Development of head control: neonate - 3 months

Author Pam Versfeld   Posted 1 January 2018

Over the first 3 months infants learn to move their heads to look in all directions as well as to keep the head and trunk steady when reaching and kicking. 

"Infants display dramatic changes in their head control during the first months of their postnatal life. Not surprisingly, head control is critical for a range of early behaviors, including those involving vision, oromotor skills, and the trunk and arms. For example, a dynamically stable head may provide less mechanical perturbation to the trunk and arms and may support the function of vision.2 Less perturbation and improved use of vision, in turn, may allow for better body control, which, in turn, assists infants in learning more complex behaviors." (Lee and Galloway 2012)

Overview 

The newborn infant has some limited control over the position of the head in supine and when supported upright. Newborn head control is characterized by: 

  • A strong tendency to turn the head to one side when at rest;
  • An aility to maintain the maintain the head in the midline when paying attention to an interesting visual event or when crying;
  • An ability to lift the head against gravity briefly, both in prone and when supported upright.

Over the next 10 weeks (the second months) the infant's control improves, in particular:

  • The ability to maintain the head in the midline
  • The ability to hold the head erect when supported in sitting 
  • The ability to hold the head up in prone 

A marked feature of head rotation in the first two months is the tendency for rotation to be coupled with neck extension and side flexion to the opposite side, which is a reflection of the balance in activity between the sternocleidomastoid (SCM) muscles and deep neck flexor muscle activity (Bly B, 1994).  

 

     Will 10w supine repose momennts 7.jpg

In the third month there is an important change in head control: head rotation is no longer coupled with neck extension. The infant now actively engages the deep neck flexor muscles and is able maintain a neutral head on neck position (chin tuck) when turning the head, but is also able to flex the head in supine in order to look down. 

Will 14w supine repose momennts 1.jpg    will 16w supine 10.jpg  



Neonate - birth to 10 days

Supine

The full term neonate will usually lie with the head rotated to one side.  The rotation is associated with head on neck extension.  This tendency to rest with the head rotated to one side is in part influenced by the round shape of the head and weakness in the neck muscles.

Infants often have a preferred side, usually to the right (Ronquist et al 1998). The reason for this tendency is unclear. 

In this position the infant may bring her hand to the face, a movement that is very familiar from extensive experience in the intrauterine environment. 

W 7d LE actions 7.jpg

If the hand is moved into the infant's field of vision, it will preferentially engage the infant's visual attention (van der Meer 1997). 

   W 7d supine notices hand 1.jpg

The head is held in the mid-position for brief periods of time when the infant is actively moving the limbs or is distressed (Cornwell et al 1985). This is possibly due to increased activity in the neck and trunk muscles associated with the kicking actions. 

Will 7d head in midline.jpg

The infant will also actively move the head when the perioral region is stimulated, the direction of the movement depending on the area that is stimulated (the rooting response). The infant does not respond to stimulation provided by their own hand.  

Supported with trunk upright 

When the trunk is supported in an upright position the neck is usually flexed, however the newborn infant is able to lift the head and hold the it erect very briefly in response to an interesting visual event. 

newborn supported sitting.jpeg      M 2w sitting.jpg

Pull to sit 

When pulled to sit, the head lags behind the body, but does not fall back fully.   Once the trunk is erect, the infant will lift the head in line with the trunk. 

Newborn pts.jpeg   newborn pts2.jpeg

Visual regard 

Newborn infants will pay attention to interesting events that come into their field of vision. If the infant's head is supported in the midline, she will pay careful attention to an animated talking face.

newborn visual regard.jpeg

If the interesting moving face sticks out her tongue, the infant will, after a little while imitate the action.  



Supine 2-7 weeks

The infant still tends to lie supine with the head turned to one or the other side.

  • Head rotation is still associated with some neck extension
  • Head turning may be associated with an ATNR posture, but is not obligatory.  

W 5w quiet moment 1.jpg    W 5w swipe 1.jpg   W 5w focus on toy.jpg   Will 7w supine repose momennts 3.jpg

The infant is able to maintain the head in the midline when his attention is directed towards an interesting object suspended above the head. 

