Ghai Essential Pediatrics8th

lies on the bed with high pelvis and knees drawn up (Fig. 3.9). At 4 weeks, the infant lifts the chin up momentarily in the midline. Theinfantlies with flat pelvis and extended hips at 6 weeks (Fig. 3.10). By 8 weeks, face is lifted up at 45° (Fig. 3.11) and by 12 weeks, the child can bear weight on forearms with chin and shoulder off the couch and face at 45° (Fig. 3.12). At 6 months, he can lift his head and greater part of the chest while supporting weight on the extended arms (Fig. 3.13). Between 4 and 6 months, he learns to roll over, at first from back to side and thenfrom back to stomach. By the age of 8 months, he crawls (with abdomen on the ground) and by 10 months, creeps (abdomen off the ground, with weight on knees and hands) (Fig. 3.14).

Sitting By the age of 5 months, the child can sit steadily with support of pillows or the examiner's hands (Figs 3.15 and 3.16). At first the back is rounded but gradually it straightens (Figs3.15 and3.16). He independently sitswith his arms forward for support (tripod or truly 'sitting with support') by the age of 6-7 months (Fig. 3.17). Steady sitting without any support generally develops at around 8 months (Fig. 3.18). By 10-11 months, he can pivot in sitting position to play around with toys (Fig. 3.19).

Fig. 3.11: In prone: face lifted to about 45° at 8 weeks

Fig. 3.12: In prone: face, head and chest off the couch at 3 months

Standing and walking By 6 months, the child can bear almost all his weight when made to stand (Fig. 3.20). At 9 months, the child begins to stand holding onto furniture and pulls himself to standing position. By 10 and 11 months, the child starts cruising around furniture. At about 12-13 months the child can stand independently (Fig. 3.21) and can walk with one hand held (Fig. 3.22). Between the ages of 13 and 15 months the child starts walking independently. He runsby 18 months and at this age he can crawl up or down stairs and pulls a doll or wheeled toy along the floor. By 2 yr, the child can also walk backwards. He climbs upstairs with both feet on one step at 2 yr. By 3 yr he can climb upstairs with one foot per step and by 4 yr he can move down the stairs in the same fashion (Fig. 3.23). He can ride a tricycle at 3 yr. He can hop at 4 yr and skip at 5 yr (Table 3.1).

Fig. 3.17: Sitting with support of hands at 6 months

Fig. 3.29: Mature grasp at 1 yr of age, note the use of thumb and index finger

Fig. 3.30: Pincer grasp approach to small objects (index finger and thumb)

Hand-to-mouth coordination At 6months,as theability to chew develops, the child can take a biscuit to his mouth andchew. At this age, he tends to mouth all objects offered to him (Fig. 3.31). This tendency abates by around 1 yr of age. By this age, he tries to feed self from a cup but spills some of the contents. By 15 months, the child can pick up a cup and drink from it without much spilling. By 18 months, he can feed himself well using a spoon.

With advancing age, the child can use hands to perform finer activities. Much of the advanced skills depend partly on the opportunity given by the caretakers to the child. At around 15 months, he turns 2-3 pages of a book at a time and scribbles on a

Fig. 3.32: Scribbles spontaneously at 15 months

Table 3.2: Key fine motor developmental milestones

Fig. 3.33: A child makes tower of 5-6 cubes at 2 yr of age

Drawing and block skills at various ages are shown in Figs 3.34 and 3.35, respectively. In general copying of the skill comes 6 months after imitating the skills (doing it while seeing).

Dressing Between 18 and 30 months of age, children are very eager to learn dressing skills. Undressing being

easier, is learned before dressing. At 1 yr the child starts to pull off mittens, caps and socks. At around 18 months, he can unzip, but fumbles with buttons. By 2 yr, he can

put on shoes or socks and can undress completely. By 3 yr, he can dress and undress fully, if helped with buttons. By 5 yr, he can tie his shoelaces as well.

