Assessment of Growth &
Development

⦁ Growth and development are sometimes used interchangeably.
⦁ Growth is defined as net increase in the size or mass of tissues. It is
largely due to multiplication of cells,increase in the intracellular
substance (quantitative )
⦁ Development is defined as maturation of functions and
acquisition of skills. (qualitative growth)
⦁ Early childhood : Cognitive growth and development difficult to
differentiate from neurologic and behavioural maturation.
⦁ Later childhood, it can be measured by communicative skills and
cognitive abilities influenced by the physical, emotional and social
environment.
INTRODUCTION

Changes in bodily proportions with age
Predictable Sequence
-Cephalo-caudal (head down to toes)
- Proximodistal (center of the body to peripheral)
- General to specific

Principles ofGrowth
1. Continous process from conception onward
Orderly - definite time limits for growth. Any time lost
during a rapid growth period may prevent catch-up
growth.
2. Unique for each individual - genetic and environment factors
3. Growth is governed by complex chain of hormonal
interactions.The growth in the first year is mainly controlled
by inherent potential of the cells and later by several factors
(environmental and genetic).

⦁ 4. Growth spurts occur in late foetal period ; pubertal
period. It is a dynamic process
• 5. Growth does not follow normal distribution
curve.
• 6. Each stage of G&D is affected by the preceding
types of development
Principles of Growth

Differential growth
• Each child grows in his/her own
unique way.
• Not all body parts grow in the same
rate at the same time
⦁ C N S :Neuronal division essentially
complete by 1 year,
⦁ Bone,Muscle,and Fat cells continue
to divide until later in childhood.
⦁ Other - Skin,gastrointestinal
epithelial cells,and liver retain the
capacity for hyperplasia throughout
life.
• Don’t progress at the same rate
(↑ periods of GR in early childhood
and adolescents & ↓ periods of GR in
middle childhood)

Stages of Growth and Development
⦁ Infancy
⦁ Neonate
⦁ Birth to 1 month
⦁ Infancy
⦁ 1 month to 1 year
⦁ Early Childhood
⦁ Toddler
⦁ 1-3 years
⦁ Preschool
⦁ 3-6 years
⦁ Middle Childhood
⦁ School age
⦁ 6 to 10 years (Girls)
⦁ 6 to 12 years (Boys)
⦁ Late Childhood (Adolescent)
⦁ Prepubescent : 10-12 yrs () 12-14 yrs ()
⦁ Pubescent : 12- 14 yrs(ƒ );14-16 yrs ()
⦁ Post Pubescent :14 -18 yrs(ƒ); 16- 20 yrs ()

Factors Affecting
Growth
1. Genetic factors
a. Race
b. Sex
c. Chromosomal
2.Nutritional Factors
3.Hormonal-Thyroxine
GH

4. Environmental factors
a) Altitude, temperature
b) Pollutants
5. Social Factors
a) Socioeconomic class
b) Education of parents
c) Education of child

Measurement of human growth
• Assessment of human growth is done using similar methods
so that their data are comparable between individuals in the
same study and between samples in different studies.
• A book “Practical Human Biology” forms the source for
many scientists who wish to use standard techniques to
anthropometric measurement
• This book also has many other techniques that are applied
in research in human biology such as dermatoglyphics,
physiological measures, salt and water balance, thermal
comfort, nutritional status, etc

Importance of growth
assessment
• Growth is fundamental characteristic of
childhood.
• Normal growth is indicator of optimum
health.
• Deviation from the normal pattern is
indicative of pathological process.
• Periodic assessment facilitates early detection
of growth faltering, which may be first
manifestation of undernutrition/infection/
disease.

Context of measurement; screening,
surveillance and monitoring
• Assessment of human growth and development is
directly dependent on the methods employed to
measure
• The context will usually be one of three types:
 Screening
 Surveillance
 Monitoring

Screening
• It is the identification of a particular subset of the
population with certain prescribed characteristics.
• is a cross-sectional, once-off activity and usually
involves large samples of children.
• it will lead on to further assessment or intervention

Requirement for screening
• Large sample sizes needed
• Need for high levels of measurement efficiency,
• only a few dimensions such as height and weight
are measured
• Instrumentation tends to be basic and portable
• Assessment is undertaken by more than one
observer

Surveillance
• It is assessing the process of growth on more than
one occasion on a sample of children
• Usually follows a screening exercise.
• Children selected to partake in a nutritional
supplementation program are re-assessed at some
future date
• This re-assessment may happen over several
months and/or years

• This leads to the identification of a child with an
unusual pattern of growth
• This child is regularly reassess in a clinical situation
with access to treatment regimes if a treatable disorder
is diagnosed.
Requirement for surveillance
• Description of growth requires more dimensions to be
assessed
• Number of observers will be fewer

Monitoring
• Long-term high-frequency assessment of a single
child or small sample of children.
Requirements for Monitoring
• Specialist setting with dedicated space
• High quality instrumentation
• Broad range of dimensions to properly assess all
aspects of the pattern of growth.

• Screening provides only cross-sectional data
• Surveillance and monitoring provides both cross-
sectional and longitudinal components.
• Surveillance and monitoring provides information
regarding both current size of the child and of the
growth rate i.e. “growth velocity”.

VIMAR
• It describes the most important elements to be
considered when designing an anthropometric scenario
Stands for:
Validity
Instrumentation
Minimum unit of measurement
Accuracy
Reliability

Validity
• It is the appropriateness of the dimension to be
assessed
• For example, relationship between height and arm
span is well recognized
• So we can use development of regression
equations to predict height from arm span
• But it is better that dimension of interest ought to
be measured and not predicted from another
dimension

Instrumentation
• whether the instrument of choice is best able to
measure the dimension of interest
• For example, an infant length measuring board is
designed to measure the supine length of infants
and produces more accurate and reliable data than
using a tape measure.

Minimum unit of measurement
• Smallest unit of measurement should be used on
the chosen instrument.
• For example, stadiometers, used to measure
height, usually have their smallest unit as
millimetres that should be used
• This has important implications for both the
accuracy and reliability of measurement.

Accuracy
• “in exact conformity with truth.”
Improve the accuracy and decrease error
by ensuring that we use a valid, specifically
designed instrument, with precision
By using a properly trained observer.

