DevPed Shortcuts

8/12/2019 DevPed Shortcuts

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Birth to 1 Year: Remember that the goal of the first year is to be able to walk (walk at 12 months). At six months you arehalfway there (remember sit at six). Just with these two milestones you can pretty much fill in everything else. Rememberthat everything is from head to toe. So 2 months (the first time we really check milestones) you check for head lifting (neckcontrol). You roll at 4 months (at level of shoulders and chest). Then, again, at six you sit. You crawl at 9 months and pull tostand (crawl, pull to stand at 9 months) which makes sense as being between sitting and walking.

In Review:2 months: lift head 45 degrees4 months: roll over (front to back first, then back to front, easier if you can push off with hands)6 months: sit (halfway to goal, halfway through year, sit at six)

9 months: crawl, stand (halfway between sitting and goal)12 months: walk (the goal)

15 months5 years: Memorize these milestones in a story as they are harder to associate with particular months like the firstyear. Using this progression story may help you.15 months: walks well18 months: throws objects24 months/2 years: up and down stairs (one foot at a time); run3 years: Tricycle (3 wheels, 3 years), jump in place4 years: up and down stairs alternating feet (2 feet x up/down = 4), balance on 1 foot for 4 seconds (legs look like a 4 whenon 1 foot), hop5 years: skip (5 looks like an Skips)Story: a child on the 1st floor of her house sits up, crawls, cruises, then 1) WALKS to stairs, 1.5) THROWS object up stairs, 2)CLIMBS up the stairs and RUNS to his trike, 3) RIDES a trike upstairs, JUMPS off, 4) RUNS down the stairs, HOPS off thestairs and 5) SKIPS away

3. Once youve memorized the months of well child checks and corresponding gross motor milestones, begin to memorize thearchetype babies for each age group. These little stories incorporate all the other milestones into a single image which ismuch easier than trying to memorize many unrelated facts. There are some ways to conceptually link milestones acrosscategories, but they are not frequent enough to be useful for fast recall and the salient milestones and timing which is whathappens on tests and during morning report.

Here are all the babies with milestones listed:

2 months: lift head 45 degrees (when laying on face), turns to sound, follows objects past midline, social smileParents Little Baby: looks up to sound, smiles because he sees both his parents, one on either side of midline

4 months: lift head 90 degrees/raise up to chest, roll over, find midline, reach for objects, puts objects in mouth, coos (theseare vowel sounds), and laughs

Fat Happy Baby: baby is rolling and laughing and cooing because he just discovered midline and is reaching for cake that hewill cram into his mouth

6 months: sit up with no head lag, raking grasp, transfer objects between hands, babbles (consonants), recognizes familiarfacesStreet-Corner Baby: sitting up on sidewalk, transferring a rake from hand to hand while babbling at people he thinks herecognizes

9 months: Crawl, pull to stand, point, specific babbling (mama, dada), stranger anxietyWatch Dog Baby: crawls to window, pulls to stand to see out, points at stranger in yard and says mama to get attention ofparents.

12 months: Walk, pincer grasp, 1 word, patacake, bye bye, peekabooPlayful Zombie Baby: walking at you, snapping pincers, repeating one word over and over (brrraaaaains), and just wants to

play patacake and peekaboo before waving bye bye.

15 months: walks well, imitates, controlled release of blocks (can stack 2)Little Sister Baby: wants to be just like big sister, walks confidently to the blocks and imitates making a 2 block tower

18 months: Throw, scribble, 4 block tower, 1 step command, uses spoon/cup, points to parts of bodySir Charming Baby: needs to get note to Rapunzel so scribbles note on paper to throw into high 4 block tower, catapult hascup on end, shoves note in with spoon, and throws note at tower, hitting Rapunzel in the face

2 years: Run, stairs (1 foot at a time), 20-50 words, 2 step command, parallel playBad Twins: mom gives two commands to twin boys to run to the stairs, then walk up the 25 stairs. Each walks up the 25 stairsnot helping the other.