Will 7w supine repose momennts 1.jpg   



Will att 10 weeks supine 

At 10 weeks Will tends to lie with the UEs abducted and extended, a position that helps to stabilize the trunk and provide a stable base for head movements and kicking. 

Will 10w supine repose momennts 5.jpg

At 10 weeks Will is able to easily maintain his head in midline, as well as rotate the head to look at interesting events (objects and people) in the environment.  

Will 10w supine repose momennts 7.jpg   Will 10w supine repose momennts 8.jpg

He also combines neck rotation with extension of the head , which allows him to direct hs gaze in different directions. 

Will 10w supine repose momennts 6.jpg

However, control of the exact position of the head is clearly still developing, as rotation is usually associated with some neck extension and lateral flexion. This combination of movements suggests that the movement is broght about by contraction of the sternocleidomastoid muscles, with limited action in the deep neck stabilizers. 

Will 10w on playmat 2.jpg   Will 10w supine repose momennts 6.jpg   

Looking, reaching and grasping - 10 weeks 

Will has learned to steady his head and trunk when reaching for toys that are suspended in easy reach. 

Will 10w on playmat 1_1.jpg

Head control when pulled to sit (PTS) - 10 weeks 

The PTS maneuver is often used to assess infant motor abilities; the infants forearms are grasped and the infant is pulled up from supine into sitting. At 10 weeks Will anticipates the movement of the head when pulled to sit, and is able to maintain the head in line with the trunk as the PTS maneuver proceeds. 

Will 10w PTS 2.jpg

Once the trunk is upright and tilted forwards a little Will is able to hold the head in line with the trunk. He is also able to lift the head erect to look at me. 

Will 10w PTS 3.jpg   Will 10w PTS 4.jpg

In the video clip you see me pulling Will up 5 times. By the fifth repeat Will's neck muscles have started to tire and he is not able to keep the head in line with the trunk at the beginning of the PTS maneuver. 

Will 10w PTS 5.jpg

Head control in supported sitting - 11 weeks 

In supported sitting Will is able to maintain his head in line with his body when his trunk is tilted forwards. This requires sustained neck extensor activity.

Will 10w sitting pelvic support 1.jpg 

He can also stabilize his head when his trunk is tilted backwards, so that the neck flexors need to work to maintain the head position.  

 Will 10w sitting with support 6.jpg

When supported upright around the chest Will is able to maintain the head erect as he engages in an interesting interaction with Pam. Holding the head erect is associated with small range exploratory movements of the head in an A-P and lateral direction as the postural stability system explores the stability limits of the head on trunk system.  The wobbling action can clearly be seen in the video clip below. 


Head control in prone - 10 weeks 

At 10 weeks Will does not enjoy being in prone. However, if he is positioned so that he takes weight on his forearms, he is able to lift his head and maintain the position briefly. 

Will 10w prone forearm support 7.jpg



The third month 

Third month supine 

Infants in the third months will usually have developed improved control of head posture spending more time with the head in the midline (Lima-Alvarez 2014), as they start to engage the deep neck muscles to balance the effect of sternocleidomastoid muscle activity which is prevalent in the second months.  

Will at 12 weeks has started to flex the head on the neck (chin tuck) as he becomes very interested in inspecting his hands which he brings together  in the midline. His LE's also tend to be flexed. 

Will 14w supine repose momennts 2.jpg   Will 14w supine repose momennts 1.jpg

At 14 weeks Will displays a variety of UE positions in supine, along with an ability to maintain the head in midline or turn to either side all the while maintaining a degree of head on neck flexion. 

will 16w supine 1.jpg   will 16w supine 10.jpg   will 16w supine 2.jpg 

Neck rotation  movements have become more fluent, with longer and fewer movement units (Lima-Alvarez 2014)

Lima-Alvarez et al (2014) have shown that "infants’ head movements are organized into a basic structure: movement units. Their number first increases, but the movement units later steadily decrease in number and lengthen in duration, particularly after peak velocity. This point to head movements becoming more fluent or better controlled after 3 months of age". 