Reliability
• An observer or instrument should consistently and
accurately measures a particular dimension.
Reliability involves 3 sources of error:
1. the observer
2. the instrument
3. the subject

The accuracy of these measurements can be maintained
by following a few simple rules:
1. Ensure the subject is in minimum of clothing so there is no
interferes with the identification of surface landmarks
2. Familiarize the subject with the instrumentation, so as to
ensure that he/she is relaxed
3. Measure the left-hand side of the body
4. Apply the instruments gently but firmly
5. Establish the reliability of measurement prior to the study
using subjects with similar characteristics (age, sex, etc.)
6. During the study create a quality control procedure by
repeating measurements on randomly selected subjects
7. Do not try to measure too many subjects in any one
session. Fatigue

MEASUREMENT PARAMETERS
Postnatal growth patterns of normal
children are well characterized, resulting
in several clinical parameters for
assessment of growth.
1.Linear growth (Length/Height)
2.Weight and body mass index
3.Weight/Height
4.Head circumference
5.Mid arm circumference
6.Body proportions (arm span and upper-to-lower
segment ratio)
7.Growth velocity
8.Growth patterns
9.Dentition
10.Bone Age

Growth can be measured in terms of:
1. Physical anthropometry
2. Assessment of tissue growth
3. Bone age
4. Dental age

Physical
anthropometry
Age dependent
anthropometry-
1. Weight
2. Length or Height
3. Head circumference
4. Chest circumference

Age independent
anthropometry
1. Midarm circumference(1-5 yrs)
2. Weight for height
3. Mid upper arm/height ratio
4. Midarm/Head circumference
ratio
5. Quetlet’s index
6. Ponderal index
7. Dugdale’s index
8. Body mass index

Calculation formulae
Weight gain
•Newborn 1st 3 months - 200 gm/ week
•Next 3 months – 150 gm/ week
•Next 6 months – 100 gm/ week
•Doubles by 4 months;Triples by 1 year
•Quadruples by 2 years;
•Thereafter 2kg /yr added on till 6
years
•Thereafter 3 kg/yr added till puberty
Length gain
Doubles ( ie.. 100 cm) by 4 years
 6 cm / year till puberty
 Triples by 12 years
Head circumference
1st 3 months: 2cm/month
Next 3 months: 1cm/month
Next 6 months : 0.5 cm/month

Weight
measurement
⦁ Weighing scales are of 3 types:
⦁ A) Beam balance
⦁ Platform scale
⦁ Beam scale/ TANSI scale
⦁ B) Spring Balance
⦁ Salters weighing scale
⦁ Bathroom scale
⦁ C) Electronic scale
Measure to the nearest 10 gm for infants and 100 gm for children.Weighing together
with mother.

Calculation of expected
weight
Weech’s formula:
• 3-12 months
Expected weight
(kg)=Age(months)+9
2
• 1-6 yrs
Expected weight (kg)=2y+8
• 7-12 yrs
Expected weight (kg)=7y – 5
2

Welcome trust classification of PEM (1970)
>80% of expected weight
Normal
60 – 80% of expected weight
W ith edema :Kwashiorkor
W ithout edema :Underweight
<60% of expected weight
With edema: Marasmic kwashiorkor
W ithout edema :Marasmus

Gomez Classifaction
Nutritional Status Weight for age(%) for 50th pecentile
of
Harvard Standard
Normal >90
Grade I 70-90
Grade II 60-70
Grade III <60
Other systems of classification :

LENGTH/HEIGHT
Below 2 yrs- supine length with infantometer.
For older children- Harpenden
Stadiometer

Prerequisites
⦁ Without footwear
⦁ Heels & back touching
the wall
⦁ Looking straight ahead
in frankfurt plane.
⦁ Gentle but firm
pressure upwards
applied to the
mastoids from
underneath
⦁ Record to last 0.1cm

Waterlow’s
classificati
on
Classification Height for Age
(% of expected)
Normal >95
First degree stunting 90-95
Second degree stunting 85-89
Third degree stunting <85

Equipment:
sitting base of a known height (e.g., 50 cm x 40 cm x 30 cm) and a wall-mounted
stadiometer
Technique:
The child is placed as erect as possible with buttocks, shoulders, and head in
contact with backboard of the stadiometer.Total height is measured.The height of
the sitting surface is then subtracted from the total height.
Plotting and Interpretation:
The measurement can be plotted on the CDC charts for stature-for-age.
Even if measurements fall below the 5th percentile, they establish a growth pattern
over time.
Sitting height

Height measurements
Iliac Height (IH)
⦁ The distance between the summit of the
iliac crest and the floor.
Subischial Leg Length (SLL)
⦁ The difference between stature and
sitting height.
⦁ It assumes that in a seated position the
proximal landmark corresponds to the hip
joint, which is very difficult to locate.
⦁ Useful to measure upper to lower body
proportions

Calculation of Target Height and Target Height Centile
Measure the parent’s heights
and make a note of their
heights on the chart.
Calculate the child’s target
height (TH) and plot it at 18
years and mark it with an
arrow on the growth chart.
This represents the child’s
projected height and the
target range is produced by
plotting two points
7.5 cms above and below for a
boy and 6 cm above and below
for a girl (representing the
10th and the 90th centile for
that child).
Cowell CT. Short Stature. In: Clinical Pediatric
Endocrinology, 3rd edn. Ed. Brook CGD.
London, Blackwell Science, 1995; pp 136-172.

WATERLOW Classification
Weight for Height
Waterlow
Classification >= 80 % < 80 %
Height for >= 90 % Normal Wasted
Age < 90 % Stunted Wasted and stunted

WHO Classification
Wt/Age Ht/Age Wt/Ht Intepretation
Normal Normal Normal Normal
Decreased Normal Decreased Acute Malnutrition
Decreased Decreased Normal Chronic Malnutrition
Decreased Decreased Decreased Acute Or
Chronic
Malnutrition

Head Circumference
Brain growth is rapid during infancy and it
is unaffected by mild to moderate degree
of malnutrition
Should not be measured within 24 hrs after birth
Bony land marks – superior orbital ridge
(ant), external occipital
protuberance (post)
Place the measuring tape around the largest circumference of the infant's head,
across the occiput and the forehead.

Expected head
circumference in
children
Age Head Circumference (cm)
At birth 35
2 months 38
3 months 40
4 months 41
6 months 42-43
1 yr 45-46
2 yr 47-48
5 yr 50-51

Approximate gain in head
circumference between 0 and 5 yrs
Age Growth velocity of head
circumference
0-3 months 2 cm/month
3-6 months 1 cm/month
7-12 months 0.5 cm/month
1-3 yrs 1 cm/6 months
3-5 yrs 1 cm/yr

Chest circumference
Not used universally
Useful measurement for comparison with the head
circumference when a problem is suspected with either the
head size or chest size.
Wrap the measuring tape around the infant's chest ideally
taken at xiphisternum / substernal notch just below the
nipple line, midway between inspiration and expiration
firmly but not tight enough to cause an indentation of the
skin. read to the nearest 0.5 cm

Chest
Circumference
• Measured at the level of nipples on
mid inspiration.
• < 5 yrs – Lying down position
• > 5 yrs – Standing position
• At birth – HC is 3cm more than CC
• At 1 year – HC = CC
• After 1 year – CC > HC

Internipple distance
⦁ Trunk physical parameter as in special situations
⦁ Internipple distance calculated by using Sliding
callipers with child at rest and at end of expiration.
⦁ Internipple Index = Internipple distance X 100
Chest circumference
Value > 28 % diagnostic

Upper-to-Lower Segment Ratio
• The upper-to-lower segment ratio is calculated
when a child's body may have inappropriate
proportions between the head and trunk to the
extremities.
• Measure the lower body segment (distance from the
symphysis pubis to the floor when a child stands).
• Calculate the upper body segment by subtracting
the lower body segment from the total height.Then
divide the upper body segment by the lower body
segment to calculate the ratio.

