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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

‫بسم هللا الرحمن الرحيم‬

Pediatric development

• Developmental examination assesses the acquisition of learned skills. It is an integral

part of pediatric examination and therefore it is essential that normal development and
normal variations are clearly understood. There is normal variation between babies so
we use ranges to differentiate the normal variations & the delayed development stage.
• Parallel to the changes in the developing brain (i.e., cognition, language, behavior) are
changes in the physical development of the body.

DEVELOPMENTAL MILESTONES

• The use of milestones to assess development focuses on discrete behaviors that the
clinician can observe or accept as present by parental report.
• This approach is based on comparing the patient’s behavior with that of many normal
children.
• The development of the neuromuscular system, similar to that of other organ systems,
is determined first by genetic endowment and then is molded by environmental
influences.
• Although a sequence of specific, easily measured behaviors can adequately represent
some areas of development, other areas, particularly social and emotional
development, are not as easy to assess.
• Easily measured developmental milestones are well established through the age of 6
years only. After age of 6 years the changes are very big so its easy to assessed.
• Other types of assessment (e.g., intelligence tests, school performance, and
personality profiles) that expand the developmental milestone approach are available
for older children.

Developmental assessment

• In general, assessment is ongoing through to adolescence but is of more importance

during the preschool period (0–6 years)

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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

• The American Academy of Pediatrics recommends the use of validated standardized

screening tools at three of the health maintenance visits: 9 months, 18 months, and 30
months. Each child in these ages come to your clinic you should be assess his growth
either is normal or delay (9, 18, 30 months).
• A child who fails to pass a developmental screening test requires more comprehensive
evaluation but does not necessarily have a delay; definitive testing must confirm.
• A thorough physical examination is essential, particularly looking for minor
abnormalities and noting size and shape of head, height and weight. Such as if there is a
child with microencephaly if you doesn’t treat him this will affect the both of the growth
(FTT) & the hall body due to problems in NS & the growth in general.
• Having established that the child does not have a physical disorder which may
influence development, assessment is then based on:
➢ Gross motor status
➢ Vision and fine motor
➢ Hearing and speech
➢ Social behavior
If the child has delay in just one field from previous 4 field we called it GROSS
DEVELOPMENTAL DELAY but if he has 2 or more delayed fields we called it GLOPAL
DEVELOPMENTAL DELAY.
• In general terms, an infant’s attention span and interest in surroundings is of more
importance than gross motor development – particularly if the latter is influenced by
obesity or a physical disorder. Those are obese don’t have physical disorder like
deformity in feet you need to go other than motor assessment and assess the general or
hall body to make sure that everything is normal.
• The initial age for developmental assessment is 6–8 weeks. Before 6 weeks is useless.
• Initial discussion including the previous history and enquiry into the general behavior
of the infant to date should be made.
• It must be stressed that at any developmental assessment examination, both mother
and infant should be put at ease and made comfortable. If you assess the baby you
couldn’t do the best except if the baby is happy & not disturbed.
• Under no circumstances should one initially attempt physical examination. Sit, watch
and observe particularly the size, appearance and general status of your patient. Don’t
touch if its not necessary (take your time in inspection).

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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

NEWBORN PERIOD

• Any asymmetric movement or altered muscle tone and function may indicate a
significant central nervous system abnormality or a nerve palsy resulting from the
delivery and requires further evaluation. Before 6 weeks we don’t do developmental
assessment but we need to do neurology assessment.

Primitive neonatal reflexes

• Primitive neonatal reflexes are unique in the newborn period and can further
elucidate or eliminate concerns over asymmetric function.
• They are survival reflexes that evolve in utero. They are under control of brain stem
(not the cortex ), the infant can’t prevent them. So its disappear by time.
• These central nervous system motor responses are eventually inhibited by 4 to 6
months of age as the brain matures and replaces them with voluntary motor activities
but may return with the presence of neurological disease.
• Several reflexes are important in the assessment of newborns and young infants.
• Suckling reflex. When the roof of the baby's mouth is touched, the baby will begin to
suck. This reflex begins at about the 32nd week of pregnancy and is not fully developed
until about 36 weeks gestational age. Premature babies may have a weak or immature
ability to suck .

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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

LATER INFANCY

• Development proceeds in a cephalocaudal direction and proximal to distal. First head

control, trunk control then walking. ‫باالول برفع راسه بعدين صدره بعدين بصير يحبي بعدين بمشي‬
• With the development of gross motor skills, the infant is first able to control his or her
posture, then proximal musculature, and last, distal musculature.
• Development leads to progression from dependence to independence
• Evaluation of vision and ocular movements is important to prevent the serious
outcome of strabismus. In the strabismus the child depend on one eye & the another is
neglected and weak could be persistent.
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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

Bottom shuffling: occurs usually between 15-18 months or at 12 months the child uses
their legs to moves on his back rather than crawling or walks.

Certain milestones on certain months

3 MONTHS:
• Gross motor. Holds head erect and steady to 30° and in ventral suspension head is
held up for prolonged period. Also can hold shoulders off table when in the prone
position.
• Vision and fine movement. Appears alert and readily follows objects. At this stage
hands are open and grasp reflex starts disappearing. 3-6 months.

