Supervised By Dr.

Amal
Fathy

GROWTH &
DEVOLOPMENT FOR 4
MONTH INFANT
Child Development
Child development is a complex process
that begins in the womb and continues until
adulthood. It is influenced by biology and
the environment and can be shaped
positively or negatively. A person's mental
health depends significantly on their
development as a child.
 Normal Child
Development
(Encoding):
[Link] reflexes appeared.
[Link] sensory reception
systems development.
[Link] sensory perception
systems development.
(Decoding):
[Link] gross motor abilities.
[Link] fine motor abilities
3. Normal cognitive abilities.
4. Normal language development.
Encoding Stage
Involuntary reactions originate from
alterations in pressure, visual stimuli, and
tactile stimulation. These stimuli and their
corresponding responses constitute the
foundation of the information-gathering
phase.
1. Normally appeared
reflexes
A. Spinal Level Reflexes
a)Flexor withdrawal reflex.
b)Extensor thrust reflex.
c)Crossed extension reflex (I,II,III)
Flexor Withdrawal Reflex
Testing Position: Infant supine, head midline,
lower extremities extended.
Stimulus: Apply a noxious stimulus to the sole of the foot.
Positive Response: Withdrawal of the stimulated foot through hip and
knee flexion.
Negative Response: Maintaining the stimulated leg in extension or a
controlled, volitional withdrawal from the stimulus.
Age: Present from 28 weeks gestation to two months postnatal in
typically developing infants. Persists throughout life, but with increasing
control.
Developmental Significance: Persistence of this reflex beyond the
typical age may indicate developmental delay or cerebral palsy.
 Extensor Thrust Reflex
Testing Position: Child supine, head midline, one leg flexed, the
other extended.
Stimulus: Stimulate the sole of the flexed leg's foot.
Positive Response: Uncontrolled extension of the stimulated
flexed leg.
Negative Response: Controlled maintenance of leg flexion.
Age: Birth to 2 months.
Developmental Significance: Persistence interferes with weight-
bearing and walking.
 Crossed Extension Reflex
Testing Position: Infant supine, head in midline, lower
extremities extended.
Stimulus: While holding one leg in extension at the
knee, apply firm pressure to the sole of that foot.
positive Response: The opposite leg flexes, adducts,
and then extends.
Negative Response: No reaction in either leg.
Age: Present from 28 weeks gestation to 1-2 months
postnatal.
Developmental Significance: Persistence of this reflex
can interfere with reciprocal kicking and later functional
activities.
 Crossed Extension Reflex III
Testing Position: Patient supine, head midline, legs
extended.
Stimulus: Tap the medial surface of one leg.
Positive Response: The opposite leg adducts, internally
rotates, and the foot plantar flexes (typical scissor
position).
Negative Response: No reaction in either leg upon
stimulation.
Age: Present from 28 weeks gestation to 1-2 months
postnatal.
Developmental Significance: This reflex can hinder
reciprocal kicking and later functional activities.
1. Normally appeared reflexes

B. Brainstem Level
[Link] tonic neck reflex (ATNR).
[Link] tonic neck reflex (STNR).
[Link] labyrinthine reflex (supine and prone).
[Link] supporting reaction.
[Link] reaction.
 Asymmetric Tonic Neck Reflex (ATNR)

Testing Position: Patient supine, head in midline, legs

extended.
Stimulus: Turn the child's head to one side.
Positive Response: The arm and leg on the side to which the
head is turned extend, while the opposite arm and leg flex.
This movement may be subtle.
Negative Response: No limb movement.
Age: Present at one month, disappears around four months.
Developmental Significance: The ATNR is a precursor to
hand-eye coordination and voluntary reaching. Persistence
beyond four months can interfere with feeding, visual tracking,
midline hand use, bilateral hand use, rolling, crawling, and
may contribute to skeletal deformities (e.g., scoliosis, hip
subluxation, hip dislocation).
 Symmetric Tonic Neck Reflex (STNR) Assessment