• Expected ratios by age are
♦At birth—1.7
♦At 3 years—1.3
♦After 7 years— 1.0
♦By about 11 years of age, adult proportions are
reached
• Increase: Rickets,achondroplasia, Untreated
hypothyroidism
• Decrease: spondyloepiphyseal dysplasia, vertebral
anomalies

Normal upper segment/ lower
segment ratio in children
Age Upper segment/lower segment ratio
At birth 1.7:1
6 months 1.6:1
1 yr 1.5:1
2 yr 1.4:1
3 yr 1.3:1
4 yr 1.2:1
7 yr 1.1:1
10 yr 1:1
18 yr 0.9:1

⦁ Arm length – Acromion to tip of 3rd finger with arm
in full extension and parallel to the body.
⦁ Upper segment of arm – Acromion to Olecranon with
elbow bent at 90º
⦁ Foream / Lower segment of arm – Olecranon process to
distal end of styloid process of radius with elbow bent
at 90º
⦁ Hand length – Distal wrist crease to tip of 3rd finger
⦁ Palm length – Distal wrist crease to prox. Crease of 3rd
finger
Individual components

Skeletal dysplasia
⦁ Rhizomelia (Upper arm / Proximal
shortening)
⦁ Mesomelia (Forearm / Middle
shortening)
⦁ Acromelia (Palm &Fingers / Distal
shortening)
⦁ Acromesomelia (Forearm, Palm, fingers
/Middle & distal)
⦁ Micromelia (Whole upper limb
shortening)

Midarm
Circumference
• Measured on left upper arm midway
b/w acromion and olecranon process
with arm hanging by side of body.
• Shakir tape
• Bangle test
• At birth: 9-11 cm
• 1-5years: 16-17 cm

Mid Upper arm circumference (MUAC)
Steps of MUAC measurement
Ask the mother to remove any clothing that covers
the child’s arm. If possible the child should stand
erect and sideways to the measurer.
Estimate the mid-point of the left arm.
Straighten the child’s arm and wrap the tape around at
the mid-point. Make sure that the numbers are right side
up. Make sure the tape is flat around the skin.
Inspect the tension of the tape on the child’s arm. Make
sure the tape has the proper tension and is not too tight
or too loose. Repeat any step as necessary.
When the tape is in the correct position and correct
tension on the arm, read and call out the measurement to
the nearest 0.1 cm.
Immediately record the measurement.

Shakir
Tape
MUAC (cm) Inference
>13.5 Normal
12.5-13.5 Borderline
<12.5 Under nutrition

Bangle
Test
• Used for quick assessment.
•Fibre glass ring of internal
diameter of 4cm is slipped up
arm.
•If it passes above elbow ,
suggests MAC <12.5 cm and
child malnourished.

QUAC STICK
• Quakers arm circumference
stick
• Consists of rod with 2 sets of
markings height
• MAC corresponding to ht
• If ht > ht for expected MAC
– child is malnourished
• Modified quack stick –
colored rod

Weight for
height
Calculated as:
weight of child(kg) X100
Expected weight for a healthy
child of same height

Classification Weight for height
(% expected of expected)
Normal >90
Mild wasting 80-90
Moderate wasting 70-79
Severe wasting <70

WHO Classification
Weight for Height Inference
Z- score < -2
(70-79% of expected)
Moderate wasting
Z- score < -3
(<70% of expected)
Severe wasting
Height for age Inference
Z- score < -2
(85-89% of expected)
Moderate stunting
Z - score < -3
(<85% of expected)
Severe stunting
Edema +/-

Quetlet
Index
• Calculated as:
weight(kg)
{
Height(cm)}2
X
100
• Normal:0.14-0.16
• <0.14 indicate
malnutrition

Ponderal
Index
Calculated
as: weight(g)
height(cm)
3
X
100
Ponderal Index Significance in newborn
>2.5 Term,AGA baby
<2 Asymmetrical
IUGR (Severe
PEM)
>2 Symmetrical IUGR

Skinfold thickness
Skinfold thickness by age and sex, as measured by
Harpenden skinfold calipers over triceps and under
scapula.
A caliper is used to measure the thickness of a
fold of the baby’s skin with its underlying layer of
fat (the subcutaneous fat).

• Measurements are taken from the following
body sites:
• Subscapular
• Flank
• Triceps
• Quadriceps

Waist circumference and waist-hip ratio:
⦁ Both waist circumference (WC) and waist-hip ratio are
indicators of visceral fat or abdominal obesity in children and
adolescents age 2–19 years.
⦁ Increased visceral adiposity measured by WC increases the risk
of obesity-related morbidity and mortality.
⦁ WC should be measured at the highest point of the iliac crest
when the individual is standing and at minimal respiration.
⦁ Waist-hip ratio is calculated as a ratio of waist circumference
(cm) and hip circumference (cm).

GROWTH VELOCITY
⦁ The most critical factor in
evaluating the growth is
determining GROWTH
VELOCITY.
⦁ Observation of child’s height
pattern in the form of
“CROSSING PERCENTILE LINES”
on a linear growth curve is the
simplest method of observing
abnormal growth velocity.
⦁ Atleast 3 measurements with
preferably 6 months interval
in between is necessary to
comment on growth pattern.

WeightVelocity
1st year :6 kg
Pre-school:2kg/year
School :3 kg/yr till puberty

Growth patterns
⦁ From the end of infancy until puberty begins, growth normally proceeds along a
channel that closely corresponds to a given height-attained percentile on cross-
sectional growth standards. A child normally establishes this channel by 2 to 3 years
age, although, on rare occasions, a gradual drift by as many as 40 percentile positions
in height attained may occur over a period of several years in normal children.
⦁ The velocity of growth (cm per year) actually decelerates slightly during this period
and averages about 6 cm per year in midchildhood.However, normal children cross
height-velocity percentiles to maintain their height channel.
⦁ A growth velocity that is consistently along the third percentile will lead to a
subnormal height.The growth channel seems to be genetically determined.
Children grow as if to reach a genetically predetermined height.
⦁ This target height, which represents the child’s genetic potential, can be
approximated by calculating the MPH.

