⦁ 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
Changes in bodily proportions with age
-Cephalo-caudal (head down to toes)
- Proximodistal (center of the body to peripheral)
- General to specific
1. Continous process from conception onward
Orderly - definite time limits for growth. Any time lost
during a rapid growth period may prevent catch-up
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
• 6. Each stage of G&D is affected by the preceding
types of development
Principles of Growth
• Each child grows in his/her own
• 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
• Don’t progress at the same rate
(↑ periods of GR in early childhood
and adolescents & ↓ periods of GR in
Stages of Growth and Development
⦁ Birth to 1 month
⦁ 1 month to 1 year
⦁ Early Childhood
⦁ 1-3 years
⦁ 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 ()
4. Environmental factors
a) Altitude, temperature
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
• 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
• Growth is fundamental characteristic of
• Normal growth is indicator of optimum
• 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/
Context of measurement; screening,
surveillance and monitoring
• Assessment of human growth and development is
directly dependent on the methods employed to
• The context will usually be one of three types:
• 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
• Instrumentation tends to be basic and portable
• Assessment is undertaken by more than one
• 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
• 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
Requirement for surveillance
• Description of growth requires more dimensions to be
• Number of observers will be fewer
• 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”.
• It describes the most important elements to be
considered when designing an anthropometric scenario
Minimum unit of measurement
• It is the appropriateness of the dimension to be
• 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
• 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.
• “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.
• 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
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
5.Mid arm circumference
6.Body proportions (arm span and upper-to-lower
Growth can be measured in terms of:
1. Physical anthropometry
2. Assessment of tissue growth
3. Bone age
4. Dental age
1. Midarm circumference(1-5 yrs)
2. Weight for height
3. Mid upper arm/height ratio
4. Midarm/Head circumference
5. Quetlet’s index
6. Ponderal index
7. Dugdale’s index
8. Body mass index
•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
•Thereafter 3 kg/yr added till puberty
Doubles ( ie.. 100 cm) by 4 years
6 cm / year till puberty
Triples by 12 years
1st 3 months: 2cm/month
Next 3 months: 1cm/month
Next 6 months : 0.5 cm/month
⦁ 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
Welcome trust classification of PEM (1970)
>80% of expected weight
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
⦁ Without footwear
⦁ Heels & back touching
⦁ Looking straight ahead
in frankfurt plane.
⦁ Gentle but firm
applied to the
⦁ Record to last 0.1cm
sitting base of a known height (e.g., 50 cm x 40 cm x 30 cm) and a wall-mounted
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
Iliac Height (IH)
⦁ The distance between the summit of the
iliac crest and the floor.
Subischial Leg Length (SLL)
⦁ The difference between stature and
⦁ 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
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
Cowell CT. Short Stature. In: Clinical Pediatric
Endocrinology, 3rd edn. Ed. Brook CGD.
London, Blackwell Science, 1995; pp 136-172.
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
Brain growth is rapid during infancy and it
is unaffected by mild to moderate degree
Should not be measured within 24 hrs after birth
Bony land marks – superior orbital ridge
(ant), external occipital
Place the measuring tape around the largest circumference of the infant's head,
across the occiput and the forehead.
Approximate gain in head
circumference between 0 and 5 yrs
Age Growth velocity of head
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
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
• Measured at the level of nipples on
• < 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
⦁ 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
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
• 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 3 years—1.3
♦After 7 years— 1.0
♦By about 11 years of age, adult proportions are
• Increase: Rickets,achondroplasia, Untreated
• Decrease: spondyloepiphyseal dysplasia, vertebral
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
⦁ Hand length – Distal wrist crease to tip of 3rd finger
⦁ Palm length – Distal wrist crease to prox. Crease of 3rd
• 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.
• Used for quick assessment.
•Fibre glass ring of internal
diameter of 4cm is slipped up
•If it passes above elbow ,
suggests MAC <12.5 cm and
• Quakers arm circumference
• Consists of rod with 2 sets of
• MAC corresponding to ht
• If ht > ht for expected MAC
– child is malnourished
• Modified quack stick –
Weight for Height Inference
Z- score < -2
(70-79% of expected)
Z- score < -3
(<70% of expected)
Height for age Inference
Z- score < -2
(85-89% of expected)
Z - score < -3
(<85% of expected)
Skinfold thickness by age and sex, as measured by
Harpenden skinfold calipers over triceps and under
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
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).
⦁ The most critical factor in
evaluating the growth is
⦁ 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.
