Development Flashcards
You are reviewing a 11-month-old baby with a viral upper respiratory tract infection. She is clinically well but at the end of the consultation her mother asks you about her development. You notice that she points and babbles ‘mama’ and ‘dada’ but has no other words. She is shy and cries when you try to examine her. There is an early pincer grip and she can roll from front to back but she cannot yet sit without support. How would you describe her development?
A. Normal development
B. Global developmental delay
C. Isolated delay in gross motor skills
D. Delay in speech + social skills, possibly early autism
E. Isolated delay in fine motor skills
C. Isolated delay in gross motor skills
Most babies can sit without support at 7-8 months so this probably represents a delay in gross motor skills. If still present at 12 months she should be considered for referral to a paediatrician. The other development features are normal for her age.
When should an infant be able to sit without support (with a straight back)?
6-8 months
When should you refer a child for not being able to sit without support?
12 months
When should an infant be able to walk unsupported?
13-15 months
When should you refer an infant for not being able to walk unsupported?
18 months
When should a child be able to run?
16 months - 2 years
When should a child be able to hop on one leg?
3-4 years
When should a child be able to pull to stand?
8-10months
When does an infant develop pincer grip?
12 months
What are the ages for making a tower of 2, 3, 6 and 9 bricks?
2 bricks - 15 months
3 bricks - 18 months
6 bricks - 2 years
9 bricks - 3 years
What does hand preference prior to 12 months suggest?
Cerebral palsy
When should an infant be able to say mama and dada?
By 9 months
When should an infant smile by? when is it a red flag?
6 weeks
-red flag at 3 months (12 weeks)
When should you refer an infant for not smiling?
At 10 weeks
What are causes of global developmental delay?
Down’s syndrome
Fragile X syndrome
Fetal alcohol syndrome
Rett syndrome
What are causes of gross motor delay?
Cerebral palsy Ataxia Myopathy Spina bifida Visual impairment
What are causes of fine motor delay?
Cerebral palsy
Dyspraxia
Muscular dystrophy
Visual impairment
What are causes of language delay?
Hearing impairment
Social circumstances
Neglect
Autism
What are causes of social delay?
Neglect
Autism
What is the first line management for ADHD?
Methylphenidate
What are side effects of methylphenidate?
Abdominal pain Nausea Dyspepsia Weight loss Growth retardation
A 23 month old boy presents to your GP practice with what you suspect is a viral URTI. During the consultation you become concerned about his development. Which of the following would make you most concerned?
A. Unable to say 6 individual words with meaning
B. Not toilet trained
C. Unable to stand on one leg
D. Started to walk independently at 17 months
E. Plays alone
A. Unable to say 6 individual words with meaning
By 23-24 months most children would have a vocabulary of between 20-50 words and will be able to join 2 words with meaning
Answer 2 - Most children become toilet trained at or after 3 years of age.
Answer 3 - Most children are able to briefly stand on one leg at 3 years of age, and hop by age 4.
Answer 4 - The limit age for walking is 18 months. Most children will be able to walk before 17 months, but this is not an immediate cause of concern.
Answer 5 - At 23 months it is very common for children to play alone.
At what age should a child squat to pick up a ball?
18 months (halfway between 1 for walk, 2 for talk)
At what age should child ask ‘what’ and ‘who’ questions?
3 years
At what age should child combine 2 words?
2 years (2 for talk)
At what age should child ask ‘why’, ‘when’ and ‘how’ questions
4 years
At what age is there little or no head lag on being pulled to sit:
3 months
At what age can a child crawl?
8-10months
A mother presents with her baby to the GP for review. She asks for advice regarding her milestones and explains that her son was born was born prematurely at 32 weeks gestation.
With the premature age in mind, when should this baby begin to show a responsive social smile?
A. 5 to 7 weeks
B. 8 to 10 weeks
C. 11 to 13 weeks
D. 14 to 16 weeks
- 17 to 19 weeks
D. 14 to 16 weeks
The corrected age of a premature baby is the age minus the number of weeks he/she was born early from 40 weeks
6 to 8 weeks is the normal age when a child should show a responsive smile.
The reference range of the corrected age is 40 weeks. In this case, the baby was born at 32 weeks gestation which means 8 weeks have to be backdated. So 14 to 16 weeks is the answer.
The corrected age is taken into consideration when looking at milestones until the age of 2.
At what age can children talk in short sentences (e.g. 3-5 words)?
2.5-3 years
At what age does child have vocabulary of 2-6 words?
12-18months
At what age will child respond to their own name?
7-12months
When does an infant have palmar grasp?
5-6 months (palmer=half of pincer, half of 12 months=6 months)
When can infant draw a circle?
3 years
When can infant build tower block of 3-4 blocks?