⦁ Growth should be measured and compared with
statistical norms in a standard chart
wit
h
growth charts.
Also called as “road-to-health" chart. It was first
designed by David Morley and was later modified by
WHO.
⦁ Growth is assessed by plotting accurate measurements on growth
charts and comparing each set of measurements with previous
measurements obtained at health maintenance visits or at other visits
if there is a concern over the child's growth pattern.
⦁ Serial measurements more useful than single measurements to detect
deviations from a particular child's growth pattern even if the value
remains within statistically defined normal limits (percentiles)
GROWTH MONITORING
Males
78
74
70
66
62
58
54
50
46
42
38
34
30
Height
Height
(cm)
2 4 6 8 10 12 14 16 18 20
Age (y)
200
190
180
170
160
150
140
130
120
110
100
90
80
70
+2
+1
0
-1
-2
Growth charts are visible display of child’s physical
growth and development.

Growth standard reference
• Rate of growth of children is one of the finest indicators of
the health of a community.
• Growth monitoring followed by suitable action prevents
illness, malnutrition and even death.
• It provides reassurance about child’s health and prevents
parental anxiety.
• A growth reference simply describes the growth of a
sample of individuals, whereas a standard describes
the growth of a healthy population and suggests an
aspirational model.

• WHO growth charts are growth standards. A
reference is representative of the existing growth
pattern of children and allows us to study the secular
trends in height, weight and obesity.
• On community and national level it helps identify
children at risk of morbidity and mortality.
• It thus helps in implementation of national
programmes for nutritional and medical
interventions like supplementary feeding, foods to
vulnerable group, underprivileged school children,
etc.
• It is also a method to evaluate programs for
improving child health and nutrition and can form
the basis for policy making.

WHO - MGRS / reference indicators
Attained growth
 weight-for-age
 length/height-for-age
 weight-for-length/height
 head circumference-for-age
 mid-upper arm circumference-for-age
 triceps skinfold-for-age
 subscapular skinfold-for-age
 body mass index-for-age
Velocity
 weight
 length
 head circumference

⦁ Deviations in growth patterns may be nonspecific or may be important
indicators of serious and chronic medical disorders.
⦁ An accurate measurement of length/height,weight,and head circumference
should be obtained at every health supervision visit.
GROWTH MONITORING

Time schedule child anthropometry
Measurement Time frame Frequency No. of visits
Weight, length, head
circumference
Birth Once 1
Weeks 2-8 Bi-weekly 14
3-12 months Monthly 10
14-24 months Bi-monthly 6
Arm circumference
Skinfold thicknesses
3-12 months Monthly 10
14-24 months Bi-monthly 6
W H O Multicentre Growth Reference Study (2006)

Bone Age Or SkeletalMaturity
• Chronological age at which skeletal maturation is normally
attained
• Radiological examination of bones is used for the
assessment of maturity.
• Usually, radiological examination of wrist and elbow is done to
assess bone age (1-13 years).
• For infants (3-9 months), radiograph of shoulder is useful.

G & P Method
• Patient’s film is
compared with the
standard of the same
sex and nearest age
• It is next compared
with adjacent
standard, both older
and younger to get
the closest match

Tanner-Whitehouse
(TW) method
The TW2 (Tanner-
Whitehouse 2) methods:
• RUS (radius-ulna-short
bones): 13 bones
including the radius,
ulna and short bones of
the thumb, middle and
little fingers
• carpus: 7 carpal bones
• 20-bones method:
combines the two

• Each bones compared to a standard set of bones at
different stages of maturation.
• A score is assigned to each bone based on maturation and
sex of the patient.
• Once all the bones have been scored, a total score is
generated and plotted on a graph to determine how the
bone age relates to the chronological age.

• Bone age
Better correlate with SMR
Predictor of future height
• Delayed bone age
Constitutional short stature
Hypothyroidism
Celiac disease
GH deficiency

Bone age: an
algorithm for boys
UnnikrishnanAG,Kumar H,J
ayakumar RV.
Bone age in a minute: a simple algorithm.
Amrita JMed 2006;2:39-41

Bone age: an
algorithm for girls
UnnikrishnanAG,Kumar H,J
ayakumar RV.
Bone age in a minute: a simple algorithm.
Amrita JMed 2006;2:39-41

C AVEATS TO INFORMATION IN BONE AGE
• Subjectivity: Interobserver variation
• Normal children radiographs comparability
possible but non-applicability to spl. context-
skeletal dysplasias, genetic causes.
BAYLEY-PINNEAU and RWT
(Roche,Wainer,Thissen) CHARTS

Dental development

Dental development
⦁ Dental development includes mineralization, eruption, and
exfoliation.
⦁ Initial mineralization begins as early as the second trimester (mean
age for central incisors, 14 wk) and continues through 3 yr of age for
the primary (deciduous) teeth and 25 yr of age for the permanent
teeth.
⦁ Mineralization begins at the crown and progresses toward the root.
⦁ Eruption begins with the central incisors and progresses laterally.
⦁ Exfoliation begins at about 6 yr of age and continues through 12 yr of
age. Eruption of the permanent teeth may follow exfoliation
immediately or may lag by 4-5 mo.The timing of dental development
is poorly correlated with other processes of growth and maturation.

Sexual maturity rating ( SMR):
• Also known as Tanners stages
• Used in older children
• Total 5 stages included in each gender
Always Perform Sexual Maturity Rating

MALES:
SMR Pubic Hair
• Stage 1 Preadolescent
• Stage 2 Scanty, long, slightly pigmented, primarily at
base of penis
• Stage 3 Darker, coarser, starts to curl, small amount
• Stage 4 Coarse, curly; resembles adult type but covers
smaller area
• Stage 5 Adult quantity and distribution, spread to medial
surface of thighs

SMR – Genitals
Penis Testes
Stage 1 Preadolescent Preadolescent
Stage 2 Slight or no
enlargement
Beginning
enlargement of
testes and scrotum;
scrotal skin
reddened, texture
altered
Stage 3 Longer Further
enlargement of testis
and scrotum
Stage 4 Larger in breadth,
glans penis develops
Testes & scrotum
nearly adult
Stage 5 Adult Adult

SMR Females
SMR Pubic Hair
• Stage 1 Preadolescent
• Stage 2 Sparse, slightly pigmented, straight, at medial
border of labia
• Stage 3 Darker, beginning to curl, increased amount
• Stage 4 Coarse, curly, abundant, but amount less than in
adult
• Stage 5 Adult feminine triangle, spread to medial surface
of thighs

SMR Breasts
• Stage 1 Preadolescent; elevation of papilla only
• Stage 2 Breast and papilla elevated as small mound;
areola diameter increased
• Stage 3 Breast and areola enlarged with no separation of
their contours
• Stage 4 Projection of areola and papilla to form
secondary mound above the level of the breast
• Stage 5 Mature; projection of papilla only, areola has
recessed to the general contour of the breast
Tanner JM. 1962. Growth at Adolescence (2nd ed.). Oxford, England: Blackwell Scientific Publications.

