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Hypoxic ischemic encephalopathy (HIE)

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What is perinatal encephalopathy?

Perinatal damage of the nervous system in newborns is a number of conditions and diseases of the brain, spinal cord and peripheral nerves united into a general group by the time of exposure of damaging factors. Perinatal period includes the antenatal, intranatal and early neonatal periods. The antenatal period begins from week 22 of fetal life and ends with an act of delivery. The intranatal period includes the act of delivery from the start of labor until birth. The neonatal period consists of early neonatal (corresponds to the first week of life) and late neonatal (from day 8 to day 28 of life inclusively) periods.

What is the cause of perinatal encephalopathy?

Perinatal encephalopathy is a frequent complication of abnormal pregnancy and labor. This condition is usually due to oxygen deficiency of the central nervous system that occurs in a problematic course of perinatal period which is complex for a child. Perinatal brain damages account for over 60 % of all pathologies of the nervous system in infants. They are responsible for such diseases as infantile cerebral palsy, epilepsy and minimal cerebral dysfunction. Various outcomes of perinatal encephalopathy depend on the damage extent of the central nervous system and correct and timely treatment: one third of patients usually need minimal rehabilitation support to get well, one third of them requires serious treatment including drug therapy, and one third of patients will have health problems in future even if medical aid was rendered properly and for a long time.

Among the reasons for perinatal brain damages, the leading position is occupied by the prenatal and intranatal (at labor) fetal hypoxia, and the second position is given to mechanical trauma of a child during labor. The latter is usually accompanied by previous intrauterine hypoxia of some intensity. Infectious (including viral) and toxico-metabolic types of nervous system damages are also included into the structure of etiopathogenetic factors of perinatal pathology. Thus, the factors that lead to perinatal damage of the CNS include the following ones:

  • intrauterine hypoxia (deficiency of oxygen) in a fetus;
  • fetal hypoxia at labor;
  • mechanical trauma at labor;
  • infectious (viral) factors;
  • toxic factors;
  • hereditary factors;
  • a combination of the factors mentioned above.

Among the risk factors of perinatal encephalopathy in children, a greater relative weight belongs to maternal morbidity. According to numerous studies, it does not only disturb the preconceptional health (the health responsible for the birth of healthy offspring and parents) but also produces a direct negative effect on the fetus.

When studying the structure of the general pathology in pregnant women during the last five years, a significant growth of their morbidity is noted. It is mainly due to the increased rate of diabetes and thyroid diseases. During pregnancy, these diseases lead to placental insufficiency, disturbed nutrient absorbability and uptake via the placenta, and deficiency in oxygen and carbon dioxide transport manifested as fetal growth retardation, intrauterine hypertrophy, immaturity of the lungs and surfactant. It is established that decreased uteroplacental blood flow is an objective index of hypoxic damage of the brain.

How is perinatal encephalopathy manifested?

Perinatal encephalopathy is clinically manifested through some complexes of symptoms. The most frequent of them are motor and mental retardation, hypertension-hydrocephalic syndrome, syndrome of muscular dystonia, and syndrome of brain stem damage.

What is psychomental retardation and how is it treated?

Infancy is the most complicated period in a child’s life. Infants have a rapid rate of growth and development. When a child is born, development of his/her organs and tissues is not completed yet. They constantly progress after the birth and look like the organs of an adult person by the structure and functions. That’s why all pediatric doctors need to study the basic development peculiarities of an infant in detail. Tracing a child’s development from infancy to 1 years of age, doctors pay attention to anthropometric data, psychomotor development (motor activity), speech development, formation of skills and abilities in a child.

Considering the features of a healthy newborn child’s psychomotor status and tracing extinction of congenital reflexes and acquisition of motor and social skills, it can be estimated whether an infant is developing properly.

Retardation of psychomotor development and motor skills is observed in various hereditary diseases, in children with the central nervous system pathology, resulting in persistent motor disturbances including infantile cerebral paralysis. Retardation is developmental delay for 2 and over months. Children with regress of previously acquired motor and psychoverbal skills should be given particular attention as this can be a sign of neurodegenerative diseases.

Mild developmental arrest is often found in premature children, in chronic non-neurological diseases and rickets. Moderate and severe developmental arrests require special examination and treatment.