3 years: Jump, Tricycle, dresses self (shirt, pants, shoes), full name, you, me, IJames Bond Baby: springs into action jumps into 3-piece suit, stands in front of mirror and says full name, jumps on

tricycle. You.Me. I, is his pickup line.

4 years: Stairs (alternating feet), hop, undresses, 1 foot (4 seconds), 4 word phrases (complete sentences), cooperative playBedtime Story Baby: really wants story time, so runs up stairs, hops on one foot to undress, so she and mom can read a storytogether. A Wrinkle in Time.


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5 years: Skip, Tie shoes, Difference between reality/fantasyOz Baby: ties ruby shoes, skips down Yellow Brick Road back to Kansas

DEVELOPMENTAL MILESTONES

Why learn it?

Development is an integral part of pediatric practice. Knowing and understanding developmental milestones has important diagnostic

application, it separates us from adult medicine, and is infinitely pimpable both by attendings and on our licensing exam. In other words,

this stuff is important to know.

How does this all fit together/Global Overview?

We will first discuss why this is clinically important, how it is used in practice, why we define development in four discrete categories

(gross motor, fine motor/vision, language/hearing, and social), go through an overview of each developmental category, and most

importantly, how to memorize this stuff in a way that is clinically/functionally relevant and will serve you when in clinic, when pimped

and, eventually, on our licensing exam.

1. Why is learning/applying developmental milestones important? Why do we use this modality?

We use milestones for two main reasons:

1. During early childhood (basically until the age of 5), when kids cannot articulate their inner state, developmental milestones are used

as clues to what is going on inside and if any pathology is brewing.

2. By assessing where the child is in each category, we can tell if delays are isolated to one category (speech delay for example) or

appears in multiple categories which will change your diagnostic concerns

2. How do we use developmental milestones in every day clinical practice?

1. We assess if the child is meeting milestones in each category for his or her particular age. There are ranges of ages when

milestones arrive (refer to Denver Scale). A lot of the classic milestones that we memorize are later in the average

range, so if a milestone is not seen by this age, this is possibly a problem. We will later go over some big red flags for

certain milestones if not seen by a certain age (a child not walking by 15 months is a concern)..

2. Example of how we evaluate a six month old at a well child check: At six months, a child should be able to sit up (gross

motor), pick up things with a raking grasp (vision &fine motor), babble (language), and recognize family members

(social). We ask parents if they see this at home, and observe whether the infant is doing these things in clinic.

3. Why do we use only these particular four categories? It seems kind of limited in scope. Does this really adequately define a childs

development or are there things we are leaving out? And why do we only really memorize these milestones to the age of 5? 1. We use these four categories because they are the most easily observable behaviors and we have therefore been able to

create norms for when we can expect children to do them.

2. There are absolutely aspects of development not covered in these four categories. How a child plays is very important in

how a child develops, but is way too diverse and individual to create any meaningful way to assess/measure it or

create norms. So the four categories that we do use, though chosen out of utility, are good enough to diagnose the

vast majority of developmental problems that may arise during a childs first five years of life.

3. We only memorize up to age 5 because after that, children are better able to communicate to us their thoughts and

feelings, and this is about the age that they enter school and any developmental issue will likely become readily

apparent when the child is placed with other children who they will have to interact using all four milestone

categories. Any deficiencies will be more obvious because things outside the norm will be visible by comparison to

other kids. Also, development is no longer as rapid after age 5, and therefore there is less urgency in diagnosing any

problems, and more reliance on things to get lagged socially or academically at school.

4. So how do I learn all this stuff? Should I learn each milestone category individually? Should I learn a milestone across each category

for each age? What information is best learned in a conceptual way? What information do I need to just memorize?

1. The goal is to learn these milestones in a way that we can use them effectively, quickly, and easily when assessing patients

(either at well child checks, outpatient urgent care appointments, or when a child is admitted to the hospital), and

also be able to answer quickly when we are pimped or when we see it on a boards exam.

