It is not uncommon for us to be referred not-yet-ambulant children just past the 18 month “upper limit of normal” age of walking.  The majority of these children are using means other than crawling to get around.  I had vague recollections of having seen a table once detailing the 97th centile for walking in children who bottom shuffle, commando crawl or roll everywhere but I spent 2 or 3 fruitless hours searching the literature for it a couple of months ago.  So I was ironically excited this month to find that Archives of Disease in Childhood had reproduced it!  One of our current registrars, Dr Amy Rogers, has kindly put together an article for Paediatric Pearls with nuggets from that paper (Sharma A Developmental Examination: Birth to 5 Years. Arch Dis Child Educ Pract Ed 2011;96:162-175 doi:10.1136/adc.2009.175901) which summarises normal development and when it would be prudent to refer children for further developmental assessment:

Approach to developmental assessment – birth to 1 year: Motor¹

 1)    Elicit parental/carer concerns.  Questions to ask: 

• Do you have any concerns about the way your baby moves his arms/legs or body? Have you ever noticed any odd or unusual movements?
• Has your baby ever been too floppy or too stiff?
• Does your baby have a strong preference for one hand and ignore the other hand?

 2)    Gather information on social/biological risk factors:

 Risk factors for poor developmental outcomes

 3)    Observe/elicit behavior and interpret findings

 Note posture and movement.  Examine tone.  Elicit primary (Moro, grasp and asymmetrical tonic neck reflex) and support reflexes (downward, sideward and forward).  Video clips of all these reflexes can be seen at http://library.med.utah.edu/pedineurologicexam/html/newborn_n.html.

 What is not normal?

• Fisting of hands beyond 3 months
• Poor head control at 4 months
• Primitive reflexes beyond 6 months
• Flexor hypertonia in lower limbs beyond 9 months
• Not sitting unsupported with straight spine by 10 months
• Not walking by 18 months

 BUT preterm infants often have delayed motor milestones, early hypotonia and longer lasting asymmetrical tonic neck reflex.  Children with atypical pre-walking movement patterns (ie. non-crawlers) are late in achieving independent sitting and walking.

 Pre-walking movement pattern and motor milestones (97th percentile)²

Refer if concerned as delayed motor development may be a marker for motor disorders and may have a negative impact on a child’s performance in the cognitive and social developmental domains.  There is more information on delayed walking in a Patient Plus article written for health professionals available at http://www.patient.co.uk/doctor/Delay-In-Walking.htm.

 1         Sharma A Developmental Examination Birth to 5 Years. ADC Educ Pract Ed 2011;96:162-175

2         Robson P. Prewalking locomotor movements and their use in predicting standing and walking. Child Care Health Dev 1984;10:317-30