What are the little warning signs to pay attention to a child’s development. Is the child progressing as they should, or is there perhaps a little flag that says, “There may be an issue here. Slow down, pay attention, and perhaps seek professional advice”? Read on for baby milestone red-flags. Written by Dr Maraschin, Expert Paediatrician
When you are on a family holiday and come to a section of the road where a person is waving a red flag, you are made aware of the possibility of a hazard enroute. The red flag doesn’t mean you are definitely heading for an accident. It is just a caution to drive slower, pay more attention and stay alert to the possibility of danger. The same goes for “red flags” in development. These are little warning signs to parents and caregivers to pay attention to a child’s development. Is the child progressing as they should, or is there perhaps a little flag that says, “There may be an issue here. Slow down, pay attention, and perhaps seek professional advice”?
CHILDREN ALL DEVELOP AT DIFFERENT RATES
Some children say their first words at nine months, while others may take time to develop language. The same would go for walking. It is considered normal for a child to walk between ten and eighteen months. That is quite a wide range; the child who walks at eighteen months is not necessarily “delayed”. The purpose of highlighting red flags is not to measure developmental milestones but to draw attention to specific areas that may impact a child’s day-to-day functioning. The beauty of this is that parents and carers can identify developmental concerns and seek the best support to address issues at an early age. The sooner a child receives help in a certain area, the less likely there will be long-term effects.
SPEAKING FROM PERSONAL EXPERIENCE
I will take my own daughter as an example. She was a 32-week prem. In utero, she was starved of food as my wife had a condition known as pre-eclampsia. There were also several other factors, which made the pregnancy less than ideal. When my daughter was born, we noticed that she was extremely high-toned. Her little body was ridged, and she tended to arch backwards when being held or lying down. We sought the assistance of a paediatric physiotherapist who worked with her and aided her movement. The therapy encouraged forward movement and flexibility. Had we not done so, crawling would have been very delayed, which would have had a ripple effect on her development. Her high tone was a red flag and alerted us to the need to intervene so that she could meet her milestones on time.
There are specific areas in which these baby milestone “red flags” can appear.
Refer to the table of developmental areas for ease of understanding, with an example below each table to highlight a red flag. I have suggested a possible diagnosis with an approach to remediate the problem. Note that none of these are absolute and the presence of just one red flag may not be a cause for concern. Your healthcare provider will take several factors into account to make a diagnosis. These are just guidelines and you should seek further advice if needed.
Social-emotional: This area of development refers to your baby’s ability to start understanding who they are, what they are feeling and what to expect when interacting with other people. An example would be for a baby to wave to someone who waves at them.
Communication: This is a process that involves sending and receiving messages through verbal and non-verbal methods. A verbal message is a word or sound. Cooing is one of the earliest forms of verbal communication. Non-verbal communication is usually a facial expression like smiling. Your baby is communicating joy.
Cognition, fine motor and self- care: Cognition refers to your baby’s ability to gain new knowledge through experiences and their senses. Fine motor skills are using small muscles to complete a task. For example, the pincer grip is needed to pick up a tiny piece of food and transfer it to the mouth. This is a fine motor skill. Self-care refers to a child’s ability to perform tasks like getting dressed, brushing their teeth or using utensils to eat.
Gross Motor: This is the ability to use the big muscles of the body to do tasks. Our legs, arms and torsos are involved. Think about riding a bicycle. Your torso keeps your body balanced while the arms steer and legs peddle. It is a whole-body movement.
I will break these items up by age group. The best way to do this is to follow the guidelines for the ages when well-baby checks should be done. If you are aware that your child lacks one or more of these skills, please make the healthcare professional aware of your concern. I give an example of a red flag below each table.
I will break these items up by age group. The best way to do this is to follow the guidelines for the ages when well-baby checks should be done. If you are aware that your child lacks one or more of these skills, please make the healthcare professional aware of your concern. I give an example of a red flag below each table.
1. Birth
Social Emotional
- Is comforted by holding or rocking
Communication
- Cries when hungry, wet or tired
Cognition, fine motor, self-care
- Baby begins to recognise and respond to your voice
- Has a grasp reflex, rooting reflex and sucking reflex
- Hands in a fist
Gross Motor
- The movements at this age are mainly involuntary
- Baby should be able to turn the head equally to both sides
- Baby should also respond to the morrow reflex, tonic reflex and stepping reflex. Your healthcare provider will check for these
“My baby favours one side.”
