1. Growth and Developmental Milestones
• Normal Growth
o Bone Age radiographs
 CAN:
• provide info about adult height potential of healthy children with a bone age of >7 years
• if BA is advanced compared to chronologic age can offer info about length of time or severity of
exposure to sex steroids
• if BA is delayed can offer info about length of time of endo d/os or nutritional d/os
• in children who have isolated premature pubic or axillary hair development, a bone age more than
1 year advanced increases the possibility of a serious underlying disorder (i.e. late onset CAH)
 CANNOT:
• Permit accurate height predictions when BA is less <7 years
• Offer appropriate height predictions for kids with abnormal growth patterns due to bone or other
growth d/os
 Children with familial short stature usually have a normal bone age
 Children with constitutional delay of growth usually have delayed bone age
o Normal head circumference of full term infant
 Boys = 36cm; Girls = 35cm
o Growth pattern of acquired microcephaly
 Primary (genetic) microcephaly is almost always present at birth
 Secondary (environmental) may be present at birth or develop from a later postnatal insult
• Growth and development of a brain that is potentially normal is impaired by an environmental
insult
• Prenatal causes include etoh exposure irradiation, IU infection (CMV, toxo, rubella)
• Other causes include significant perinatal asphyxia
 Microcephaly = HC more than 2 standard deviations below the mean for age and sex
o Distinguish between hydrocephaly and macrocephaly
 Hydrocephaly = congenital or acquired enlargement if the ventricular system
 Macrocephaly = head circumference >2SD above the mean based on age and sex; causes include
hydrocephalus, megalencephaly, thickened skull and space occupying lesions

2. o Normal and abnormal variations in head shape
o Growth pattern of familial macrocephaly
♦ Atypical Growth
o The cause of FTT is nonorganic in the majority of patients
o Extensive lab eval of FTT should be deferred until outpt dietary management has been tried
o Observation of feeding can elicit nonorganic causes of FTT
o Poor feeding technique is a cause of FTT
o Distinguish between NOFTT and organic causes of growth deficiency
 NOFTT: describes the child who has grown poorly and has no identified medical condition
 Organic causes of growth deficiency: infant or toddler has grown poorly and has a medical disorder
known to interfere with growth, including malabsorptive diseases, genetic syndromes, endo disorders
and neuro dysfunction
o Distinguish between organic and nonorganic causes of FTT (above)
o Formula preparation is a major factor in infant undernutrition
o Inadequate intake is the most common cause of FTT
o Long term consequences of FTT in infancy:
 Most kids with poor growth show adequate improvement in dietary intake with intervention
 Some may continue on to be picky eaters; may have anxiety disorder, few may have autism spectrum
d/o
 Cognitive and school outcomes of kids with h/o FTT are worse than for those who have not
experienced undernutrition
 They should be monitored for developmental and behavioral problems
o FTT may be an expression of parental neglect/inadequacy
o Differential dx for infant with FTT:
 3 broad categories: FTT with microcephaly, FTT with short stature, FTT with adequate height for age
and nl head circumference
 FTT with microcephaly AND prominent neuro features : TORCHES, teratologic conditions, genetic
syndromes, brain injury
 flow chart in article for others
♦ Surveillance and Screening

