Embed Size (px)
DESCRIPTION
university
Citation preview
1
Developmental MilestonesDevelopmental Milestones
Pr Hakam Yaseen, MD, CES(Ped), DU(Neonat)
[France], FRCPCH, [UK]
2
Case scenario 1Case scenario 1
• Mother is worried because her 1 month old baby boy who is not responding to her stimulation ,and he is not smiling?
• What is your comments?
3
Case scenario 2Case scenario 2
• Parents brought their 10 month-old baby to your clinic.
• They are worried because their baby is still not able to sit down?
4
Case scenario 3Case scenario 3
• 5-month baby not able to transfer toys from one hand to another, what is your comment?
5
Case scenario 4Case scenario 4
• Mother is asking : When my baby waves bye bye?
6
Case scenario 5Case scenario 5
• A 3 years old who says mama dada? But he can not say for example give me teddy? Do you reassure parents?
7
• What are the Objectives of developmental paediatrics?
8
Objectives of developmental paediatricsObjectives of developmental paediatrics
• To early detect and manage delayed development
• To act for the care and management of the child with special needs.
9
Areas of DevelopmentAreas of Development
10
Areas of DevelopmentAreas of DevelopmentMost obvious area of development
Fine motor skills require good vision- that’s why they are grouped together
Speech & language require good hearing
They explain the child’s psychological development
Note: A deficiency in any skill area can have an impact on other areas! (e.g. hearing defect can affect social, emotional and behavioral area
11
When do you assess developmental milestones?
12
When do you assess developmental When do you assess developmental milestones?milestones?
• As part of a child health surveillance program.
• If there is parental concern• When the child comes for another reason
(as admission or in OPD) : it might be done briefly.
13
AgeAge
When considering developmental milestones: The median age • the age when half of a standard
population of children achieve that level • It is a guide to when stages of
development are likely to be reached but does not tell us if the child's skills are outside the normal range.
• Limit ages are usually 2 standard deviations from the mean.
14
Variation in Variation in raterate of development of development
Example• The percentage of children walking unsupported:• 25% by 11 months• 50% by 12 months• 75% by 13 months• 90% by 15 months• 97.5% by 18 months• This shows that not all children develop the same.• Setting a limit age (18 months in this example) will allow
earlier identification of delayed walking in children • It will also increase the number of children labeled as
delayed who are in fact normal, but these children are only a small minority (in this example is 2.5%).
15
not crawling??not crawling??
• Mother is worried because her 9 months old baby is not crawling like the baby of her neighbor!!!
• What is your opinion?
16
Variation in Variation in patternpattern of development of development
17
Variation Variation in patternin pattern of development of development
• Normal motor development is the progression from immobility to walking, but not all children do so in the same way
• Most achieve mobility by crawling (83%), some bottom-shuffle and others crawl with their abdomen on the floor, called commando crawling (creeping)
• A very few just stand up and walk • Hence, the limit age of 18 months applies to
children who crawl.
18
Adjusting for prematurityAdjusting for prematurity
• Adjust the age of the premature child (< 2 years) from the expected date of delivery.
