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Research in Developmental Disabilities 34 (2013) 894901

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Research in Developmental Disabilities

Infants with Down syndrome: Percentage and age for acquisition of gross
motor skills
Karina Pereira a,*, Renata Pedrolongo Basso b, Ana Raquel Rodrigues Lindquist c,
Louise Gracelli Pereira da Silva b, Eloisa Tudella b
a
Department of Physical Therapy, Federal University of Triangulo Mineiro (UFTM), Uberaba, Minas Gerais, Brazil
b
Department of Physical Therapy, Federal University of Sao Carlos (UFSCar), Sao Carlos, Sao Paulo, Brazil
c
Department of Physical Therapy, Federal University of Rio Grande do Norte (UFRN), Natal, Rio Grande do Norte, Brazil

A R T I C L E I N F O A B S T R A C T

Article history: The literature is bereft of information about the age at which infants with Down syndrome
Received 21 August 2012 (DS) acquire motor skills and the percentage of infants that do so by the age of 12 months.
Received in revised form 21 November 2012 Therefore, it is necessary to identify the difference in age, in relation to typical infants, at
Accepted 21 November 2012 which motor skills were acquired and the percentage of infants with DS that acquire them
Available online 2 January 2013 in the rst year of life. Infants with DS (N = 20) and typical infants (N = 25), both aged
between 3 and 12 months, were evaluated monthly using the AIMS. In the prone position,
Keywords: a difference of up to 3 months was found for the acquisition of the 3rd to 16th skill. There
Down syndrome
was a difference in the percentage of infants with DS who acquired the 10th to 21st skill
Motor skills
(from 71% to 7%). In the supine position, a difference of up to one month was found from
Postures
Alberta Infant Motor Scale (AIMS)
the 3rd to 7th skill; however, 100% were able to perform these skills. In the sitting position,
a difference of 14 months was found from the 1st to 12th skill, ranging from 69% to 29%
from the 9th to 12th. In the upright position, the difference was 23 months from the 3rd
to 8th skill. Only 13% acquired the 8th skill and no other skill was acquired up to the age of
12 months. The more complex the skills the greater the difference in age between typical
infants and those with DS and the lower the percentage of DS individuals who performed
the skills in the prone, sitting and upright positions. None of the DS infants were able to
stand without support.
2012 Elsevier Ltd. All rights reserved.

1. Introduction

Down syndrome is a genetic change responsible for causing delay in motor development. For this reason, in the last 20
years, researchers have attempted to characterize the development of children with this syndrome, describing the
acquisition of various motor skills such as manual reaching (Campos, Francisco, Savelsbergh, & Rocha, 2011; Campos, Rocha,
& Savelsbergh, 2010; Charlton, Ihsen, & Oxley, 1996); kicks (McKay & Angulo-Barroso, 2006; Ulrich & Ulrich, 1995), postural
control (Haley, 1986, 1987; Nishizawa, Fujita, Matsuoka, & Nakagawa, 2006; Polastri & Barela, 2002, 2005; Shumway-Cook &
Woollacott, 1985; Tudella, Pereira, Basso, & Savelsbergh, 2011); and gait (Agiovlasitis et al., 2011; Angulo-Barroso, Wu, &
Ulrich, 2008; Hampton, Stasko, Kale, Amende, & Costa, 2004; Mauerberg-Castro & Angulo-Klinzler, 2000).
Infants with Down syndrome have delayed acquisition of fundamental motor patterns such as rolling, sitting and
crawling. Few studies have reported the diversity and details of the acquisition of motor skills performed in prone and supine

* Corresponding author at: Av Leopoldino de Oliveira, 579, Block 10, Apt. 204, 38081-000, Uberaba, MG, Brazil. Tel.: +55 34 33138445.
E-mail addresses: kpereira@sioterapia.uftm.edu.br, ft.pereira.ka@gmail.com (K. Pereira).

