Neonatal neurodevelopmental follow-up recommendations: Four month visit

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This page provides recommendations to encourage development in babies who have spent time in the NICU or CCCU, or who require care a neonatal follow-up clinic.

Key points

  • Babies who have been in the NICU or CCCU may be at risk for developmental issues due to medical problems before delivery, during delivery or after birth.
  • Recommendations at four months focus on tummy time play, basic interactions with your baby and practicing safe sleep habits.
  • Parents and caregivers should follow these recommendations to encourage neurodevelopment.

Talking and playing with babies are two of the most important things parents and caregivers can do to help them develop. There are many ways to encourage development. The recommendations provided are general and not all inclusive. The recommendations provide strategies to help promote gross motor skills, fine motor skills, early language development, and socialization.

  • Gross motor skills include big movements such as rolling, crawling, standing or walking.
  • Fine motor skills include hand movements such as reach and grasp.
  • Early language development includes cooing, babbling, and a baby’s first words.

What is the Neonatal Follow-Up Clinic?

The Neonatal Developmental Follow-Up Program is a specialized clinic for children who had medical complications related to, or immediately after, their birth. This clinic assesses gross-motor skills, fine-motor skills, social development, language and learning ability at specific ages to determine if the child is developing normally.

The majority of patients seen in the Neonatal Follow-Up Clinic are referred from a Neonatal Intensive Care Unit (NICU) or a Cardiac Critical Care Unit (CCCU). Babies who have been admitted to the NICU or CCCU may be at risk for developmental issues due to medical problems before delivery, during delivery or after birth. These recommendations may be used to encourage development in babies who have not spent time in the NICU or CCCU, but still require care in the Neonatal Follow-Up Clinic. Talk to your child’s doctor to see if you should be following these guidelines with your baby.

Babies and toddlers are assessed at specific ages in the clinic and given recommendations that parents and caregivers can refer to at home to help their baby achieve their maximum potential. These recommendations are for corrected age, as most of the babies followed in the clinic were premature at birth.

If you are concerned about your baby’s development, speak with your primary health-care provider.

Neonatal follow-up clinic recommendations at four months

Gross motor

  • Practice floor time for play as much as possible. The bed is NOT an appropriate or safe place for your baby to play. The floor provides a safer and firmer surface for your baby to practice and learn movement. Interlocking (Jigsaw) foam mats can be purchased at many different stores.
  • Practice tummy time (between 50-60 minutes total per day, in short periods) to improve head and trunk control.
  • Practice rolling to both the left and right sides.
  • Encourage side-lying position for play (left and right side-lying).
  • If your child is demonstrating right or left-sided preference – present faces, toys, objects, and other stimulation to the opposite side your baby favours.
  • Sitting with less support (hold your hands as low as possible on infant’s body).
  • Carry infant with at least one arm or leg flexed towards the midline (middle of the body) to promote trunk control.
  • Avoid standing devices (e.g. Jolly Jumpers and Exersaucers).

Fine motor

  • Encourage hands and toys to mouth to promote orientation to the midline.
  • Encourage open hands by stroking the back of your baby’s hand.
  • For babies with thumbs held across the palm, encourage holding thicker round rattles or squishy toys.
  • Offer toys that allow two-handed exploration and play.
  • Use supported and reclined sitting to encourage early reaching and grasping of toys at the midline.
  • Present a variety of objects with different textures, shapes, and sizes for exploration with hands and mouth.


  • Be face to face with your baby and be animated. Use lots of gestures as you interact.
  • Respond to communication; smile and engage when they make sounds.
  • Play social communication games (i.e., peek-a-boo).
  • Repeat any sounds your baby makes.
  • Crying is a baby’s way of letting you know they need your attention, so respond by interacting with your baby to promote healthy attachment.
  • Sing and read books to your baby daily.
  • Electronic media use by children younger than two years old is not recommended. This includes phones, television, computers, and tablet devices.


  • Continue regular visits to your family doctor/paediatrician to monitor your child’s growth.
  • Head re-shaping – position baby on their side, lying off flattened side.
  • Introduce solids at four to six months corrected age, if your doctor has said this is safe for your child to do.


  • Start a bedtime routine.
  • Practice safe sleep habits: back to sleep on a separate firm flat surface in your room at least for the first six months.

For more information on neonatal neurodevelopmental recommendations at different ages, please see the links below:

Parental mental health and well-being

All caregivers are encouraged to have ongoing discussions about their mental health and well-being with their family doctor. There are free community services available to promote coping and resilience for caregivers. Consider learning more about the following supports and interventions.

Last updated: March 30th 2021