18 months
When can infant ride a tricycle using pedals?
3 years
At what age would the average child start to play alongside, but not interacting with, other children?
2 years
A newborn is noted to have an intermittent squint at the newborn baby check.
What is the most appropriate management?
A. Start a trial of patching the stronger eye
B. Refer if still present at 8 weeks
C. Refer urgently to the paediatric ophthalmology team
D.Reassure the parents and discharge back to the community
E. Refer immediately to the paediatric team
B. Refer if still present at 8 weeks
what is the limit age for children to feed themselves with a spoon?
2-2.5 years
What’s the formula for correcting for gestational age? When is it used?
Correction for gestational age: Age (w) – (40 – gestational age (w))
or Adjusted age = chronological age - weeks of prematurity (from 40 weeks)
It’s required for babies born younger than 30 weeks of gestation and is usually used until the child is 2 years old, by which time their gestation does not represent a significant amount of their life anymore.
Eg. If born at 28 weeks, a child would be expected to meet their milestones 3 months (12 weeks) later than other children of similar birth age.
What is the limit age for a child to engage in symbolic play (eg Cause toys to make noise by shaking, banging, and squeezing them)?
2.5 years
When does stranger anxiety usually occur?
6 months
A 4-month old girl is attending for her routine vaccination schedule with dad. When held, she has good head control but is not able to sit unsupported. She babbles and turns to dad’s voice but dad is not sure she smiles all that much. She does not fix and follow objects through the midline and does not grasp with her palm.
What aspect of her development would you be concerned about?
A. Hearing and Speech
B. Social skills
C. Vision
D. Gross Motor skills
E. Fine Motor skills
C. Although the lack of definite smiling is concerning, at this age and in view of her ability to fix and follow, it is likely to be a direct consequence of her poor vision. Being able to see parent’s smiles in order to copy them is a fundamental prerequisite for a child to learn to smile socially.
Not B: Children will start following moving objects by 6 weeks of age, and it is expected that a child will be able to fix and follow by 3 months (limit age). The inability of this 4-month-old to fix and follow objects is concerning with regards to her visual ability, given that she is meeting all other developmental milestones for her age so far. Delays in visual development will have an impact on the progression of fine motor skills, hence it is important to detect these early.
when does head righting reflex (HRR) happen?
4-6months (similar to sitting age), putting head in perpendicular position
when does parachute reflex happen?
7-9months (similar to standing age): head down, child puts hands outs to fall on them
chronology of gross motor skills:
add 6 months to each one
head control (6weeks)—>sitting (6m)—> walking (12m)—> running (18m)—> walking up stairs (24m)—> jumping (30m)—> standing on one leg (36m)
1st sign of visuospatial awareness:
ATNR (asymmetric tonic neck reflex):
arm is extended, neck turns towards extended arm
language at 1 yr/2yrs:
-at 1 year: single words
-2 years; 2 words eg mummy hungry, daddy tired
egs of primitive reflexes
-sucking and rooting
-palmar grasp
-stepping
-pincer grip
-asymmetric tonic neck reflex (ATNR)
-moro reflex (parachute reflex, puts baby’s hands together in midline and observe arms outwards when head is dropped)
-babinski reflex (upwards fanning of toes)
when is 2 feet to 1 step achived?
2 years
what does babinski reflex mean in kids (normal vs abnormal)
(upwards fanning of toe when stroking sole of foot (lateral to medial), but if this happens in adults: UMN reflex (downgoing plantars=normal)
when should fixing and following happen? what type of development is affected?
starts at 6 weeks and should be maintained at 3 months.
fine motor and visual skills
hand fisting in child what development type affected?
fine motor skills affected
diagnosis of global developmental delay: support approach?
2 or more areas of development
-MDT approach (eg
-gross motor skills—> physiotherapists, fine motor skills–> occupational therapists, speech and language–> SALT & also school support where the child will be gaining skills for rest of their lives and safeguarding)
where local education authority liase with school:
=EHCP
Education, Health and Care Plans (EHCPs)
+/-paediatric neurologist (eg seizures, demyelination)/CAHMS (eg autism, ADHD)
summary of milestones
There are clearly individual variations and the effect of prematurity needs to be considered. However, average milestones are quoted which are seen in the majority of children at their respective ages. A child would not be able to feed from a spoon until the age of 2. Four and five-word sentences would not be used until the late 3rd year. Similarly, screwing and unscrewing lids and sorting objects by shape and colour would be expected at about age 3.
standing on tiptoe:
2 years
kicks ball:
3 years
hops & stands one 1 foot up to 5 secs
4 years
hops, skips & somersaults:
5 years
turns towards familiar sounds & voices:
1 month
begins to babble:
3 months
“dada” and “mama” (one word):
12 months
several single words:
18 months
2-4 word sentences:
2 years
uses pronouns & some plurals:
3 years
tells stories:
4 years
uses future tense:
5 years
A 4-months-old baby girl is brought to clinic by her dad who is concerned about her development and growth. She has three older siblings who have all developed and grown appropriately. She was born at term via normal vaginal delivery. Her 5-day blood spot test was normal. The parents have noticed that the baby seems “floppy” and is unable to hold her head up at an age when her other siblings could. She makes no effort to reach for toys and seems uninterested in following objects with his gaze. The parents could be convinced that she occasionally smiles but does not coo or vocalise.