0891-4222/$ see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ridd.2012.11.021
K. Pereira et al. / Research in Developmental Disabilities 34 (2013) 894901 895

(horizontal), sitting and standing (vertical) positions during the rst year of life (Dyer, Gunn, Rauh, & Berry, 1990; Palisano
et al., 2001; Tudella et al., 2011). An earlier study conducted by Tudella et al. (2011) concluded that during the rst year,
subscale and total AIMS scores were lower in infants with Down syndrome than in typical infants, demonstrating that the
former had a slower development rate. However, to date, there are no literature studies that describe the minimum and
maximum ages required for infants with Down syndrome to acquire each motor skill at the different positions, in accordance
with the AIMS, or the percentage of infants that were able to perform these skills by the age of 12 months.
The AIMS is a widely used scale to assess gross motor development in infants, identifying motor delays or deviations from
birth to the development of independent gait. This scale describes not only simple motor skills such as those observed in
prone and supine positions, but also more complex ones performed when standing (Piper & Darrah, 1994). Furthermore, it
identies the moment at which motor skills begin and when they are incorporated into the infants motor repertoire.
In this respect, the present study aimed to identify the difference in age, compared to typical infants, at which those with
Down syndrome acquire gross motor skills and the percentage who have acquired these skills in prone and supine
(horizontal) and sitting and standing (vertical) positions from 3 to 12 months of age.
Importantly, in clinical practice, therapists have stimulated infants and children with Down syndrome in order to
minimize motor delay. Knowing the age for acquisition of motor skills in these infants could provide important contributions
to scheduling therapy according to capacities and deciencies expected at each position and age, resulting in evidence-based
interventions.
The hypothesis of this study is that, when compared to typical infants, those with Down syndrome take longer to acquire
the skills in the prone and supine positions and are not able to perform all motor skills for the sitting and standing positions
described in AIMS by the age of 12 months.

2. Materials and methods

This is a longitudinal study with a non-probabilistic convenience sample. Infants were divided into two groups: (1)
experimental group: infants with Down syndrome and (2) control group: typical infants. Infants in the experimental group
were recruited from rehabilitation institutions in three different cities in the state of Sao Paulo and typical infants from Basic
Health Units. Study sample composition is shown in Fig. 1.
As inclusion criteria, it was established that both groups should be healthy and have no neurological, sensory or
orthopedic alterations unrelated to Down syndrome in the case of the experimental group.
The Down syndrome group consisted of 20 infants (11 girls), with Apgar score of 7 or 8 in the rst minute and 7 or 9 in the
5th minute. The average weight and length at birth was 2.832 g (0.682) and 45.92 cm (4.60), respectively. All infants in this
group underwent physiotherapy during data collection, based on both the Bobath concept and the Sensory Integration method.
The group of typical infants was composed of 25 babies (10 girls), with Apgar score of 8 or 9 in the 1st minute and 9 or 10
in the 5th minute. The average weight and length at birth were 3266 g (431) and 48.68 cm (2.49), respectively.
Infants who missed more than three consecutive evaluations were excluded.
The study was approved by the Research Ethics Committee of the University and all parents/guardians gave their
informed consent.

2.1. Materials

Babies were evaluated using the Alberta Infant Motor Scale, a validated scale to assess infants from birth to achieving
independent gait and identify risks of developmental delay. It is an observational instrument that assesses the infants motor
behavior in supine (9 skills), prone (21 skills), sitting (12 skills) and standing (16 skills) subscales. Each subscale contains a

Number of individuals (N =
86)

Infants with Down Typical infants (N = 60)


syndrome (N = 26)

Discontinued evaluation (N Discontinued evaluation (N


= 6) = 35)

Group of infants with Down Group of typical infants (N


syndrome (N = 20) = 25)

Fig. 1. Study sample composition.


896 K. Pereira et al. / Research in Developmental Disabilities 34 (2013) 894901

sequence of motor skills and for every skill, weight bearing, posture and antigravity movements are observed (Piper &
Darrah, 1994).

2.2. Procedures

Infants were assessed on a monthly basis from the third month of life, using date of birth as reference 5
days. During assessments, infants were in the active or inactive alert state (Prechtl & Beintema, 1964). Environmental
conditions such as temperature, noise and lighting were controlled. When infants cried during evaluation,
guardians attempted to calm them; otherwise, they were assessed at a later time, respecting the time interval described
(Tudella et al., 2011). Guardians were allowed to remain in the room in silence, interacting with infants whenever
requested.
Each baby was assessed at least three times during the period between 3 and 12 months. Thus, among the 20 infants with
Down syndrome, there was a variation of 310 assessments, but only seven were evaluated 10 times. Moreover, the 25
typical babies were evaluated monthly, that is 10 times.
The examiner was experienced in the use of AIMS.

