the end of the 1-2 month period:

  • infants are more inclined to hold their head in the midline
  • they easily turn their head to scan and observe the environment and are able to combine neck rotation with extension of the head to look upwards

Infants tend to lie with their upper limbs abducted and extended, a position that helps to stabilise the trunk and provide a stable base for head movements and kicking.[4]

Infants can visually follow an object from the side to the midline and follow an object moving in a downward direction.

Upper Extremity Posture and Movements[edit | edit source]

Note the upper extremities in this photo demonstrate the "fencing position."

During periods of relative quiet, the one-month-old infant adopts a variety of postures of the upper limbs:

  • abduction of shoulders with upper arms resting on the support surface:
    • allows the upper extremities to stabilise the trunk against movements of the head and lower extremities
    • this strategy decreases towards the end of this period as infants begin to bring their hands into the midline[2]

Head rotation may be associated with the fencing position (extension of the elbow on the side to which the infant has turned their head, and flexion of the elbow on the opposite side).

At the beginning of this period:

  • infants produce large-range swiping movements of the upper extremities in supine, which are associated with elbow extension and finger extension
    • during these movements, the hand comes close to the object but rarely makes contact
  • over the coming weeks, the infant gains more control over reaching movements - they start to reach towards objects within easy reach with greater success[2]
    • they bring their hand close to the toy and use small-range movements of the shoulder and elbow to explore different ways of touching and grasping the toy

By the end of this period:

  • infants are better able to steady their head and trunk while reaching with the upper extremities
  • they can bring their hand into contact with a toy and explore with their fingers
    • this marks the beginning of the ability to stabilise their hand position in space while using independent finger movements to gather information about objects
    • visual attention also improves and provides additional information about objects
Postural Sway and Stability[edit | edit source]

Exploratory movements allow the postural system to gather the sensory information needed to estimate the position of the body as a whole and explore the most effective strategies to maintain a stable posture.[12]

Lower Extremity Posture and Movements[edit | edit source]

  • Supine posture during relative periods of calm: feet rest on the support surface with varying amounts of hip and knee flexion
  • Infants at this stage still engage in extended periods of kicking: movement patterns include repeated single-leg kicking with alternate leg kicking and bilateral hip and knee flexion and extension
  • Hip and knee movements are still coupled:
    • ankles remain in dorsiflexion with intermittent flexion and extension of the toes
    • plantar flexion ROM has increased
Lower Extremity Bridging[edit | edit source]
  • From time to time, the infant pushes one or both feet down on the support surface
  • Pushing down with one foot is associated with head and trunk extension and lateral weight shift
Pull-to-Sit  [edit | edit source]

The infant's response to the pull-to-sit manoeuvre is often used as a test when assessing motor development. It provides a good measure of the infant's neck muscle strength and the development of effective anticipatory postural responses.

By the end of the 1-2 month period, infants have learned to anticipate being lifted and will participate in the pull-to-sit manoeuvre by engaging their neck and trunk flexor muscles, stiffening their upper limbs and flexing their hips. The head is held in line with the trunk as the shoulders are lifted.

Once in the upright position, the head is held erect, and the infant can lift their face to look at the examiner.

Supine Development in the 3-4 Month Period[edit | edit source]

  • Infants at this stage spend more time in an alert, awake state, which allows for more time to observe, explore and interact with the social and physical environment  
  • They become aware of their ability to engage caregivers, are learning how to attract their attention, and engage in social interaction using smiles, facial mirroring (imitation) and vocalisation[13]
  • They are better able to self-regulate their levels of arousal as they learn to self-soothe and turn away from visual events that they find unpleasant
  • Fidgety movements can still be observed[10]

Head Control and Neck Movements[edit | edit source]

  • An infant's ability to maintain their head in the midline becomes fully established, which allows them to visually focus on people and toys presented in the midline
  • Infants now easily turn their head through full range of motion, and can keep their head in flexion without associated side flexion. Rotation of the neck does not affect the position of the extremities
  • They are also able to rotate and extend their neck to look at an object to the side and above their head
  • Flexion of the head on the neck also allows the infant to look down to bring objects that they are holding into the centre of their field of vision for detailed inspection (foveal vision)
Visual Convergence and Tracking[edit | edit source]
  • Infants are now able to track an object moved from one side to the other across the midline
  • Tracking upwards is also present, but tracking downward is less consistent
Being Lifted[edit | edit source]

Infants increasingly anticipate being lifted when they see their caregiver preparing to pick them up. The caregivers's intention is signalled by their hands moving towards the infant's chest who in turn starts to recruit their neck and trunk muscles in anticipation of being lifted.[14]