2. I have tried to memorize these milestones many times since Step 1. I never got a good sense of understanding how

everything fits. Ive had to rememorize these things many times (3 rdyear pediatric exam, Step 2, Step 3, intern year,

board exam) which is clearly not efficient and likely not very effective.

3. So how do we learn this? It is a mix of conceptual understanding and rote memorization. The best way we have been able

to figure out is to (1) Generate an overarching understanding of the development categories (2) Learn why each

milestone category progresses as it does in children (why do we crawl before we walk?), and (3) use some memory

tricks to learn the most clinically important and most tested milestones for each age. This way you create an overallunderstanding of what is going on (which is actually fascinating in and of itself) but are still able to quickly recall

necessary/important milestones for assessing children and getting pimped.

General Understanding of Each Domain/Domain Overview


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The Categories: We use four categories for assessing child development- Dont memorize the rest of this section, it is only for getting a

conceptual overview of the categories, so when we start memorizing details we have a framework to understand the progression of

kids acquisition of skills.

Gross Motor: this category is the use of all muscles in a way that does not involve hand/eye coordination, which ends up being

essentially everything except eye/finger movements: head control, rolling over, sitting, walking, running, throwing (overhand, from the

shoulder), stairs, riding bikes, etc.

Fine Motor/Vision: this group is called fine motor but should be called hand/eye coordination. Initial milestones involve fixating and

following objects with their eyes, and eventually manipulating objects with hands and fingers. Both dexterity and vision are necessary to

achieve many of these milestones (block stacking) so that is why these abilities are grouped together.

Language/Hearing: like fine motor, language should include hearing as the two are intertwined. If you cant hear, your language is

going to be delayed or nonexistent. Language is divided into two categories; the distinction is clinically important. How someone speaks

and how many words they know are often the most obvious milestones, and are examples of expressive language (remember Broca).

But language is also receptive (does a child understand what is being said; think Wernicke) and this may be less obvious init ially.

Receptive language deficits are rarer but more concerning, assuming hearing is intact, as it then implies a brain/cognitive problem, as

opposed to expressive language deficits which are more likely to be secondary to mechanical issues. For example, kids with Cerebral

Palsy may be intelligent and fully aware of their surroundings, but often the initial erroneous assumption on the part of the provider is

that they have poor cognition.

Social: This is how a child interacts with other people. Does a child respond to other peoples behavior and show recognitionthat other

people are sentient beings? For example, do they attempt to draw another persons attention to an object, indicating that they

understand other people even have attention to redirect? Kids with Autism can have trouble with this kind of understanding.

General Overview of Milestones for Each Category

It is very helpful to understand the general progression of each milestone category so you can conceptually understand the

progression of each category and why most children develop in a predictable manner. This is most helpful in gross motor development,

which we will use as a base on which to memorize the milestones of all the other categories for a particular age. Also, we choose which

months to assess a child based on when they have well-child visits (because we most commonly wont see these kids except at these

times)

Gross motor Development: Children develop their gross motor skills from head to toe because myelination of nerves happens from head

to toe during the first year of life. You first lift your head up (neck), then you roll (using arms), then you sit (waist), then you crawl

(knees), then you stand, and then you walk. The goal of the first year is to walk.

Fine Motor Overview: since children dont use their hands until a few months old, early on we focus on whether the child appears to be

able to see things (track objects with their eyes for example). Around four months the fingers come in to play. The goal of the first yearis to have a controlled pincer grasp,which is the infant being able to pick up small things using the tips of their thumb and index

finger. So you look for vision until 4 months, then the kid can grasp objects with all fingers, then discovers their thumb, then learns to

use the thumb and fingers together in a controlled way.

Language Overview: just as we watch for vision first in fine motor, a child has to be able to hear to learn to speak. Thus evidence that the

child can hear is an important part of the early milestones. The goal of the first year is to be able to say one word(with meaningi.e.

the child says the word with intent and it means the same thing every time). After the first year, we start looking for increased

vocabulary, better pronunciation, and combining words into phrases and sentences.

