Pediatrics Growth and Development

Well Child Exam

• Main component is assessment of development

• Frequent and routine exams allow a view of a child as they grow and develop

• Becoming familiar with development and behavioral issues is essential in pediatric practice

• Knowledge of normal development and behavior will allow you to address parental concerns, provide reassurance, and enable you yo provide access to early intervention services

What are the 5 Development Areas?

• Gross motor (large muscles): walking, crawling, standing

• Fine motor (small muscles in the hand): pinch and hold, grasp with entire hand

• Cognition

  • Thinking, learning, memory, object permanence, attention, construction of knowledge about objects and people

• Language

  • Communication and comprehension of words

• Social/Emotional

  • Interacting with people and environment

Screening Tools Recommendations

• Screening tools should be used at 3 selected visits during the first 3 years: typically 9 months, 18 months, and 2-3 years

• Allows for us to earlier be able to identify developmental concerns and delays

• Screening tools provide a much more accurate assessment of development and can pick up 70% of delays that would have been misses

Developmental Screening: Denver II

• Common but older

• Screens from birth to age 6

• Have 125 tasks in four domains: personal/social, fine motor, gross motor, language

  • Takes 20 additional minutes to perform

• Does not assess socio-emotional development or cognitive development

Developmental Screening: PEDS (Parent’s Evaluation of Developmental Status)

• 10 questions to parents that provider interprets (parent does in waiting room)

• Helps to guide concerns during a well child exam

• Questions: concerns about

  • Child’s learning development/behavior

  • How your child talks and makes speech sounds

  • How your child understands what you say

  • How your child uses his hands and fingers

  • How your child uses his arms and legs

  • How your child behaves

  • How your child gets along with others

  • How your child is learning to do things for themselves

  • How your child is learning pre-school or school skills

  • Anything else

Developmental Screening: PEDS DM (Pediatric Evaluation of developmental screening-developmental milestones)

• 6-8 item survey focused in each developmental domain

• Takes 5 minutes to complete and 1 minute to score

• Designed for children age birth -8

Screening: Other developmental tests

• Age and stages questionnaire: ages 4-48 months, administered by parent

• Battelle Developmental Inventory: ages 0-8 years old, administered by psychologist or developmental MD (usually for someone who has failed initial screen: secondary screening tool)

• Bayley Scales of Infant Development II: ages 0-8 years old, administered by psychologist or developmental MD (usually for someone who has failed initial screen: secondary screening tool)

Gross Motor Development: Primitive Reflexes

• Involuntary reflexes (have at birth): elicited at newborn well child exams

• May help to indicate muscle group coordination and neurologic/CNS function

Gross Motor Development: Moro Response

• Moro Response:

  • One of the best known primitive reflexes

  • Occurs during loud noises or startling

  • Abrupt extension of a baby’s neck, baby will first abduct and extend their arms then adduct and flex them

  • Abnormal if only had one arm that elicited reflex

  • Should disappear by 4 months: if not, can identify congenital/MSK abnormalities/brachial or neuro. plexus injury

Gross Motor Development: Hand grasp

• Place finger in palm of newborn → will automatically grip it

Gross Motor Development: Sucking reflex

• Can test with gloved finger or pacifier: infant should suckle finger

Gross Motor Development: ATNR (asymmetric tonic neck reflex/Fencer position)

• The position of a baby’s head will influence the limb motion/position

• By turning a baby’s head to one side (passive or active), they will extend the arm they are looking at and the other arm should come up and bend with their hand almost by their head or behind their head

• When gaze is redirected, the fencer position is gone

Gross Motor Development: Muscular control

• Development of muscle control develops in an organized fashion from head to toe

• Prior to 6 months:

  • When infant is pulled from lying to sitting the head lags after the shoulders

  • Have good neck control during this time period: spasticity (investigate)

• At 4-6 months:

  • The infant senses movement and should flex the neck before the shoulders lift

  • Over 4-6 months with no head control: hypotonia

Gross Motor Development: Protective Equilibrium

• In a sitting position if the infant is pushed off balance: will outreach their hand and arm away from the force and try to support themselves

• Appears around 6 months of age

Gross Motor Development: Parachute Response

• When holding an infant or young child horizontally flying and allow them to fall downward → will outstretch both arms and legs to distribute weight for stability

• Should have by 10 months

Gross Motor Development: Trunk Control

• An infant lying prone is tightly flexed

• Control of the upper trunk in the first few months develops along with a decrease in flexor tone (head to toe muscle control progression): should be able to control the weight of the upper trunk on their forearms by 4 months

• Should not see floppiness or a 4 month old that cannot extend their arms (spasticity)

