The Neonatal & Paediatric Physiotherapist

When your infant is on the Neonatal Unit he/she may be referred to the physiotherapist. This may be because your child was born before 30 weeks, has a low birth weight (<1500 grams) or has orthopaedic or neurological concerns.

The role of the Physiotherapist on the unit is to assess your baby, once he/she is medically stable, and provide advice on positioning and handling as appropriate.

Premature babies miss out on the final stages of pregnancy when they would have been tightly curled up in the mother’s womb. After birth, gravity affects the baby and may cause a premature baby’s arms and legs to flop out to the side.

Aims of positioning are to:

  • Encourage your baby to lie in a curled up position; also providing the feeling of security he/she would have felt in the womb.
  • Arms and legs are curled up, with the knees and elbows tucked towards the middle of the body. The spine should be curved and the head should be tucked slightly forwards.
  • Encourage your baby to be symmetrical.
  • Encourage your baby to take his/her hands towards the middle of the body or to the mouth.
  • Occasionally turn your babies head to either side so that he/she is not always looking one way.

‘Nests’ using rolled blankets may be used to give your baby a boundary and allow him/her to maintain a curled up position. As your baby grows less support/ use of ‘nests’ will be needed.

After your baby has been discharged home he/she may be monitored for their development e.g. rolling, sitting, crawling. Advice will be provided on positioning and handling. This may continue until your child is walking.

Physiotherapists provide examination, evaluation, and treatment to patients with impairments, functional limitations, disease, and disability. Physiotherapists specializing in paediatrics assist children in developing and enhancing mobility so they may safely participate in activities at home, in the community, in the classroom, and on the playground. Paediatric physiotherapists are concerned with a child’s gross motor skills, strength, balance, and coordination focusing on a child’s ability to take part in important movement activities such as crawling and walking, running, jumping, playing games, and participating in sports and other physical interactions.

Collage of two photos of young girl undergoing physiotherapy.

Therapists provide evaluation, intervention and consultation in the following areas:

  • Gross motor development
  • Muscle tone and strength
  • Motor planning
  • Posture/postural control
  • Pre-gait and gait training
  • Locomotion patterns
  • Neuromuscular function
  • Endurance
  • Body alignment
  • Environmental adaptations

Treatment programs are always individualized to meet each patient’s needs. Examples of treatment include:

  • Positioning and posture alignment
  • Range of motion and strengthening exercises
  • Balance activities
  • Developmental activities
  • Endurance training
  • Gait training
  • Functional mobility training

How do you know if your child needs an evaluation?

An evaluation may be suggested by a doctor, a teacher or other medical professionals.  If you are concerned that your child’s skills are not where they should be, he or she might benefit from an evaluation with paediatric physical therapist.

Gross Motor Milestones and Red Flags

Skills for 0-6 months

  • When positioned on belly, raises head and shoulder
  • Rolls from front to back
  • Reaches for objects with one hand
  • Visually tracks people and objects
  • Props on forearms (6 months)

When to be concerned

  • Can not lift head off surface (by 3 months)
  • Poor Head Control
  • Stiff legs that move very little
  • Presents with head lag when pulled to sit
  • Does not reach for toys with hands
  • Unable to roll, bilaterally
  • Can not play in mid-line or demonstrates hand preference

Skills for 7-12 months

  • Rolls from back to belly (6-7 months)
  • Creeps/crawls on stomach
  • Sits independently
  • Transitions from belly to sitting
  • Crawls up stairs on belly
  • Pulls to stand using furniture
  • Stands at supported surface
  • Cruises on furniture
  • Walking/ambulation start to emerge

When to be concerned

  • Unable to sit independently and play with toys
  • Difficulty crawling or unable to crawl

Skills for 13 to 18 months

  • Independent with ambulation
  • Pushes to stand by going through 4 point
  • Stoops and recovers
  • Walks backwards
  • Walks sideways
  • Starts running but may fall frequently
  • Ascends stairs using step-to pattern with railing/support
  • Throwing a small ball overhead
  • Kicking a ball forward, with decreased control
  • Seats self in small chair
  • Climbs into adult chair
  • Walks up/down stairs holding on to railing, with 2 feet per step (18 months)

When to be concerned

  • Walks on toes or legs are very stiff and straight
  • Can’t stand independently
  • Can’t walk independently
  • Falls frequently

By 15-18 months:

  • Lowers to use hands or crawl up the stairs

Skills for 19-24 months

  • Running becomes more controlled
  • Stands on one foot briefly
  • Walks on line/balance beam with 1 foot on the line
  • Lowers to pick up objects from floor without falling
  • Jumping up with both feet
  • Jumping down from objects
  • Walks up stairs, both feet per step without rail
  • Walking backwards emerges

When to be concerned

  • Falls frequently when running
  • Not able to clear the floor when jumping up
  • Can’t jump up keeping feet together

