University Developmental Milestones, Reduced

1
Developmental Milestones
Pr Hakam Yaseen, MD,
CES(Ped), DU(Neonat)
[France], FRCPCH, [UK]
2
Case scenario 1
Mother is worried because her 1 month
old baby boy who is not responding to her
stimulation ,and he is not smiling?
What is your comments?
3
Case scenario 2
Parents brought their 10 month-old baby
to your clinic.
They are worried because their baby is still
not able to sit down?
4
Case scenario 3
5-month baby not able to transfer toys
from one hand to another, what is your
comment?
5
Case scenario 4
Mother is asking : When my baby waves
bye bye?
6
Case scenario 5
A 3 years old who says mama dada? But
he can not say for example give me
teddy? Do you reassure parents?
7
What are the Objectives of
developmental paediatrics?
8
Objectives of developmental paediatrics
To early detect and manage delayed
development
To act for the care and management of the
child with special needs.
9
Areas of Development
10
Areas of Development
Most obvious
area of
development
Fine motor
skills require
good vision-
thats why they
are grouped
together
Speech & language
require good hearing
They explain the
childs
psychological
development
Note: A deficiency in any skill area can have an impact on other areas!
(e.g. hearing defect can affect social, emotional and behavioral area
11
When do you assess
developmental milestones?
12
When do you assess developmental
milestones?
As part of a child health surveillance
program.
If there is parental concern
When the child comes for another reason
(as admission or in OPD) : it might be
done briefly.
13
Age
When considering developmental milestones:
The median age
the age when half of a standard
population of children achieve that level
It is a guide to when stages of
development are likely to be reached but
does not tell us if the child's skills are
outside the normal range.
Limit ages are usually 2 standard deviations from the
mean.
14
Variation in rate of development
Example
The percentage of children walking unsupported:
25% by 11 months
50% by 12 months
75% by 13 months
90% by 15 months
97.5% by 18 months
This shows that not all children develop the same.
Setting a limit age (18 months in this example) will allow
earlier identification of delayed walking in children
It will also increase the number of children labeled as
delayed who are in fact normal, but these children are
only a small minority (in this example is 2.5%).
15
not crawling??
Mother is worried because her 9 months
old baby is not crawling like the baby of
her neighbor!!!
What is your opinion?
16
Variation in pattern of development
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Variation in pattern of development
Normal motor development is the progression
from immobility to walking, but not all children do
so in the same way
Most achieve mobility by crawling (83%), some
bottom-shuffle and others crawl with their
abdomen on the floor, called commando
crawling (creeping)
A very few just stand up and walk
Hence, the limit age of 18 months applies to
children who crawl.
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Adjusting for prematurity
Adjust the age of the premature child (< 2 years)
from the expected date of delivery.

E.g. a 9-month baby (chronological age) born 3
months earlier will have the same development
as a 6-month baby (corrected age)

This is only applied for children less than 2 years
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Note
If developmental delay
affect all the areas
It is called : GLOBAL DELAY
If one or more field is affected
It is called :
SPECIFIC DEVELOPMENTAL
DELAY
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Developmental Milestones
21
Gross motor development
22
T
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4
-
6