Personal and Social Development and

General Understanding

Much of the cognitive development and understanding is reflected by the attainment of important milestones in this sphere. Beginning at around 1 month, the child intently watches his mother when she talks to him (Fig. 3.36). He starts smiling back (social smile) when anyone talks to him or smiles at him by 6-8 weeks of age (Fig. 3.37). It is important to differentiate social smile from spontaneous smile (smile without any social interaction), which is present even in neonates. By 3 months, he enjoys looking around and recognizes his mother. By 6 months, he vocalizes and smiles at his mirror image (Fig. 3.38), and imitates acts such as cough or tongue protrusion.

Fig. 3.36: At 1 month, the babyshowing intent regard of his mother's face as she talks to him

Fig. 3.37: Social smile

Fig. 3.38: A child smiles at himself in the mirror at 6 months of age

The child becomes anxious on meeting strangers (stranger anxiety) by 6-7 months of age. At this age he inhibits to "no". At 9 months, he waves "bye-bye" and also repeats any performance that evokes an appreciative response from the observers. By 1 yr, he can understand simple questions, such as "where is papa", "where is your ball", etc. By 15 months, he points to objects in which he is interested. By 18 months, he follows simple orders and indulges in domestic mimicry (imitates mother sweeping or cleaning). At 2 yr, when asked he can point to 5-6 familiar objects, name at least 2-3 objects and point to 3--4 body parts. He begins to count, identify 1-2 colors and sing simple rhymes by age of 3 yr. Much of these milestones depend on the caretaker's interaction and opportunities provided to the child. The left and right discriminationdevelopsby4 yr. By this age, play activities are also very imaginative. By 5 yr of age, children can follow 3 step commands, identify four colors and repeat four digits (Table 3.3).

Language

Throughout the development of language it is the receptive ability and understanding which precedes expressive

Table 3.3: Key social and adaptive milestones

abilities. Soon after appearance of social smile at around 6 to 8 weeks, the child begins to vocalize with vowel sounds such as 'ah, uh'. At 3-4 months, he squeals with delight and laughs loud. He begins to say 'ah-goo', 'gaga' by 5 months of age. By 6 months, he uses monosyllables (ba, da, pa). Later, he joins consonants to form bisyllables (mama, baba, dada).

Before developing true meaningful speech, at around 9-10 months the child learns to imitate sounds derived from his native language. At his first birthday, he can usually say 1-2 words with meaning. At 18 months, he has a vocabulary of 8-10 words. Thereafter, the vocabulary increases rapidly to around 100 words by 2 yr, at which time 2-3 words are joined to form simple sentences. By3 yr, the toddler continually asks questions and knows his full name. He can give a coherent account of recent experiences and events by the age of 4 yr (Table 3.4).

Vision and Hearing

Adequate sensory inputs are essential for development. Both normal vision and hearing are of paramount importance for child development. The ability to see and hear is apparent even in the newborn. Thereafter maturation of visual and hearing pathways are reflected by specific visual and auditory behaviors.

Vision The best stimulus to check visual behavior is the primary caretaker's face. At birth, a baby can fixate and follow a moving person or dangling ring held 8-10 inches away up to a range of 45°. This increases to 90° by4 weeks and 180° by 12 weeks. At around 1 month, the baby can fixate on his mother as she talks to him(Fig. 3.39).

At about 3-4 months, the child fixates intently on an objectshownto him('graspingwith the eye') as if thechild wants to reach for the object(Fig. 3.40). Binocular vision begins at around 6 weeks and is well established by 4 months. By 6 months, the child adjusts his position to follow objects of interest, can follow rapidly moving objects by 1 yr. Later the child displays more maturity in

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Fig. 3.40: Grasping 'with the eye' at 3 months

vision by not only identifying smaller objects but also being able to recognize them.

