Have you ever wondered how we manage everyday tasks like writing, dressing, or using utensils? It all starts with a crucial skill called 

. This involves using our thumb and fingers to 

move and control objects within a single hand

. While seemingly simple, in-hand manipulation is a foundational skill for numerous daily activities.

This blog post dives deeper into in-hand manipulation, exploring its importance, and its components, and engaging activities to support its development in your child. Stay tuned to learn how 

contributes to significant developmental 

The ability to hold an object in one hand and move it without assistance from the other hand.

Children start to develop these skills between 2-4 years old with a single object. The order of development of these skills is first finger-to-palm translation, palm-to-finger translation, rotation, and lastly shift. By the ages of 6-7, children can manipulate and stabilize more than one small object within their hand. This allows children to use these in-hand manipulation skills more purposefully and functionally to complete everyday tasks. 

A child with poor in-hand manipulation can be observed manipulating objects with both hands and/or stabilizing the object with a table or body. Children who have difficulty with in-hand manipulation may be unable to complete certain tasks, require additional time, or may appear clumsy when handling objects. Many daily tasks required these higher-level hand skills. Examples include: using a fork and knife, adjusting the grip on paper when cutting with scissors, positioning a grip when writing/drawing, manipulating clothing fasteners, and operating tools. 

Poor or delayed in-hand manipulation skills can result in difficulties with the following: 

The components of in-hand manipulation: 

 The ability to turn an object end over end. An example of this is flipping a pencil over in one hand to use the eraser instead of writing with the tip of the pencil.

Simple rotation is the ability to roll a small object between the thumb and fingertips. An example of simple rotation is using the fingertips and thumb to open a small jar. 

 Complex rotation is the ability to turn an object end over end. An example of this is flipping a pencil over in one hand to use the eraser instead of writing with the tip of the pencil.

simple or complex rotation is being performed while holding an object with the hypothenar aspect of the hand (ring and pinky finger). 

 The ability to move objects between the fingers. A couple examples of this are when you try to separate two pieces of paper that are stuck together, or when you move your fingers closer to the end of your pen/pencil to begin writing. 

the ability to move an object in a linear manner with fingertips while holding an object with the ring and pinky finger.

 Translation can be broken into two separate skills: finger-to-palm translation and palm-to-finger translation. Kids use finger-to-palm translation when they pick up small objects like pebbles, marbles, or cheerios one at a time, moving them with the fingers of only one hand into their palm. They use palm-to-finger translation when they move those small objects from their palm back to their fingertips one at a time to place them on the floor or table.

 the ability to move an object from fingertips to the palm of the hand. Ex: picking up marbles with fingers and thumb and moving them into the palm. 

 the ability to move an object from the palm of the hand to the fingertips. Ex: moving coins from the palm of the hand to the fingertips to insert them into a piggy bank.  

 holding an object with the ring and pinky finger while moving objects from palm to fingertips or fingertips to palm.

Activities that promote in-hand manipulation skills

In-hand manipulation may seem small, but it unlocks a world of possibilities for your child. Support their development with fun activities, and remember, early intervention is key.

Marshall Pediatric Therapy wants to help your family build skills for life. Take our 

evaluation with an occupational therapist

. We want to come alongside you in making growing fun for your child!

In-Hand Manipulation

Are you running out of indoor activities to occupy your kids during the winter? Eating more family meals at home together is a blessing; however, it can create more mess and more mounds of garbage. Why not use those empty containers and boxes to have some fun with your kids?

Upcycled Adventures: Developing Skills and Smiles from Everyday Items 

Hey there! We are pediatric occupational and speech therapists who specialize in tethered oral tissues, feeding, lactation, and infant massage. We are also mothers who have experienced feeding difficulties due to tethered oral tissues with our children. The recent New York Times article discussed lip and tongue ties as a trend, causing fear-mongering with the most severe outcomes and monetizing procedures. It is important to take into consideration the facts from trained medical professionals who specialize in this area, as this can continue gaslighting mothers who are attempting to advocate for their children in times of distress. We are here to untie the knot. 

Preferred providers consist of a team approach. This team will assess oral function, feeding, swallowing, speech sound disorders, and muscular tension. Pre-op care is 

 in order to rule out alternate factors including reducing fascial restrictions, training caregivers, avoiding oral aversions, and establishing clinical baselines (Walsh, 2023). The following are considered preferred providers as a part of the multidisciplinary team.

It is critical to not only look at structure (frenulum or the “string” under your tongue) when diagnosing tongue ties. Function must be assessed in order to make a differential diagnosis. For example, 

 is the structure functioning in the presence of tight tissue impacting feeding, speech, body tension, breathing, sleep, etc? The structure 

 have a negative impact on function to warrant a diagnosis (Bulkin, 2023). This is typically first noticed in infancy; however can later be identified in children, adolescence, or adulthood.