Non-drug management of psychomotor arrest in infants includes as follows:

Physical rehabilitation: different kinds of therapeutic massage, therapeutic gymnastics, position treatment (setup, braces, collars, etc.), Vojta therapy, water exercises and hydromassage; dry immersion (weightlessness imitation); physiotherapy (alternating magnetic field, sinusoidal modulated currents, electrophoresis, paraffin therapy, laser therapy, light and color therapy).

Psychological and pedagogical management: correction (conductive) education, psychotherapeutic correction in the pair of a mother and a child (skin-to-skin, kangaroo-type contacts); music therapy, esthetic therapy, tactile and kinesthetic stimulation. It is especially recommended to use a combination of two or three soft methods of physical effect with psychoemotional and psychosensory management. It helps gaining an effect of the so-called sensory rooms used during rehabilitation of elder patients.

Drug therapy utilized by neurologists to manage the motor and mental development during the first year of life is mainly represented by peptide drugs. The drugs launch endogenous mechanisms of compensation and bring a child’s development back to normal.

What is a syndrome of muscular dystonia and how it should be treated?

In an infant, tonus disturbances can be local (associated with one group of muscles) or general (associated with several groups of muscles). According to the change type in the muscular tonus, they are subdivided into hypotonus (decreased tonus) and dystonia (improper combination of increased and decreased tonus).

Infantile torticollis is the most common local tonus disturbance.

Torticollisis usually due to mild underdevelopment of traumatic injury to the sternocleidomastoid muscle and roots running from C5 – C6 segments of the spinal cord or accessory nerve. Torticollis usually disappears by the age of 6–9 months. However, mild symptoms of torticollis can be found in elder children, too. Resistance is felt when the head is rotated toward the opposite side of the affected muscles.


Treatment can include applications, electrophoresis, Traumeel injections, Viburcol rectal suppositories, right positioning of the head using a special pillow.

Muscular hypotonia (floppy baby syndrome) is mainly manifested through reduced resistance to passive movements and increased range of motions (laxity of joint). In severe cases, hypotonia influences a child’s posture: frog position is a diagnostic clinical finding of diffuse muscular hypotonia. A floppy baby syndrome can be seen in a wide spectrum of diseases: severe neurological disorders, rickets, severe perinatal hypoxia (oxygen lack) and birth trauma leading to cerebral palsy, metabolic disorders, neuromuscular diseases, developmental abnormalities and degenerative diseases of the nervous system, chromosomal syndromes and some forms of endocrine pathology.



Diffuse muscular hypotonia is often found in a congenital pathology. It can be accompanied by a slight body weight and height gain, epileptic seizures, and acute cerebrovascular accidents. Premature children often have severely decreased muscular tone. By the age of 3–6 months, hypotonia can be transformed into a spastic syndrome.

Severe persistent muscular hypotonia combined with delay in psychomotor development requires regular rehabilitation courses (massage, exercise therapy, physiotherapy, hydro- and balneotherapy, acupuncture, lessons with a speech therapist, drug therapy).

Muscular hypertonia can range from mild (not inhibiting movements and development) to severe including spastic syndrome (extreme form of hypertonia). Increased muscular tone can accompanied by activated tonic reflexes and delay in extinction of unconditioned reflexes.


Tonic reflexes combined with an increased muscular tone produce a pathological effect on a child. The picture is often observed in premature and immature children or in infantile cerebral palsy. In the last case, unconditioned reflexes can even be more intense.


Dystonia and hyperkinesis (wrong, excessive and superfluous movements) are often delayed and seen after 3–6 months of age or after birth.

Hyperkinesis usually characterize affection of cerebral basal ganglia often combined with other neurological symptoms (for instance, with diminished hearing). Hypertonia and dystonia are long-term effects of bad posture leading to skeletal deformities in children. Thus, in case of motor disturbances, a child must be examined not only a neurologist, but also by an orthopedist.

Diagnosis is followed by restorative treatment. Restorative treatment (if there are no cardiovascular, respiratory adverse events, epileptic seizures, etc.) includes massage, exercise therapy, orthopedic positioning, physiotherapeutic treatment, hydro- and balneotherapy, acupuncture, lessons with speech therapists, working in sensory rooms.