Neck rotation is associated with head on neck flexion or extension depending on the direction of his looking. 

 will 16w supine 3.jpg   will 16w supine 5.jpg   

Will tends to extend the neck when rolling from supine to side lying. 

will 16w supine 8.jpg   

Third month sitting and pull-to-sit

When supported in sitting, Will is able to maintain his head erect for extended periods of time, and is able to rotate the neck with varying degrees of head on neck flexion depending on the direction of his looking.  

will 14w sitting 1.jpg      will 14w sitting 2.jpg  will 13w PTS 2.jpg

When pulled to sit Will actively flexes his neck as well as his trunk and UE flexors. 

will 13w PTS 4.jpg     will 13w PTS 5.jpg   will 13w PTS 6.jpg

When lowered from sitting to supine, Will actively flexes the neck.

will 13w PTS 6.jpg   will 13w PTS 3.jpg

Third month prone 

In prone Will is able to lift his head with the face at a 45 degree angle, and maintain this position for extended periods of time. 

W 12w prone 15.jpg   Will 14w prone 12.jpg


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TOMT subscribers

You can view the video clips of Will's development here: Will's development in supine, prone and sitting

Useful resources 

New born exam: University of Utah    https://library.med.utah.edu/pedineurologicexam/html/newborn_n.html

References and bibliography

Bentzley, J. P., Coker-Bolt, P., Moreau, N., Hope, K., Ramakrishnan, V., Brown, T., … Jenkins, D. (2015). Kinematic Measurement of 12-week Head Control Correlates with 12-month Neurodevelopment in Preterm Infants. Early Human Development, 91(2), 159–164. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324091/#R28

Cornwell, K. S., Fitzgerald, H. E., & Harris, L. J. (1985). On the state‐dependent nature of infant head orientation. Infant Mental Health Journal, 6(3), 137-144.

Duncan K, Goodworth A, Da Costa CSN, Wininger M, Saavedra S. Parent handling of typical infants varies segmentally across development of postural control. Exp Brain Res. 2017 Dec 28. doi: 10.1007/s00221-017-5156-4. [Epub ahead of print] PubMed PMID: 29285555.

Dusing, S. C., Thacker, L. R., Stergiou, N., & Galloway, J. C. (2013). Early Complexity Supports Development of Motor Behaviors in the First Months of Life. Developmental Psychobiology, 55(4), 404–414. http://doi.org/10.1002/dev.21045

Lee HM, Galloway JC. Early intensive postural and movement training advances head control in very young infants. Phys Ther. 2012 Jul;92(7):935-47.  

Lima-Alvarez CD, Tudella E, van der Kamp J, Savelsbergh GJ. Effects of postural manipulations on head movements from birth to 4 months of age. J Mot Behav. 2013;45(3):195-203.

Lima-Alvarez CD, Tudella E, van der Kamp J, Savelsbergh GJ. Early development of head movements between birth and 4 months of age: a longitudinal study. J Mot Behav. 2014;46(6):415-22. 

Pineda, R. G., Reynolds, L. C., Seefeldt, K., Hilton, C. L., Rogers, C. L., & Inder, T. E. (2016). Head Lag in Infancy: What Is It Telling Us? The American Journal of Occupational Therapy, 70(1),   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4690596/

Reddy, V., Markova, G., & Wallot, S. (2013). Anticipatory Adjustments to Being Picked Up in Infancy. PLoS ONE, 8(6), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3688725/

Rönnqvist L, Hopkins B. Head position preference in the human newborn: a new look. Child Dev. 1998 Feb;69(1):13-23. PubMed PMID: 9499553.

Van der Meer, a L. (1997). Keeping the arm in the limelight: advanced visual control of arm movements in neonates. European Journal of Paediatric Neurology : EJPN : Official Journal of the European Paediatric Neurology Society, 1(4), 103–8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10728203