Download - Developmental Milestones
Pediatric Growth and Development
Objectives
• Growth vs Development
• Growth: Weight, Height, Head Circumference
• Discrepancies in Measurement
• Normal Development & Psychosocial Assessment
• Developmental Screening
• Milestones
• Language Screening and Speech Delays
• Adolescence
Growth vs Development Growth: in size of the body • Normal growth pattern:
between 3rd and 97th percentiles • Body Mass Index (ages 2y-20y)
– Wt(kg)/ht(cm)2 x 10,000 – Overweight is >95th percentiles – Risk of being overweight is in 85-95 percentiles
Development: in function of
processes related to body and mind
Rule of Thumb :Weight • Wt loss in 1st few days of life: 5-10% of BW • Return to BW at 7-10 days of
age
Double BW at 4-5mo Triple BW at 1 yr
Quadruple BW at 2 yr
• Daily wt gain – 20-30g/day for 3-4mo – 15-20g/day for rest of 1st yr • Avg Annual Wt gain – 5 lbs between 2yr-puberty
• Average Wts – Birth: 3.5 Kg – 1 yr: 10 Kg – 5 yr: 20 Kg – 10 yr: 30 Kg
Rule of Thumb : Height
• Birth length increases by 50% by age 1y • Birth length doubles by age 4y • Birth length triples by age 13y • Avg lengths
– Birth: 20 in – 1 yr: 30 in – 3yrs: 3ft – 4 yrs: 40 in (double birth length)
• Avg annual ht increase: 2-3 in between 4yrs and puberty
Rule of Thumb : Head Circumference • Avg HC at birth: 35 cm (13.5in) • HC increases: - 1cm/month for 1st 6months
(fastest in 1st 3 months) - 0.5 cm/month for 6-12months
• Plot HC until 3 years of age • Re-Check HC
• Large shifts in percentiles warrant attention, as do large discrepancies among height, weight, and head circumference percentiles.
• Children growing <5cm/yr should be evaluated for GH deficiency or hypothyroidism
• Inadequate caloric intake Weight Height Head Circumference
Normal Development • Newborn Period
– Primitive neonatal reflexes are consequence of continued development of the CNS
– Growth of the nervous system is the most rapid in the first 2 years
– Normal reflexes: Moro Rooting Sucking Grasp Tonic neck
Reflexes in the Newborn Period Moro: Allowing head to gently
move back suddenly results in abduction and upward movement of the arms followed by adduction and flexion - Disappears at 4-6 mo
Rooting: Touching the corner of the mouth results in lowering of the lip and tongue movement towards the stimulus.
– Disappears at 4-6 mo
Reflexes in the Newborn Period Sucking: Put an object in the
mouth and the baby responds with vigorous sucking. Replaced by voluntary sucking
Grasp: Palmar disappears at 3-4 mo
Plantar disappears at 6-8 mo
Asymmetric tonic neck reflex: In supine position, baby, turns head to the side ipsilateral extension of the arm and leg with contralateral flexion
– Diappears at 2-3 mo
Later in Infancy • Control of posture
– Proximal (1st) and then distal musculature
• Check for ortho deformities – Fixed deformities warrant a consult
• Evaluation of vision and ocular
movements to prevent outcomes
of strabismus – Check cover test and light reflex
Late School Age - Early Adolescent Child
• Comprehensive sports physical exam and evaluation of the Cardiovascular system
• Worrisome signs/ symptoms/ history: – Hx of heart disease or murmur
– Dyspnea, CP on exertion, Irregular HR, Syncope, Seizure
– Fam Hx of atherosclerosis < 50 yrs or sudden death
• Contact sports: assess for vulnerabilities (ex. WPW, kidney disease/damage)
• Assess vision
Adolescence • Show sensitivity
• Scoliosis
• Obesity
• Trauma Ortho probs
• Sexual Maturity Rating
• Menstrual cycles, Dysmenorrhea
• Gynecomastia
Psychosocial Assessment • Bonding - occurs shortly after birth and reflects the
feelings of the parent toward the newborn (unidirectional)
• Attachment - involves reciprocal feelings (bidirectional) between parent and infant and develops gradually over the first year (*postpartum)
• Stranger Anxiety- between 9 and 18 mo
• Autonomy – ages 2-3 yrs
• School Readiness— depends on autonomy and the ability of the parent and child to separate for hours at a time.