• E.g. a 9-month baby (chronological age) born 3 months earlier will have the same development as a 6-month baby (corrected age)
• This is only applied for children less than 2 years
19
NoteNote
If developmental delay affect all the areas
It is called : GLOBAL DELAY
If one or more field is affected It is called :
SPECIFIC DEVELOPMENTALDELAY
20
Developmental MilestonesDevelopmental Milestones
21
Gross motor developmentGross motor development
22
Limbs flexed, symmetrical postures
Sits without support-at 6 mo: with round back-at 8 mo: with straight back
Raises head to 45 degrees
Marked head lag on pulling up
Newborn Newborn
6-8 weeks 6-8 months
Gross motor development (median ages)Gross motor development (median ages)
23
15 months12 months
10 months8-9 months
Crawling Walks around furniture
Walking unsteadily broad gait, hands apart
Walks alone steadily
Gross motor development (median ages)Gross motor development (median ages)
24
Primitive Reflexes present at birthPrimitive Reflexes present at birth(Should disappear by 4-6 months)(Should disappear by 4-6 months)
Reflex Mode of eliciting it Description
Moro Sudden head extension Symmetrical extension,then flexion of all limbs
Grasp Object placed in the palm at the base of fingers
Flexion of fingers
Rooting Stimulus near the mouth The head turns towards the stimulus
Placing Infant held vertically and the dorsum of the feet brought into contact with a surface
Lifts first one foot, placing it on the surface, followed by the other foot
Positive supportive
reflex
Infant held vertically, feet on a surface Legs take body weight, may push up against gravity
tonic neck reflex
Lying supine, the head is turned by the examiner to one side
Infant adopts a fencing posture: arms outstretched on the side to which the head is turned
30
Fine motor Fine motor and and
visionvision
31
Fine motor and visionFine motor and vision6-8 weeks
4 months
6 months 7 months
Reaches out for toys
Newborn- follows face in midlineFollows moving object on face by turning the head
Palmar graspTransfer toys from one hand to another
32
10 months 16-18 months
14 months- 4 years 2-5 years
Mature pincer grip Makes marks with crayon
Fine motor and visionFine motor and vision
33
Hearing, Speech and languageHearing, Speech and language
34
Hearing, Speech, LanguageHearing, Speech, Language(Median ages)(Median ages)
Newborn 2-3 months
7 months 7-10 months
aa aa
Dada mama
Startles to loud noisesVocalises alone or when spokento, coos and laughs
Turns to soft sounds out of sight
At 7 months, sounds used indiscriminatelyAt 10 months, sounds used discriminately to parents
35
Hearing, Speech, Language Hearing, Speech, Language (median ages)(median ages)
12 months 18 months
2years 2½-3 years
dink
Give me
teddy
Push mefast daddy!
Where is your nose?
Two to three words other than mama, baba
Uses two or more words to make simple phrases
6-10 words. Shows two parts of thebody
Talks constantly in 3-4 word sentences
36
Social, emotional, and behavioural Social, emotional, and behavioural development (median ages)development (median ages)
37
Social, emotional, and behavioural Social, emotional, and behavioural development (median ages)development (median ages)
6 -8 weeks 6-8 months
10-12 months 12 months
Smiles responsively Puts food in mouth
Waves bye bye, plays peek-a-boo
Drink from a cup with two hands
38
Social, emotional, and behavioural Social, emotional, and behavioural development (median ages)development (median ages)
18 months 18-24 months
2 years 3 years
Holds sppon and gets food safely into mouth
Symbolicplay
Dry by day, pulls off some clothing Parallel play, interactive play
evolving. Takes turn.
39
Red lights!Red lights!
40
Red lights!Red lights!
41
Summary of developmental milestones Summary of developmental milestones Age Gross motor Vision and
fine motorHearing, speech
and languageSocial,
emotional behavioral
Newborn Flexed posture Fixes and follows face
Stills to voiceStartles to loud noise
Smiles (6 weeks)
7 months
Sits without support
Transfers objects from one hand to another
Turns to voicePolysyllabic babble
Finger feedsFears strangers
1 year
Stands independently
Pincer grip (10 months)Points
1-2 wordsUnderstands name
Drinks from cupWaves
18 months
Walks independently
Immature grip of pencil
6-10 wordsPoints to 4 body parts
Feeds himself with spoonHelps with dressing
2½ years
Runs and jumps Draws 3-4 word sentenceUnderstands 2 joined commands
Parallel playClean and dry
42
Cognitive DevelopmentCognitive Development
• It refers to higher mental function• It progresses with age• Assessed by the formal IQ tests.Disadvantages:• Could be affected by cultural background and
linguistic skills• Do not test all skill areas• Do not necessarily reflect the child’s ultimate
potential• Could be compromised by individual disabilities
such as motor disorder as in cerebral palsy.
43
Shortcut approach for assessing Shortcut approach for assessing developmental progressdevelopmental progress
• Detailed assessment is unnecessary when checking the development in normal clinical practice.
• A shortcut approach can be adopted.