Gross Motor Development: Rolling

• Develops after control of the shoulders and upper trunk develop

• Belly to back comes first around 4 months: use arms for this

• Back to belly comes at 5-6 months: need to rely on core (abdomen, lumbar spine, hips)

• Because we innervate from top down, belly to back comes first and as we gain more control we can roll from back to belly

Gross Motor Development: Commando Crawling

• 5-6 months

• Coordination of upper arms pulling and dragging legs

• Some kids will never do this: normal

Gross Motor Development: Creeping/Crawling

• 6-9 months

• Getting up on hands and knees: baby has control over hips and legs

Gross Motor Development: Cruising

• 9-10 months

• Supported standing: stepping/walking while supported on furniture or holding onto a parents hand

Gross Motor Development: Walking

• 9-17 months

• Unassisted walking with 3 or more steps

Gross Motor Development: Milestones

Early Gross Motor Milestones Normal

Potential Causes of Delayed Gross Motor Development

Global Developmental Delay

• Genetic syndromes

• Chromosomal abnormalities

• Endocrine disorders

• Intellectual disability

• Congenital infection

• Neurodegenerative disease

Motor Dysfunction

• CNS damage: kernicterus, stroke, trauma, infection, HIE

• Spinal cord dysfunction

• Peripheral nerve dysfunction (brachial plexus injury, neuropathy)

• Muscular disorders

Motor intact but otherwise restricted

• Congenital malformation

• Decreased energy: malnutrition, chronic illness

• Environmental

• Sensory deficits

• Trauma

Fine Motor Development:

• Control develops in the hand from proximal to distal

Fine Motor Development: Involuntary grasp

• Primitive

• At birth, an infant is tight fisted

• Disappears in a couple of months and infant should develop voluntary grasp

Fine Motor Development: Voluntary grasp 2-3 months

• Hands can be brought together in midline

Fine Motor Development: Voluntary grasp 3-4 months

• Reaches toward and misses objects (swipes/waves at toys)

Fine Motor Development: Voluntary grasp 4 months

• Reaches and grasps objects and brings them to mouth

Fine Motor Development: Voluntary grasp 4-5 months

• Entire hand used to bring item near by (claw raking)

  • Thumb adducted, proximal thumb joint flexed, distal thumb joint flexed

Fine Motor Development: Voluntary grasp 5-7 months

• Grasps objects, brings it to midline, and can transfer to other hand

  • Grasp uses radial palm (not fine pincer fingers)

Fine Motor Development: Voluntary grasp 9-12 months

• Pincer grip (thumb and index finger) and baby starts to finger feed themselves

Fine Motor Development: Voluntary grasp 15-18 months

• Uses of spoon and fork, scribbles, stacks 2 blocks, makes a line with a crayon

Fine Motor Development: Voluntary grasp 24 months

• Stacks 6 blocks, imitates vertical or circular strokes

Fine Motor Development: Voluntary grasp 36 months

• Copies circle, builds a bridge with 3 cubes

Fine Motor Development: Voluntary grasp 4 y/o

• Copies cross or intersecting lines

Fine Motor Development: Voluntary grasp 5 y/o

• Copies squares and draws triangles

Fine Motor Development: Red Flags

• A child who does not have pincer grip by age 1

• A young child who shows a preference for one hand before age 2 (should use both hands equally)

• A child who can’t hold a crayon/pencil and copy a line on paper (age 3), copy a circle (age 4)

Cognitive Development:

• The first 2 years: focused on sensory and motor abilities

Cognitive Development: Infant

• Fixes and follows a face

Cognitive Development: 4-8 months

• Tracks a toy that fell to the floor

• Explores toys by touch, mouthing, and shaking to provide sensory input

Cognitive Development: 9-12 months

• Object permanence: hide and object and they watch and can find where you put it

• Likes to play peek a boo

• Waves bye

Cognitive Development: 15 months

• Figures out on their own how to make a toy work

• Pretend play

• Imitates (phone)

• Indicates some needs by pointing

Cognitive Development: 15-18 months

• Wants to share experience of toys (you do not want to see a child this age isolate themselves or always playing with the same toy)

• Able to follow simple 1-2 step directions (take this and throw it out)

Cognitive Development: 18 months-2 years

• Completes simple puzzles

• Learns body parts/animal noises

Cognitive Development: 2-3 y/o

• Learns colors

• Learns shapes

• Counting numbers

• ABCs

Language Development:

• Receptive language develops faster then expressive (can understand before we can speak)

• Word comprehension starts by 9 months

• Understands language and follows instructions by 15 months

• Encourage parents to read to their child starting in infancy

• Children who are not reaching these language milestones need a hearing evaluation and referral to a speech pathologist (language delays very common)