  • As the infant's neck strength increases, caregivers provide less neck support while lifting the infant
  • Infants tend to have improved control of neck lateral flexion and extension than flexion against gravity
  • Turning infants as they are lifted allows them to maintain control of the position of their head
Pull-to-Sit[edit | edit source]
  • Infants increasingly anticipate being lifted from supine into sitting when the caregiver grasps and pulls on their hands:
    • infants flex their neck and trunk, recruit their upper extremity muscles in response to the traction on their hands, and lift the lower extremities off the support surface
  • When tipped backwards from sitting, infants can flex their neck to control the position of their head as their torso is lowered to the support surface
Postural Stability[edit | edit source]

When supine on a firm, flat surface, infants are very active, with repeated bouts of kicking, reaching for toys within easy reach, and actively using their hands and feet to explore the surrounding surfaces and their bodies. They are very curious and turn their heads to look at interesting and novel events in the environment.

  • This activity is important for strengthening the trunk and limb muscles. Moreover, infants with high activity levels of the upper extremities, as measured by full-day wearable sensors, have been shown to have higher cognitive, language and motor scores[15]
  • This period also sees an increasing ability to stabilise the trunk when moving the extremities, which allows the infant more control to engage in intentional and goal-directed reaching and exploratory movements of the hands and feet

Upper Extremity Posture and Movements[edit | edit source]

During periods of relative quiet, 3-4-month-old infants adopt a variety of postures of the upper limbs, sometimes with their shoulders in abduction and their extremity held away from the torso, but frequently with the hands together in the midline.  

Hands together in midline:

  • infants will visually inspect their hands for long periods
  • this visual attention is aided by the infant's ability to flex their head on their neck and, at the same time, look downwards to bring their hands into the centre of their field of vision for a clearer view
  • reaching towards a toy presented in the midline is bilateral, with one hand usually making contact before the other

Lower Extremity Posture and Movements[edit | edit source]

3-4-month-old infants have acquired the ability to move their lower extremities in a variety of ways due to their ability to flex and extend their hips and knees in different combinations.

In supine, during periods of relative quiet:

  • infants may lie with their hips and knees flexed, with their feet lifted off the support surface - this is associated with posterior pelvic tilt
  • hip flexion and extension are associated with some hip abduction

By the end of this period:

  • hip extension ROM increases
  • hip abduction ROM in extension decreases
  • crossing legs at the feet is frequently seen
Bridging[edit | edit source]

The infant will often put one or both feet flat on the support surface with their knees flexed:

  • pushing down on the support surface with both feet does not yet result in lifting the buttocks up (bridging)
  • pushing down with one foot leads to extension of the ipsilateral hip with forward rotation of the pelvis; this action may initiate rolling to the side
Kicking[edit | edit source]
  • Periods of repeated unilateral and reciprocal kicking continue at this stage
  • the trunk is held steady and is symmetrical during periods of active kicking
Foot Movements[edit | edit source]
  • Infants bring their feet together and engage in exploratory ankle movement
  • Isolated ankle dorsiflexion and plantar flexion movements are frequently seen
Rolling[edit | edit source]
  • Rolling from supine to side-lying becomes more frequent
  • Infants use a variety of patterns to initiate rolling

Supine Development in the 5-6 Month Period[edit | edit source]

  • At this stage, an infant's behaviour and actions become more intentional and goal-oriented (e.g. using hands and feet to explore objects and surfaces)
  • Infants become increasingly aware of their ability to initiate social encounters and know how to attract and maintain the attention of social partners[13]
  • Infants are increasingly able to adapt postural alignment, stability and movements to achieve a desired goal
  • Infants become more mobile as they learn to roll from supine to prone and start to use this mobility to move around on a supportive surface
Emerging Abilities During this Period[edit | edit source]
  • Improved ability to steady the trunk when the limbs are moving
  • Increasing hip and trunk flexor muscle strength, which allows the infant to lift both feet off the support surface in a sustained manner
  • Posterior pelvic tilt is associated with bilateral hip flexion, which allows the infant to reach for their feet and bring one foot to their mouth
  • Uncoupling of hip and knee flexion allows for increased ability to perform isolated movements of the lower extremity joints
  • Increased control while reaching for objects
  • Increasing ability to hold an object with one hand and explore its properties with the other
  • Emerging tendency to bang and shake toys and pass them from one hand to the other
  • Prominence of exploratory movements of the hands and feet
  • Ability to actively initiate and control rolling from supine to side-lying and prone

Head and Trunk Stability[edit | edit source]

  • At this stage, infants have full neck rotation ROM
  • They can visually follow a moving object in all directions, including from one side to the other and across the midline
  • Head-on-neck flexion is well established and allows the infant to watch their hands while reaching for or manually inspecting a toy held in midline above the chest
  • They are able to keep their head and trunk steady when moving the extremities, which allows for more control of intentional upper extremity movements and holding

Lower Extremity Posture and Movements[edit | edit source]