2.3. Statistical analysis

The age of motor skill acquisition in the different positions was presented in terms of median, minimum and
maximum. The percentage indicated the number of typical infants and those with Down syndrome who acquired each
motor skill in different positions. Non-parametric methodology was used given that the scores are ordinal variables. The
MannWhitney test was applied to compare the age for acquisition of a certain motor skill between the experimental
and control groups, from 3 to 12 months of age. Fishers chi-square test was also used for two independent samples to
compare the percentage of typical infants and those with Down syndrome who developed particular motor skills
between 3 and 12 months of age. However, it is important to underscore that it was impossible to apply Fishers chi-
square test to some of the skills, since the percentage of infants was low or zero. A signicance level of 5% was adopted
for all analyses.

3. Results

3.1. Difference in age and percentage of infants who acquired motor skills in the prone position

Table 1 shows that the difference in age for infants with Down syndrome to develop the 3rd to 16th motor skill was 13
months compared to typical infants ( 4.596 < Z  1.906; p  0.05). From the 17th to 21st motor skills, it was not possible to
compare age for acquisition between groups, since only 13% of infants (N = 2) with Down syndrome performed the 17th skill
and 7% (1 infant) the 18th to 21st, by the age of 12 months.
The percentage of infants with Down syndrome who performed the skills was signicantly lower than that of typical
infants from the 10th to 21st skill, and decreased from 71% of infants performing the 10th task to 7% executing task 21
(p  0.012).

3.2. Difference in age and percentage of infants who acquired motor skills in the supine position

Table 2 shows that the difference in age for infants with Down syndrome to acquire the 3rd to 7th skill was one month
compared to typical infants ( 3.469 < Z < 0.000, p  0.012). There was no difference in the percentage of infants in terms of
skill acquisition, since, in the 8th month, 100% of infants in both groups were able to perform all the motor skills from the
supine position.

3.3. Difference in age and percentage of infants who acquired motor skills in the sitting position

Table 3 shows that the difference in age for infants with Down syndrome to develop the 1st to 12th skill was 14 months
compared to typical infants ( 5.275 < Z < 2.691, p  0.004).
The percentage of babies with Down syndrome who performed the skills was signicantly lower than typical infants from
the 9th to 12th skill, and declined from 69% of infants performing task 929% executing task 12 (p < 0.01).

3.4. Difference in age and percentage of infants who acquired motor skills in the standing position

Table 4 shows that the difference in age for babies with Down syndrome to acquire the 3rd to 8th skill was 23
months compared to typical infants ( 5.356 < Z < 1.953, p  0.045). It is noteworthy that the percentage of infants
with Down syndrome who developed the 2nd skill onward fell signicantly from the 3rd to 8th skill (p < 0.01). Only 13%
(2 infants) from the Down syndrome group developed the 8th skill and no other skill was acquired by the age of 12
months.
K. Pereira et al. / Research in Developmental Disabilities 34 (2013) 894901 897

Table 1
Age of acquisition of motor skills in typical infants and those with Down syndrome in the prone posture.

Motor skills in the Infants with Down syndrome Typical infants


prone posture
Number of Infants who Age of acquisition Number Infants who Age of acquisition
infants acquired of infants acquired
motor skills (%) Min. Median Max. motor skills (%) Min. Median Max.
a
1. Prone lying 8 100 3 3 3 25 100 3 3 3
2. Prone lyingb 8 100 3 3 4 25 100 3 3 4
3. Prone prop 9 100 3 4 6 25 100 3 3 4
4. Forearm supportc 13 100 4 6 7 25 100 3 4 5
5. Prone mobility 14 100 5 7 7 25 100 3 4 7
6. Forearm supportd 16 94 5 7 7 25 100 4 6 7
7. Extended arm support 16 94 5 7 9 25 100 4 6 7
8. Rolling prone to supine 14 86 5 8 10 25 100 5 6 9
without rotation
9. Swimming 15 87 6 8 10 25 100 5 7 9
10. Reaching with 14 71 6 8 9 25 100 6 7 10
forearm support
11. Pivoting 15 73 8 10 10 25 100 6 8 10
12. Rolling prone to 16 69 8 10 11 25 100 6 8 12
supine with rotation
13. Four-point kneeling 15 53 10 11 12 25 92 7 8 11
14. Propped lying on side 15 33 10 10 11 25 88 7 9 11
15. Reciprocal crawling 15 33 10 11 12 25 88 7 9 11
16. Four-point kneeling to 15 27 11 12 12 25 88 7 10 11
sitting or half-sitting
17. Reciprocal creepinge 15 13 11 12 12 25 88 7 10 12
18. Reaching from extended 15 7 11 11 11 25 88 7 10 12
arm support
19. Four-point kneeling 15 7 12 12 12 25 84 8 10 12
20. Modied four-point kneeling 15 7 12 12 12 25 84 8 10 12
21. Reciprocal creepingf 15 7 12 12 12 25 72 9 11 12

