Child development and milestones

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.

• Primitive reflexes are reflexes that are normally present during infancy and disappear with the development of inhibitory pathways to the subcortical motor areas (usually within the 1^st year of life)
• Primitive reflexes persistence
  • In children; : indicates impaired brain development
  • In adults; : suggests frontal lobe lesions; (frontal release signs)

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]

Developmental milestones in childhood ^[10][11]

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.

• Normal weight-for-age velocity
  • Term neonates lose up to 7% of their birth weight in the first few days after delivery and normally regain it within 2 weeks.
  • Birth weight should double by 4 months, triple by 1 year and quadruple by 2 years of age.
• Normal height/length-for-age velocity
  • An infant's height/length increases by approx. 30% within the first 6 months and by approx. 50% within the first year.
  • Midparental height (target height):
    • ♀ height = [mother's height in cm + (father's height in cm - 13)]/2
    • ♂ height = [father's height in cm + (mother's height in cm + 13)]/2
  • From birth to 6 months: 2.5 cm (1 in) per month
  • From 6 months to 1 year: 1.3 cm (0.5 in) per month
• Weight-for-height/length
  • Useful in detecting malnutrition in children < 5 years of age
  • Height/length at 1 year of age should be ∼ 50% more than the birth height/length.
• Head circumference-for-age: used for microcephaly and macrocephaly screening, especially during the first 3 years of life
  • In a healthy infant, head circumference increases by
    • 5 cm during first 3 months.
    • 4 cm between 3–6 months.
    • 2 cm between 6–9 months.
    • 1 cm between 9–12 months.
  • Microcephaly
    • A head circumference that is > 2 standard deviations below the mean size for a given age and sex (usually < 3^rdpercentile)
    • Seen in chromosomal trisomies, fetal alcohol syndrome, congenital TORCH infections, cranial anatomic abnormalities, neural tube defects
  • Macrocephaly
    • A head circumference that is ≥ 2 standard deviations above the mean size for a given age and sex (usually ≥ 97^thpercentile)
    • Seen in hydrocephalus, neurofibromatosis, tuberous sclerosis, skeletal dysplasia, acromegaly, intracranial hemorrhage, cerebral metabolic diseases (e.g., Tay-Sachs disease, maple syrup urine disease)

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: < 5^thpercentile
  • Length-for-age: < 5^thpercentile
  • Body mass index-for-age: < 5^thpercentile
  • Deceleration of weight velocity that crosses 2 major lines on the growth chart

Etiology

• Nonorganic FTT (∼ 90% of cases) ^[20]
  • No underlying disorder
  • Usually associated with:
    • Wrong feeding practices
    • Wrong preparation of formula feeds
    • Child neglect
    • Poor socioeconomic status
    • Intrauterine growth restriction
    • Prematurity and low birth weight
• Organic FTT (∼ 10% of cases) is associated with disorders that:
  • Prevent nutrient intake
    • Cleft palate and/or lip
    • Gastroesophageal reflux disease
  • Prevent nutrient absorption
    • Hypertrophic pyloric stenosis
    • Food intolerance
    • Celiac disease
    • Inflammatory bowel disease
    • Inborn errors of metabolism
  • Cause excessive calorie loss
    • Cystic fibrosis
    • Congenital heart defects (CHDs)
    • Malignancies
    • Other chronic diseases

Clinical features

• Developmental delay
• Failure to gain weight despite adequate feeds
• Recurrent vomiting and diarrhea
• Recurrent infections
• General signs of malnutrition (e.g., lymphadenopathy, edema, organomegaly)

Diagnostics

• History of feeding habits (e.g., number and frequency of feeds, food refusal)
• Laboratory studies
  • Complete blood count and ESR
  • Urinalysis
  • Hepatic and renal function tests
  • Thyroid function tests
  • Immunoglobulin levels assessment: to evaluate for underlying immunodeficiencies (e.g., HIV, tuberculosis)
• Imaging
  • Hand and wrist x-ray
  • Echocardiogram
  • Upper gastrointestinal series with small bowel follow-through

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.

• Physical examination
  • Charting of growth and recording of developmental milestones
  • Evaluation of resolution of primitive reflexes (in infants)
  • Blood pressure measurement: routinely screened after 3 years of age at each well-child examination
  • Abdomen: for palpable masses (e.g., Wilms tumor, neuroblastoma) at each well-child examination
  • Heart: for new murmurs, rate/rhythm disturbances at each well-child examination
  • Spine: once the child is able to stand; assess for scoliosis
  • Evaluation for developmental dysplasia of the hip in neonates and tibial torsion, femoral torsion, and metatarsus adductus in the first 2–4 years of age
  • Genital exam: for testicular descent and congenital hydrocele in all male infants, imperforate hymen in all female infants, and inguinal hernias in all infants; pubescent genital development (see Tanner stages for details)
• Screening for visual development and acuity ^[25]
  • Ocular motility and visual acuity assessment
  • Photoscreening: A pediatric vision test used to detect errors of refraction, screen for amblyogenic risk factors, and test visual acuity in preverbal and/or non-cooperative children.
  • Physiologic red reflex evaluation; (in newborns): absence or leukocoria should prompt further workup (see also “Differential diagnosis of leukocoria”)
  • Strabismus and amblyopia screening: Strabismus is a normal finding in children < 3 months of age.
• Screening for hearing loss in children ^[26][27]
  • Recommended for newborns and then at ages 4, 5, 6, 8, and 10 years
  • Recommended at other ages if there are ≥ 1 risk factors for hearing loss, which include:
    • Family history of childhood hearing loss
    • TORCH infections
    • History of meningitis/head trauma
    • Recurrent or persistent otitis media
    • Neonatal intensive care unit (NICU) stay for > 5 days
  • Screening tests include:
    • Electric response audiometry
    • Tympanometry
    • Otoacoustic emissions
  • Undetected hearing loss in children:
    • Can cause speech, language, or social delay
    • May be mistaken for a neurodevelopmental disorder, especially communication disorders

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)