Psychosocial Assessment • Preacademic Skills: colors, counts to 10, knows age,
names, address, phone number, copies shapes, stands on 1 foot, skips, bounces a ball and can dress him or herself.
• At 3-4 years, Preschool helps develops socialization,, improve language, increase skill buidling and problem solving.
• Kindergarten helps develop emotional maturity, social skills, cognitive abilities, and fine and gross motor skills. Children do better in kindergarten if their 5th b-day is at least 4-6 months before starting school. Girls are usually ready earlier than boys.
Development
18% of children in the US have
Developmental and Behavior disabilities
25% have Psychosocial Problems
Developmental Screening
• Compares the developmental skills of a child with the skills of a population of children to identify delays and who will need further testing.
• <= 6y : Assess achievement of milestones
• > 6y : Ask about academic achievement and behavior
Denver Developmental Screening Test II
Age birth to 6 years
Testing Four Domains:
1. Gross motor 2. Fine motor-adaptive 3. Personal-social 4. Language
Other Screening Tests
• Ages and Stages Questionnaires
• Child Development Inventories
• Parents’ Evaluations of Developmental Status
Parent reported screenings have good validity compared with office based screenings
Age Newborn
- 2w 1m 2m 4m 6m 9m
12m 1y
15m 18m 2y
Age Motor Cognitive Behavioral
Language Social
Full Term Infant
(+)Moro Reflex
Alert to sound of Voice
Fixates on face and briefly follows
2m -Follows objects past midline -Lifts head and shoulders off bed when placed in prone position
Coos
4m *Head lag and Moro disappear* -Bears weight on forearms when prone -Rolls back to front -Bears weight while held standing -Holds hands open predominantly
Laughs outloud Squeals!
Imitates social interaction
Age Motor Cognitive Behavioral
Language Social
6m -Transfers objects from hand to hand -Reaches/rakes for objects -Sits with support -Rolls over both ways -Bangs/shakes toys
Turns directly to sound/voice
- Babbles consonant sounds - Imitates speech
9m -Bangs two blocks together -Sits without support! -Inferior pincer grasp
-Turns when name is called -Plays peekaboo -Plays pattycake
Mama-Dada (nonspecific)
-Stranger anxiety -Recognizes common objects and people
12m -Pulls to stand/cruises -Takes a few steps -Walks with one hand held -Waves bye-bye -Fine pincer grasp -Drinks from cup held by another person
Assists with dressing
-Mama- Dada (specific) -One additional word
Follows a single step command with a gesture
Age Motor Cognitive Behavioral
Language Social
15m -Gives and takes ball -Drinks from a cup -Puts cube into a cup -Walks independently -Stoops to floor and recovers to standing
-3-6 additional words - Points to one body part
Follows a single step command without gesture
18m -Self feeding with a spoon -Stacks 2-3 cube tower -Throws a ball -Walks upstairs while holding hand -Climbs into and sits on chair -Spontaneous scribbling
Imitates household chores
10-20 words
24m -Builds a 6 cube tower -Washes and dries hands -Throws a ball overhand -Removes clothing -Kicks a ball -Jumps with 2ft
>50words -Pronouns -Speech 50% intelligible to stranger
Follows 2step commands
Age Motor Cognitive Behavioral
Language Social
3y - Copies a circle -Puts on shirt/shorts -Builds a 8 cube tower -Balances on 1ft for 1-2s -Pedals tricycle -Goes up stairs with alternating feet -Hops once
- Knows the name of a friend - Understands basic adjectives
-5-8word sentences -Uses pronouns correctly -Speech 75%intelligible to strangers -Starts using “what” and “who”
4y - Hops on one foot several times -Walks up and down stair -Balances on 1ft or 4s -Draws a person with 4 body parts