% = Percentage of infants who have acquired the skill, median = median age, min. = minimum age max. = maximum age.
a
Physiological exion.
b
Head rotated 458.
c
Head in the midline at 458 and elbow aligned with shoulders.
d
Tuck chin and elbows in front of shoulder.
e
Reciprocal crawling with lumbar lordosis.
f
Reciprocal crawling with lumbar rectication.

Table 2
Age of acquisition of motor skills in typical infants and those with Down syndrome in the supine posture.

Motor skills in the Infants with Down syndrome Typical infants


supine posture
Number of Infants who Age of acquisition Number Infants who Age of acquisition
infants acquired motor of infants acquired
skills (%) Min. Median Max. motor skills (%) Min. Median Max.
a
1. Supine lying 9 100 3 3 3 25 100 3 3 3
2. Supine lyingb 9 100 3 3 3 25 100 3 3 3
3. Supine Lyingc 9 100 3 4 4 25 100 3 3 4
4. Supine lyingd 10 100 3 4 4 25 100 3 3 5
5. Hands to knees 12 100 3 5 6 25 100 3 4 5
6. Active extension 15 100 3 6 6 25 100 3 5 6
7. Hands to feet 14 100 4 7 7 25 100 4 6 8
8. Rolling supine to 18 100 5 7 9 25 100 5 7 11
prone without rotation
9. Rolling supine to 16 100 6 8 10 25 100 5 8 11
prone with rotation
% = Percentage of infants who have acquired the skill, median = median age, min. = minimum age max. = maximum age.
a
Physiological exion, head rotated and hand in the mouth.
b
Head rotated to medial position without the presence of RTCA.
c
Head at midline and arms along the body.
d
Chin tuck and hands in the midline.
898 K. Pereira et al. / Research in Developmental Disabilities 34 (2013) 894901

Table 3
Age of acquisition of motor skills of typical infants and those with Down syndrome in the sitting posture.

Motor skills in the Infants with Down syndrome Typical infants


sitting posture
Number Infants Age of acquisition Number Infants who Age of acquisition
of infants who acquired of infants acquired
motor skills (%) Min. Median Max. motor skills (%) Min. Median Max.

1. Sitting with support 9 100 4 5 6 25 100 3 3 3


2. Sitting with propped arms 12 100 3 6 7 25 100 3 4 6
3. Pull to sit 13 100 5 7 7 25 100 3 5 7
4. Unsustained sitting 15 100 6 7 8 25 100 4 5 7
5. Sitting with arm support 14 100 7 9 10 25 100 5 6 7
6. Unsustained sitting 15 100 7 10 10 25 100 5 6 7
without arm support
7. Weight shift in 14 86 7 10 10 25 100 5 7 8
unsustained sitting
8. Sitting without 13 85 8 10 11 25 100 6 7 9
arm supporta
9. Reach with rotation 13 69 9 10 11 25 100 6 7 9
in sitting
10. Sitting to prone 14 57 10 11 12 25 96 7 8 11
11. Sitting to four-kneeling 14 29 10 12 12 25 88 7 9 11
12. Sitting with arm supportb 14 29 10 12 12 25 88 8 9 11

% = Percentage of infants who acquire the skill, median = median age, min. = minimum age, max. = maximum age.
a
Sitting without support and trunk rotation.
b
Sitting without support and easily shifting posture.

Table 4
Age of acquisition of motor skills of typical infants and those with Down syndrome in the standing posture.

Motor skills in the Infants with Down syndrome Typical infants


standing posture
Infants who Age of acquisition Number Infants who Idade de aquisicao
acquired of infants acquired
Number of infants motor skills (%) Min. Median Max. motor skills (%) Min. Median Max.

