Occupational Therapy for Infants and Toddlers: Milestones, Reflexes and Play
How OT helps babies and toddlers: early reflexes, milestones, red flags, NICU and feeding support, sensory play, tummy time and the best toys by age.
Infants and toddlers
- Infant: a very young child or baby. We call them an infant, baby or newborn. A child between birth and 12 months of age is an infant.
- Toddler: a young child between about 13 months and 36 months (up to 3 years). The toddler years are a time of great cognitive, motor, emotional and social development.
Infants grow very fast and develop basic life-saving skills in this vulnerable phase of life, while depending completely on their parents.
Early reflexes and why they matter
Infants show basic reflexes that are essential for them, such as sucking, rooting and the Moro reflex. These reflexes help infants feed, grow and stay safe. Each reflex has its own importance and is part of normal development. As the brain matures, these early reflexes “integrate”, or fade, and voluntary movement takes over.
| Reflex | What it looks like | Usually fades by |
|---|---|---|
| Rooting | Turns towards a touch on the cheek, mouth open, ready to feed | About 4 months |
| Sucking | Sucks automatically when something touches the roof of the mouth | Becomes voluntary by about 4 months |
| Moro (startle) | Throws arms out, then brings them in, at a sudden noise or drop | About 4–6 months |
| Palmar grasp | Fingers close tightly around a finger placed in the palm | About 4–6 months |
| Asymmetrical tonic neck reflex (ATNR) | 'Fencing' pose: when the head turns, the arm on that side straightens | About 4–6 months |
| Plantar grasp | Toes curl when the sole of the foot is touched | About 9–12 months |
Ages are approximate. A reflex that persists well beyond these ages, is very strong, or is missing should be checked by a doctor or therapist.
If the reflexes don’t integrate with age, or an infant is developmentally delayed and not reaching typical milestones, they may need expert help to intervene early. Conditions associated with developmental delay in babies and toddlers include Down syndrome, cerebral palsy, autism, ADHD and more.
Milestones from birth to 2 years
- 2 months
- Holds head up when on tummy
- Moves both arms and both legs
- Opens hands briefly
- 4 months
- Holds head steady when held
- Holds a toy put in their hand
- Brings hands to mouth
- Pushes up onto elbows on tummy
- 6 months
- Rolls from tummy to back
- Reaches to grab a toy
- Leans on hands to support themselves when sitting
- 9 months
- Sits without support
- Moves things from one hand to the other
- Rakes food towards themselves with fingers
- 1 year
- Pulls up to stand
- Walks holding on to furniture
- Picks up small things with thumb and pointer finger
- 15 months
- Takes a few steps on their own
- Stacks two small objects
- 18 months
- Walks alone
- Scribbles
- Tries to use a spoon
- 2 years
- Kicks a ball and runs
- Eats with a spoon
Source: CDC, Learn the Signs. Act Early. (2022). For full checklists see our gross motor and fine motor guides.
The role of occupational therapy for infants
A pediatric occupational therapist provides early intervention for infants. In infants, developmental delays can be missed at first. But babies born prematurely, with low birth weight, with a physical impairment or with a chromosomal or genetic condition may need intervention as early as possible. Occupational therapy for infants and toddlers includes assessment and intervention for these babies.
Occupational therapy assessment in infants
Premature babies often have weak early reflexes, most importantly the rooting and sucking reflexes needed for feeding. Developmental delays in infants and toddlers can affect:
- Language and speech
- Vision
- Gross motor skills
- Reflexes
- Fine motor skills
- Social and emotional skills
- Thinking and cognitive skills
To assess these skills, the occupational therapist takes a developmental history and interviews the parents. The therapist may also use tests such as:
- Denver Developmental Screening Test II
- Bayley Scales of Infant and Toddler Development
- Toddler and Infant Motor Evaluation (TIME)
- Infant/Toddler Sensory Profile
Motor delays may affect gross motor skills such as standing and walking, or fine motor skills such as grasping a toy. Social and emotional delays may be early signs in children who are later diagnosed with autism or ADHD.
Occupational therapy intervention for infants and toddlers
After assessing the areas of difficulty, the OT sets goals and objectives depending on the areas of delay. Intervention goals usually include improving motor skills, social skills and cognitive and perceptual skills.
Occupational therapy in the NICU
Occupational therapists may work in the neonatal intensive care unit (NICU) with newborns (birth to 28 days, called neonates) who have sensory or motor difficulties. The OT provides oral-motor stimulation to premature babies to improve their rooting and sucking responses, by gently stimulating different parts of the face and mouth. NICU OTs also help with positioning, handling, calming and preparing parents for feeding at home.