-Dresses and brushes teeth without help -Names 4 colors -Can identify opposites -Counts to 4
-Asks questions - Speech 100% intelligible to stranger
Pretend plays
Age Motor Cognitive Behavioral
Language Social
5y - Draws a person with 6 body parts -Skips -Walks backwards -Prepares a bowl for food -Holds pencil correct way -Ties a knot -Prints letters
-Plays board games -Counts to 5 -Names all primary colors
-Defines words
6y -Ties Shoelaces -Rides bike
-Writes name -Knows left from right -Counts to 10
-
Milestones
Language Screening
Age (y) 1y 2y 3y 4y
Divide by
4
1 / 4
2/4
3/ 4
4/4
%
25%
50%
75%
100%
Language Delay
Consider hearing deficit
High Risk Conditions:
• Hyperbilirubinemia (Bili > 19; exchange transfusion)
• Infection (congenital rubella, meningitis)
• Structural anomalies
• Hypoxemia (apnea, persistent fetal circulation)
• Ototoxic drug exposure (aminoglycosides, loop diuretics)
Dysfluency (aka stuttering) is common is 3-4 yr olds, transient
S ensorineural P sychomotor E nvironment A utism K inetics
Physical Growth and Development of Adolescents
• Sexual Maturity Rating (SMR) aka Tanner Stages
• Stages I-V
• Biological maturation can be related to specific lab values and physical conditions – Higher hematocrit values in adolescent boys are the result
of greater androgenic stimulation of the BM
– Alkaline phosphatase levels increase during puberty because of rapid bone turnover, especially during a growth spurt
Girls • Average age for puberty: 11 yrs (range: 8-13 yrs)
• SMR Stage II
– Thelarche: Breast budding under the areola. Mean age 9y – Adrenarche/Pubarche: Mean age of adrenarche 10y. Mean age of menarche 12y
• Peak growth spurt occurs 1 yr after thelarche
• Interval from thelarche to onset of menarche: 2 yrs
• Precocious puberty = pubertal changes before 6 -7 yo
Tanner Stages for Girls • Stage I: Breasts are
preadolescent. Elevation of the papilla only
• Stage II: Breast bud stage.
Areolar diameter increases • Stage III: further enlargement of
breast and areola • Stage IV: Projection of the areola
and papilla to form a secondary mound
• Stage V: Mature female, areola
has recessed to the general contour of the breast
Tanner Stages for Girls
Boys
• Adrenarche: Followed by pubic hair development at the base of the penis
• Growth spurt occurs 10-16 yrs (late event)
• Deepening of the voice, facial hair, acne indicate early stages of puberty
Tanner Stages for Boys • Stage I: penis, testes, and
scrotum are of childhood size • Stage II: enlargement of the
scrotum and testes only, scrotal skin reddens
• Stage III: further growth of
testes and scrotum, enlargement of the penis in length
• Stage IV: Increased size of the penis in breadth
• Stage V: Adult in size and
shape
Objectives
• Growth vs Development
• Growth: Weight, Height, Head Circumference
• Discrepancies in Measurement
• Normal Development & Psychosocial Assessment
• Developmental Screening
• Milestones
• Language Screening and Speech Delays
• Adolescence
“I am a child, I last a while . . . You can’t conceive of
the pleasure in my smile.” -Neil Young
References
• Frankenburg, W.K., et al. (1992). The Denver II: A Major Revision and Restandardization of the Denver Developmental Screening Test. Pediatrics, 89 (1), 91-97.
• Kliegman, R.M., Marcdante, K.J., Jenson, H.B., Behrman, R.E. (2006). Nelson essentials of pediatrics (5th ed.). Pennsylvania: Elsevier Saunders.
• LaRosa, A., Glascoe, F.P. “Developmental Surveillance and Screening in Primary Care.” Up to Date (1997). Online. Internet. Available: www.uptodate.com
• Robertson, J., & Shilkofski, N. (Eds). (2005). The Harriet Lane Handbook (17th ed.). Pennsylvania: Elsevier Saunders.