In an excerpt from Dr. Richard Baxter’s response to the NYT’s article, 

This pre-procedure therapy accomplishes many objectives: “It allows the professional to assist in preparation for the procedure (what to expect, common troubleshooting issues, red flags, etc). If you think about knee replacement surgery, we want a strong calf and a strong hip to support that new structure.  

with tongue tie release.  We want to work on the jaw, lips, cheeks, etc.  Think about who heals better: An Olympic athlete or someone who does no physical activity?  We want to work to tone, strengthen, coordinate, and sequence patterns while inhibiting compensations prior to a procedure”   (Henning, 2019). 

Rushing a release can lead to suboptimal outcomes and it’s critical to wait for the optimal timing of release per your providers’ recommendations and child’s readiness. The body needs to be properly prepped: including a full-function oral motor assessment combining desensitization for oral aversion, decreasing tension patterns or discomfort, and regulating the nervous system.

“Due to wound healing principles, any wound left open post-procedure will try to contract and stabilize by reattaching. It is highly important for patients/parents to be instructed on active wound management techniques. The time to learn this is prior to the procedure for the best success” (Henning, 2019). 

 change in symptoms immediately after a release, however, continued improvements are observed after completion of post-op therapy to retrain the orofacial muscles on how to function with their 

“The goal is to gain and/or restore optimal function so you or your child can thrive” (Bulkin, 2023). As healing continues and skills increase, you may notice: Quiet nasal breathing, closed mouth posture with lingual palatal suction, improved sleep, infants who are 

 with decreased colic-like symptoms, quicker feeds, weight gain in infants, less grazing in children, increased speech intelligibility, decreased gagging/choking, and reduced hiccups, reflux, and constipation.

I decided in my pregnancy that I wanted to breastfeed for as long as possible with a personal goal of 1 year. I decided that I wasn’t going to check for ties until I noticed signs. I wanted an unbiased opinion so I could relate to my families at work on a more personal level. Unfortunately, these signs came earlier than anticipated. My son immediately demonstrated difficulties latching, regardless of position. I’ll never forget the overwhelming emotions I experienced- I felt anxious, defeated, like a failure, or at fault. I began hand-expressing colostrum and syringe feeding until he could latch successfully. I received lactation support in the hospital (it is difficult to be a mom

 therapist), however the possibility of ties was never discussed. We finally got a latch, and although it was shallow and painful, we powered through. He was 7lbs 7oz at birth and 7lbs 1oz at discharge. My anxiety then quickly transformed into concern. After a few days at home, I started experiencing significant discomfort including nipple trauma, painful latch, and vasospasms. I remember holding my breath, clenching my toes, and dreading each feeding. At this point, I knew there were ties and it was time to check. Sure enough, my son had upper and lower lip ties, buccal or “cheek” ties, and a tongue tie. I got established with an IBCLC, CST, and chiropractor. My team addressed compensatory patterns, strengthened oral motor skills, and released body tension. Once therapeutic readiness was identified, we scheduled with a pediatric dentist for releases at 3 weeks of age. My son latched 

 after his procedure. The pain had diminished and he was transferring more volume at the breast. It was amazing the difference- even I couldn’t believe the change! We continued seeing our team to ensure appropriate wound healing and retraining of orofacial muscles. Now, my son is 1 year old and we are still breastfeeding. I am forever grateful for this team who helped us navigate through this feeding journey and supported us along the way. Advocate! Breastfeeding 

 be painful and reaching your feeding goal 

Sitting in the hospital bed after my baby was born, I remember thinking when latching my son for the first time “ Am I doing this right?”.  I was a first-time mom. The overwhelming emotions of welcoming a child into the world, doctors and nurses in and out of my room, and my body aching from delivery heightened all my sensations. I made sure to check with lactation several times in the hospital to ensure our breastfeeding journey would be successful. Our first night home, my son cried the ENTIRE night. He nursed all night and wasn’t satisfied. His latch was completely shallow. I immediately knew something was off and made an appointment that week to meet with lactation from the hospital. At our appointment, she agreed his latch was very shallow and he was not transferring enough ounces to feel satisfied. She suspected ties and recommended seeing a speech therapist who specializes in feeding. My son was colicky, gassy, had horrible hiccups, constantly fell asleep at the breast, and had a poor latch with the bottle. We tackled triple feedings via breast, bottle feeding, and pumping around the clock every 2 hours. Sure enough, when our appointment arrived, we discovered he had a tongue and lip tie. I made sure to set up the necessary steps for pre-care therapy including a chiropractor, physical therapist, and speech therapist. My son had his release by a pediatric dentist at 3 weeks of age and we continued to work with our team for post-care and body tension.  At 6 weeks old, I made the decision to change course from breastfeeding to exclusively pumping and bottle feeding until my son was 12 months old. He is now a healthy thriving 5 year old! After my son was born, I knew what signs and symptoms to look for. I delivered a daughter 22 months later and my third child, another son, two years after her. Both of which had difficult feeding journeys after birth. Both of these two would latch at the breast; however, struggled to gain weight, were colicky, gassy, did not sleep well, and required triple feedings. With my two youngest children, we moved to Kentucky from a different state. Knowing the process, I scheduled appointments with a team of providers for consultations. Both my daughter and youngest son were diagnosed with bilateral buccal, tongue, and lip ties. We set up care with an IBCLC, CST, chiropractor, and speech therapist. My daughter had her release by a pediatric dentist at 6 weeks old and my youngest son had his release at 5 weeks old. With these two, I made a personal goal to try to breastfeed as long as I could. I wanted to try again after my first! I successfully breastfed both my now 4-year-old daughter, and 2-year-old son for 14 months each. My experience as a mother of three with feeding difficulties has inspired me to educate families on the benefits of therapy and establishing success for functional feeding. Let us be a part of 