Towards the end of the pregnancy, babies often find themselves in a confined space, and their heads get stuck in one position. After birth, the baby may hold the head in the same position as they have a “torticollis” (stiff neck). Baby may find it difficult to feed from both breasts and won’t turn its head fully to track sounds and sight. Your healthcare provider may refer you to a physiotherapist to treat the muscle spasm.
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2. 6 to 8 weeks
Social Emotional
- Smiles at familiar faces or voices
Communication
- Coos
- Smiles
- Makes vowel like sounds
Cognition, fine motor, self-care
- Follows large objects
- Hands unfisted 50% of the time
- Holds hands together
- Opens mouth at the sight of the breast or bottle
Gross Motor
- Is able to hold head up for a while when lying on tummy
- Head bobs when held in a sitting position
“My baby doesn’t smile at familiar faces or voices. Baby is not cooing or making vowel sounds.”
When babies are in utero, their ears, noses, and mouths are full of amniotic fluid. It takes time for this fluid to drain away from the ears after birth. The presence of fluid makes hearing difficult, and there are also hearing problems. For this reason, all babies should have their hearing tested. An audiologist can perform a quick, simple test to ensure the baby is hearing well. This is especially important if there is a red flag as suggested above in our example.
3. Four months
Social Emotional
- Smiles spontaneously when happy
- Stops crying when parent or carer speaks
- Responds with sounds when spoken to
Communication
- Laughs out loud
- Vocalised when alone
Cognition, fine motor, self-care
- Shakes or reaches for a rattle
- Follows a person crossing the room
- Clutches at clothes
- Reaches out
- Holds onto breast or bottle
Gross Motor
- Sits with trunk support
- Head comes up with the body when pulled to sit
- Rolls front to back
“My baby seems floppy and doesn’t sit supported. She isn’t attempting to roll over.”
Your baby may have low tone, which should be assessed by your healthcare provider. Low tone affects a baby’s gross motor movement and can cause a delay in development. A paediatric physiotherapist can assist.
4. Six months
Social Emotional
- “Stranger Danger” baby is anxious with strangers
- Smiles and interacts with people
- Follows objects close by- about 30cm
- Follows a large object set further away-about 2 meters away
- Loves to see an image of himself/herself in the mirror and will try to touch it
Communication
- Babbling (aah ooh)
- Gurgles, squeals and laughs
- Begins to respond to name
- Responds to “no”
- Gestures for up
- Begins to play “peek a boo”
Cognition, fine motor, self-care
- Explores objects with mouth, eyes and hands
- Brings hands together at the midline
- Transfers hand to hand
- Reaches and grasps
- Refuses food when full
- Gums soft foods
- Finds partially hidden objects
Gross Motor
- Holds head and shoulders up with good control when lying on tummy
- Is able to hold his or her head up while sitting supported.
- Can turn side to side when seated
- Can sit momentarily when seated propped on his or her hands
“My baby doesn’t appear to notice objects moving at a distance of about two meters away from her. I find it difficult to get her to respond to her image in the mirror. She only appears to track when an object is close by.”
A newborn’s vision is usually blurry, but by about three months, a baby’s eyes should be working together, tracking and focusing on objects. A baby that doesn’t track objects further away may be short-sighted. Objects close by are clear, but the baby may not see objects further away clearly. Your healthcare provider will likely refer your baby to an ophthalmologist (eye specialist) for further investigations and treatment.
VISIT: Baby developmental milestones: birth to 24 months
5. Nine months
Social Emotional
- Uses sounds to get attention
- Recognises familiar faces
- Shares enjoyment with others using facial expression and eye-contact
- Follows a point
- Suffers separation anxiety from parents and caregivers
Communication
- Uses a two-part babble like “Mama”, Dada”
- Is able to point at objects
- Begins to imitate tones and speech sounds
- Babbles in syllables
- Enjoys gesture games (clap hands)
- Enjoys cuddles from familiar people
- May be shy of strangers
Cognition, fine motor, self-care
- Holds onto objects
- Will share an object with someone else “taa”
- Puts objects in a box
- Can find a toy under a cloth
- Transfers a toy from one hand to another
- Can pull a string to ring a bell
- Rakes objects with fingers
- Begins to chew lumps in the food
Gross Motor
- Begins to crawl
- Can take weight on his or her legs when held in a standing position
- Pulls on objects to a standing position
- Sits independently
- Gets into a sitting position alone
- Walks like a bear with all 4 limbs straight when supported
“My baby isn’t rolling over. He isn’t rocking on all fours. He isn’t attempting to crawl. “
Your baby may be suffering from low tone. The muscles aren’t strong enough to allow baby to get into a crawling position. Your healthcare provider will likely refer your child for physiotherapy to strengthen core muscles and encourage crawling. Remember that a child who does not crawl does not cross the mid-line. The inability to cross the midline may affect the child’s ability to read at a later stage. A child with low tone will find it very difficult to sit up straight at school. It is vital that we see how delays at one stage of life impact on later years.