Language Development: 9 months

• Babbles

• 2 syllables

Language Development: 12 months

• 1-3 words

Language Development: 15 months

• 3-6 words

• 1-2 body parts

• Responds to simple commands

Language Development: 18 months

• 5-20 words

• 5+ body parts

• Points to what they want

• Points to 2 pictures

Language Development: 2 y/o

• 50+ words

• 2 word phrases

• 50% intelligible by a stranger

• Names a few pictures

• Follows 2 part command

Language Development: 3 y/o

• 900+ words

• 3-5 word phrases

• 75% intelligible

Language Development: 4 y/o

• Thousands of words

• 5 word phrases

Social Development: Newborn

• Focuses on parent’s face (1ft away)

Social Development: 4-6 week old

• Social smile

• Calms with comfort

Social Development: 4 month

• Laughs at silly faces and sounds

Social Development: 6-8 months

• Baby is upset by parent leaving room

• Loves to interact with caregiver

• Wave by and clap

Social Development: 9-12 months

• Stranger anxiety

• Plays peek a boo

Social Development: 15 months

• Crawling/walking away from parent to toy and returning for encouragement

Social Development: 18 months

• Asks for help

• Feeds self

Social Development: 2 y/o

• Parallel play: I want to be next to you playing but I do not want you touching my stuff (having an experience where someone is allowed to be there but do not share)

• Does not want to share

• Enjoys asking why, what, that

• Helps undress

• Listens to stories

Social Development: 3 y/o

• Includes other children in play

• Tries to cooperate and communicate with friends

• Engages in sharing and playing

• Doesn’t understand rules in a game

• Fantastic imagination

• Role playing and fantasy

• Do not have these/stuck in parallel play: early sign of autism

Social Development and Sense of Self: 9 months

• Wants to feed themselves

Social Development and Sense of Self: 9-12 months

• Able to drink from a sippie cup

Social Development and Sense of Self: 12-15 months

• Imitates helping at home

Social Development and Sense of Self: 15-18 months

• Feeds self with fork and spoon

Social Development and Sense of Self: 18-24 months

• Helps to get clothes off

Social Development and Sense of Self: 2-2.5 y/o

• Helps to put clothes on

• Helps to brush teeth

Social Development and Sense of Self: 3 y/o

• Unbuttons clothes

• Puts on shoes

Evaluating Social Development

• At well child exam observe relationship between parent and child

• Notice infant wanting parent for comfort, eye contact, or physical contact

• Red flag

  • Children that have limited eye contact, who may not be affectionate with parent, who don’t participate in relationship exchanges (could be indicative of autism, poor social situation at home, etc…)

Assessment of child with suspected development delays considerations (7)

• Remember that following a child across time with regular exams is important: one delay may not be significant

• Not all children show consistent age appropriate development

• A provider needs to look at multiple skills

• Consider factors such as

  • Health of child

  • Socioeconomic status

  • Opportunity for learning

• Preterm child or child with chronic health issues may show delays at first but should catch up by age 2

• Subtle problems are more common than severe delays but harder to identify (child may not always show problem at visit)

• A child that is normal as an infant or toddler may not develop skills expected in pre-school or school age periods

Evaluating for Developmental Delays: History

• Medical history

  • Pregnancy (use of drugs, X-ray exposure, abnormal screens)

  • Labor and delivery

  • Newborn infection

  • Apnea

  • Elevated bilirubin

  • Failure to thrive

  • Chronic illness

  • Hospitalization

  • Abuse

• Learning and Education

  • Performance and behavior in classroom

  • Standardized testing

• Psychosocial history

  • Family/parents/caregivers

  • Upbringing

  • Parent language, cultural background, discipline, marriage, drug/alcohol abuse

  • Family resources

• Developmental history

  • Age that milestones achieved

• Family history

  • Intellectual disability

  • CNS disorders

  • Learning disabilities

  • History of mom’s other pregnancies and health of other children

Evaluating for Developmental Delays: Physical Exam

• Dysmorphic features

• Abnormal movements

• Clumsiness

• Vision/hearing exams

• Neurological exam

Evaluating for Developmental Delays: Emotional/Social behavior

• Often done by psychologist

Evaluating for Developmental Delays: Complete Neuropsychological evaluation

• Evaluation of intelligence and achievement

• Done by psychologist: very detailed

Referring Suspected Delays

• Refer if delays occur in more than 1 area or development of 1 area but lingering

• Refer as soon as possible

• CT: Birth to 3

  • State system works on skills

  • Free of charge

• Ages > 3 y/o

  • Preschool/school system is screening and evaluating

• Evaluations by PT, OT, audiologist, speech, psychologist, development pediatrician, etc… may be necessary

• Educate parents: anticipatory guidance (what they should expect at the next visit)