ASSESSMENT OFDEVELOPMENT
• Development is a process of acquiring variety of competencies for
the optimal functioning in the society.
• Development is a qualitative change.
• If developmental delay is recognized early, intervention to
reduce long term sequel can be started.
• It is important to monitor growth and development at every
stage.
• A child is said to have developmental delay if the child does
not reach the expected developmental milestones for the
age.

Purposes of developmental assessment
• To determine if any developmental delay exists.
• To identify strengths and needs.
• To develop strategies for intervention.
• To serve as a basis for reporting to parents.
• To determine the progress on significant
developmental achievements.

What is developmental delay?
◦ Developmental Delay is when a child does not
reach their developmental milestones at the
expected times.
◦ It is an ongoing major or minor delay in the
process of development.
◦ Delay can occur in one or many areas—for
example, gross or fine motor, language, social, or
thinking skills.

◦ Developmental delay is not uncommon and occurs in
2-3% of all children.
◦ The term developmental delay is often used until the
exact nature and cause of the delay is known.
◦ The significance of the delay is often only
determined by observing the child’sdevelopment
over time.

Transient developmental delay
◦ Some children have a transient delay in their
development.
◦ For example, some extremely premature babies may
show a delay in the area of sitting, crawling and
walking but then progress on at a normal rate.
◦ Other causes of transient delay may be related to
physical illness and prolonged hospitalization,
immaturity, family stress or lack of opportunities to
learn.

Persistent developmental delay
◦ If the delay in development persists it is usually related
to problems in one or more of the following areas:
 understanding and learning
 moving
 communication
 hearing
 seeing.
◦ An assessment is often needed to determine what area
or areas are affected.
◦ Disorders which cause persistent developmental delay are
often termed developmental disabilities.

Developmental disability
◦ Developmental disability is estimated to occur in 5-10%
of the population with enormous psychological, motional,
and economic impact on the affected individuals and
society.
◦ Studies have shown that developmentally delayed children
who are recognized at an early age receive more
developmental optimization and greater gains than those
who are identified later in life.
◦ Early recognition of children with developmental problems
is therefore important.
◦ There are several disabilities in the classification
of developmental delay:

Disability Description
Gross motor delay Significant delay in fine or gross motor skills
with no impairment in other developmental
areas
Developmental language disorders Significant delay in receptive and/or expressive
language skills with no delay in other
developmental domains
Global developmental delay Significant delay in two or more developmental
streams as measured by appropriate
standardized screening tests. This term is
reserved for children less than 5 years of age
Cerebral palsy Early-onset non-progressive motor
impairment with associated abnormalities in
muscle tone
Hearing sensory impairment A reduction in the ability to hear sound, ranging
from slight to complete deafness

Disability Description
Visual sensory impairment An optically or medically diagnosable condition
in the eye(s) or visual system that affects the
development and normal use of vision, ranging
from slight to complete blindness
Learning disabilities Significantly lowered individual achievement
than predicted by intellectual ability as
measured by standardized psycho-educational
tests assessing reading, mathematics, or written
expression
Pervasive developmental delay (PPD) /
Autism
Impairments in social skills, communication
skills and restrictive / repetitive patterns of
behavior
Pervasive developmental disorders not
otherwise specified / Autism Spectrum
Disorder
Similar to PDD but not enough symptoms to
warrant a PDD diagnosis

What are developmental milestones?
◦ Developmental milestones are a set of functional
skills or age-specific tasks that most children can do
at a certain age range.
◦ A pediatrician uses milestones to help check how a
child is developing.
◦ Although each milestone has an age level, the actual
age when a normally developing child reaches that
milestone can vary quite a bit. Every child is unique!
◦ CDC’s milestone checklists

In these categories…
◦ Gross motor: using large groups of muscles to sit, stand, walk,
run, etc., keeping balance, and changing positions.
◦ Fine motor: using hands to be able to eat, draw, dress, play,
write, and do many other things.
◦ Language: speaking, using body language and gestures,
communicating, and understanding what others say.
◦ Cognitive: Thinking skills: including learning, understanding,
problem-solving, reasoning, and remembering.
◦ Social: Interacting with others, having relationships with
family, friends, and teachers, cooperating, and responding to the
feelings of others.

1month
• Makes jerky, quivering arm thrusts
• Brings hands within range of eyes
and mouth
• Moves head from side to side
while lying on stomach
• Head flops backward if
unsupported
• Keeps hands in tight fists
• Strong reflex movements
Movement
Milestones

1month
• Focuses 8 to 12 inches (20.3 to 30.4 cm)
away
• Eyes wander and occasionally cross
• Prefers black-and-white or high-
contrast patterns
• Prefers the human face to all other
patterns
• Hearing is fully mature
• Recognizes some sounds
• May turn toward familiar sounds and
voices
Visual and
Hearing
Milestones

1month
• Prefers sweet smells
• Avoids bitter or acidic smells
• Recognizes the scent of his own
mother’s breastmilk
• Prefers soft to coarse sensations
• Dislikes rough or abrupt
handling
Smell and
Touch
Milestones

3 months
• Raises head and chest when lying on stomach
• Supports upper body with arms when
lying on stomach
• Stretches legs out and kicks when lying on
stomach or back
• Opens and shuts hands
• Pushes down on legs when feet are placed on
a firm surface
• Brings hand to mouth
• Takes swipes at dangling objects with hands
• Grasps and shakes hand toys
Movement
Milestones

3 months
• W
atches faces intently
• Follows moving objects
• Recognizes familiar objects and people at
a distance
• Starts using hands and eyes in
coordination
• Smiles at the sound of your voice
• Begins to babble
• Begins to imitate some sounds
• Turns head toward direction of sound
Visual and
Hearing
Milestones

3 months
• Begins to develop a social smile
• Enjoys playing with other people
and may cry when playing stops
• Becomes more communicative and
expressive with face and body
• Imitates some movements and
facial expressions
Social and
Emotional
Milestones

7 months
• Rolls both ways (front to back, back
to front)
• Sits with, and then without,
support of her hands
• Supports her whole weight on her
legs
• Reaches with one hand
• Transfers object from hand to hand
• Uses raking grasp (not pincer)
Movement
Milestones

7 months
• Develops full color
vision
• Distance vision matures
• Ability to track moving
objects improves
Visual
Milestones