Hearing Newborns respond to sounds by startle, blink, cry, quieting or change in ongoing activity. By 3 to 4 months, the child turns his head towards the source of sound. Hearing, may be checked by producing sound 11h feetawayfromthe ear(out of field of vision), andapattern of evolving maturity of hearing can be observed. At 5 to 6 months the child turns the head to one side and then downwards if a sound is made below the level of ears. One month later he is able to localize sounds made above the level of ears. By the age of 10 months the childdirectly looks at the source of sound diagonally(Fig. 3.41).

Developmental Assessment

Developmental delay is estimated to be present in about 10% of children. It is possible to recognize severe developmental disorders early in infancy. Speech impairment, hyperactivity and emotional disturbances are often not detected until the child is 3-4 yr old. Learning disabilities are not picked up until the child starts schooling.

Fig. 3.41: Diagonal localization of the source of sound at 10 months

Prerequisites

Thedevelopmentassessmentshould be assessedin aplace which is free from distractions. It is important that the child should not be hungry, tired, ill or irritated at time of development assessment. It would be desirable to assess him when he is in a playful mood with his mother around. Adequate time should be spent in making the child and family comfortable. Observation for alertness, concen­ tration and skills of the child is an integral part of assess­ ment carry a development kit (Box 3.1).

Steps

History A detailed history is the starting point for any development assessment. Observations by parents are fairly accurate. Hence, a well taken history will help in

(i) determining the details of probable risk factors affecting development, (ii) evaluation of rate of acquisition of skills and differentiating between delay andregression, and (iii) forming a gross impression about the development age of the child. This helps to choose the appropriate tools for further evaluation and confirmation.

Box 3.1. Equipment for development assessment

•A red ring (diameter 6-7 cm) tied to a string

•Nine red cubes

•Paper pellets

•Spoon

•Cup with handle

•A book with thick pages

•Picture book

•Red pencil, paper

•Doll and mirror

Examination Tlm, should be done to (i) assess physical growth and head circumference, (ii) do a physical assessment, particularly for dysmorphism, stigmata of intrauterine infections and signs of hypothyroidism, (iii) screen for vision and hearing, and (iv) conduct neurological examination and examine for primitive reflexes (if required).

Adequate time should be spent in observing the baby especially social responsiveness, alertness, concentration, interest and distractibility. It would be appropriate to assess vision and hearing at the outset so that further observations are not confounded by lack of sensory stimuli. The vocal responses, particularly the nature, frequencyandquality arenoted. Subsequently,fine motor skills should be assessed, including the interest, alertness and rapidity of responses.

The annoying maneuvers, including assessment of reflexes, headcircumference, ventral suspension and pull to sit should be done at the end. It is preferable to perform the developmental assessment before the systemic examination so that the child's cooperation is solicited.

By the end of the evaluation one shouldbe able to arrive at a conclusion whether the neurological status and cognitive statusarewithin normal range or not. Significant delays on screening is an indication for a detailed formal assessment of development status. Byassessment,one can assign developmental quotient (DQ) for any develop­ mental sphere. It is calculated as:

Average age at attainment---=----'=-- xlOO

Observed age at attainment

A DQ below 70% is taken as delayandwarrants detailed evaluation. To obtain a DQ of a child, a formal assessment by an individual trained in developmental assessment using appropriate tools/tests is needed. There are several tests to assess DQ. Each test has its own psychometric properties. They give different kinds of estimates of development like an overall score of development and subscores for gross motor, fine motor, visual perception, receptive language, expressive language, etc.

IQ tests mainly assess the cognitive/adaptive behavior part of the development. The age at which a particular test can be applied depends on the test items. However, in younger children (<5 yr), it is more meaningful to have a global assessment of abilities; hence DQ testing is more comprehensive. Specific IQ tests (Stanford-Binet intelli­ gence scales) are available to asses IQ starting from 2 yr of age.

Interpretation

In babiesbornpreterm,correctedage rather than postnatal age is used for determining developmental status till two years of age. For example, a child born at 32 weeks gesta­ tion (gestational age) seen at 12 weeks of age (postnatal age) should be consideredas a 4-week-old (corrected age) child for development assessment.