In efforts to discontinue the spread of medical misinformation, here are some helpful resources. Families deserve to thrive! 

Helping your family build skills for life is our priority.  

 with one of our expert therapists if you have concerns about your child or want more information about the topic of tethered oral tissues! 

All Tied Up: Lip & Tongue Ties from Professional and Personal Perspectives

Flashcards have been a classic tool for building children’s vocabulary but did you know that this teaches children memorization rather than functional communication? We want children to be motivated and engaged in language. Flashcards are fun to look at a few times but end up getting tossed to the back of a shelf because your child thinks it's “boring”. 

When flashcards are used correctly, they can be a great on-the-go tool that strengthens your little one’s language skills. 

Try one of these activities next time you pull out the deck!

As parents, we strive to make every learning moment memorable and effective for our children. From object matching to scavenger hunts, describing details, and the thrill of hide-n-seek, these activities not only make language acquisition fun but also foster generalization and deeper understanding. So, let's redefine the way we utilize flashcards – not just as a tool but as a gateway to a world where language becomes an exciting journey for our little learners.

Helping your family build skills for life is our priority. If you are looking for personalized tools to build your child’s vocabulary and communication skills, 

 with one of our expert speech and language pathologists. They will provide you with creative games and activities that will engage your child while strengthening their speech and language skills!

Are Flashcards Outdated? 

When most people think of healthy vision, they typically think of getting their eyes checked by their regular optometrist to make sure they can see clearly and that their eyes are free of disease.  While this is a very critical and important thing to do as a part of overall wellness, this isn’t where the road ends. There is SO much more to healthy vision than seeing 20/20.

 Getting an annual eye exam is not the end; it is just the beginning!

 help to emphasize the relationship that the eyes, brain, body, and mind all have with one another. We have worked closely with the NVPI team to provide our families with a helpful snapshot of some information regarding the visual system and overall eye wellness. 

Kids (and adults) go through life working so much harder than they have to because the optometrist tells them they see 20/20, YET they still have trouble seeing …the words are still blurry, they get frequent headaches, and their eyes always feel fatigued. This is because their eyes are not working together as a team to gather information. The structure is there but the function is not.

70-90% of what we learn and perceive is actually processed through our visual system. It also takes from birth to age 15 for our visual skills to process. 

Did you know that there are actually a total of 17 visual skills and generally ONE of those (Central Distant Acuity), is tested on most eye exams? NVPI actually tests all 17 skills to ensure proper results and diagnosis.

 seeing objects at the sides when continuing to look straight ahead

 understanding whether seen objects are close to or far from each other

 both eyes working together to achieve clear, comfortable vision

the eyes’ ability to quickly move or “jump” between different focal points

 both eyes’ smooth movements tracking a moving target

both eyes working together, toward each other, to focus on a nearby object

 the eye continues to change its focus between near and distant objects

the eyes’ ability to maintain focus on close-up activity

an analysis of the information about an image (visual/spatial learning or picture thinking

employing visual information to direct the body’s movements in a coordinated way

employing visual information to control the movement of hands, fingers, and feet

understanding what is being seen and using cognition to process this information

using vision together with other senses in order to perform complex tasks

The two videos below from Dr. Graebe at NVPI help to best explain what Vision Therapy is, as well as best explain the correlation between one’s vision and learning. It is very often that the school struggles your child might be experiencing, go hand-in-hand with vision-related concerns. 

From Our Experts

In-Hand Manipulation

Upcycled Adventures: Developing Skills and Smiles from Everyday Items

All Tied Up: Lip & Tongue Ties from Professional and Personal Perspectives

Are Flashcards Outdated?

Healthy Vision - More Than Seeing 20/20