7 months
• Responds to own name
• Begins to respond to “no”
• Distinguishes emotions by tone
of voice
• Responds to sound by making
sounds
• Uses voice to express joy and
displeasure
• Babbles chains of consonants
Language
Milestones

7 months
• Finds partially hidden
object
• Explores with hands and
mouth
• Struggles to get objects that
are out of reach
Cognitive
Milestones

7 months
• Enjoys social play
• Interested in mirror images
• Responds to other people’s
expressions of emotion
and appears joyful often
Social and
Emotional
Milestones

12months
• Gets to sitting position without assistance
• Crawls forward on belly by pulling with arms
and pushing with legs
• Assumes hands-and-knees position
• Creeps on hands and knees supporting trunk on
hands and knees
• Gets from sitting to crawling or prone (lying
on stomach) position
• Pulls self up to stand
• Walks holding on to furniture
• Stands momentarily without support
• May walk two or three steps without support
Movement
Milestones

12months
• Uses pincer grasp
• Bangs two cubes together
• Puts objects into container
• Takes objects out of container
• Lets objects go voluntarily
• Pokes with index finger
• Tries to imitate scribbling
Milestones
In Hand
and Finger
Skills

12months
• Pays increasing attention to speech
• Responds to simple verbal requests
• Responds to “no”
• Uses simple gestures, such as shaking
head for “no”
• Babbles with inflection
• Says “dada” and “mama”
• Uses exclamations, such as “oh-oh!”
• Tries to imitate words
Language
Milestones

12months
• Explores objects in many different ways
(shaking, banging, throwing, dropping)
• Finds hidden objects easily
• Looks at correct picture when the
image is named
• Imitates gestures
• Begins to use objects correctly (drinking
from cup, brushing hair, dialing phone,
listening to receiver)
Cognitive
Milestones

12months
•Shy or anxious with strangers
•Cries when mother or father leaves
•Enjoys imitating people in play
•Shows specific preferences for certain people and toys
•Tests parental responses to his actions during feedings
(What do you do when he refuses a food?)
•Tests parental responses to his behavior (What do you
do if he cries after you leave the room?)
•May be fearful in some situations
•Prefers mother and/or regular caregiver over all others
•Repeats sounds or gestures for attention
•Finger-feeds himself
•Extends arm or leg to help when being dressed
Social and
Emotional
Milestones

2 years
• Walks alone
• Pulls toys behind her while walking
• Carries large toy or several toys while walking
• Begins to run
• Stands on tiptoe
• Kicks a ball
• Climbs onto and down from furniture
unassisted
• Walks up and down stairs holding on to
support
Movement
milestones

2 years
• Scribbles spontaneously
• Turns over container to pour
out contents
• Builds tower of four blocks or
more
• Might use one hand more
frequently than the other
Milestones
in hand
and finger
skills

2 years
• Points to object or picture when it’s named for
him
• Recognizes names of familiar people, objects,
and body parts
• Says several single words (by fifteen to eighteen
months)
• Uses simple phrases (by eighteen to twenty-
four months)
• Uses two- to four-word sentences
• Follows simple instructions
• Repeats words overheard in conversation
Language
milestones

2 years
• Finds objects even when
hidden under two or three
covers
• Begins to sort by shapes and
colors
• Begins make-believe play
Cognitive
milestones

2 years
• Imitates behavior of others, especially adults
and older children
• Increasingly aware of herself as separate
from others
• Increasingly enthusiastic about company of
other children
• Demonstrates increasing independence
• Begins to show defiant behavior
• Increasing episodes of separation anxiety
toward midyear, then they fade
Social and
emotional
milestones

3-4 years
• Hops and stands on one foot up to five
seconds
• Goes upstairs and downstairs without
support
• Kicks ball forward
• Throws ball overhand
• Catches bounced ball most of the time
• Moves forward and backward with agility
Movement
milestones

3-4 years
• Copies square shapes
• Draws a person with two to
four body parts
• Uses scissors
• Draws circles and squares
• Begins to copy some capital
letters
Milestones
in hand
and finger
skills

3-4 years
• Understands the concepts of
“same” and “different”
• Has mastered some basic rules of
grammar
• Speaks in sentences of five to six
words
• Speaks clearly enough for strangers to
understand
• Tells stories
Language
milestones

3-4 years
• Correctly names some colors
• Understands the concept of counting and
may know a few numbers
• Approaches problems from a single point
of view
• Begins to have a clearer sense of time
• Follows three-part commands
• Recalls parts of a story
• Understands the concept of same/different
• Engages in fantasy play
Cognitive
milestones

3-4 years
•Interested in new experiences
•Cooperates with other children
•Plays “Mom” or “Dad”
•Increasingly inventive in fantasy play
•Dresses and undresses
•Negotiates solutions to conflicts
•More independent
•Imagines that many unfamiliar images may be
“monsters”
•Views self as a whole person involving body,
mind, and feelings
•Often cannot distinguish between fantasy and
reality
Social and
emotional
milestones

4-5 years
• Stands on one foot for ten
seconds or longer
• Hops, somersaults
• Swings, climbs
• Maybe able to skip
Movement
milestones

4-5 years
• Copies triangle and other geometric
patterns
• Draws person with body
• Prints some letters
• Dresses and undresses without assistance
• Uses fork, spoon, and (sometimes) a
table knife
• Usually cares for own toilet needs
Milestones
in hand
and finger
skills

4-5 years
• Recalls part of a story
• Speaks sentences of more
than five words
• Uses future tense
• Tells longer stories
• Says name and address
Language
milestones

4-5 years
• Can count ten or more objects
• Correctly names at least four
colors
• Better understands the concept of
time
• Knows about things used every
day in the home (money, food,
appliances)
Cognitive
milestones

4-5 years
• Wants to please friends
• Wants to be like her friends
• More likely to agree to rules
• Likes to sing, dance, and act
• Shows more independence and may even visit a
next-door neighbor by herself
• Aware of sexuality
• Able to distinguish fantasy from reality
• Sometimes demanding, sometimes eagerly
cooperative
Social and
emotional
milestones

What are the
Warning signs of
a physical
developmental
delay ?