Methods of infant development and drug therapy are patient-specific and depend on intensity of the syndrome and its combination with delay in development, hyperkinetic and dystonic syndromes.

Drug therapy given to manage the muscular tone in children under one year of age consists of agents decreasing muscular tone (anti-spastic medicines) and agents that manage muscular hypotonia.

What is a hypertension – hydrocephalic syndrome and how it must be treated?

By 1 year of age, normal growth in head circumference is 11–12 cm:

  • within the first trimester, head circumference is increased by 4 cm (1.5 cm per month);
  • it is increased by 3 cm within the second trimester (1 cm per month);
  • within the third trimester, head circumference is increased by 3–4 cm (0.5 cm per month).

Pathological growth in head circumference as a symptom of hydrocephaly is due to obstruction of liquor passages at various levels and disturbed relations between production and absorption of spinal fluid.

Hydrocephalus:


Congenital hydrocephaly is formed in a fetus during pregnancy and is present at birth. Principal causes of congenital hydrocephaly: development defects; in rare cases, intrauterine infection; in very rare cases, ventricular hemorrhage in a fetus.

Acquired hydrocephaly is developed after the child is born, sometimes at the most early stages of life. Causes of acquired hydrocephaly: intraventricular hemorrhages, infection damaging the central nervous system such as meningitis, encephalitis, craniocerebral trauma, cerebral traumas.

Clinical symptoms of intracranial hypertension:

  • changes in a child’s behavior: anxiety, frequent and monotonous crying, head lag, frequent regurgitation;
  • delay in mental, motor and psychoverbal development;
  • sagittal suture is wider than 0.5 cm, bulging anterior fontanel;
  • change in the cranial shape with a high forehead (acrocephaly) or outstanding occipital prominence in combination with a rapid increase in head circumference, predominance of head circumference over chest circumference;
  • graefe's sign, congestive changes in the fundus;
  • increased muscular tone, predominantly in the hands and feet;
  • tremor of hands with their opening.


Apart from hydrocephalus, children with a dome-shaped head may be diagnosed as follows:

  • rickets;
  • children born with big heads;
  • infants with syndrome-based conditions and inherited diseases.

To provide an adequate assessment, the head circumference must always be compared to the chest circumference, head dimensions of the child’s parents must be assessed, results of additional methods of examination must be taken into account (fundus examination, neurosonography, CT, MRI).

Drug therapy to manage the hydrocephalus syndrome at the first year of age mainly includes diuretic and vascular agents.

Hydrocephalus is treated not by a neurologist, but by a neurosurgeon. A neurologist can’t decide on hydrocephalus treatment without being consulted by a neurosurgeon. If surgical treatment of hydrocephalus is not possible due to any reasons, the patient must be observed by both a neurologist, and a neurosurgeon.

Insufficient increase in the head circumference is observed in progressive congenital degenerative diseases, severe organic lesions (secondary microcephaly, when not growing brain slows down the growth of the skull), and in craniostenosis (cranial bone pathology that needs to be treated by a neurosurgeon).

It is of note that the rate of anterior fontanel occlusion differs and is probably rather associated with the features of mineral metabolism than with the nervous system pathology. A presence of an anterior fontanel by the end of the second six months of life and absence of neurological complaints are not the reasons for concern. The same goes for a rapid occlusion of the anterior fontanel which is not a reason to stop the planned prevention of rickets in an infant.

What is a convulsive disorder and how it can be treated?

During practice, a pediatric neurologist comes across many conditions that arise on a sudden, exist for a short term and terminate all at once. Epileptic seizures usually accompanied by loss of consciousness are examples of paroxysms. However, loss of consciousness is developed not in all paroxysms; some of them have unusual symptoms leading to diagnostic mistakes.

Detection and differentiation of various paroxysmal conditions in infants is especially difficult. In order to choose a proper treatment, we need to differentiate between paroxysmal conditions of epileptic and non-epileptic origin. Only an experienced neurologist-epileptologist can name the cause of paroxysms and give a prognosis.