Testing Position: The infant is placed in a prone position over the examiner's knee,
with the examiner supporting the infant's trunk.
Stimulus: The examiner passively flexes and extends the infant's neck.
Positive Response: Flexion of the head results in flexion of the upper extremities
and extension of the lower extremities. Extension of the head results in extension of
the upper extremities and flexion of the lower extremities.
Negative Response: No change in muscle tone is observed in the upper or lower
extremities.
Age: This reflex may be present from birth to 4 months of age and can be considered
a pathological sign if persistent beyond this period.
Developmental Significance: Persistence of the STNR can interfere with several
developmental milestones, including:
Propping on arms in prone. Attaining and maintaining a hands-and-knees position.
Reciprocal [Link] balance while visually scanning the environment. Using
hands while looking at objects held in the hands while sitting.
 Tonic Labyrinthine Reflex (TLR) –
Supine
Testing Position: Supine
Stimulus: Supine position
Positive Response: Extensor tone dominates. Passive limb
flexion is restricted due to increased extensor tone.
Negative Response: No change in tone
Age: Birth to 6 months
Developmental Significance: Persistence of the TLR impedes: (1)
activities requiring graded co-activation of flexor and extensor
muscles; (2) flexing the trunk and hips to attain a sitting position
from supine; and (3) rolling, sitting, or standing due to full body
extension.
 The Tonic Labyrinthine – Prone

Testing position: prone

Stimulus: Prone positioning.
Positive Response: Flexor tone dominance restricts passive limb
extension.
Negative Response: No tone changes.
Age: Birth-6 months
Developmental Significance: Persistent Tonic Labyrinthine Reflex
(TLR) hinders graded flexor/extensor co-activation, impacting
rolling and prone elbow propping with extended hips.
 Positive Supporting Reaction
Testing Position: Infant held vertically, feet contacting the
surface.
Stimulus: Bounce the infant several times on the soles of their
feet.
Positive Response: Increased extensor tone in both lower
limbs and plantar flexion.
Negative Response: No increase in tone (legs voluntarily flex).
Age: 3–8 months.
Developmental Significance: Interferes with stable standing
and walking.
 Associated Reactions Test
Position: Infant supine.
Stimulus: Squeeze an object in one hand.
Positive Response: Mirroring in the opposite
limb and/or increased tone in other body
parts.
Developmental Significance: Interferes with
motor control.
1. Normally appeared
reflexes
C. Midbrain level
1- Neck righting acting on body.
2- Body righting acting on body.
3- Flexion righting reaction.
4- Landau.
5- Vertical righting reflexes
 Neck Righting Acting on Body

Testing Position: Supine

Stimulus: Manually turn the child's head to one side.
Immature Response: Log rolls to a side-lying position.
Mature Response: Segmental roll.
Age: Birth-6 months
Developmental Significance: This reflex enables rolling from
supine to side lying. Persistence beyond six months may
indicate the child rolls to rise rather than sitting up directly.
Asymmetry could suggest unilateral brain impairment.
 Flexion Righting Reaction

Testing Position: Supine

Stimulus: Pull the child to a sitting position.
Partial Response (3-4 months): Head aligned with the
body, without head lag.
Mature Response(6-7 months): Neck flexion to maintain
head and trunk alignment against gravity.
 Landau
Testing position: (Prone Suspension):

Stimulus: With the child held prone in space, supported under

the abdomen, the examiner observes the response to head
raising (actively or passively).

immature response: shows incomplete body extension, with

spine and legs remaining flexed.

mature response: demonstrates neck, trunk, and leg extension.

Age: (3-10 months)

 Prone Head Righting Labyrinthine
Test: Hold the blindfolded patient prone in space.
Stimulus: Prone positioning.
Immature Response: Head does not lift to a vertical
position.
Mature Response: Head raises to vertical, face vertical,
mouth horizontal.
Age: 1–2 months and ongoing.
 1. Normally appeared
reflexes.

6- Optical righting acting on head/ prone:

Testing position; Hold child prone in space.
Stimulus Prone in space.
Immature Response ; Head does not raise
automatically to the normal position.
Mature Response; Head raises to normal position,
face vertical, mouth horizontal
Age ; 1-2 months and continue
1. Normally appeared reflexes.

Reflexes respond to touch:

Palmar grasp reflex Plantar reflex Rooting
reflex

Rooting reflex
1. . Normally appeared
reflexes.
Palmar grasp reflex
Testing position ; Supine lying position.
Stimulus ; Pressure in palm on ulnar side of hand.
+Ve Response ; Flexion of 4fingers [not thumb] causing
strong grip.
-Ve Response ; No palmer grasp Age ; Birth to 4
months

Developmental significance Interferes with:

- Ability to grasp and release object voluntarily.
- Weight bearing on open hand for propping responses
crawling, protective responses.
 1. Normally appeared
reflexes.
Plantar grasp reflex Testing
position ; Supine lying position. Stimulus ; touch
base of toes

+Ve Response ; Toe flexion

-Ve Response ; No toe flexion
Age ; 28 weeks of gestation to 9 months.
Developmental significance ;

-Ability to stand with feet flat on surface.