Newborn to 2 months
• After 2 months, doesn't hold his head up when
you pick him up from lying on his back
• After 2 months, still feels particularly stiff or
floppy
• After 2 months, overextends his back and neck
(as if he's pushing away from you) when cradled
in your arms
• After 2 or 3 months, stiffens, crosses, or
"scissors" his legs when you pick him up by the
trunk

3 to 6 months
• by 3 or 4 months, doesn't grasp or reach for toys
• by 3 or 4 months, can't support his head well by 4
months, isn't bringing objects to his mouth
• by 4 months, doesn't push down with his legs when
his feet are placed on a firm surface
• after 4 months, still has Moro reflex (when he falls
backward or is startled, he throws out his arms and
legs, extends his neck, and then quickly brings his
arms back together and begins to cry)

3 to 6 months
• after 5 or 6 months, still has the asymmetrical tonic neck
reflex (when his head turns to one side, his arm on that
side will straighten, with the opposite arm bent up as if
he's holding a fencing sword)
• by 6 months, can't sit with help
• after 6 months, reaches out with only one hand while
keeping the other fisted
• doesn't roll over in either direction (back to front or front
to back) by 5 or 6 months

7 to 9 months
• at 7 months, has poor head control when pulled to a
sitting position
• at 7 months, is unable to get objects into his mouth
• at 7 months, is not reaching for objects
• by 7 months, doesn't bear some weight on
his legs
• by 9 months, can't sit independently

9 to 12months
• after 10 months, crawls in a lopsided manner,
pushing off with one hand and leg while dragging
the opposite hand and leg
• at 12 months, is not crawling
• at 12 months, can't stand with support

13 to 24 months
• by 18 months, can't walk
• after several months ofwalking, doesn't
walk confidently or consistently walks on
toes
• after his second birthday, is growing less than 2
inches per year

36 months
• Falls frequently or is unable to use the stairs
• Drools persistently
• Can't manipulate small objects

Why is finding a cause important?
◦ Establishing a cause has many benefits for the child
and family and improves overall quality of life:
◦ The family gains understanding of the condition,
including prognostic information.
◦ Lessens parental blame.
◦ Ameliorates or prevents co-morbidity by identifying
factors likely to cause secondary disability that are
potentially preventable e.g. surveillance of other
systems such as vision and hearing.

Why is finding a cause important?
◦ Appropriate genetic counselling about recurrence risk
for future children and the
• wider family.
◦ Accessing more support (e.g. within education
services and specific syndrome support groups).
◦ To address concerns about possible causes e.g. events
during pregnancy or delivery.
◦ Potential treatment for a few conditions.

Causes of Global Developmental Delay
◦ Global developmental delay can be the presenting feature of a
huge number of neurodevelopmental disorders (from learning
disability to neuromuscular disorders).
◦ It is not possible to provide an exhaustive list.
◦ Careful evaluation and investigation can reveal a cause in 50-70%
of cases.
◦ This leaves a large minority where the cause is not determined.
◦ It is still useful to investigate globally delayed development
whatever the age of the child (occasionally older children with
significant disability may not have been investigated adequately)

Causes of global developmental delay

An Approach to a Child with
Developmental Delay
◦ A child’s development is a dynamic process, and assessment at any
point in time is merely a snap shot of the bigger picture and should be
interpreted in the context of the child’s history from conception to
the present.
◦ While a child may appear to have normal development for the first
twelve months of life, a deviation in the course of the child’s
development in subsequent years is indicative of an underlying
disability.
◦ It is important to keep this in mind as you assess a child, and to keep
reassessing children in subsequent office visits.

• Developmental assessment involves three aspects:
1. Screening
2. Surveillance
3. Definitive diagnostic assessment

Developmental screening
• It is a process of identifying children who may need
more comprehensive evaluation.
• It is a brief assessment procedure designed to identify
children who should receive more intensive
diagnosis or assessment.
• This is accomplished in the pediatrician’s office
through thorough history taking +/- the use of
screening tools such as the Denver or Bayley Scales
of infant development.

Developmental surveillance
• It is a continuous process whereby the child is followed
over time to pick up on subtle deficiencies in the child’s
developmental trajectory.
• The components of developmental surveillance include
⁃ eliciting and attending to parental concerns
⁃ obtaining a relevant developmental history
⁃ observing the child’s development in the office and
referring for further assessment of development by other
relevant professionals such as OT/PT for motor
developmental concerns or hearing tests for concerns
with language acquisition.

Diagnostic assessment
◦ It is performed on a child who has been identified as
having a potential problem.
◦ This step requires extensive involvement of various
team players such as a psychologist, educator, social
worker, developmental pediatrician, geneticist, and/or
other medical professionals.

History
• To perform a developmental assessment, a detailed
history from conception to the present is required to
assess developmental level.
• Knowing the appropriate milestones is key to this
assessment.
• Any signs of developmental regression should be
regarded as a medical emergency and an urgent medical
workup is indicated.
• An underlying etiology for developmental delay
should be sought through attention to the following
clues on history:

Prenatal History
◦ Complications
◦ Prenatal diagnoses made (eg. Down Syndrome)
◦ Infections (eg. TORCH includes toxoplasmosis, others
(syphilis, hepatitis B), rubella, cytomegalovirus, herpes simplex.)
◦ Exposures (eg. FetalAlcohol Syndrome)

Obstetrical History
◦ Complications
◦ APGAR scores
◦ Infections (eg. Group B Strep)
◦ Seizures
◦ Hearing test performed
◦ Newborn screening performed

Past medical history and
medications
◦ Ototoxic antibiotics eg. Gentamicin
◦ Frequent ear infections may lead to effusions
affecting hearing

Behavior since birth
◦ Behavioral disturbances – aggression, self injury,
defiance, inattention, anxiety, depression, sleep
disturbances, stereotypic behaviors, poor social
skills, hyperactivity, difficult temperaments

Family History
◦ Relatives with developmental delay,genetic
abnormalities, syndromes
◦ Consanguinity

Social History
◦ Evidence of neglect or abuse which may have a
negative influence on development.
◦ Primary languages. ESL children may have relative
delay in English language acquisition.
◦ In children with a previously identified delay it is
important to assess the resources already accessed
to support the family such as personal tutors in the
educational system, OT/PT for speech and language
therapy,etc.

Screening Tools
• Standardized tools are used for screening
developmental changes in a systematic way.
• Compare the achievements listed for normal
children with developmental history and physical
examination findings.
• Children are observed for their activities.

The Denver Developmental Screening Test
(DDST) (Age Range 2 Weeks To 6 Years)
• Developed by Frankenburg and Dodds,
• It is simple, economic and useful test for screening
developmental delays during infancy and
preschool period.
• Used as a screening tool.

Assessment is done in four areas.
 Social skills
 Fine motor skills
 Language skills
 Gross motor skills
• Make sure the child listens and pays attention to each
task.
• After scoring the test, interpret the results and inform
the parents

Bayley scale of infant development
• It is used to evaluate children between 6 and 30
months of age.
• Three general areas are evaluated
1. Mental development
2. Psychomotor development
3. Behavioral development.

Brigance screening tool
• Brigance is a screening tool widely used by schools
for students in Pre-Kindergarten, Kindergarten and
First Grade
• Consists of 12 assessments, including language
development, science and math proficiencies
and gross motor skills.
• Total score of 100 points.
• Score is compared to a national average scale to
indicate if the student is above, below, or of
average ability level.