6. One year
Social Emotional
- Plays games like peekaboo, pat-a-cake or rolling balls
- Enjoys looking for items e.g. under a chair
- Has firm attachments to familiar people
- Waves good-bye
Communication
- Responds to familiar words like mama, bottle, dog
- Babbles various sounds so that it seems the child is talking
- Begins to say simple words such as up, no, out
Cognition, fine motor, self-care
- Begins to stack blocks, puts lids onto jars or put shapes into a sorter
- Bangs 2 blocks together
- Copies actions like banging on a table or drum
- Has a good pincer grip. Can pick up small pieces of food
- Can hold a bottle
- Is able to feed himself or herself with finger foods
- Eats a variety of textures of food without gagging
Gross Motor
- Can move independently e.g. crawling or bottom shuffling
- Cruises along furniture
- Walks with support
- Pulls self to standing
“My baby seems different to other children. He is often irritable, doesn’t enjoy being strapped into a car chair and over-reacts to sensory triggers like loud noises or bright light. He is a difficult eater and gags when offered certain foods.”
Some children have difficulty responding to information they receive via their senses. This can involve the sense of sound, sight, touch, taste or smell. Their senses appear to be on high alert, and they tend to overreact to one or more stimuli. The child may cover their ears when people speak. They may dislike the feeling of certain fabrics on their skin. The child may not enjoy walking on the grass or sand. They are often picky eaters. These children have a “Sensory Processing Disorder”. Because of the heightened or lowered sensitivity to input, it leads to challenges in everyday life. A healthcare professional should assess these children. The child may need to be referred to a physiotherapist or occupational therapist who is trained in Sensory Integration therapy.
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7. Eighteen months
Social Emotional
- Engages in pretend games like a tea party or speaking on the phone
- Kisses by touching lips to skin
- Begins to show shame when he or she does something wrong
- Begins to be possessive- “mine”
- Enjoys interacting with others
- Notices when you or the caregiver leaves the room
Communication
- Has a vocabulary of 10 to 25 words
- Imitates sounds in the environment like a dog barking
- Can name a picture in a book
- Understands requests such as “where is your nose?”
- Points to show things
Cognition, fine motor, self-care
- Scribbles with a crayon
- Stacks blocks
- Is able to remove items of clothing
- Can pick up a cup and dink from it
- Fetches and carries objects
- Can put round pegs into a board
Gross Motor
- Walks up stairs with one hand held
- Is able to walk backwards
- Can stand on one foot with minimal support
- Throws a ball while standing
- Runs well
“My child is difficult to handle. He has terrible tantrums and appears to push the boundaries. He misbehaves in public and struggles to get on with other children.”
There is so much happening emotionally for children in this age group. They start to experience new emotions like possessiveness and excitement, shame, guilt, anger and frustration. Tantrums are very normal as these little people try to deal with these big emotions. I advise my parents to adopt “positive parenting” techniques. Distraction, ignoring negative behaviour and being encouraging are excellent parenting skills. If your own techniques don’t make family life easier, please seek professionals’ support. Your healthcare provider will help you with this. Behavioural problems become evident at this stage. If you don’t deal with them effectively, they can become big issues later. Your healthcare provider may suggest a cognitive psychologist to help your child manage behaviour. The psychologist will also guide you on the appropriate parenting style to support your child.