Breath-holding spell is a short-term interruption of breathing when crying with a child turning pale or blue. Breath-holding spells need to be differentiated from the syndrome of apnoe (arrest of breathing) which frequently occurs in premature or immature infants and in children with cardiovascular, respiratory and brain stem pathology. Polysomnography, which records your brain waves, heart rate and breathing and determines what causes difficulty breathing in a child, is done to ensure strict differentiation. Breath-holding spells are not epileptic but are more likely to transform into epilepsy.

Paroxysmal sleep disturbances unite a large group of conditions which must be differentiated from non-neurological disorders and epileptic paroxysms. Nightmares when a child starts crying and yelling without awakening or not reacting to what is around him/her are typical examples of paroxysmal sleep disturbances. Frequently occurring nightmares show that there are mental problems.

Febrile convulsions belong to the most common type of paroxysmal conditions in children. Febrile convulsions (FC) include paroxysms of various duration in the form of seizures that occur in infants and younger children whose body temperature is 37,8–38,5 °C. There is a high risk that FC can be transformed into epilepsy.

We differentiate between typical and atypical FC. Typical FC are short-term (to 15 minutes) and generalized (all limbs are involved, short-term loss of consciousness is developed); values of a child’s psychomotor development conform to the age, EEG shows no typical changes. In atypical FC, an attack lasts over 15 minutes (to several hours), limbs on one side are involved; attacks are sometimes followed by Todd's paresis or transient muscular weakness in the convulsive limbs (in 0.4 % of cases), EEG shows common epileptic focal changes.

Neonatal seizures (NS) are developed within the first 4 weeks of life in a mature newborn (from day 1 to day 28) and later in immature ones. It is very difficult to differentiate between neonatal seizures and good movements based on clinical features only. Electroencephalographic (EEG) monitoring and video recording is required. Myoclonic attacks have the most severe prognosis. They can show there is an onset of early severe epilepsy.

Epilepsy is a chronic brain disorder characterized by recurrent provoked convulsive seizures causing impaired motor, sensory, vegetative, intellectual or mental functions which occur due to excessive neuron discharge in the brain cortex. Among children epilepsy is seen in 10 cases per 1,000.

Epilepsy is a very unpleasant but very common neurological disease, especially in childhood. Apart from life threatening conditions in continuous and complicated seizures in infants, epilepsy leads to remote negative consequences disturbing the cognitive, psycho-social and motor development of a child. Novel anti-seizure medications control many forms of epilepsy, but parents are afraid to use the medications due to negative experience of an older generation who used the agents and came across adverse effects. Discuss your worries with a specialist. Do not deprive your child of healthy future because of prejudices.

What are the symptoms of brain stem lesions and how they can be treated?

The brainstem (or brain stem) is the posterior part of the brain, continuous with the spinal cord.


It contains vitally important centers responsible for respiration, swallowing, cardiac activity, concordant movements of the eye, etc. In newborns with neurological problems, the centers can be not properly formed or damaged. Underestimation of brain stem lesion symptoms can result in critical consequences.

Bulbar and pseudobulbar disturbances in children with an injury to the nervous system are found since their birth. They appear as weak suckling ability, choking with saliva, food, water, passage of food through the nose, changed tone of the tongue, disturbed speech development.

Oculomotor disorders are very typical of infants with CNS pathology. Possible disturbances include nystagmus (rapid and repetitive movement of the eyes) and different types of heterotropy. Vision impaired patients are related to a very important group as in them, oculomotor disturbances can be the first symptoms of visual function disturbance (for example, the floating nystagmus of the blind). The patient need to be observed by a neurologist and ophthalmologist.

Disturbed restoration and cardiac rhythm are also typical of patients with the disturbed function of brain stem structures. Premature infants and infants with low weight are at risk for respiratory disturbances, apnea and arrhythmia. In this situation, differential diagnostics of neurological and non-neurological (cardiological, respiratory) causes of the found disturbances is crucial. These patients require proper diagnostics and need to be examined by a neurologist, pulmonologist, cardiologist and ENT specialist.

Do not forget to ask doctors about brainstem disturbances in your child. The consequences can be very severe (for instance, apnea type respiration disturbances result in the sudden infant death syndrome, while disturbed swallowing and chronic choking lead to severe aspiration pneumonia). However, correct and proper care (correct posture of a child while sleeping, feeding with a raised head and special diet) enables to avoid the difficulties even without additional drug intake.