3. o Understand the variations in the developmental sequence that are associated with prematurity
 Preterm babies (<37 weeks) should have their developmental ages corrected for the degree of
prematurity for at least the first 12 months after birth, and some may do this up to 24 months
 Infants born at 32-36 weeks GA have a 1.4-fold increase in risk of intellectual disabilities
 Infants born earlier than 32 weeks GA have 7-fold risk
 Greater risk of neurological/behavioral problems if low birth weight (<2500g), IUGR, h/o maternal drug
use; medical complications like IVH, cardiac lesions, BPD, feeding probs and ROP
 Preterm infant with a grade 3 or 4 IVH has a 35-90% increased risk of neurodevelopmental disability
o Understand the variations with developmental sequence that are associated with congenital visual
impairment
 Children with congenital or acquired blindness without associated neurological abnormalities are NOT
at increased risk for motor or cognitive impairment
 They are not at increased risk for language based learning disabilities or autism spectrum disorders
 May begin to walk later due to different exposure to motor exploration (start walking at 18-22 months)
 Typically develop language skills at same time as sighted children
 Should be provided with much physical contact and comforting and encouraged to partake in self help
skills and exploration of their environment
o Recognize the effects of visual impairment on motor, language, and emotional development in infants and
preschool children
 See above
o Understand the variations in hearing development that are associated with congenital hearing impairment

o Recognize the effects of deafness on motor, language, emotional and cognitive development

o Recognize the importance of regular, periodic, standardized developmental and behavioral screening for
the well child population
 AAP statement to
• Elicit and attend the parents’ concerns about child’s development
• Document and maintain a developmental hx
• Conduct accurate observations of your child’s development
• Identify risk and protective factors

4. • Document the process and findings from developmental surveillance
 Do screenings at 9, 18 and 24/30 months visit
o Know the commonly used screening tests and their limitations
 Developmental surveillance: PEDS (Parents’ Evaluation of Developmental Status) or ASQ (Ages and
Stages Questionnaire)
 Developmental Delay in high risk population (preterm birth, economic disadvantage): ASQ or BINS
(Bayley Infant Neurodevelopmental Screener; for up to age 24 months) or CAT/CLAMS (Cognitive
Adaptive Test/Clinical Linguistic Auditory Milestone Scale; a practitioner administered instrument)
 To identify specific delays: language disorders = LDS (Language Development Survey) or CLAMS; for
autism = MCHAT
 Limitations for all the tests include time, costs, practice management constraints, selection of screening
test; for parent administered tests/surveys issues include literacy, language barriers
o Know the methods of developmental and behavioral screening (See above)
♦ Developmental Milestones: Milestones for infants and young children
o Recognize the normal motor developmental milestones for 2 months of age
 Regards object, follows 180 degrees, lifts head and shoulders off bed in prone position
o Know that lack of visual fixation by 2 months of age is abnormal
o Recognize the normal cognitive/behavioral developmental milestones for 4 months of age
 Laughs out loud, squeals, initiates social interaction
o Know that lack of visual tracking by 4 months of age is abnormal
o Know that failure to turn to sound or voice by 6 months of age is abnormal
o Know socioemotional milestones at 28 weeks of age
 Takes solid foods well, places feet to mouth when supine, reaches for a mirror and pats image
o Know that inability to sit by 9 months is abnormal
o Know that lack of babbling consonant sounds by 9 months is abnormal
o Recognize the normal developmental milestones for 12 months
 Pulls to a stand and cruises, takes a few independent steps, neat pincer grasp
o Recognize the gross normal motor developmental milestones for 15 months of age
 Plays ball with examiner, gives and takes a toy, drinks from a cup, makes a line with a crayon, makes a
two cube tower, walks independently, stoops to floor and recovers to standing
o Recognize the normal cognitive/behavioral developmental milestones for 15 months of age

5.  Says 3-6 specific words, follows simple commands, uses jargon, indicates some desires or needs by
pointing
o Recognize the normal cognitive/behavioral developmental milestones for 18 months of age
 Imitates household tasks, says 7-10 words, uses words for wants or needs, identifies one or more body
parts
o Know that inability to walk independently by 18 months is abnormal
o Know that failure to use single words by 24 months is abnormal
o Know that failure to speak in 3 word sentences by 36 months is abnormal
♦ Milestones for kindergarten readiness
o Know the indications of social readiness to attend school:
 Ability to separate from parents for several hours at a time
 Plays well with other children
 Takes turns
 Able to follow directions in a group activity
 Able to relate to personal experiences
 Tell stories