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Child development and milestones

Last updated: October 1, 2021

Summarytoggle arrow icon

Growth charts and developmental milestones are among the most important tools of pediatric screening and monitoring. Growth charts are used to assess height and weight for age, while developmental milestones define the physical, intellectual, and behavioral skills a child with normal development is expected to have acquired by a certain age. Child growth and development are assessed during routine well-child visits at regular intervals. Children whose growth and weight are far below or above average and those who do not meet the developmental milestones for their age group should be evaluated for underlying diseases and receive treatment accordingly. Failure to thrive (FTT) in infants is a condition in which an infant's growth and weight-gain are far below average, the most common cause of which is inappropriate feeding practices. Global developmental delay is defined as the significant developmental failure in two or more domains in children under 5 years of age. The regression of previously achieved milestones may also be a sign of global developmental delay. The persistence of primitive reflexes indicates impaired brain development.

Reflex Description Age of resolution Clinical significance
Moro reflex
  • 3–6 months
Rooting reflex
  • Stroking the cheek elicits turning of the head towards the stimulus and opening of the mouth.
  • 4 months
Sucking reflex
  • Touching the roof of the mouth elicits a sucking motion.
Palmar grasp
  • Stimulation of the palm elicits a grasping motion.
  • 3–6 months
Plantar grasp
  • 3 months

Plantar reflex

  • Stroking the sole of the foot from heel to toe elicits dorsiflexion of the foot with concomitant extension of the big toe and fanning of the other toes.
  • 12 months
Stepping reflex
  • Holding the infant upright with feet on the examination table elicits a stepping motion with alternating flexion and extension of the legs.
  • 2 months
Galant reflex
  • Holding the infant in the prone position and stroking it on one side of the paravertebral region elicits flexion of the lower back and hip towards the stimulus.
  • 2–6 months
Asymmetrical tonic neck reflex (ATNR)
  • 3–4 months
  • The ATNR aids in the development of hand-eye coordination.

Glabellar tap sign

  • Tapping the glabella elicits blinking.
  • 4–6 months
Landau reflex
  • 24 months
Snout reflex
  • Tapping or applying light pressure to closed lips elicits puckering.
  • 4 months
Parachute reflex
  • Holding the infant in an upright position, followed by sudden lowering towards the examination table elicits extension of the infant's arms.
  • This reflex appears at 6–9 months of age.
  • Persists

Plantar grasp and plantar reflex are two different types of primitive reflexes!

To remember the age of resolution for Moro reflex (3–6 months): Marilyn Monroe died at age 36.

References:[3][4][5][6][7][8][9]

Developmental milestones in infancy [10][11][12]

Age Gross motor Fine motor Language Social/Cognitive
2 months
  • Raises head and chest when prone
  • Follows objects past midline
  • Coos
  • Smiles back (social smile)
  • Recognizes parents

4 months

  • Holds head straight
  • Rolls over front to back
  • Props himself/herself up on wrists in prone position
  • Holds and shakes rattle
  • Laughs
  • Makes consonant sounds
  • Localizes sound
6 months
  • Sits without support
  • Rolls over back to the front
  • Grabs and transfers objects from one hand to the other
  • Raking grasp
  • Babbles
9 months
  • Crawls
  • Stands when holding on to something
  • Pincer grasps (9-12 months)
  • Says “ma-ma”, “da-da
  • Orients to name
  • Imitates actions
  • Has separation anxiety
12 months
  • Starts to walk
  • Can throw objects
  • Points at objects
  • Knows 1–5 words
  • Follows simple commands

Developmental milestones in childhood [10][11]

Age Motor development Speech development Social development/cognitive development
Gross motor Fine motor
1.5 years
  • Starts to run
  • Stacks up to 4 blocks
  • Uses spoon and cup
  • Knows 10–50 words
  • Plays pretend
2 years
  • Walks up and downstairs, stepping with both feet on each step
  • Kicks ball
  • Jumps
  • Stacks up to 6 blocks (number of blocks = age in years x 3)
  • Draws a line
  • Knows ≥ 50 words
  • Uses sentences of up to 2 words
  • Engages in parallel play (2–3 years)
  • Moves away and comes back to the parent
  • Follows 2-step commands
  • Removes clothes
3 years
  • Alternates feet when walking up and down the stairs
  • Pedals a tricycle
  • Stacks up to 9 blocks
  • Copies a circle
  • Mostly intelligible speech
  • Knows ≥ 300 words, understands > 1000 words
  • Uses sentences of up to 3 words
  • Understands gender difference
  • Brushes teeth and grooms self
  • Has bladder and bowel control (however, bed-wetting until 5 years of age is considered normal )
  • Plays away from parents
4 years
  • Hops on one foot
  • Catches and throws ball overhand
  • Copies a square
  • Tells complex stories
  • Can identify some colors and numbers
  • Plays cooperatively
  • May have imaginary friends
5 years
  • Skips
  • Walks backwards
  • Copies a triangle
  • Can tie shoelaces
  • Can write some letters
  • Speaks fluently
  • Counts 10 or more things
  • Uses sentences of up to 5 words
  • Learns how to read
  • Understands directions (left and right)
  • Plays dress up

Chronologic age must be adjusted for gestational age for premature infants below 2 years old!