Do all deviations in a child’s development require a special therapy?

During the first year of life, the following events are considered as normal variants:

  • Physiological tremor is a rapid transient tremor found in the limbs and sometimes the chin during crowing or feeding. It can be found in a half of children not elder than 3 months of age. In premature infants, tremor can be observed until they are 6 months old.
  • Physiological astasia-abasia is inability of 2- to 5-month-old children to bear some weight on their legs when supported. As their legs are tucked under, no stepping motions are present due to extinction of support reflexes.
  • Jactation is a tossing or shaking of the body and/or head, especially before sleeping. They are typical of parentless children.
  • Animation complex includes various chaotic movements of a child experiencing positive emotions. They are especially common for children with immobilized limbs (for instance, receiving treatment with gypsum or orthopedic appliances).

Thus, all children with perinatal encephalopathy need long-term dynamic observation by specialists and individually -tailored recurrent courses of restorative treatment with at least 3-month break and regular control of its effectiveness within the first year of life at out-patient rehabilitation centers, in-patient facilities and district polyclinics.

It is not enough to involve healthcare specialists in the rehabilitation process. A child’s family members must participate as well. Professionals interested in products of their labor will be glad to teach mothers basic exercise therapy, early swimming and methods of early infant development. Albeit the entrenched view, restorative treatment of children with the perinatal lesion of the nervous system must be initiated soon after diagnosis and terminated when the child is equal to his/her peers considering physical, motor and psychoverbal development.



O. V. Bykova

Doctor of Med. Sc., Principal Researcher of the Centre for Applied Research in Pediatric Psychoneurology

of Moscow Health Department

It is necessary to know age-appropriate normal values to understand whether your child is developed properly. Basic criteria of normal first year development are given below.

Anthropometric measurements (weight, standing height, head and chest circumference) are landmarks of an infant’s growth and development rates and dietary habits. Most importantly, they enable us to notice certain abnormalities in growth and development.

Physical development of a child is a sequential process of growth due to increased weight, length, development of some body parts and biological maturation of a child in accordance with the age.

Body length (height) of a mature newborn ranges from 46 to 56 cm. The average height is 50.7 cm for boys and 50.2 cm for girls.

Approximate body length (BL) of a first-year-old child is calculated as per the formula:

BL (for the first three months of life) = BL (at birth) + 3 x N, where:

BL is body length; N is a number of months of life; 3 cm is an average monthly body length gain during the first quarter of infancy.

The monthly height gain is 2.5 cm for the first quarter, 2 cm for the third quarter. In the fourth quarter, height is increased by 1 cm on a monthly basis.

Within the first year of life, infants grow on an average by 25–27 cm. The height of one-year-old child is 75–77 cm.

Weight is the basic anthropometric measure. In the majority of mature newborns it ranges from 2,700 to 4,000 g.

According to a large number of studies, the average weight of a newborn boy is 3,200–3,500 g (average weight is 3,493 g), while the average weight of a newborn girl is 3,200–3,400 g (average weight is 3,348 g).

The formula below is used to calculate the approximate weight in a child of the first half of the year of age:

Weight (W) = W (at birth) + 800 x N, where:

W is an approximate weight of a child; 800 g is an average weight gain within the first half of the year; N is a child’s weight in months (1–6).

Head and chest circumferences are two other important anthropometric measures.

Head circumference of a mature newborn is averagely equal to 34 cm. Within a year, head circumference is increased approximately by 12 cm. During the first months of life, the head is growing intensively. By the end of the 1st month of life, head circumference is increased by 1.5–2 cm. The subsequent monthly head circumference gain is 1–1.5 cm.

Head circumference (HC) is measured with the same measuring tape along the line passing through the most outstanding prominences of cranial bones (through the occipital prominence behind and through the superciliary line in front).

The formula below is used to calculate the head circumference (HC) in a child under 1 year of age:

HC (first half of the year of age) = HC (at birth) + 1.5 x N;

HC (second half of the year of age) = HC during the first half of the year of age + 1.0 x N; where N is an amount of months of life.