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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

• Hearing and speech. More responsive to noise and may turn to sound.
• Social. Smiles (2 months).
4–5 MONTHS:
• Gross motor. Head control further established, back is straighter, rolls front to back.
• Vision and fine movement. Regards dangling object and follows, tries to reach with
hands.
• Hearing. Very vocal. Look and listen.
• Social. Laughs and squeals.
6–8 MONTHS:
VERY IMPORTANT EXAMINATION
• Gross motor development at this time will include sitting without support, rolling over
and the ability to extend the arms and lift the chest in the prone position.
• Visual acuity can now be reasonably well assessed. Improving visual acuity allows for
significant development of hand/eye coordination where an infant can reach out and
with palmar grasp, retrieve a small object (brick) which will be examined, probably
transferred to the other hand and finally put to the mouth.
• The infant at this age will also turn to sound. The sounds used as stimulus include
crumpled paper, rattle, and cup and spoon.
• Will respond to talking and will be babbling more precisely: that is ‘dada’, and ‘baba’.
• Socially, the infant is usually happy with strangers, laughs easily.
-Warnings and red flags:
• Maternal anxiety. Specially in mothers have experience (that have more than 2
children), will start to compare between the baby , his brothers & sisters.
• Head circumference less than 3rd centile
• Hypotonia– poor head control
• Hypertonia – brisk reflexes and clonus
• Not alert – failure to fixate or strabismus
• Not turning to sound
• Persistent primitive reflexes.

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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

9–10 MONTHS:
• Motor
- Can move on floor – rolling, crawling.
- Does not like being moved from sitting to lying supine.
• Vision and fine motor
- Pincer grasp with good manipulation
- Looks after fallen toy
- Grasps bottle when feeding
- Holds, bites and chews biscuit
• Hearing and speech
- May know and turn to name.
- Babbles loudly.
• Social
- Beginning of suspicion of strangers. Stranger anxiety develops between 9
and 18 months of age
-The infant comprehends simple commands – waves ‘bye-bye’, clap hands.
-Very observant
-Warnings and red flags
• Maternal anxiety
• Head circumference < 3rd centile
• Not sitting
• Asymmetry of tone
• Brisk reflexes or clonus
• Poor vocalization
• Poor response to sound
• Unable to chew.

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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

12 MONTHS:
• At 12 months there may be considerable variation in developmental status,
particularly in gross motor.
• Most will be crawling or have a variation thereof to include rolling over, bottom-
shuffling, side-stroking and bear walk (back legs extended).
• Standing with or without support should be achieved. Some will walk holding on or on
their own.
• Visual acuity has improved. Objects are now picked up, using the more sophisticated
thumb-index finger or pincer grasp.
• The baby will search for an object falling from view (9-12m).
• Vocabulary has improved both in pronunciation and number of words (two to three).
• Socially the infant is now wary of strangers and clings to his mother. He responds to
his own name and plays purposefully with toys (9 - 12m).
• At this age major areas of delay should have surfaced to include poor brain growth,
gross motor delay, visual and hearing impairment , etc.
18 MONTHS:
• Gross Motor:
- walks - may run straight - creeps backwards downstairs - picks up toy from floor
without falling.
• Vision and fine motor:
- builds four bricks - points to distant objects (outside) - hand preference appearing -shows
distinct interest in human face. Kicks a ball.
• Hearing and language:
- vocalizes freely - responds quickly to simple commands.
• Social:
- drinks without spilling - hands cup back to adult - has stopped putting toys into
mouth. Removes garment.
-Warnings:
• maternal anxiety
• not standing not walking
• poor attention span.

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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

3 YEARS:
• Stands on one foot momentarily – may be able to ride tricycle.
• Builds tower of blocks.
• Dresses with help. (Removes garment 18m, puts on clothes 2 yrs)
• Says three-word sentences.
• May know one or two colors.
• Probably knows full name.
4 YEARS:
• Assessment of children in this age group is of considerable importance, particularly
because of the advent of school.
• Comprehensive ophthalmological assessment should be carried out at this age.
• Gross motor activity has become much more sophisticated to include ability to stand
and hop on one foot, can walk downstairs in adult fashion one foot at a time, and can
catch a ball.
• Can dress and undress without much help. The use of a pencil to draw objects such as
circles, square, a man. Now knows three to four colors.
• Toilet training is well established. Speech has become more sophisticated, talks, asks
questions – tells stories.

Locomotion variants - range of normality.

• Some infants never crawl: they stand and walk.

• Some do normal crawl with flexed knees + some do sidestroke (swing) crawl, some
commando crawl – crawling on elbows rather than hands.
• Some do bear walk (knees extended).
• Some bounce around floor or ‘bottom-shuffle’.

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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

Conditions considered high risk for associated hearing deficit.

• Congenital hearing loss in first cousin or closer relative

• Bilirubin level of more than 20 mg/dl.
• Congenital viral infections.
• Defects in the ear, nose or throat.
• BW of less than 1500 g.
• Multiple apneic episodes.
• Exchange transfusion.
• Meningitis.
• 5-min Apgar score of less than 5
• Persistent fetal circulation( primary pulmonary hypertension).
• Ototoxic drugs( aminoglycosides and loop diuretics)

Developmental delay

• Global: delay in two or more domains.

• Gross motor delay.
• Fine motor delay.
• Speech and language delay.

To conclude..

• Developmental assessment is an integral part of every clinic visit.

• Accurate developmental examination will facilitate early detection of neuromuscular
problems.
• Loss of primitive reflexes is paralleled by a gain of positive skills.
• The rate of development does vary between children (spectrum).
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ATHAR QNL PEDIATRIC MAJOR SALAH ALDEEN & FARES

• There is a sequence of development within each field, but the development in one
field does not necessarily run parallel with that in another. (Dissociation).

‫ وأره مكانه‬،‫ واسقه من شراب أهل الجنة‬،‫الله ّم أطعم أبي من الجنة‬

‫ ادخل من أي باب تشاء برحمتك وجودك‬:‫ وقل له‬،‫من الجنة‬
.‫وإحسانك يا أرحم الراحمين‬

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