In supine, during periods of relative quiet:

  • infants lie with their feet resting on the support surface, particularly when engaged with a toy or observing the environment
  • they often lie with both hips flexed, commonly with knee flexion. Hip flexion ROM increases with improving trunk muscle strength and control of posterior pelvic tilt
  • they start to reach for and grab their feet
Kicking[edit | edit source]
  • Infants continue to move their lower limbs vigorously, using a variety of patterns, including (1) reciprocal kicking movements, (2) bilateral hip and knee flexion, and (3) bilateral hip and knee extension
Bridging[edit | edit source]
  • With both feet on the support surface, infants begin to lift their buttocks off the support surface (into a bridge)
Rolling[edit | edit source]
  • Infants become progressively more adept at rolling from supine to prone
  • They explore different options for initiating rolling

Atypical Development and Developmental Delay[edit | edit source]

Typical infant development occurs via an interaction between the development of the nervous system and various organ systems and stimulation from the infant's social and physical environment.[16] Infants who demonstrate atypical or developmental delay tend to be (1) less physically active, and (2) lack movement repetition. Therefore, they miss opportunities for motor learning and sensory integration.

To learn more about paediatric diagnoses which can cause developmental delays, please review the following Physiopedia Pages:

The management and treatment of developmental delay should be an interdisciplinary team effort. The team should include primary care providers, neurologists, developmental and behavioural paediatricians, speech and language therapists (pathologists), occupational therapists, physiotherapists, and nutritionists. Treatment strategies are usually multi-modal[17] and often require input from multiple medical and rehabilitation disciplines, with strong family support.

Resources[edit | edit source]

Optional Additional Reading:[edit | edit source]

References[edit | edit source]

  1. ↑ Smythe T, Zuurmond M, Tann CJ, Gladstone M, Kuper H. Early intervention for children with developmental disabilities in low and middle-income countries–the case for action. International health. 2021 May;13(3):222-31.
  2. ↑ 2.0 2.1 2.2 Von Hofsten C. Developmental Changes in the Organization of Pre-reaching Movements. Developmental Psychology. 1984;20(3):378-88.
  3. ↑ 3.0 3.1 Einspieler C, Marschik PB, Prechtl HFR. Human motor behavior prenatal origin and early postnatal development. Journal of Psychology. 2008;216(3) 148-54.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Bly L. Motor Skills Acquisition in the First Year, 1994. 
  5. ↑ Rönnqvist L, Hopkins B. Head position preference in the human newborn: a new look. Child Dev. 1998;69(1):13-23.
  6. ↑ Cornwell KS, Fitzgerald HE, Harris LJ. On the state‐dependent nature of infant head orientation. Infant Mental Health Journal. 1985;6(3):137-144.
  7. ↑ Von Hofsten C, Rönnqvist L. The structuring of neonatal arm movements. Child Dev. 1993;64(4):1046-57.
  8. ↑ Nagy E, Pal A, Orvos H. Learning to imitate individual finger movements by the human neonate. Dev Sci. 2014;17(6):841-57.
  9. ↑ Anekar AA, Bordoni B. Palmar Grasp Reflex. 2020.
  10. ↑ 10.0 10.1 10.2 Einspieler C, Peharz R, Marschik PB. Fidgety movements–tiny in appearance, but huge in impact. Jornal de Pediatria. 2016 May;92:64-70.
  11. ↑ Doroniewicz I, Ledwoń DJ, Affanasowicz A, Kieszczyńska K, Latos D, Matyja M, Mitas AW, Myśliwiec A. Writhing movement detection in newborns on the second and third day of life using pose-based feature machine learning classification. Sensors. 2020 Oct 22;20(21):5986.
  12. ↑ Dusing SC, Harbourne RT. Variability in postural control during infancy: implications for development, assessment, and intervention. Physical Therapy. 2010;90(12):1838–49.
  13. ↑ 13.0 13.1 Brazelton TB. Touchpoints Birth to Three, 2006.
  14. ↑ Reddy V, Markova G, Wallot S. Anticipatory adjustments to being picked up in infancy. PLoS ONE. 2013;8(6):e65289.
  15. ↑ Shida-Tokeshi J, Lane CJ, Trujillo-Priego IA, Deng W, Vanderbilt DL, Loeb GE, Smith BA. Relationships between full-day arm movement characteristics and developmental status in infants with typical development as they learn to reach: An observational study. Gates open research. 2018;2:17.
  16. ↑ Brown KA, Parikh S, Patel DR. Understanding basic concepts of developmental diagnosis in children. Translational pediatrics. 2020 Feb;9(Suppl 1):S9.
  17. ↑ Khan I, Leventhal BL. Developmental delay. 2020.
Retrieved from "https://www.physio-pedia.com/index.php?title=Infant_Development_in_Supine&oldid=350167"