Reflex integration through NDT
3 years ↑
-
Motor planning of fine movements2–3 years
-
Integration of the two sides of the body, body-part awareness and motor planning of gross movements1–2 years
-
Maturation of righting and equilibrium reactions9–12 months
-
Integration of primitive postural reflexes3–9 months
-
Integration of the tactile subsystem0–3 months
Birth
An occupational therapist helps integrate these reflexes and reactions when they haven't developed on time in a child with developmental delay.
Sensory integration
The occupational therapist follows the principles of sensory integration for sensory difficulties, adapted to the baby’s age:
- Sensory modulation for tactile defensiveness, over- or under-responsiveness and sensory seeking. The OT gives deep, firm touch where the baby can see where it comes from, which is usually easier to tolerate than light touch, and begins with slow linear movement and deep pressure.
- Tactile discrimination. The OT provides graded activities that use different textures and items.
- Proprioceptive and vestibular input. The OT provides slow linear movement and push or pull activities, always watching the baby’s cues.
Tummy time
Tummy time builds the neck, shoulder, arm and core strength that rolling, crawling, sitting and later hand skills depend on. The rule is simple: back to sleep, tummy to play.
- Start in the first days with short sessions of a few minutes, several times a day, while your baby is awake and watched.
- Lie your baby on your chest, across your lap or on a firm mat. Get down at eye level and talk or sing.
- Add a rolled towel under the chest, a mirror or a high-contrast book if your baby protests.
- Build up the time gradually as your baby gets stronger.
Play
The occupational therapist uses play as the main medium of intervention with infants and toddlers, matched to the baby’s developmental level. Play builds cause-and-effect learning (“when I shake it, it makes a sound”). With parents’ help, the therapist promotes play with siblings and peers, giving cues or support so the child completes the activity. Play helps a child learn new skills and master old ones.
Occupational therapy toys for infants and toddlers
The occupational therapist sees play as the primary occupation of an infant or toddler, and recommends toys that teach new skills. Many parents ask which toys to buy for their baby. The therapist suggests toys and games for the child’s developmental level.
| Toy | Skill it builds |
|---|---|
| Hand-held toys that make a sound or light up (large enough to be safe) | Reaching, grasping and attention |
| Music box or wind chimes | Turning towards sound and head control; babies love gentle music and follow the sound |
| Textured sensory toys | Touch exploration |
| Bright rattles | Grasp, shaking and cause and effect |
| Soft toys | Comfort, affection and a sense of belonging |
| Teething rings | Mouth exploration and oral-motor skills |
| Stacking blocks and cups | Perception, grasp and release |
| Ring stackers | Colour identification and size discrimination |
| Soft balls | Rolling, pushing and early catching and throwing |
| Shape sorters | Shape and size discrimination |
| Toy | Skill it builds |
|---|---|
| Building blocks and large bricks | Constructive play and two-handed coordination |
| Push-pull toys and sturdy push walkers | Proprioceptive input and walking practice |
| Ride-on toys (pushed with the feet) | Leg strength, balance and coordination |
| Climbing gym | Gross motor skills |
| Chunky crayons and paper | Scribbling and pre-writing skills |
| Puzzles | Perception and problem solving |
| Manipulative toys such as pop-ups and busy boards | Creativity, finger control and cause and effect |
Summary
Occupational therapy promotes play and functional skills in babies and toddlers with developmental delays. The occupational therapist may use approaches such as NDT, sensory integration and play to improve motor skills, perceptual skills and daily living skills, always working with the family. Read more: occupational therapy for children.
Related guides: Primitive reflexes, W-sitting, Toe walking, Vestibular activities for babies, Oral motor activities for toddlers.
References
- Centers for Disease Control and Prevention. CDC’s developmental milestones.
- American Academy of Pediatrics. Injuries associated with infant walkers. Pediatrics. 2001;108(3):790–792.
- Case-Smith J, O’Brien JC. Occupational Therapy for Children and Adolescents. Elsevier.
- Kramer P, Hinojosa J. Frames of Reference for Pediatric Occupational Therapy. Lippincott Williams & Wilkins.
Frequently asked questions
Can babies have occupational therapy?
What does an occupational therapist do for a baby?
What are signs my baby might need occupational therapy?
How much tummy time does my baby need?
What are the best toys for babies' development?
Are baby walkers good for development?
Written by
Payal Mehta, OT
Payal Mehta is a practising occupational therapist and co-founder of Occupational Therapy OT. She writes on pediatrics, sensory integration, and mental-health practice.
All articles by Payal →This article is for general education and is not a substitute for individualized assessment or treatment by a licensed occupational therapist. Always seek the guidance of a qualified professional for specific concerns.
