Milestones: Six to Nine Months

If your infant has required lengthy or frequent hospitalizations since discharge from the NICU, or your infant is still on supplemental oxygen, feeding tubes, and/or a large number of medications, she may not be able to put forth much effort to accomplish developmental milestones at this time (just like you would be unlikely to get up and learn a new dance step if you were home in bed with the flu or just recovering from surgery).  If your child is still in the NICU at this time her developmental progress will definitely be affected by her health status.

Infants who have had significant medical issues over the course of their short lives may also not be growing as well as expected for their corrected age.  Some babies must use more effort and energy to breathe and move than healthier children, utilizing more calories despite lower overall activity.  Between health issues and slow growth your child may have decreased muscle mass and display weak tone.  Your baby may require a higher calorie diet or diet supplements.  You should work in close consultation with your child’s primary care provider and/or a pediatric nutritionist to establish and maintain proper growth trends.  This is a time when your infant needs energy to learn new skills and the brain needs appropriate nutrition to develop properly.

If your child has suffered from bronchopulmonary dysplasia (BPD), reaching and sitting independently may be difficult milestones to achieve.  Many children with severe BPD pull their shoulders back to expand their chest and lung capacity to its fullest.  The result of using the shoulders in this way to assist with breathing is a tightening of the shoulders, called "shoulder retraction."  A child who is learning to sit needs to use a position that curves the back slightly forward.  At first the child needs her arms down at her sides to help keep balanced.  Shoulder retractions prevent your child from achieving this position and can affect her ability to sit independently.  If your child demonstrates difficulties in this area, try placing rolled diapers or blankets behind the shoulders when your child is in a car seat, highchair or infant seat.  This will move her arms toward the midline, increasing the likelihood that your child will play with her hands or reach for toys.  It will also help to stretch the muscles in the shoulders.  In addition, when holding your child for feeding, position the arm closest to you in front of your body, as if you were going to have her hold the bottle.  If this position can not be maintained for breast feeding use this position when the infant is held at other times.  This has the same effect as using the rolls behind the shoulders.  If you find over several weeks you are unable to begin to relax your child’s shoulders, consult with your primary care provider.  A referral for a physical or occupational therapy consult may be needed.

Infant "walkers" are discouraged by the American Academy of Pediatrics because of the increased risk of accidents in children who use them.  For children born premature there is, in addition, the risk of the walker promoting hyperextension and stiffness of the lower extremities because propelling oneself in a walker is frequently done with the use of the toes.  For children who were born early, use of a walker may increase the risk of developing hyperextension and stiffness of the legs.  This can result in "toe-walking" or prevent the child from maintaining balance for independent walking.  You can help avoid toe walking by not using a walker. (Some prematurely born children will walk on their toes and/or have tightness in the ankles whether they use a walker or not.)  Also, floor play strengths the muscles needed for walking much better than can be accomplished upright in a walker.

If your child has documented significant vision problems you will need help with providing appropriate stimulation and reading your infant’s cues.  The child with significant vision problems may go through some of the outlined milestones differently.  Working with a program like Georgia PINES or BEGIN will help you understand the impact of vision on developmental milestones.  If your child's visual problems are severe she may qualify for the Babies Can't Wait Program.

As your child’s health becomes more stable her development should progress more evenly.  Once your child is eating, gaining weight, and is off oxygen or medications, you should notice a steady increase in abilities over time.

It is not generally possible to tell if a young infant’s delay(s) will be of significance to later development. However, by noting these problems early and providing appropriate services the impact of delays may be minimized, skills may be enhanced, and the level of skills may be maintained.  It is important to remember that a child’s medical history can be critical in determining whether or not a further evaluation or referral for service will be necessary.  A particular delay in development may require a different response depending on the infant’s previous medical and developmental course.  For children who have no history of health problems, a "wait and see" approach may be appropriate for some delays.  However, developmental delays in a high-risk infant generally warrant more immediate attention.

If you notice any of the behaviors listed below speak to your child’s primary care provider about your concerns.  Your child’s primary care provider can help decide if your baby needs an evaluation by a pediatric audiologist, pediatric ophthalmologist, developmental psychologist, physical/occupational/speech therapists, or other specialists.

It may be of concern if by nine months corrected age an infant:

• cannot sit independently.
• cannot bear weight on her feet when supported in a standing position.  She frequently collapses at the knees or holds her feet up so they do not touch the floor.
• stands up on her toes like a ballerina when supported in a standing position and cannot bring her heels down to the floor.
• does not turn to locate the source of a sound and/or does not react to a sudden loud noise.
• does not vocalize and has not begun holding "conversations," taking turns vocalizing with another person.
• still rakes small objects into the hands with the whole fist.
• cannot consistently reach out and pick up a toy on the first try.
• has made no improvement towards straightening strabismus (crossed eyes) or has strabismus but is not being followed by a Pediatric Ophthalmologist.
• moves herself across the floor on her belly, pulling herself forward with the strength of her arms, rather than crawling up on hands and knees.
• has recently begun or increased gagging or choking with bottle or breast feeding.