Social Overview: this covers how children relate to other people. We start by looking for how they react to people, initially with a smile,

laughs, and then whether they can discriminate parents vs strangers. After that we we assess when a child develops the insight that

other people are thinking beings (and thus different from other objects). They will show this by pointing to draw attention, peekaboo,

and more advanced ways of playing and interacting). A child with autism will not be attracted to people, faces and language as distinct

from objects.

How to Commit This Stuff to Memory

1. First memorize the months of the well child checks. This is important for creating a framework for memorizing the milestones and will

also help when you start memorizing vaccine schedules. The timing of both milestones and vaccines is based on this well child check

schedule. The visits are 2 days, 2 weeks, 2 months, then add 2 months twice (4 months, 6 months) then space it out as we get less

anxious and the rate of expected milestone acquisition declines. So 2d, 2w, 2m, 4m, 6m, 9, 12, 15, 18, 24m, 3y, 4y, 5y.

-So initially think 2, 2 days, 2 weeks, 2 months, 4 months, 6 months

-after month 6, it is by 3 for four visits, so 9, 12, 15, 18

-after this it is by full years, 2, 3, 4, 5

2. Once this is down, we memorize the gross motor milestones for each visit. This will be the only milestone category that we have to

rotely associate with months. We will use it as a memory base and hook the other milestones in to it.

A good way to memorize motor is to divide these milestones into two categories: birth to 1 year, and 15 months to 5 years.

Birth to 1 Year: Remember that the goal of the first year is to be able to walk (walk at 12 months). At six months you are halfway there

(remember sit at six). Just with these two milestones you can pretty much fill in everything else. Remember that everything is from

head to toe. So 2 months (the first time we really check milestones) you check for head lifting (neck control). You roll at 4 months (at

level of shoulders and chest). Then, again, at six you sit. You crawl at 9 months and pull to stand (crawl, pull to stand at 9 months) which


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makes sense as being between sitting and walking.

In Review:

2 months: lift head 45 degrees

4 months: roll over (front to back first, then back to front, easier if you can push off with hands)

6 months: sit (halfway to goal, halfway through year, sit at six)

9 months: crawl, stand (halfway between sitting and goal)

12 months: walk (the goal)

15 months5 years: Memorize these milestones in a story as they are harder to associate with particular months like the first year.

Using this progression story may help you.

15 months: walks well

18 months: throws objects

24 months/2 years: up and down stairs (one foot at a time); run

3 years: Tricycle (3 wheels, 3 years), jump in place

4 years: up and down stairs alternating feet (2 feet x up/down = 4), balance on 1 foot for 4 seconds (legs look like a 4 when on 1 foot),

hop

5 years: skip (5 looks like an Skips)

Story: a child on the 1 stfloor of her house sits up, crawls, cruises, then 1) WALKS to stairs, 1.5) THROWS object up stairs, 2) CLIMBS up

the stairs and RUNS to his trike, 3) RIDES a trike upstairs, JUMPS off, 4) RUNS down the stairs, HOPS off the stairs and 5) SKIPS away

3. Once youve memorized the months of well child checks and corresponding gross motor milestones, begin to memorize the archetype

babies for each age group. These little stories incorporate all the other milestones into a single image which is much easier than trying to

memorize many unrelated facts. There are some ways to conceptually link milestones across categories, but they are not frequent

enough to be useful for fast recall and the salient milestones and timing which is what happens on tests and during morning report.