- Balance reactions and weight shifting in standing
 1. Normally appeared
reflexes.
Rooting reflex
Testing position ; Supine
Stimulus ; Touch cheek
+Ve Response ; Newborns turns head in direction of
stimulus, opens mouth, and begins to suck when cheek, lip,
or corner of mouth is touched with finger or nipple Age ;
At birth [it assists in breast feeding]- four months.
Developmental significance;

- Its persistence will interfere with:

Oral- motor development Development of midline control of
head Optical righting, visual tracking, and social interaction.
1. Normally appeared
reflexes.

Reflexes respond to pressure and pain:

Withdrawal reflex.
Crossed extension.
Babiniski reflex.
 1. . Normally appeared
reflexes.
Babinski reflex
Testing position ; Supine
Stimulus ; Stroke sole or lateral portion of foot
+Ve Response ; The big toe then moves upward or
toward the top surface of the foot. The other toes fan
out.
-Ve Response ; Great toe turns downward Age ; 1It is
normal in children up to 1 year, Developmental
significance;
The presence of a Babinski's reflex after age of 1 year is
a sign of damage to corticospinal tract.
 1. . Normally appeared
reflexes.

Reflexes respond to kinesthetic

stimuli:
Asymmetrical tonic neck reflex.
Symmetrical tonic neck reflex.
Moro reflex.
Head righting on body.
Body righting on body.
Tendon reflexes
 1. Normally appeared
reflexes.

Tendon reflexes •
Stimulus Tendon tapping Response Muscle contraction•

Age Throughout life Function For diagnosis of •

UMNL ; exaggerated response •
LMNL ; depressed or absent response. •
 1. Normally appeared
reflexes.
Moro reflex
Testing position ; Supine lying position
Stimulus ; Lifting the baby's shoulders up from the bed at a 45 ͦ angle,
then allowing the baby's head to gently drop back into the other
hand i.e. sudden movement or loud noise.
+Ve Response ; The baby will fling their arms out, fan their fingers,
extend their legs and then quickly pull their arms back in towards
their body in an 'embrace' position.
Age ; Birth-4-6 months Developmental significance

- If persistence,will interfere with

: - Balance reactions in sitting.
- Delay sitting & head control if persists
- Eye-hand coordination, visual tracking
 1. Normally appeared
reflexes.

Reflexes respond to visual and

auditory stimuli:
Blink reflex
Optical righting, labyrinthine
1. Normally appeared
reflexes.
Blink reflex
Position ; Supine
Stimulus ; Stimulation of the cornea (such as by touching a
foreign body), or bright light, though could result from any
peripheral stimulus.
Response; An involuntary blinking of the eyelids Age ; This
reflex should not become inhibited.
Significant ; The purpose of this reflex is to protect the eyes
from foreign bodies and bright lights.
2. Normal sensory By the age of 4 months, newborn

reception systems
children appear critical advance in
how they take in and handle data from

development their environment. Usually known as

tangible encoding, which alludes to the
method by which the brain gets input
from the faculties and begins to
organize and translate it. This handle
plays a key part in early learning and
memory, shaping the establishment for
passionate holding, engine
advancement, and social interaction.
2. Normal sensory
reception systems Taste:
development A newborn can distinguish
between sweet, salty, sour, and
bitter tastes. She shows a
preference for sweet taste, such
as breast milk, and for salty
tastes later on. Your baby will
achieve a full sensitivity to taste
by 12 to 19 months.
2. Normal sensory
reception systems Smell:

development A newborn’s sense of smell is so acute that

she can already tell the difference between
the smell of her mother’s milk and that of
another mother. Researchers conducted
experiments where two breast pads (one
from the infant’s mother, the other from
another lactating mother) were placed at
the sides of the newborns’ heads. The babies
reliably turned towards the breast pad of
their own mothers. By about age five, your
child can identify some foods by smell.
2. Normal sensory
reception systems Hearing:
development Newborns can’t hear certain very
quiet sounds. But, for the most part,
their sense of hearing is already well
developed. After about three
months, sh e will show you she hears
a sound by turning her head toward
the direction of the sound. By four to
eight months, she will hear the full
range of sound frequencies.
2. Normal sensory Touch:

reception systems Touch remains one of the foremost

c r e a t e d faculties a t this age. Tender
development touch can relieve the newborn child,
and skin-to-skin contact plays a huge
p a r t in passionate holding. Newborn
children start to investigate
surfaces by getting delicate toys or
their claim hands. Their grasp is still
reflexive but is getting to be more
deliberate
2. Normal sensory
reception Vision:
Newborns can focus on objects about
Systems eight to 15 inches away. By one month,

development she will see about three feet away. At

birth, she has limited color vision. But by
two months, she can discriminate
between basic colors. She will achieve
full color vision between four and seven
months of age. Depth perception
develops between three and seven
months. It will achieve full adult acuity
(20/25) during her second year.
 How babies perceive sensory information

individualhow understandto importantisIt

babies perceive sensory information. With
poor processing, babies may bump into
furniture (vestibular and proprioceptive
systems) as they roll, crawl or walk, as they
have not yet developed a good awareness of
where their body is in space.