Chest circumference in a mature newborn is 32–35 cm. In norm, its 1.5–2 cm less than the head circumference. By the age of three months, the ratio becomes adjusted, i.e. the chest circumference is equal to the head circumference. Then the ratio is changed due to a more intense development of the chest and a rapid increase of its size. The chest circumference is measures as follows: wrap the tape measure around the body under the armpit and over the scapula or shoulder blades at the back and back to the front of the bust line. Within a year, the chest circumference in a newborn is increased averagely by 16 cm.


Special indices are used to determine the proportionality (consistency) of infants’ physical development.

Weight and height index is weight-to-height ration (at birth). In norm, the index must exceed 6. If it is less than 6, we deal with congenital hypertrophy or insufficient weight, if it is over 7, we have excessive weight.

Comparison of head and chest circumferences: at birth, the head circumference is 1.5–2 cm greater than the chest circumference, by the 3 month the circumferences are equal, by the age of 1 the chest circumference is greater than the head circumference based on age of a child expressed in cm.

To control the head and chest circumferences of a baby, it’s better to get an own measuring tape as modern measuring devices differ by the value of divisions.

Table 1. Average weight and height gain in children under one year of age (WHO, 2006)

Age, months

Height gain per month, cm

Height gain during the elapsed period, cm

Monthly weight gain, g

Weight gain during the elapsed period, g

1

3

3

600

600

2

3

6

800

1,400

3

2.5

8.5

800

2,200

4

2.5

11

750

2,950

5

2

13

700

3,650

6

2

15

650

4,300

7

2

17

600

4,900

8

2

19

550

5,450

9

1.5

20.5

500

5,950

10

1.5

22

450

6,400

11

1.5

23.5

400

6,800

12

1.5

25

350

7,150


Mental and motor development of children under one year of age

A child develops mental and motor sills along with physical development. However, the cut-off point physiology i.e. motor features of a newborn must be understood properly to make an adequate assessment of psychomotor development dynamics (table 2).

Table 2. Congenital unconditioned reflexes of a child under one year of age:

Grasping reflex

It is induced by stroking the palm or slightly touching with an object. The baby will instinctively grasp anything that touches the palm. He/she can hold an object weighing up to one kg in one hand. If the child can grasp an object with two hands, he or she can even be lifted into the air.

Search reflex

When something touches a neonate's cheek, he or she instinctively turns his or her head toward the touch. This reflex is an essential part of the food searching instinct.

Suckling reflex

It causes the child to instinctively suck anything that touches the roof of their mouth. It is linked with the nutritional instinct.

Babinski reflex

The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out.

Moro reflex

The legs and arms are put apart and then brought together reacting to a loud and sudden sound. The same happens when a child is tossed.

Babkin reflex

During to the application of pressure to a palm, the infant rotates his or her head and opens the mouth.

Swimming reflex

If an infant is placed face down, he or she will begin to paddle and kick in a swimming motion.

Walking reflex

When the soles of the infant’s feet touch a flat surface they will attempt to walk by placing one foot in front of the other.

Psychomotor development of a healthy mature child during the first year of life:

Age

Psychoverbal development

Motor development

Infancy

  • Hearing – eye blink and startling are caused by sudden sounds
  • Since week 2 – auditory concentration (a child stops crying in a loud sound and tries to listen)
  • Vision – the child narrows his or her eyes in bright light, turns his or her head towards the light
  • The child fixes the eyes on the moving object for a while
  • He or she sleeps a lot, he wakes up only to eat or when he or she is wet
  • In fetal position, the limbs are bent and drawn up to the torso, hands are kept in a tight grip
  • Movements are chaotic
  • Mild convergent strabismus is possible for a while
  • Rare tremor of the chin and hands of high frequency during screaming or feeding

1 month


  • Short-term eye fixation, can follow a moving object
  • Auditory concentration
  • Stops or changes the manner of crying when hears an adult’s voice
  • Speech – separate postdorsal sounds ‘g’ and ‘k’ appear
  • First smile when communicating with adults or while sleeping
  • The child is able to lift and hold the head from a prone position for a while
  • Motor skills – lifts the head from a prone position and tries to hold it
  • Emotions – opens the mouth when an adult is talking to him or her (attention to a talker's mouth)