⦁ 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
Also called as “road-to-health" chart. It was first
designed by David Morley and was later modified by
⦁ 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)
2 4 6 8 10 12 14 16 18 20
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
• 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
• 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,
• 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
mid-upper arm circumference-for-age
body mass index-for-age
⦁ 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.
Time schedule child anthropometry
Measurement Time frame Frequency No. of visits
Weight, length, head
Birth Once 1
Weeks 2-8 Bi-weekly 14
3-12 months Monthly 10
14-24 months Bi-monthly 6
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
• 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
standard, both older
and younger to get
the closest match
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
• 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
Bone age: an
algorithm for boys
Bone age in a minute: a simple algorithm.
Amrita JMed 2006;2:39-41
Bone age: an
algorithm for girls
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
⦁ Dental development includes mineralization, eruption, and
⦁ 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
⦁ 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
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
• Stage 5 Adult quantity and distribution, spread to medial
surface of thighs
SMR – Genitals
Stage 1 Preadolescent Preadolescent
Stage 2 Slight or no
testes and scrotum;
Stage 3 Longer Further
enlargement of testis
Stage 4 Larger in breadth,
glans penis develops
Testes & scrotum
Stage 5 Adult Adult
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
• Stage 5 Adult feminine triangle, spread to medial surface
• 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
• 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.
• 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
• A child is said to have developmental delay if the child does
not reach the expected developmental milestones for the
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
What is developmental delay?
◦ Developmental Delay is when a child does not
reach their developmental milestones at the
◦ 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
◦ 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
Transient developmental delay
◦ Some children have a transient delay in their
◦ 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
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
◦ 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 is estimated to occur in 5-10%
of the population with enormous psychological, motional,
and economic impact on the affected individuals and
◦ 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:
Gross motor delay Significant delay in fine or gross motor skills
with no impairment in other developmental
Developmental language disorders Significant delay in receptive and/or expressive
language skills with no delay in other
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
Hearing sensory impairment A reduction in the ability to hear sound, ranging
from slight to complete deafness
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
Pervasive developmental delay (PPD) /
Impairments in social skills, communication
skills and restrictive / repetitive patterns of
Pervasive developmental disorders not
otherwise specified / Autism Spectrum
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.
• Makes jerky, quivering arm thrusts
• Brings hands within range of eyes
• Moves head from side to side
while lying on stomach
• Head flops backward if
• Keeps hands in tight fists
• Strong reflex movements
• Focuses 8 to 12 inches (20.3 to 30.4 cm)
• Eyes wander and occasionally cross
• Prefers black-and-white or high-
• Prefers the human face to all other
• Hearing is fully mature
• Recognizes some sounds
• May turn toward familiar sounds and
• Prefers sweet smells
• Avoids bitter or acidic smells
• Recognizes the scent of his own
• Prefers soft to coarse sensations
• Dislikes rough or abrupt
• 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
atches faces intently
• Follows moving objects
• Recognizes familiar objects and people at
• Starts using hands and eyes in
• Smiles at the sound of your voice
• Begins to babble
• Begins to imitate some sounds
• Turns head toward direction of sound
• 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
• Rolls both ways (front to back, back
• Sits with, and then without,
support of her hands
• Supports her whole weight on her
• Reaches with one hand
• Transfers object from hand to hand
• Uses raking grasp (not pincer)
• Develops full color
• Distance vision matures
• Ability to track moving
• Responds to own name
• Begins to respond to “no”
• Distinguishes emotions by tone
• Responds to sound by making
• Uses voice to express joy and
• Babbles chains of consonants
• Finds partially hidden
• Explores with hands and
• Struggles to get objects that
are out of reach
• Enjoys social play
• Interested in mirror images
• Responds to other people’s
expressions of emotion
and appears joyful often
• 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
• 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
• 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
• 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)
•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
•Extends arm or leg to help when being dressed
• 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
• Walks up and down stairs holding on to
• Scribbles spontaneously
• Turns over container to pour
• Builds tower of four blocks or
• Might use one hand more
frequently than the other
• Points to object or picture when it’s named for
• Recognizes names of familiar people, objects,
and body parts
• Says several single words (by fifteen to eighteen
• Uses simple phrases (by eighteen to twenty-