3. Normal sensory perception

systems development.
Some babies are very sensitive to sensory input. They may become
more agitated or distressed than other babies when they hear loud
noises or are around lots of people (auditory and visual systems),
or in reaction to clothing labels (tactile system) which may feel like
knives cutting into their skin. Other babies are less sensitive to
sensation. Some do not notice pain (tactile system) when burned or
bumped.
 How babies perceive sensory information
Some babies crave more calming input such as slow
while system)(vestibularmovementrhythmical
3. Normal sensory others may crave more aggressive and alerting
perception systems input such as rapid movement and swinging.
Observe your child to learn what they seek or
development. avoid. They may feel and behave differently from
one day to the next. Follow your child’s lead and
progress slowly to help them become used to
sensory inputs that may be perceived as
uncomfortable.

Organize the suggestions below around typical

daily routines so that they are easier to carry out.
Watch for reactions to play. If your child becomes
wild or upset, they may be over stimulated. Deep
hugs or pressure, and slow rocking (calming) are
useful strategies to try at such times. Feeling
comfortable and safe can help with selfregulation
(ability to manage emotions and behavior).
 3. Normal sensory
perception systems
development.

The 8 sensory systems Babies take in

sensory information (what they see or
hear) from the environment around them,
make sense of it and then use it to help
them understand themselves and how they
can influence that environment. This helps
them to participate in everyday
activities such as play or sleep
 (touch): system Tactile
Provides information
regarding shape, size,
texture and temperature.

Vestibular system (balance

Visual (sight): 3. Normal sensory and movement):

Provides information about
Helps babies detect colors,
shapes and social cues perception systems where our head is in relation to
gravity and about the speed

development. and direction of movement.

Proprioception system (body awareness):

Provides information from muscles and joints, tells
us where our body is in space and about how
much force to use for activities.
 1. Tactile
System fully developed at birth. Babies
prefer soft gentle touch and cuddles, crave
skin to skin contact, calm with touch; palms
grasp reflexively in response to touch.
Activity suggestions: o Skin-to-skin contact,
touch with different textures; daily gentle
massage o Provide touch input during daily
routines such as bath time and diaper
changes, naming body parts

[Link]
systems development. (0-4 2. Vestibular
Various reflexes, such as fencing position,
month) affect movement in first 6 months.
Activity suggestions: o Variety of positions;
movement such as rocking, swaying while
holding o Become aware of reactions to
various movements, which ones help to calm
vs. alert (wake up) the baby
 3. Proprioception
Babies begin to smile, imitate facial
movements, suck to drink.
Activity suggestions:
o Move body arms/legs together and then
a p a r t during play and daily routine, gently
o Play and c a r r y in different positions

3. Normal sensory
perception systems 4. Visual
Babies cannot see all colours a t first; they p re fe r black
development. (0-4 month) and white and human faces.
At 1 month, babies can focus short distances (approx. 1
foot).
At 2 months, they can follow a toy when it is moved close to
face. Eye movement is not yet fully coordinated so may seem
cross eyed a t times; beginning to make eye contact.
Activity suggestions:
o Simple patterns of black and white on toys, books; mobiles
and overhead gyms o Eye contact; smile a t baby, re a d and sing
to baby
o C a r r y baby so they can see where they/you a r e going
 3. Normal sensory
perception systems
development. (0-4 month)

5. Olfactory
Fully developed sense; babies will turn
toward source of food; prefer pleasant
smells (e.g. milk vs. spoiled food); prefer 6. Auditory
what mother ate during pregnancy. Fully developed at birth; babies prefer the
Activity suggestions: sound of human voices and a r e calmed by
o Familiar smells, such as breast milk, are soft voice; startled, sometimes cry with
calming; give baby blanket that parent has slept loud noise; begin to coo, make sounds.
with Activity suggestions:
o Coo, talk, and smile, sing songs, play music,
dance with infant, making eye contact
o Squeaky toys or toys that make noise
 7. Gustatory
Babies are attracted to sweet taste as breastmilk
as opposed to sour or bitter;
anticipate feeding.