2 months

  • Good sleeping and awakening patterns The child does not fall asleep at once though he is not hungry and not wet, he or she is awake and content
  • Smiles when communicating with adults
  • Long-term fixation behavior
  • Rotates the head searching for the source of sound
  • Expressive crying
  • Starts babbling
  • The child is able to hold the head from a prone position for a long time, but not constantly from the vertical position
  • Holds a given toy for a while

3 months

  • Active awakening
  • Animation complex during communication (active movements, smile when communicating with adults or seeing an interesting toy)
  • Continues babbling
  • Follows a toy in any direction
  • Combined rotation of the head and eyes towards the sound
  • Moves a hand to the toy
  • Touches and feels his or her hands
  • Stays pronate with the head in the midline and lets extremities rest by the side at an acute angle
  • Holds the head well from the vertical position
  • Physiological muscular hypertonicity is constantly removed: the legs and arms are easily extended, hands stop being clenched in a fist
  • Can roll to the side or even stomach
  • Can accidentally touch the hanging toys
  • When supported. bends the knees or rests slightly due to integration of the support reflex

4 months

  • Orientation response to communication prior to animation complex Recognizers family members and strangers
  • Continuous babbling, laughter
  • Reaches out for a toy and grasps it
  • Touches and feels his or her hands, clothing
  • Puts the hands in the mouth
  • Locates a sound in different locations Differentiate between voices of family members
  • Stays pronate with the head in the midline and lets extremities rest by the side at a right angle
  • When supported, flexes arms at elbows, lifts his head and pulls up from the supine position
  • Rolls from back to side or stomach


5 months

  • Orientation response is replaced by animation complex or fear
  • Confidently distinguishes between family members and strangers
  • Adequately reacts to the tone, displays anxiety or animation when hearing a mother’s voice
  • Continuous babbling, sounds, laughter, whining
  • Follows objects
  • Reaches out for a toy and grasps it, shifts toys from hand to hand, puts a toy in the mouth, holds a bottle with two hands
  • Leans forward with arms or one arm stretched out for support from the prone position
  • When supported, reaches after the hands and takes a seat from the supine position
  • Rolls from back to stomach confidently
  • Stands straight with support


6 months

  • Clear orientation response; displays anxiety or animation at mother’s sight
  • Examines objects and people
  • Optic support of hands; grasps a toy from any direction Holds objects in each hand, shifts toys from hand to hand
  • Reacts to a sound if his or her attention is not distracted by a toy or adult (active attention)
  • Reacts to his or her name
  • Uses a spoon while eating, drinks from a cup
  • Speech – can communicate with self for long Starts babbling (separate syllables like ‘ba’, ‘ma’)
  • Leans forward with arms or one arm stretched out for support from the prone position
  • Sits when pulled to a sitting position by the arms from the supine position.
  • Stays in a sitting position supporting herself or himself with two arms
  • Rolls from back to stomach and back

7 months

  • Examines adults attentively prior to communication Fear is replaced by cognitive interest
  • Distinguishes between family members and strangers
  • Recognizes the voices of family members
  • Active babbling
  • Grasps toys with generalized active movements Shifts toys from hand to hand, pats on a toy
  • Focuses on a familiar object at an adult’s request
  • Drinks from a cup held by an adult
  • Rolls from stomach to back and back
  • When seated, sits without arm support
  • Stands with support
  • Uses a crawling position
  • Commando crawling


8 months

  • Playing with adults; babbling and gesture as a means of communication
  • Confidently distinguishes between family members and strangers Distinguishes between faces of people. Knows his or her name
  • Active and expressive babbling
  • Pushes and throws an object away, taps objects, manipulates 2–3 objects
  • Claps his or her hands, plays patty-cake, waves bye-bye, goes into adult’s arms He or she is good at taking fine objects, putting them in larger objects, displays interest in a pyramid Copies adult’s behavior, understands some words such as ‘give me’, ‘here you are’, ‘where?’, plays with adults
  • Can hold a small piece of toasted bread, an apple, etc. and eats them
  • Sits unsupported
  • Goes on his or her hands and knees
  • Stands on his or her knees and legs without support