m
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Body_ID: None
Reflex - mode of eliciting it Description
Body_ID: T003001.50
Moro - sudden head extension Symmetrical extension, then flexion of all limbs
Body_ID: T003001.100
Grasp - an object is placed in the palm at the base of the fingers Flexion of the fingers of the hand
Body_ID: T003001.150
Rooting - stimulus near the mouth Turning of the head towards the stimulus
Body_ID: T003001.200
Placing - infant held vertically and the dorsum of the feet brought into contact with a
surface
Lifts first one foot, placing it on the surface, followed by the other
Body_ID: T003001.250
Positive supporting reflex - infant held vertically, feet on a surface Legs take body weight, may push up against gravity
Body_ID: T003001.300
Atonic neck reflex (ATNR) - lying supine, the head is turned by the examiner to one
side
Infant adopts a 'fencing' posture, with the arm outstretched on the side to which the head
is turned
T
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Body_ID: None
Body_ID: T003001.50
Body_ID: T003001.100
Body_ID: T003001.150
Body_ID: T003001.200
surface
Body_ID: T003001.250
Body_ID: T003001.300
side
is turned
T
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Body_ID: None
Body_ID: T003001.50
Body_ID: T003001.100
Body_ID: T003001.150
Body_ID: T003001.200
surface
Body_ID: T003001.250
Body_ID: T003001.300
side
is turned
Limbs flexed, symmetrical postures
Sits without support
-at 6 mo: with round back
-at 8 mo: with straight back
Raises head to 45 degrees
Marked head lag on pulling up
Newborn Newborn
6-8 weeks 6-8 months
Gross motor development (median ages)
23
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Body_ID: None
Body_ID: T003001.50
Body_ID: T003001.100
Body_ID: T003001.150
Body_ID: T003001.200
surface
Body_ID: T003001.250
Body_ID: T003001.300
side
is turned
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Body_ID: None
Body_ID: T003001.50
Body_ID: T003001.100
Body_ID: T003001.150
Body_ID: T003001.200
surface
Body_ID: T003001.250
Body_ID: T003001.300
side
is turned
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Body_ID: None
Body_ID: T003001.50
Body_ID: T003001.100
Body_ID: T003001.150
Body_ID: T003001.200
surface
Body_ID: T003001.250
Body_ID: T003001.300
side
is turned
15 months 12 months
10 months 8-9 months
Crawling
Walks around furniture
Walking unsteadily
broad gait, hands
apart
Walks alone
steadily
Gross motor development (median ages)
24
Primitive Reflexes present at birth
(Should disappear by 4-6 months)
Reflex Mode of eliciting it Description
Moro Sudden head extension Symmetrical extension,then
flexion of all limbs
Grasp Object placed in the palm at the base
of fingers
Flexion of fingers
Rooting Stimulus near the mouth The head turns towards the
stimulus
Placing Infant held vertically and the dorsum
of the feet brought into contact with a
surface
Lifts first one foot, placing it
on the surface, followed by
the other foot
Positive
supportive
reflex
Infant held vertically, feet on a surface Legs take body weight, may
push up against gravity
tonic neck
reflex
Lying supine, the head is turned by
the examiner to one side
Infant adopts a fencing
posture: arms outstretched
on the side to which the head
is turned
25
Moro reflex
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Walking/stepping reflex

27
Rooting reflex

28
Tonic neck reflex

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Palmar grasp reflex

30
Fine motor
and
vision
31
Fine motor and vision
6-8
weeks
4 months
6 months 7 months
Reaches out for toys
Newborn- follows face in midline
Follows moving object on face by
turning the head
Palmar grasp
Transfer toys from one hand to
another
32
10 months 16-18 months
14 months- 4 years
2-5 years
Mature pincer grip Makes marks with crayon
Fine motor and vision
33
Hearing, Speech and language
34
Hearing, Speech, Language
(Median ages)
Newborn 2-3 months
7 months
7-10 months
aa aa
Dada
mama
Startles to loud noises
Vocalises alone or when spoken
to, coos and laughs
Turns to soft sounds out of sight
At 7 months, sounds used
indiscriminately
At 10 months, sounds used
discriminately to parents
35
Hearing, Speech, Language
(median ages)
12 months
18 months
2years 2-3 years
dink
Give
me
tedd
y
Push me
fast
daddy!
Where is
your nose?
Two to three words other than
mama, baba
Uses two or more words to make
simple phrases
6-10 words. Shows two parts of the
body
Talks constantly in 3-4 word
sentences
36
Social, emotional, and behavioural
development (median ages)
37
6 -8 weeks 6-8 months
10-12 months 12 months
Smiles responsively
Puts food in mouth
Waves bye bye, plays peek-a-
boo
Drink from a cup with two hands
38
18 months
18-24 months
2 years 3 years
Holds sppon and gets food
safely into mouth
Symbolic
play
Dry by
day, pulls
off some
clothing
Parallel play, interactive play
evolving. Takes turn.
39
Red lights!
40
Red lights!
41
Summary of developmental milestones
Age Gross motor Vision and
fine motor
Hearing, speech
and language
Social,
emotional
behavioral
Newborn Flexed posture Fixes and
follows face
Stills to voice
Startles to loud
noise
Smiles (6 weeks)
7
months
Sits without
support
Transfers
objects from
one hand to
another
Turns to voice
Polysyllabic babble
Finger feeds
Fears strangers
1
year
Stands
independently
Pincer grip (10
months)
Points
1-2 words
Understands name
Drinks from cup
Waves
18
months
Walks
independently
Immature grip
of pencil
6-10 words
Points to 4 body
parts
Feeds himself
with spoon
Helps with
dressing
2
years
Runs and
jumps
Draws 3-4 word sentence
Understands 2
joined commands
Parallel play
Clean and dry
42
Cognitive Development
It refers to higher mental function
It progresses with age
Assessed by the formal IQ tests.
Disadvantages:
Could be affected by cultural background and
linguistic skills
Do not test all skill areas
Do not necessarily reflect the childs ultimate
potential
Could be compromised by individual disabilities
such as motor disorder as in cerebral palsy.
43
Shortcut approach for assessing
developmental progress
Detailed assessment is unnecessary when
checking the development in normal
clinical practice.
A shortcut approach can be adopted.
44
Gross motor development: an explosion of skills occurs during the first
year of life
Vision and fine motor: more evident acquisition of skills from 1 year
onwards
Hearing, speech and language: a big expansion of skills from 18 months
Social, emotional and behavioral: most obvious from 2 years
45
Understanding the time when acceleration of skills
occurs guides the doctor on how to quickly take
a developmental history.