Developmental Indicators for Assessment of
Learning- Revised(DIAL-R)

Ages and Stages
Questionnaire (ASQ)
• It looks at children’s skills in five developmental
areas including:
1. Communication
2. Fine Motor
3. Gross Motor
4. Problem-Solving
5. Personal-Social
• This developmental check-up is available for
children 2-60 months.

Parents' Evaluation of
Developmental Status (PEDS)
• Parents’ Evaluation of Developmental Status
(PEDS) is an evidence-based method for
detecting and addressing developmental and
behavioral problems
• Assessed in children aged from birth to seven
years.
• PEDS is a simple, 10-item questionnaire that is
completed by the parent.

Physical Examination
◦Athorough physical examination is important
in the assessment of a developmentally
delayed child.
◦Characteristic findings on physical exam may
provide clues as to the cause of the
developmental delay.
◦Some clinical signs and their corresponding
clinical significance are listed below:

Growth Parameters
◦Microcephaly: eg in Rett’s Disorder
◦Macrocephaly: eg in hydrocephalus
◦Short stature: Turner syndrome, Williams
syndrome
◦Obesity: Prader-Willi syndrome, Beckwith-
Wiedemann syndrome

Head and Neck
◦ Flat occiput: Down syndrome, Zellweger syndrome
◦ Prominent occiput: trisomy 18
◦ Craniosynostosis: Crouzon syndrome, Pfeiffer
syndrome
◦ Midface hypoplasia: Fetal Alcohol Syndrome (FAS),
Down syndrome
◦ Prominent nose and chin: Fragile X syndrome
◦ Round facies: Prader-Willi syndrome

Head and Neck
◦Triangular facies: Turner syndrome
◦Hypertelorism: Fetal hydantoin syndrome
◦Hypotelorism: maternal PKU effect
◦Brushfield spots: Down syndrome
◦Prominent eyes: Beckwith-Wiedemann
syndrome
◦Lisch nodules: neurofibromatosis

Head and Neck
◦Large pinna: Fragile X syndrome
◦Malformed pinna: Treacher Collins syndrome,
CHARGE association
◦Broad nasal bridge: Fragile X syndrome
◦Low nasal bridge: Down syndrome
◦Long philtrum: FAS

Head and Neck
◦Cleft lip and palate: may either be isolated or
part of a syndrome
◦Micrognathia: Robin sequence
◦Macroglossia: Beckwith-Wiedemann
syndrome
◦Abnormal hair whorls: Down syndrome
◦Webbed neck: Turner syndrome

Genitourinary
◦Macroorchidism: Fragile X
syndrome
◦Hypogonadism: Prader-Willi
syndrome

Extremities
◦Small hands: Prader-Willi syndrome
◦Clinodactyly: trisomies including Down
syndrome
◦Transverse palmer crease: Down
syndrome

Skin
◦Nail hypoplasia or dysplasia: FAS
◦Facial port wine hemangioma: Sturge-
Weber syndrome
◦Café au lait spots: Neurofibromatosis
◦Ashleaf spots: Tuberous Sclerosis

Neurological Exam
◦ Cranial nerves
◦ Specific vision tests: red reflex, normal fundi,
response to visual stimuli, field of vision
◦ Specific auditory tests: response to auditory stimuli
◦ Receptive or expressive language delay
◦ Abnormal speech (eg. articulation)
◦ Persistently present Babinski response (older than 2
years of age)

Neurological Exam
◦Hyper- or Hypotonia
◦Sensory
◦Motor strength
◦Gait
◦Deep tendon reflexes
◦Primitive reflexes – Moro, Gallant
◦Postural reflexes – propping response

Investigations: Genetics
◦Karyotyping to assess for chromosomal
abnormalities
◦FISH analysis to assess for microdeletions
◦Many of these investigations will be
performed through specialist referral. Medical
Genetics consultation should be done at this
time.

Endocrinology
◦TSH, free T4
◦Referral to endocrinology should be
considered.

Metabolic
◦Metabolic screening – glucose, electrolytes,
serum lactate, ammonia, liver function tests,
pyruvate, albumin, triglycerides, uric acid,
serum quantitative amino acids, urine organic
acids, acylcarnitines, creatine phosphokinase
(if suspecting myopathy)
◦Referral to metabolic diseases specialists
should be considered.

Neurology
◦EEG
◦Head CT
◦Referral to Neurologists if any of these tests
are considered.

MANAGEMENT

◦ After completion of a comprehensive medical and
developmental evaluation of the child with developmental
problems and the establishment of developmental diagnoses and
identification of associated medical conditions, a plan for active
treatment and comprehensive management can be initiated by
the physician.
◦ Beginning with early identification of these problems, an
affected child can receive educational and intervention services
aimed at improvement of the child’s development through local
early intervention and special education programs, as established
in the United States through federal law under the Individuals
with Disabilities Education Act.

◦ Beginning as early as birth and continuing through age 3
years, any child with a known disability, significant delay, or
condition with a high risk for disability (eg, Down syndrome)
is entitled to early intervention services that provide
developmental therapies intended to improve performance in
one of the developmental spheres.
◦ These can include traditional therapies, such as physical
therapy, occupation therapy, and speech-language therapy, as
well as broader services such as special instruction,
counseling, and family training.

◦ Many programs provide for parent training or home-
based therapy to allow for generalization of skills
learned.
◦ For children 3 years and older and continuing into
the school-age years, the child with disabilities is
entitled to an individualized, free, and appropriate
education along with related therapy services.

◦ Specific medical treatments targeted towards a child’s related
medical conditions should also begin with diagnosis.
◦ For example, along with receiving physical therapy and other
early intervention services, the child with cerebral palsy
should be considered for medical treatment of tone
abnormalities with oral agents, intramuscular botulinum
toxin, or intrathecal baclofen.
◦ The child with behavior disorders accompanying a
communication or intellectual disability is a candidate for
psychopharmacologic treatments, such as stimulants for
ADHD and risperidone for aggression.

◦ Finally, the child with a developmental disability should have
a medical home as a child with special health care needs.
◦ This allows the primary care provider a program of chronic
condition management for regular health monitoring for
chronological age and developmental monitoring in order to
provide anticipatory guidance for developmental age.
◦ Specialized, condition-related office visits, written care plans,
explicit co-management with medical specialists, appropriate
patient education, and an effective system for monitoring and
tracking should be put in place

◦ Both the primary care physician and the specialist can refer
the family to community-based support services, such as
respite care, parent-to-parent programs, and advocacy
organizations.
◦ Parent organizations such as Family Voices, and condition-
specific organizations, such as Autism Speaks and The Ark,
can provide further support, assistance, and information.
◦ Some children will qualify for additional benefits such as
Supplemental Security Income, public insurance, waiver
programs, and state programs for children with special health
care needs.