9 months

  • Plays with adults Displays various emotions when communicating with mother
  • Responds to words with actions Searches a hidden toy Communicates using gestures
  • Grasps fine objects with two fingers
  • When babbling, uses different combinations of sounds: separate syllable imitating words, intonational-melodic imitation of a phrase
  • Starts learning to go to the pot displaying the urge to go
  • Drinks from a cup holding it
  • Balances while sitting manipulating with objects
  • Stands holding the support
  • Walks well near the support and when supported by both hands
  • Crawls, stands on his or her knees

10 months

  • Expresses displeasure with some situations
  • Lets know of biological needs using the voice
  • Copies sounds and syllables
  • Different combinations of sounds
  • Babbling words
  • Copies hand movements (patty-care, waving good-bye)
  • Plays with an adult
  • Puts fingers in holes under visual control Grasps a toy with fingers
  • Plays with toys as appropriate: rolls a car, collects a pyramid, throws a ball, stacks blocks
  • Points at a person’s body parts
  • Is able to stand unsupported
  • Walks when held by the hand or holding the support with one hand
  • Climbs up and down the low stairs


11 months

  • Complies with some requests, shows attitude to the surrounding
  • Slow downs when told ‘no’
  • Babbling words ‘ma-ma’, ‘da-da’, ‘tya-tya’
  • Throws toys out of bed Puts fingers in holes by touch Collects a pyramid using rings with wide holes, likes stacking blocks and playing a ball Copies movements – turns pages, starts a car Points at the own body parts
  • Stands unsupported
  • Bends his or her knees
  • Walks supported with one hand, makes some steps unsupported

12 months

  • Treat those around in a different way Follows some instructions
  • Communicates with adults using combinations of sounds
  • 5–6 babbling words, request intonation
  • Babbling sounds are related to faces and objects
  • Puts one object into another one, opens a box or case
  • Likes being read books, points at familiar characters and objects in a book
  • Uses a spoon and a comb as appropriate
  • Walks unsupported
  • Bends his or her knees and stands up

If a child as born immature and/or had low weight at birth, acceptable terms of skill acquisition are shifted. However, an acceptable age range is available in this case as well.

Features of psychomotor development of children with weight deficit at birth

SP

Weight over 1,000 g

Visual and auditory concentration at 2–3 months of age

Holds the head well from the vertical position at 3–4 months of age

Rolls from back to stomach at the age of 6.5–7.5 months

Rolls from stomach to back at the age of 7.5–8.5 months

Sits unsupported at the age of 9–12 months

Stands unsupported at the age of 11–12 months

Walks unsupported at the age of 14–15 months

Starts saying words at the age of 12–14 months

SP

SP

Weight 1,000 g to 1,500 g

Visual and auditory concentration at 2–2.5 months of age

Holds the head well from the vertical position at 3–4 months of age

Rolls from back to stomach at the age of 6–7 months

Rolls from stomach to back at the age of 7–8 months

Sits unsupported at the age of 8–10 months

Stands unsupported at the age of 11–12 months

Walks unsupported at the age of 14–15 months

Starts saying words at the age of 12 months

SP

SP

Weight 1,500 g to 2,000 g

Visual and auditory concentration at 1.5–2 months of age

Holds the head well from the vertical position at 2 months of age

Rolls from back to stomach at the age of 5–6 months

Rolls from stomach to back at the age of 6–-7 months

Sits unsupported at the age of 7–8 months

Stands unsupported at the age of 9–10 months

Walks unsupported at the age of 11–13 months

Starts saying words at the age of 12–14 months

SP

SP

Weight 2,000 g to 2,500 g

Visual and auditory concentration at 1–1.5 months of age

Holds the head well from the vertical position at 1.5–2 months of age

Rolls from back to stomach at the age of 5–5.5 months

Rolls from stomach to back at the age of 6–-7 months

Sits unsupported at the age of 6–7 months

Stands unsupported at the age of 9 months

Walks unsupported at the age of 11–12 months

Starts saying words at the age of 11–12 months

SP



O. V. Bykova

Doctor of Med. Sc., Principal Researcher of the Centre for Applied Research in Pediatric Psychoneurology

of Moscow Health Department


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