44
Shortcut approach for assessing Shortcut approach for assessing developmental progressdevelopmental progress
•Gross motor development: an explosion of skills occurs during the first year of life•Vision and fine motor: more evident acquisition of skills from 1 year onwards•Hearing, speech and language: a big expansion of skills from 18 months•Social, emotional and behavioral: most obvious from 2½ years
45
Shortcut approach for assessing Shortcut approach for assessing developmental progressdevelopmental progress
Understanding the time when acceleration of skills occurs guides the doctor on how to quickly take a developmental history.
•If the child <18 months: most useful to ask about gross motor abilities, acquisition of vision and hearing, followed by questions about hand skills•If the child is 18 months - 2.5 years: ask about acquisition of speech and language, fine motor skills. •If the child is 2.5 – 3.5 years: Focus your initial questions around speech, language and social emotional and behavioral skills.
This method is quick, and more appropriate
It assesses the current abilitiesrather than making the parents Trying to remember the ages when their child acquired the skill
46
For more knowledge :For more knowledge :
--Developmental ProblemsDevelopmental Problems - -Specific global delaySpecific global delay
47
Abnormal developmentAbnormal developmentDEFINITIONSDEFINITIONS
• Delay: slow acquisition of all skills (global delay) or of one particular field or area of skill (specific delay) particularly in relation to developmental problems in 0-5 years.
• Learning difficulty: used in relation to children of school age and may be cognitive, physical or both (complex)
• Disorder: mal-development of a skill
48
Global developmental delayGlobal developmental delay
• Implies delay in acquisition of all skill fields.
• Apparent in the first 2 years of life.• More likely to be associated with cognitive
difficulties, they may be apparent later in life.
49
Causes of global developmental delayCauses of global developmental delay1- prenatal:
• Genetic: chromosomal/DNA disorders, Cerebral dysgenesis• Metabolic: hypothyroidism, phenylketonuria• Teratogenic: alcohol, drugs• Congenital infection: Rubella, toxoplasmosis, cytomegalovirus
2- Perinatal:
• Extreme prematurity• Birth asphyxia• Metabolic (symptomatic hypoglycemia, hyperbilirubinemia)
3- postnatal:
• Infection: meningitis, encephalities• Anoxia: suffocation, near drowning, seizures• Trauma: head injury• Metabolic: hypoglycemia, inborn error of metabolism
4- Other: unknown (about 25%)
50
Specific global delay
51
Abnormal Motor developmentAbnormal Motor development
• Concerns starts between 6 months and 2 years • Presents as delay in:1. Head control2. Rolling3. Sitting4. Standing5. Walking6. Problems with balance7. Abnormal gait8. Asymmetry of hand use (suggests hemiplegia)9. Involuntary movements
52
CausesCauses
1. Cerebral palsy• Has many causes, 10% hypoxic ischeamic encephalopathy• Usually presents in infancy with abnormal tone and posture,
delayed motor milestones, feeding difficulties• Could be spastic, ataxic hypotonic, dyskinetic or mixed.
2. Congenital myopathy, primary muscle disease3. Spinal cord lesion e.g. spina bifida4. Global developmental delay as in many
syndromes or of unidentified cause.
53
Abnormal speech and language Abnormal speech and language developmentdevelopment
Could be receptive or expressive speech and language disorder or both.
Causes:• Hearing loss• Global developmental delay• Difficulty in speech production due to anatomical
defect e.g. cleft palate or oromotor incoordination eg. Cerebral palsy
• Environmental deprivation and lack of opportunity for social interaction
• Normal variant/familial pattern
54
Speech and language disordersSpeech and language disorders
These include:• Language comprehension (receptive dysphasia): inability
to understand and speech and language• Language expression (expressive dysphasia): difficulty
in producing speech whilst knowing what is needed to be said
• Phonation and speech production such as stammering, dysarthria, verbal dyspraxia
• Pragmatics (difference between sentence meaning and speaker’s meaning), construction of sentences, semantics, grammar.
• Social/communication skills (autistic spectrum disorder)
55
Abnormal development of Abnormal development of social/communication skillssocial/communication skills
• It includes Autistic spectrum disorder• It presents at 2-4 years with1. impaired social interaction2. speech and language disorder 3. imposition of routines with ritualistic and
repetitive behavior4. Co-morbidities: learning and attention
difficulties, seizures• Managed by behavior modification using
applied behavior analysis
56
Thank youThank you