The definition of developmental delay varies depending on the state but as a general rule, developmental delay should be suspected when the child's age is > 25% of the mean age at which a particular milestone is attained or > 1.5 standard deviations on a standardized developmental screening test.

Twins, like all other children, develop at different speeds and each twin should be evaluated separately for any delays in obtaining milestones.

References:[13][14][15][16]

Growth charts are used to calculate a child's growth percentile by plotting the child's weight and height/length on standardized graphs. Height is usually measured standing up, whereas length is measured while the child is lying down.

According to the Rule of Fives, normal growth rates in children can be approximated by multiples of five: birth–1 year (50–75 cm, 25 cm/year), 1–4 years (75–100 cm, 10 cm/year), 4–8 years (100–125 cm, 5 cm/year), 8–12 years (125–150 cm, 5 cm/year).

References:[17][18][19]

Definition

  • Inadequate growth of a child for their age
  • Seen in up to 10% of children in the United States (most < 18 months of age)
  • Anthropometric criteria of FTT
    • Weight-for-age: < 5thpercentile
    • Length-for-age: < 5thpercentile
    • Body mass index-for-age: < 5thpercentile
    • Deceleration of weight velocity that crosses 2 major lines on the growth chart

Etiology

Clinical features

Diagnostics

Treatment

  • Treatment of the underlying cause
  • Counseling parents on appropriate child nutrition
  • Formula supplementation for infants and nutritional supplementation for toddlers
  • Close follow-up and monitoring of the child's growth

References:[21][22][23]

Overview

  • Definition: a preventive health care schedule used for general pediatric health assessment, early disease detection, and prompt management.
  • Schedule
    • 3–5 days after birth (in-hospital examination)
    • During the first year: at 1, 2, 4, 6, 9, and 12 months
    • During the second year: at 15, 18, 24, and 30 months
    • Between 2 and 10 years of age: annual visits

Contents of the visit [24]

Physical examination and screenings

A well-child examination always includes a physical examination. Depending on the age of the child, specific screening tests will be performed.

Children with behavioral abnormalities should be tested for hearing loss.

Anticipatory guidance to parents or caregivers

Anticipatory guidance is a form of proactive counseling on physical, emotional, psychological, and developmental changes that can be expected to occur in a patient (e.g., child) before their next care visit. Topics include:

  • Child safety
    • Child passenger safety: Children under 13 years of age are required by law to ride in the backseat on an age- and weight-appropriate safety seat or booster. [28]
      • 2–4 years (or until the child outgrows the seat): rear-facing seat
      • 4–8 years: forward-facing car seat
      • 8–12 years (or as soon as the child outgrows the forward-facing car seat): booster seat
    • Supervised play
      • 3–5 years: Continuous supervision during play is necessary. [29]
      • 6–8 years: Supervision during play is necessary near bodies of water or during risky activities (e.g., climbing). [30]
    • Abuse prevention: Children should continuously be taught age-appropriate safety as of the age of 3 years
    • Road traffic safety
      • Children should always wear protective gear when engaging in activities with an increased risk of injury (e.g., cycling, skateboarding)
      • Children should be taught safe street habits (e.g., how to safely cross the road).
    • Water safety
      • Children should not be left unattended near bodies of water.
      • Children should be taught how to swim early to reduce the risk of drowning.
    • Household safety
      • Potentially harmful household products and tools should be kept out of reach.
      • Fire alarms should be installed and fire escape plans implemented
      • Firearms should be locked out of reach of children (unloaded with ammunition stored separately)
  • Media use: sedentary screen time for 2–5-year-old children should not exceed 1 hour a day [29]
  • Sleep [31]
    • 3–5 years: 10–13 hours of sleep are recommended, including naps
    • 6–12 years: Children should sleep between 9 and 12 hours; daytime naps should not be forced
  • Cognitive and social development
    • Teaching appropriate behavior and language
    • Parental guidance on preventing behavioral problems (e.g., temper tantrums, aggressive behavior, school problems)
    • Techniques to reinforce good behavior and avoid unrealistic expectations
  • Health
    • Personal hygiene (e.g., hand washing after using the toilet, after sneezing/coughing, and before handling food; not sharing hair brushes/combs, oral hygiene)
    • Immunization schedules including immunizations for travel
    • Nutrition (e.g., providing healthy foods, limiting sugary drinks and foods)
    • Physical development (e.g., encouraging at least 60 minutes of physical activity daily)
    • Education on oral development, which includes providing information about dental development and conditions such as:
      • Teething
        • The physiological process by which an infant's deciduous teeth emerge through the gums; usually begins with the lower central incisors between 6 and 10 months of age and ends with the molars at 2–3 years of age
        • Manifestations fluctuate with the eruption of teeth and include drooling, irritability, disrupted sleep, and/or swelling/inflammation of the gums.
        • Providing infants with a chilled teething ring to chew on safely can reduce discomfort.
      • Dental malocclusion (e.g., discourage nonnutritive sucking habits e.g., thumb sucking and pacifier use beyond 3 years of age)
      • Dental care and caries prevention (e.g., brush teeth twice a day with fluoridated toothpaste and floss once a day)
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