• Uses two- to four-word sentences
• Follows simple instructions
• Repeats words overheard in conversation
• Finds objects even when
hidden under two or three
• Begins to sort by shapes and
• Begins make-believe play
• Imitates behavior of others, especially adults
and older children
• Increasingly aware of herself as separate
• Increasingly enthusiastic about company of
• Demonstrates increasing independence
• Begins to show defiant behavior
• Increasing episodes of separation anxiety
toward midyear, then they fade
• Hops and stands on one foot up to five
• Goes upstairs and downstairs without
• Kicks ball forward
• Throws ball overhand
• Catches bounced ball most of the time
• Moves forward and backward with agility
• Copies square shapes
• Draws a person with two to
four body parts
• Uses scissors
• Draws circles and squares
• Begins to copy some capital
• Understands the concepts of
“same” and “different”
• Has mastered some basic rules of
• Speaks in sentences of five to six
• Speaks clearly enough for strangers to
• Tells stories
• Correctly names some colors
• Understands the concept of counting and
may know a few numbers
• Approaches problems from a single point
• 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
•Interested in new experiences
•Cooperates with other children
•Plays “Mom” or “Dad”
•Increasingly inventive in fantasy play
•Dresses and undresses
•Negotiates solutions to conflicts
•Imagines that many unfamiliar images may be
•Views self as a whole person involving body,
mind, and feelings
•Often cannot distinguish between fantasy and
• Stands on one foot for ten
seconds or longer
• Hops, somersaults
• Swings, climbs
• Maybe able to skip
• Copies triangle and other geometric
• Draws person with body
• Prints some letters
• Dresses and undresses without assistance
• Uses fork, spoon, and (sometimes) a
• Usually cares for own toilet needs
• Recalls part of a story
• Speaks sentences of more
than five words
• Uses future tense
• Tells longer stories
• Says name and address
• Can count ten or more objects
• Correctly names at least four
• Better understands the concept of
• Knows about things used every
day in the home (money, food,
• 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
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
• 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
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
• 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
• 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
• after his second birthday, is growing less than 2
inches per year
• 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%
◦ 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)
An Approach to a Child with
◦ 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
◦ 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
◦ It is important to keep this in mind as you assess a child, and to keep
reassessing children in subsequent office visits.
• 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.
• It is a continuous process whereby the child is followed
over time to pick up on subtle deficiencies in the child’s
• 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.
◦ 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.
• 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
• 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 diagnoses made (eg. Down Syndrome)
◦ Infections (eg. TORCH includes toxoplasmosis, others
(syphilis, hepatitis B), rubella, cytomegalovirus, herpes simplex.)
◦ Exposures (eg. FetalAlcohol Syndrome)
◦ 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
• Standardized tools are used for screening
developmental changes in a systematic way.
• Compare the achievements listed for normal
children with developmental history and physical
• 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
• Used as a screening tool.
Assessment is done in four areas.
Fine motor skills
Gross motor skills
• Make sure the child listens and pays attention to each
• After scoring the test, interpret the results and inform
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
• 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.
Ages and Stages
• It looks at children’s skills in five developmental
2. Fine Motor
3. Gross Motor
• 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
• Assessed in children aged from birth to seven
• PEDS is a simple, 10-item questionnaire that is
completed by the parent.
◦Athorough physical examination is important
in the assessment of a developmentally
◦Characteristic findings on physical exam may
provide clues as to the cause of the
◦Some clinical signs and their corresponding
clinical significance are listed below:
◦Microcephaly: eg in Rett’s Disorder
◦Macrocephaly: eg in hydrocephalus
◦Short stature: Turner syndrome, Williams
◦Obesity: Prader-Willi syndrome, Beckwith-
Head and Neck
◦ Flat occiput: Down syndrome, Zellweger syndrome
◦ Prominent occiput: trisomy 18
◦ Craniosynostosis: Crouzon syndrome, Pfeiffer
◦ Midface hypoplasia: Fetal Alcohol Syndrome (FAS),
◦ 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
◦Lisch nodules: neurofibromatosis
Head and Neck
◦Large pinna: Fragile X syndrome
◦Malformed pinna: Treacher Collins syndrome,
◦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
◦Abnormal hair whorls: Down syndrome
◦Webbed neck: Turner syndrome
◦Nail hypoplasia or dysplasia: FAS
◦Facial port wine hemangioma: Sturge-
◦Café au lait spots: Neurofibromatosis
◦Ashleaf spots: Tuberous Sclerosis
◦ 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)
◦Karyotyping to assess for chromosomal
◦FISH analysis to assess for microdeletions
◦Many of these investigations will be
performed through specialist referral. Medical
Genetics consultation should be done at this
◦ 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
◦ 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
◦ 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
◦ 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