8. Two years
Social Emotional
- Uses toys appropriately. Cuddles, stacks, sorts. Doesn’t just throw or drop them
- Separation anxiety is lessened
- Has some defiant behaviour “I do it myself”
- Plays alongside other children
- Interacts with people in a social settling- schools, birthday parties, family events
- Is comfortable with a change in routine
- Interacts well with siblings and other family members
Communication
- Puts two words together “go outside”
- Has spontaneous speech, doesn’t just repeat your words
- Has a vocabulary of 50 words plus
- Refers to himself/ herself by name
- Learns new words all the time
Cognition, fine motor, self-care
- Can perform everyday tasks like feeding himself, dressing with some assistance
- Sucks through a straw
- Opens a door
- Switches on a light
- Can make a single line with cubes (train)
- Pulls off pants
- Begins potty training
- Shows interest in many different toys
Gross Motor
- Walks down stairs holding onto a rail
- Throws a ball overhand
- Can kick a ball
“My child is two years old and doesn’t appear to speak as she should. I have read the literature and understand that she should be able to say at least 50 words and understand a lot more. “
We are getting into an area of complex red flags. A child who is not speaking may have other features that a healthcare professional needs to assess. After raising your concern, your healthcare professional may refer your child to a speech therapist. The speech therapist can evaluate your child’s ability to communicate. If speech is the only area of concern, then speech therapy may be recommended. If the speech therapist finds other areas of concern, other specialities may be called in. The speech therapist will liaise with you and the referring doctor.
9. Three years
Social Emotional
- Interacts with other children
- Engages in pretend play
- Shares without being asked to do so
- Enjoys a variety of toys and activities
- Can tell you how old he or she is
- Matches letters and numbers
- Is able to draw a person in a simple form
Communication
- Begins to speak in simple sentences
- Familiar people understand the child’s speech
- Names body parts
- Can point to body parts in a picture
- Uses 200 words or more
- Says three-word sentences
- Uses plurals like “shoes”
Cognition, fine motor, self-care
- Eats independently
- Can put on shoes that don’t have laces
- Can undo large buttons
- Strings beads
- Can build a bridge with blocks
- Can copy a circle
- Begins to cut with scissors
- Knows his or her gender
- Understands concepts like big and small or long and short
Gross Motor
- Walks heal to toe
- Can climb stairs with alternating legs
- Can balance on one foot for about 3 seconds
- Is able to run and to jump
- Will pedal a tricycle
”My child isn’t speaking yet. I have noticed that he prefers to play alone and doesn’t really acknowledge his siblings. When he gets stressed, he tends to flap his hands a lot. He loves his toy cars and insists on lining them up in a straight line. No one dares to disturb him as this will lead to a tantrum.”
We are getting into more challenging territory now. Our example gives a list of areas that are of concern. It is not just a single item. If we look at the table above, this child needs to catch up in several areas. The areas include speech, inability to socialise and repetitive behaviour. A child with this number of red flags needs to be assessed by someone qualified in neurodevelopmental issues. With so many problems, there is a possibility that this child may fall somewhere on the autism spectrum. It is a complex diagnosis, and one would only suggest such a diagnosis once a full assessment has been carried out and any other causes for the red flags are excluded. The critical point to be made here is that early intervention definitely affects the outcome. Some children begin to show signs of autism from as early as 18 months. Parents and caregivers should not be afraid to seek medical advice if they are concerned. How well the child adapts to everyday life is closely linked with early diagnosis and intervention.
ALSO READ: How to improve your baby and toddler’s sensory development
Conclusion
Development is always a sensitive issue because we are talking about our babies. It is also a sensitive issue because children develop at different rates. However, if you are concerned, the overriding point I want to make in this blog is to seek help. If your child suddenly loses a skill that he or she had mastered, get help. If your child begins to favour one side of the body over the other, get help. If friends and family say things like, “he’s a boy; he’ll grow out of it”, get help. The developmental guidelines put out by the CDC do not differentiate between boys and girls when it comes to meeting milestones. I have two children of my own. In their early years, they both required assistance to overcome developmental difficulties. I am so grateful that we were brave and tackled the issues, allowing each of them to reach their full potential. Every child has a different level of potential, but whatever that is, let us provide them with the best possible support. You are brave, and you can face difficulties and help your child become the best version of themselves.
References:
- https://mcpress.mayoclinic.org/parenting/5-developmental-red-flags-in-your-kid-that-may-surprise-you/
- https://www.webmd.com/parenting/baby/recognizing-developmental-delays-birth-age-2
- https://www.hopkinsmedicine.org/health/conditions-and-diseases/ataxia
- https://kotm.org/sensory-processing-disorder-vs-autism-whats-the-difference
- https://www.unicef.org/parenting/child-development/your-toddlers-developmental-milestones-18-months
- https://www.courts.michigan.gov/4a2bc8/siteassets/educational-materials/cws/supplemental-handouts/developmental-red-flags-birth-to-age-5.pdf
- https://heeoe.hee.nhs.uk/sites/default/files/dr_s_ozer_development_red_flags.pdf
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