“Learn the Signs. Act Early.”: Updates and Implications for Physical Therapists

Abstract

Purpose: In early 2022, the Centers for Disease Control and Prevention (CDC) updated their developmental surveillance milestone checklists. The purpose of this article is to clarify and interpret the updates from a physical therapist perspective and to discuss implications of the new milestones for physical therapists. Summary of Key Points: The CDC's updated checklists provide clear, consistent, easy to use, and evidence-based developmental milestones to prompt discussion with families. The new checklists do not represent a lowering of standards and will likely increase, not decrease, referrals for screening, evaluation, and services. Crawling has been removed from the milestone checklists, as the current evidence suggests that crawling is highly variable and not essential for development. Conclusions and Recommendations for Clinical Practice: The updated milestone checklists will facilitate bringing vital services to children who need them. Physical therapists should support our primary care colleagues in implementing this useful program.

Early Mobility and Crawling: Beliefs and Practices of Pediatric Physical Therapists in the United States

“…A therapist who believes that skipping crawling has lasting effects on development would want children who do not crawl to be flagged for assessment and intervention. As we have discussed elsewhere, 22 the exclusion of crawling, a highly variable milestone with limited normative data, was consistent with the CDC' s goals to simplify materials for use by families and to ensure that the materials are evidence-based. Ongoing research will be important to assess the effect of these revisions on referrals for comprehensive developmental assessments and early intervention services.…”

“…1,2,[13][14][15][16][17][18][19][20][21] However, evidence is less clear regarding benefits of the specific skill of crawling on hands and knees. 22 Gap in the evidence: Pediatric physical therapists' (PTs') beliefs and clinical approaches regarding crawling have not been quantified.…”

“…Contrary to conventional wisdom, there is little evidence for specific effects of crawling experience on developmental outcomes. 22 In addition, considerable variability in the timing and form of prewalking mobility 23,24 and well-known cross-cultural differences 7,25,26 suggest that the prototypical hands-and-knees crawl is not a universal or essential developmental milestone. The omission of crawling from the most recent version of the Centers for Disease Control and Prevention (CDC)' s "Learn the Signs.…”

“…The omission of crawling from the most recent version of the Centers for Disease Control and Prevention (CDC)' s "Learn the Signs. Act Early" developmental milestone checklists has been debated among pediatric PTs in the United States, 22 leading to increased discussion of the role of crawling in development and the implications for pediatric PT practice.…”

“…19,20 Strikingly, Nearly as many PTs believed that hands-and-knees crawling specifically is important for development, and a smaller majority believed that failure to crawl has lasting developmental effects, as these beliefs rest on uncertain empirical evidence. 22 Outcomes believed to be influenced by crawling were wide-ranging. Effects on gross motor outcomes (upper extremity/trunk strength and bilateral coordination) were the most endorsed, but effects on sensory, neurologic, fine motor, and cognitive outcomes were also endorsed by many participants; 33% to 48% of participants reported that crawling experience is necessary for the development of these outcomes.…”