1. Supported standinga 9 100 3 3 6 25 100 3 3 3


2. Supported standingb 11 91 3 6 7 25 100 3 3 4
3. Supported standingc 13 69 6 9 11 25 100 4 6 8
4. Pulls to stand with support 15 40 7 12 12 25 100 6 9 11
5. Pulls to stand/stands 15 27 9 12 12 25 100 7 10 11
6. Supported standing 15 20 10 12 12 25 100 7 10 11
with rotation
7. Cruising without rotation 15 20 10 12 12 25 100 8 10 11
8. Half-kneeling 15 13 10 12 12 25 100 8 10 12
9. Controlled lowering 15 n.a.s. 25 96 8 10 12
through standing
10. Cruising with rotation 15 n.a.s. 25 92 9 11 12
11. Stands alone 15 n.a.s. 25 76 9 11 12
12. Early stepping 15 n.a.s. 25 44 10 11 12
13. Standing from 15 n.a.s. 25 40 10 12 12
modied squat
14. Standing from 15 n.a.s. 25 36 10 12 12
quadruped position
15. Walks alone 15 n.a.s. 25 36 10 12 12
16. Squat 15 n.a.s. 25 16 11 12 12

n.a.s. = Non acquired skill, % = percentage of infants who acquired the skill, median = median age, min. = minimum age; max. = maximum age.
a
Standing with support from an adult, maintaining head and trunk exion.
b
Standing with support from an adult, head aligned with the trunk.
c
Hips in line with shoulders, active control of trunk e variable movements of legs.

4. Discussion

The causes of motor delay in children with Down syndrome have been reported in a number of studies (Agullo & Agullo,
2006; Dyer et al., 1990; Lauteslager, Vermeer, & Helders, 1998); however, no comparison has been made with typical
children. Data from this study will contribute to the literature by presenting the difference in age for each position and the
percentage of infants with Down syndrome that exhibited delay or did not acquire skills compared to typical babies in the
K. Pereira et al. / Research in Developmental Disabilities 34 (2013) 894901 899

rst year of life. Therefore, this study could contribute both to understanding the gross motor development of infants with
Down syndrome and to help therapists use specic intervention strategies that favor the emergence of skills in each position.

4.1. Motor development in prone and supine positions (horizontal)

In the prone position, all infants with Down syndrome acquired the rst ve skills, while all typical infants were able to
roll prone to supine with rotation (12th skill). From the 13th skill onward (four-point kneeling), there was a sharp reduction
in the percentage of babies with Down syndrome that acquired the skills in this position. This result suggests that such skills
are more complex than previous ones, because infants with Down syndrome only developed them at a mean age of 11
months, demonstrating a delay of up to 3 months compared to typical infants.
An important feature of Down syndrome that can inuence motor skill acquisition time is the structure of the central
nervous system. There is decient neural growth in dendritic proliferation and myelination of cortical and subcortical brain
structures (Abraham et al., 2012; Battaglia et al., 2008; Pinter, Eliez, Schmitt, Capone, & Reiss, 2001; Silva & Kleinhans, 2006).
Furthermore, the cerebellum is smaller, inuencing posture adjustment and the sensory system (Florez & Troncoso, 1997).
Other intrinsic limitations of the syndrome, such as hypotonia, ligamentous laxity and joint hypermobility (Galli, Rigoldi,
Brunner, Virji-Babul, & Albertini, 2008; McKay & Angulo-Barroso, 2006; Nishizawa et al., 2006; Rigoldi et al., 2012; Ulrich &
Ulrich, 1993) inuence postural control.
According to the AIMS, from the 13th prone position onward (rolling prone to supine with rotation), infants should be
moved away from the support surface, thereby decreasing their contact with this surface; for example, adopting the four-
point position, and having infants reach out in this position. Furthermore, at this moment, infants should adopt dissociated
positions and move on the transverse plane (such as four-point kneeling to sitting or half-sitting and modied four-point
kneeling). However, to be able to adopt these positions and move according to these demands, infants with Down syndrome
must have greater muscle strength, postural alignment and develop adequate muscular synergy. In the rst year of life, the
neuromuscular and musculoskeletal systems of these infants are undergoing self-organization, attempting to control the
degrees of liberty of the joints of the axial and appendicular skeleton, which are increased, interfering in body support in
static and dynamic positions.
Motor skills seem to be more difcult to acquire in the prone than supine position. This conclusion is supported by the
nding that the nine skills corresponding to the supine position were acquired by all the infants with Down syndrome, on
average by age of 8 months, with delays only from the 3rd to 7th skill in relation to typical babies. It is important to
underscore that the 3rd to 7th skills, as well as those executed in the prone position, require greater muscle strength against
gravity, dissociated positions and movements in the transverse plane. Despite these difculties, infants with Down
syndrome acquire the ability to roll with torso dissociation, on average at 8 months of age, as do typical infants
In agreement with the results and hypotheses raised in this study, a number of authors report that babies with Down
syndrome have difculty in contracting the exor muscles of the neck, torso, and upper and lower limbs, especially in the
rst year of life, and remain in static and relaxed positions for a long time, not activating the antigravity muscles in prone and
supine positions (Lauteslager, 1995; Lauteslager et al., 1998; Nishizawa et al., 2006).
Given the results found in this study with respect to supine and prone positions, it is important to initiate therapeutic
intervention before the age of 6 months, emphasizing the adoption of positions and antigravity movements. An attempt is
made to facilitate concentric and eccentric contraction of torso muscles and body displacement in space, aiming at muscle
synergy necessary for the emergence of more complex skills, primarily in the prone position. Therefore, helping these infants
to perform functional activities, explore the environment, act on the proposed task and in different contexts is expected to
decrease the time difference in age for acquisition of motor skills in relation to typical infants and minimize possible
musculoskeletal alterations typical of Down syndrome at more advanced ages.