If the child <18 months: most useful to ask about gross motor abilities,
acquisition of vision and hearing, followed by questions about hand skills
If the child is 18 months - 2.5 years: ask about acquisition of speech
and language, fine motor skills.
If the child is 2.5 3.5 years: Focus your initial questions around speech,
language and social emotional and behavioral skills.
This method is quick, and
more appropriate

It assesses the current abilities
rather than making the parents
Trying to remember the ages when
their child acquired the skill
46
For more knowledge :

-Developmental Problems
-Specific global delay
47
Abnormal development
DEFINITIONS
Delay: slow acquisition of all skills (global
delay) or of one particular field or area of
skill (specific delay) particularly in relation
to developmental problems in 0-5 years.
Learning difficulty: used in relation to
children of school age and may be
cognitive, physical or both (complex)
Disorder: mal-development of a skill
48
Global developmental delay
Implies delay in acquisition of all skill
fields.
Apparent in the first 2 years of life.
More likely to be associated with cognitive
difficulties, they may be apparent later in
life.
49
Causes of global developmental delay
1- prenatal:

Genetic: chromosomal/DNA disorders, Cerebral dysgenesis
Metabolic: hypothyroidism, phenylketonuria
Teratogenic: alcohol, drugs
Congenital infection: Rubella, toxoplasmosis, cytomegalovirus

2- Perinatal:

Extreme prematurity
Birth asphyxia
Metabolic (symptomatic hypoglycemia, hyperbilirubinemia)

3- postnatal:

Infection: meningitis, encephalities
Anoxia: suffocation, near drowning, seizures
Trauma: head injury
Metabolic: hypoglycemia, inborn error of metabolism

4- Other: unknown (about 25%)
50

Specific global delay
51
Abnormal Motor development
Concerns starts between 6 months and 2 years
Presents as delay in:
1. Head control
2. Rolling
3. Sitting
4. Standing
5. Walking
6. Problems with balance
7. Abnormal gait
8. Asymmetry of hand use (suggests hemiplegia)
9. Involuntary movements
52
Causes
1. Cerebral palsy
Has many causes, 10% hypoxic ischeamic encephalopathy
Usually presents in infancy with abnormal tone and posture,
delayed motor milestones, feeding difficulties
Could be spastic, ataxic hypotonic, dyskinetic or mixed.
2. Congenital myopathy, primary muscle disease
3. Spinal cord lesion e.g. spina bifida
4. Global developmental delay as in many
syndromes or of unidentified cause.
53
Abnormal speech and language
development
Could be receptive or expressive speech and
language disorder or both.
Causes:
Hearing loss
Global developmental delay
Difficulty in speech production due to anatomical
defect e.g. cleft palate or oromotor
incoordination eg. Cerebral palsy
Environmental deprivation and lack of
opportunity for social interaction
Normal variant/familial pattern

54
Speech and language disorders
These include:
Language comprehension (receptive dysphasia): inability
to understand and speech and language
Language expression (expressive dysphasia): difficulty
in producing speech whilst knowing what is needed to be
said
Phonation and speech production such as stammering,
dysarthria, verbal dyspraxia
Pragmatics (difference between sentence meaning and
speakers meaning), construction of sentences,
semantics, grammar.
Social/communication skills (autistic spectrum disorder)
55
Abnormal development of
social/communication skills
It includes Autistic spectrum disorder
It presents at 2-4 years with
1. impaired social interaction
2. speech and language disorder
3. imposition of routines with ritualistic and
repetitive behavior
4. Co-morbidities: learning and attention
difficulties, seizures
Managed by behavior modification using
applied behavior analysis
56
Thank you

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