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Pediatrics

Development

Not hundreds of milestones: the progression across four domains, the red flags that end the waiting, and how to ask a caregiver. Then three children to assess.

Gross motor

Sits without support; gets to a sitting position

Fine motor

Transfers objects hand to hand; rakes food toward self; bangs two things together

Language

Babbles with consonants ('mamamama', 'bababa'); looks when name is called

Social and adaptive

Shy or clingy with strangers; shows facial expressions; plays peek-a-boo

Ask the caregiverDoes he sit on his own? Does he turn when you say his name?

Ages at which most children (75 percent or more) have the skill, after the 2022 CDC and AAP milestone revision and the Rourke Baby Record. A single late skill is rechecked; a red flag or regression is referred.

The progression, shown

Developmental Milestones by H. Hodges, B. Shagrin

OPENPediatrics (Boston Children's Hospital) · embedded with attribution; their teaching, not ours

The milestones from birth to five years across the domains, with the red flags and the guidance for parents.

Watch for

  • The progression within each domain rather than isolated ages
  • The red flags that prompt a referral rather than a wait
  • How the questions are asked of a caregiver
Watch on YouTube

Red flags

When to stop watching and refer

  • Any ageLoss of any previously acquired skill (regression)
  • Any ageParental concern, which is more sensitive than any screening question
  • 3 monthsNo social smile; not fixing and following; persistent fisting
  • 6 monthsNot reaching for objects; poor head control; not turning to sound
  • 9 monthsNot sitting without support; no babble; not responding to name
  • 12 monthsNot pulling to stand; no pointing or gesturing; strong hand preference before 12 to 18 months (suggests weakness of the other side)
  • 18 monthsNot walking independently; no single words with meaning; not pointing to show interest; not following a simple instruction
  • 2 yearsNo two-word phrases; fewer than 50 words; not running; no pretend play; not following a two-step command by 30 months
  • 3 yearsSpeech unintelligible to strangers most of the time; not playing with other children; unable to climb stairs
  • 4 yearsNot using sentences; not toilet trained by day (a soft flag with a wide range); cannot draw a circle; unable to hop

Surveillance

  • Development is surveyed at every visit and screened with a validated tool at set ages (the Rourke schedule, the 18-month enhanced visit in Ontario)
  • Ask open questions first ('What is he doing now that he was not doing a month ago?'), then specific ones
  • Correct for prematurity until 2 years
  • Watch the child while you take the history: much of the examination is observation of play

Interpretation

  • A single missed milestone in one domain, with everything else on time, is usually watched and rechecked
  • Delay across domains (global delay), any regression, or a red flag is a referral, not a wait
  • Language delay is the commonest: a hearing test is the first step, every time
  • Social communication concerns (not pointing, not responding to name, not sharing interest) are asked about early, because early intervention for autism changes outcomes

What to ask, by domain

  • Gross motor: sitting, walking, running, stairs
  • Fine motor: pincer grasp, stacking, drawing, dressing, feeding self
  • Language: understanding versus expression; words, phrases, intelligibility; hearing
  • Social: smiling, pointing, play with others, separation, behaviour

Practice

What would you ask, and what would concern you?

9 months

A 9-month-old at a routine check. Sits with a hand down for support, transfers a rattle, babbles 'bababa', turns to her name, and is wary of you.

Which element, if any, should prompt closer follow-up?

18 months

An 18-month-old boy brought because he 'does not talk much'. He walks and runs, stacks three blocks, has two words, does not point at things he wants or finds interesting, and does not turn reliably when his name is called.

What is the most important next step?

3 years

A 3-year-old girl at a check. Rides a tricycle, copies a circle, speaks in three-word sentences and a stranger understands her about three quarters of the time. Her parent says she was walking at 13 months and 'started school ready to boss everyone'.

What is the assessment?

Quick fire

Normal for age?

Normal for age?

0/0 · 4 items

18 monthsDevelopment

Not yet walking independently, cruising along furniture