Which one of these investigations would be most useful in identifying the cause for this child’s symptoms?
A. Genetic Karyotyping
B. Thyroid function test
C. EEG
D. Creatine kinase
E. MRI
A. Genetic Karyotyping
The combination of a normal birth with no complications and early onset of global developmental delay makes genetic syndromes highly likely and genetic karyotyping would be invaluable in identifying the cause. NICE has also recently recommended in view of emerging research that genetic karyotyping should be the first line investigation in all children presenting with global developmental delay, and it is the highest yield investigation, most likely to highlight a cause for any delay.
NOT B: TFTs
Her 5-day blood spot check would have excluded congenital hypothyroidism, therefore this test would not be as useful at present, although it would likely be included in any blood work-up panel done in a child presenting with these features.
D. Creatine kinase
Creatine kinase would be elevated in muscular dystrophies such as Duchenne – although Duchenne can result in a global developmental delay in severe cases, it usually causes a specific motor or speech delay which is usually apparent in toddlers rather than younger children. Also, Duchenne is extremely rare in girls, therefore this investigation would not be first line.
Fine motor and vision milestones red flags summary
Good fine motor skills relies on good vision.
Thus, a reason why some children might lack fine motor skills could be due to their vision rather than a neurological/muscular problem.
This explains why both fine motor and vision are linked together in the set of milestones below.
Gross motor summary
what is object permanence?
Object permanence involves understanding that items and people still exist even when you can’t see or hear them.
fine motor and vision summary
language and hearing summary
social skills and self-care summary
when does complete weaning from breastmilk usually take place?
Between 2-4 years
useful sources of information for parents about child’s development
- NHS choices website
- Back of redbook (key milestones & when they should be achieved by)
- Health visitor; very experienced and parent should flag any concerns with them first
summary milestones 12months-4years
summary milestones (6weeks-18months)
when should babies transfer objects?
by 6 months
when can they draw a cross?
3.5-4yrs
what is dyspraxia?
Dyspraxia, also known as developmental co-ordination disorder (DCD), is a common disorder that affects movement and co-ordination. Dyspraxia does not affect your intelligence. It can affect your co-ordination skills – such as tasks requiring balance, playing sports or learning to drive a car (eg drawing, writing, performance in sports)
-problem is not due to general delay in development or learning disabilities/cerebral palsy
-RFs: IUGR, prematurity, maternal alcohol, family history
-MDT diagnosis
when can child draw a square?
4 years
By age 2, how many words should children be using?
50 words or more
at what age do children usually start to involve other children in playing (no longer parallel play eg sitting or standing next to each other)?
3 years
babies sitting up (ie unsupported):
-At 4 months, a baby typically can hold his/her head steady without support
- 6 months, he/she begins to sit with a little help
- At 9 months he/she sits well without support and gets in and out of a sitting position but may require help
- At 12 months, he/she gets into the sitting position without help.
normal weight loss after birth:
A healthy newborn is expected to lose 7% to 10% of the birth weight, but should regain that weight within the first 2 weeks or so after birth. During their first month, most newborns gain weight at a rate of about 1 ounce (30 grams) per day.
definition of delayed puberty (boys vs girls):
Delayed puberty is classed as no pubertal development by the age of :
14 in boys
13 in girls
what is the most common cause of delayed puberty:
The most common cause of delayed puberty is constitutional delay of growth and puberty, in which children are ‘late bloomers’ and enter normal puberty later than their peers.
They will eventually reach full normal height and development.
how is constitutional delay diagnosed?
Constitutional delay is confirmed with a hand-wrist X-ray to confirm bone age, which is delayed in constitutional bone delay because the epiphyseal plates are late to fuse.
rare causes of delayed puberty:
Low gonadotrophin secretion induces pituitary disorders (craniopharyngiomas, Kallmann syndrome (anosmia), panhypopituitarism or isolated gonadotrophin deficiency), hypothyroidism, or systemic disease (e.g. cystic fibrosis or Crohn’s).
High gonadotrophin secretion causes include chromosomal disorders (Turner’s XO, Klinefelter’s XXY), congenital adrenal hyperplasia, or acquired hypogonadism (e.g. after chemotherapy)