4.2. Motor development in sitting and standing positions (vertical)

At 3 months of age, in the sitting position, some infants with Down syndrome showed no alignment between head and
torso and adopted a position of pelvic retroversion, abduction and external rotation of the hip, which probably caused the
delay of 24 months compared to typical babies in acquiring other skills. For the infant to be able to view the environment,
reaching and handling objects in the sitting position, postural adjustment and head and torso control are required. Thus, the
acquisition delay in achieving sitting can also interfere with the manual reaching of these infants (Von Hofsten, 1979).
Of the 12 skills that make up the sitting position, all the infants with Down syndrome acquired the rst 6 skills at 10
months, while typical babies did so at around 6 months. The last two skills, moving from sitting to four supports and sitting
without arm support, were achieved by only four infants (29%) with Down syndrome at 12 months of age, while 88% of
typical infants acquired them at around 9 months. Thus, it is suggested that transfers from the sitting position require greater
control in transverse planes, increased mobility and will be perfected after the age of one year.
Skills in the standing position were considered the most difcult for infants with Down syndrome to develop in the rst
year of life. Standing with support, aligning head, shoulders and hips, was achieved by the majority (69%) of infants with
Down syndrome at around 9 months, while typical infants acquired the skill at a mean age of 6 months. This is because if
infants have no symmetry and postural alignment in a standing position, their motor repertoire will remain poor (Thelen,
1986). The results of the present study corroborate those obtained by the aforementioned author as well as Piper and Darrah
900 K. Pereira et al. / Research in Developmental Disabilities 34 (2013) 894901

(1994), namely that learning new skills in the standing position is achieved after acquiring the 3rd skill of AIMS, a position in
which infants must accomplish postural alignment between the head, torso and hip (standing with postural alignment).
It is important to point out that in the standing position, at 12 months old, only 40% of the 15 children assessed were able
to perform the 4th skill (pulls to stand with support) and this percentage declined sharply up to the 8th skill (half-kneeling),
the last one acquired by infants with Down syndrome by the age of 12 months.
Given that most of the babies with Down syndrome were able to sit without support around 10 months of age, it is
suggested that difculty is not related to the torso or lack of alignment between the shoulders and hips, but rather is a result
of weak upper and lower limb muscles for pulling and remaining upright. For the same reasons, the other positions were not
observed. We speculate that infants with Down syndrome might be able to acquire new skills in the standing position after
the rst year of life, when postural control is expected to be established.
It is concluded that typical babies and those with Down syndrome acquire gross motor skills at different ages. The more
complex the skills, the greater the time difference. Up to the age of 12 months, a minority of infants with Down syndrome
perform movements in the transverse plane and none remain standing without support. In the rst year of life, a high
percentage of babies with Down syndrome showed difculties in the prone, sitting and standing positions, which require
greater postural control.
It is suggested that intervention should be initiated up to the age of 4 months, since from this age onwards, infants with
Down syndrome exhibit a greater difference in the age for acquisition of new skills, particularly those requiring greater
muscle coactivation against gravity. To acquire skills in the sitting and standing positions (vertical), infants must rst
experiment in the prone and supine positions (horizontal), skills that demand active muscle control against gravity.
Further longitudinal studies are needed in order to monitor the gross motor development of infants with Down syndrome
after the age of 12 months, using a larger sample so that results can be generalized.

Acknowledgements

We thank the parents/guardians and infants for participating in this study.

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