8. Interoception
Normal sensory Babies will be calm but react to
perception systems discomfort from hunger, fatigue,
development. (0-4 month) dirty diaper.
Activity suggestions:
o Attend to physical needs, cuddle, keep
warm
o Attend to environmental input; e.g.
bright lights should be dimmed for
sleeping
 Decoding stage :
As higher brain centers gain greater
control of the sensorimotor apparatus,
the infant is able to process information
to form information processing stage
 1. Normal gross motor abilities.
At this age:
Your baby can lift their head and chest when lying on their
stomach and lean on their forearms.
When sitting in your lap, they reach forward to grasp at objects
They turn their head in all directions to follow a toy with their eyes
when lying on their back or stomach.
They can lie on their side without rolling onto their back.
They bring both hands to their chest and keep their head straight
when lying on their back.
They can stretch out their arms and legs and keep them in the air
for about 3 seconds while lying on their stomach.
 1. Normal gross motor abilities.
Your baby can touch objects at chest level with both hands and
follow them with their eyes if they’re brought toward their belly
button.
They can bring toys to their mouth.
They keep their head steady when held in a sitting position and
may prefer to sit instead of lying down.
They can support their weight on their feet and stay upright
when being held around the chest.
( But don’t forget about tummy time: according to the Canadian
Pediatric Society, babies should be placed on their stomach for
10 to 15 minutes at least 3 times a day.
 2. Normal fine motor abilities
1. Your baby’s hands 2. They can grip nearby
gradually start to objects as if they were
open up and aren’t wearing mittens (i.e.,
balled up into fists as they’ll use their fingers
much. but not their thumbs).

3. They can bend their

elbows and bring their arms
to the centre of their chest
to touch or grab an object.
 2. Normal fine motor abilities
5. Your baby brings objects
4. They start using both hands to their mouth, which allows
to reach for them to practise certain
objects that are placed in front reflexes and mouth
movements. This prepares
of them.
them for eating solid foods.

6. They hold their hands

away from their body in 7. Their eyes move from one
order to look at them and object to another and they
play with their fingers. focus on nearby toys
 3. Normal cognitive abilities

Cognitive development is the process by which the brain forms

the abilities to learn and remember.
This development follows a typical pattern in the first 12
months of life.
Between 1 and 2 months of age, infants become interested in
new objects. They will turn their gaze toward them. They also
gaze longer at more complex objects. They seem to thrive on
novelty, as though trying to learn as much about the world as
they can.
 3. Normal cognitive abilities
At around 3 months of age, infants are able to anticipate
coming events. For example, they may pull up their knees
when placed on a changing table. Or they may smile with
gleeful anticipation when put in a front pack for an outing.
At around 4 months, babies develop keener vision. Babies'
brains now are able to combine what the babies see with
what they taste, hear, and feel (sensory integration).
Infants wiggle their fingers, feel their fingers move, and
see their fingers move. This adds to an infant's sense of
being an individual.
 4. Normal language development
make eye contact with you
Makes sounds back when you talk to him Turns head towards the sound of your
voice
Your baby can make more vowel sounds like a, e, and i.
They play with the sound of their voice by changing how quickly or loudly they
talk.
They show pain, fear, or loneliness by crying, and show joy or interest by cooing.
They play with their mouth and tongue (e.g., by making bubbles, fart noises).
They laugh when they think someone's funny.
babble and combine vowels and consonants from 4 months, like ‘ga ga ga ga’, ‘ba
ba ba ba’, ‘ma ma ma ma’ and ‘da da da da’.
 4. Normal language development

Newborns use crying as their main form of

Crying & communication . You may even learn to differentiate
between their cries (hunger vs tiredness etc.),
Cooing common crying and grunting are sounds that
originate from the chest.
After that, at around 2 months old, children
typically begin to vocalize with different sounds,
called cooing, Cooing comes from the larynx, the
organ in the neck that contains the vocal cords, and
involves different mouth muscles than crying does.
Made By
202003901 Mohamed Atef Abdelftah Sharaf

202002967 Ahmed Mohamed Ali Sanad

202003553 Mohamed Hatem Abdellatif
202002928 Mohamed Ayman Mohamed El Sayed
202002930 Ali hamdy nasr Ali
202003652 Norhan Ezz Ahmed
201916212 Marwa Mahmoud Mohamed Hasanin
202305108 Somia Abdelshakour Mohamed Abdelqader

202003927 Abdelaziz Adel Assran

202305164 Ibrahim Khamis Saad Yousef
Thank You