Here are all the babies with milestones listed:

2 months: lift head 45 degrees (when laying on face), turns to sound, follows objects past midline, social smile

Parents Little Baby: looks up to sound, smiles because he sees both his parents, one on either side of midline

4 months: lift head 90 degrees/raise up to chest, roll over, find midline, reach for objects, puts objects in mouth, coos (these are vowel

sounds), and laughs

Fat Happy Baby: baby is rolling and laughing and cooing because he just discovered midline and is reaching for cake that he will cram

into his mouth

6 months: sit up with no head lag, raking grasp, transfer objects between hands, babbles (consonants), recognizes familiar faces

Street-Corner Baby: sitting up on sidewalk, transferring a rake from hand to hand while babbling at people he thinks he recognizes

9 months: Crawl, pull to stand, point, specific babbling (mama, dada), stranger anxiety

Watch Dog Baby: crawls to window, pulls to stand to see out, points at stranger in yard and says mama to get attention of parents.

12 months: Walk, pincer grasp, 1 word, patacake, bye bye, peekaboo

Playful Zombie Baby: walking at you, snapping pincers, repeating one word over and over (brrraaaaains), and just wants to play

patacake and peekaboo before waving bye bye.

15 months: walks well, imitates, controlled release of blocks (can stack 2)

Little Sister Baby: wants to be just like big sister, walks confidently to the blocks and imitates making a 2 block tower

18 months: Throw, scribble, 4 block tower, 1 step command, uses spoon/cup, points to parts of body

Sir Charming Baby: needs to get note to Rapunzel so scribbles note on paper to throw into high 4 block tower, catapult has cup on end,

shoves note in with spoon, and throws note at tower, hitting Rapunzel in the face

2 years: Run, stairs (1 foot at a time), 20-50 words, 2 step command, parallel play

Bad Twins: mom gives two commands to twin boys to run to the stairs, then walk up the 25 stairs. Each walks up the 25 stairs not

helping the other.

3 years: Jump, Tricycle, dresses self (shirt, pants, shoes), full name, you, me, I

James Bond Baby: springs into action . . . jumps into 3-piece suit, stands in front of mirror and says full name, jumps on tricycle.

You.Me. I, is his pickup line.

4 years: Stairs (alternating feet), hop, undresses, 1 foot (4 seconds), 4 word phrases (complete sentences), cooperative play

Bedtime Story Baby: really wants story time, so runs up stairs, hops on one foot to undress, so she and mom can read a story together.

A Wrinkle in Time.

5 years: Skip, Tie shoes, Difference between reality/fantasy

Oz Baby: ties ruby shoes, skips down Yellow Brick Road back to Kansas

Review of Approach to Memorization

1. Learn ages of well child checks from birth to 5 years. Its not important to memorize in and of itself, but will really help you keep

milestones and vaccine schedules straight:

-be able to rattle off all the checks (2, 4, 6 . . . remember 2-5 years are only annual checks so you really only have to memorize up to 2

years old)


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-a flash card is helpful for this, just know it cold.

2. Learn associated gross motor milestones for each visit (make sure you understand the physiologic basis for the gross motor milestone

progression as it will help you figure things out if you ever forget a particular milestone for a given month and can only remember the

milestones around that month)

-flashcards helpful

3. Learn the archetype baby for each age (make sure you can visualize everything that baby is doing, the more vivid the picture, the

faster you learn it, the easier it is to retain, and the faster you will be able to recall the milestones)

-again, flashcards helpful

That should do it! Knock this stuff out early in residency so you can move on to learning more conceptually difficult stuff. Here is a few

examples of how youll see it during your education.

Example of questions you will see on boards:

You are seeing a 6 month old boy for his well child check. He is smiling at you, very talkative (no intelligible words), is able to pick up a

block and change it from hand to hand, and has just started rolling over. At this time is he developmentally appropriate?

Example of how attendings will pimp you:

1. Can a baby roll off the bed at 3 months old and hit head of floor like mom is saying? (assessing for abuse)no, this milestone only

comes in at 4 months, a 3 month old should not be able to do this so your concern for non-accidental trauma is increased (though not

definitive as some kids mature faster)

2. What would you expect this 9 month old to be able to do?

How this is used in clinic?

A mother brings her 11 month old concerned that he has not started talking at all and still cannot walk. What do you tell her?

Hope this helps.

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