Skills for 2-3 years

  • Ascends/descends stairs independently using step to pattern
  • Walking on a line/balance beam with improved balance
  • Walking on tiptoes
  • Jumping forward
  • Rides a tricycle
  • Catches playground ball, securing ball by bending arms towards chest
  • Throws ball overhand 3-7 feet
  • Kicks ball forward 3-6 feet using opposing arm/leg movements

When to be concerned

  • Requires railing for ascending/descending stairs

Skills for 3-4 years

  • Can sustain single leg stance for 5 seconds
  • Can sustain static tiptoes for 3 seconds
  • Kicks ball forward with control
  • Catches ball with hands, without pulling ball to chest
  • Throws ball at target

Skills for 4+

  • Hopping on one foot
  • Galloping and skipping start to emerge
  • Jumps over objects
  • Jumping-Jacks start to emerge
  • Bounces and catches ball


Other Physical Concerns

  • W-Sitting – Limits necessary trunk rotation. May be damaging to hips and knees.
  • Toe-Walking – When prolonged, may indicate sensory-seeking behaviors

Physical Therapy and the Classroom

  • Low muscle tone in the trunk/core muscles can result in difficulty sitting upright
  • Low trunk tone can result in difficulty sitting still in class as well as difficulty attending
  • Decreased proximal stability results in decreased distal stability for handwriting/fine motor tasks


Motor Planning

  • Motor planning is the ability of the brain to conceive, organize, and carry out a sequence of unfamiliar actions.
  • More parents have probably heard the term Apraxic, the inability to conceive, organize, and carry out an unfamiliar action; or Dyspraxic, difficulty in conceiving, organizing, and carrying out an unfamiliar action.
  • Children with motor planning difficulties (dyspraxia) have problems learning new skills that involve using the body. They tend to require extra practice and reinforcement when learning new motor skills, and do not usually generalize these skills to new situations with ease. (Therefore, it is important to introduce activities in a variety of environments).
  • Some children become so frustrated with any game or activity that challenges motor skill, they avoid these tasks whenever possible.
  • These children tend to be disorganized in their use of time and materials, and often have difficulty becoming independent with simple routines involving household or school responsibilities.

*** Expect that teaching new skills will require considerable practice and repetition.

Physical Therapy and Sensory Integration

The Proprioceptive System & The Vestibular System are both very important components of physical therapy treatment

The Proprioceptive System

  • Proprioception refers to the sensory input and feedback that tells us about movement and body position.
  • Proprioceptive receptors are located within our muscles, joints, ligaments, tendons, and connective tissues.
  • The receptors tell the brain when and how the muscles are contracting and stretching, how the joints are bending or extending or being pulled/compressed, which enables the brain to know where each part of the body is and how it is moving.
  • It is one of the deep senses, and is often referred to as the position sense.

 The Vestibular System

  • The sensory system that provides the dominant input about movement and balance.
  • Located within the inner ear, it provides information about gravity, body movement within space, and head movement.
  • The sensory system that responds to the positioning of the head in relation to gravity and acceleration/deceleration of movement. It integrates neck, eye, and body adjustment to movement.
  • The vestibular system sends signals primarily to the neural structures that control our eye movements and to the muscles that keep us upright.

Fine Motor and Cognition Red Flags

6 months

  • Not reaching for or grasping toys
  • Hands frequently clenched

9 months

  • Unable to hold/release toys
  • Cannot move toys from one hand to the other

12 months

  • Majority of nutrition still liquid or pureed
  • Cannot chew solid food
  • Unable to pick up small items using the index finger and thumb

18 months

  • Not holding or scribbling with a crayon
  • Does not attempt to tower blocks

2 years

  • No interest in self-care skills ie dressing, feeding

3 years

  • Difficulty helping with self-care skills ie dressing, feeding
  • Difficulty manipulating small objects ie threading beads

4 years

  • Not toilet trained by day
  • Unable to draw lines or circles

5 years

  • Concerns from teacher about school readiness
  • Not independent with eating or dressing
  • Cannot draw simple pictures ie stick people

Social and Emotional Red Flags

6 months

  • Does not smile or squeal in response to people

9 months

  • Not sharing enjoyment with others using eye contact or facial expression

12 months

  • Does not notice something new
  • Does not play easily turn taking games ie peekaboo, rolling a ball

18 months

  • Lack of interest and interacting with others

2 years

  • When playing with toys tends to bang, drop or throw them rather than use them for their purpose ie cuddle doll, build blocks

3 years

  • No interest in pretend play or other children
  • Difficulties in noticing and understanding feelings in themselves and others ie happy, sad

4 years

  • Unwilling/unable to play cooperatively

5 years

  • Play is different than their friends

Red Flags At Any Age

  • Not achieving indicated developmental milestones
  • Strong parent concerns
  • Significant loss of skills
  • Lack of response to sound or visual stimuli
  • Poor interaction with adults and other children
  • Difference between right and left sides of the body in strength, movement or tone
  • Loose and floppy movements (low tone) or stiff and tense (high tone)