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Developmental Milestones

Rebecca J. Scharf, MD, MPH,* Graham J. Scharf, MA, Annemarie Stroustrup, MD, MPH
*Division of Developmental Pediatrics, Center for Global Health, Department of Pediatrics, University of
Virginia, Charlottesville, VA.

Institute for Advanced Studies in Culture, Charlottesville, VA.

Division of Newborn Medicine, Departments of
Pediatrics and Preventive Medicine, Icahn
School of Medicine at Mount Sinai, New York, NY.

Practice Gap
Clinicians should be aware of developmental milestones for children and
especially areas of concern that may prompt referral of a child for further
evaluation. Pediatric clinicians should carefully monitor developmental
progress in children born preterm.

Objectives After completing this article, readers should be able to:

1. Discuss progress in typical development in motor, language, social, and

cognitive domains.
2. Note differences in development for children born preterm.
3. Identify delays that warrant referral for further evaluation.


The rst years of development are crucial for lifelong learning and development.
Milestones follow predictable courses in infants and children, and later devel-
opmental skills build on previous ones achieved. Understanding normal devel-
opment can help clinicians to recognize delayed development. Early identication
of developmental delays allows for referral to therapeutic services, and children
referred for early intervention are more likely to make gains in developmental
milestones. Research into outcomes of intervening early in a childs life has
shown a great variety of benets when a child receives needed speech/language
therapy, physical therapy, occupational therapy, or special education services in
a language-rich preschool classroom environment. (1)(2)(3)(4) Coordination of
these services is often provided by state-based early intervention programs. These
services may also be found in health care settings or departments of education.
AUTHOR DISCLOSURE Drs Scharf and Manning and associates (5)(6) created a useful summary of some of the positive
Stroustrup and Mr Scharf have disclosed no results seen in intervention, which may be considered in economic analyses as
nancial relationships relevant to this article.
well as policy (Table 1). Targeted early intervention services may provide particular
This commentary does not contain a
discussion of an unapproved/investigative benet for children living in families with access to fewer resources or low
use of a commercial product/device. educational status.

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TABLE 1. The Benets of Early Childhood Intervention (5)

Increase in Improved school Earlier identication Improved living Decrease in teen Improved parent-
intellectual readiness of children at risk conditions pregnancies child relationships
Positive home-school Reduction in juvenile Improved Improved work skills Reduction in child Increased self-respect
relationships delinquency knowledge of abuse
Increased parental Increase in child- Increase in medical Increase in family Elimination of infant Acceptance of
involvement in a school engagement check-ups income and child homicide personal
childs schooling responsibility
Improved literacy Less disruptive Decrease in licit and Increased Development of social Mental health
behavior in illicit drug use employment rates support networks benets;
classroom environment with
reduced stress
Improved school Improved parent-child Improved prenatal Decrease in welfare Increased familiarity Self-efcacy
achievement relationships care dependence with local health
care/social service
support systems
Less need for Reduced participation Fewer emergency Improved peer Lower rates of family
remedial in criminal activity department visits relationships adversity and
assistance conict
Less school failure Reduced social isolation
Higher school Improved networks of
completion rates support

Reprinted with permission from Homel et al.(6)

SURVEILLANCE AND SCREENING as the Denver Developmental Screening Test and the
Ages & Stages Questionnaires, assess milestones across
Surveillance is attentiveness to population trends in disease,
multiple domains. Other tools, such as the Modied Check-
and screening involves administration of specic assess-
list for Autism in Toddlers, examine specic areas of concern,
ments to detect disease or disorder in individual children at
such as autism spectrum disorders. Clinicians should use a
a period when intervention would improve developmental
tool, such as those recommended by the AAP, for screening
trajectories. Screening is not intended for diagnosis but
children at routine intervals during health supervision visits.
rather for more rapid identication of individuals who
These tools and their use are discussed further in several
require further evaluation. Children identied via screening
useful articles. (7)(8)(9)
as positive for a particular disorder can be referred for
further evaluation, which usually entails more comprehen- DOMAINS OF DEVELOPMENTAL DELAY
sive history, testing, and examination to elucidate diagnoses
Specic developmental skills are described within larger
more clearly.
domains (Table 2). In children, developmental delays are
classied as specic or global. Children with global devel-
opmental delay have delays in multiple domains of devel-
Various valid tools are available for standardized screen- opment, while children with specic delay may have a
ing of childhood disorders and concerns. The American delay in only one area of development, such as language or
Academy of Pediatrics (AAP) recommends that clinicians motor skills. Delays in one domain may affect skills in
screen children for general development using standard- another. For example, a child with severe motor delays
ized, validated tools at 9, 18, and 24 or 30 months and for may not have as many opportunities to play and explore,
autism at 18 and 24 months or at any point when a thus affecting the cognitive domain, or a child with
caregiver or the clinician has a concern. Some tools, such language impairment may not be able to interact as well

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TABLE 2. Developmental Domains

Gross Motor Movements using the large muscles

Fine Motor Movements using the hands and smaller muscles, often involving daily living skills
Language Receptive and expressive communication, speech, and nonverbal communication
Cognitive Reasoning, memory, and problem-solving skills
Social-Emotional and Behavioral Attachment, self-regulation, and interaction with others

with playmates, thus slowing progress in the social may still exhibit head bobbing when supported in a seated
domain. position.


By 4 months of age, head-lag disappears when infants are
Developmental milestones have been established in gross
pulled to sitting. The infant is learning to roll from prone
and ne motor skills, self-help, problem-solving, social/
to supine positions. However, because of the current
emotional, and receptive and expressive language domains
recommendation that all infants be put to sleep on their
(Table 3). (10)(11)(12)
backs to prevent sudden infant death syndrome, rolling
from front to back is sometimes delayed. Occasionally,
Neonatal infants learn to roll back to front rst, despite it being
The 4 weeks after birth set the stage for the infants rst generally easier to roll prone to supine. Infants at this
year. Parents are learning to care for their infant, and early age can reach for objects consistently, put them in their
patterns of feeding, sleeping, and alert times are set. mouths, and shake a rattle. Interaction with others blossoms
Infants learn to look at faces, discriminate parents voices and infants laugh out loud.
from others, cry, make noises with their throats, and raise
their chins when prone. During this time, as well as Six Months
prenatally, infants hear their parents voices, beginning From 5 to 6 months of age, infants learn to roll supine to
the attachment process. Infants are learning that their prone and sit with hands propped in front of them. They
caregivers meet their needs, initiating a sense of security can sit upright for a brief time, and when sitting is
in these early days. All infants should receive hearing supported, they can use their hands to transfer an object
screenings in the neonatal period, and older infants or from one hand to the other. They reach for objects and
young children who do not alert to sounds or visually xate can hold two objects simultaneously. Infants begin to
on objects within a few inches of their face should be feed themselves easy foods such as crackers and may
referred for further hearing and vision assessments. hold a bottle. At this age, children move from cooing
Infants whose muscle tone is too low to allow for adequate (using vowel sounds such as aaah and oooo) to babbling
feeding or movement should be referred for evaluation. (using consonants to make duplicating noises with
Neonatal protective reexes are a useful way for the sounds such as ba, ma, and da). They smile and make
clinician to assess neurologic and motor function (Table noises in front of a mirror. At this age, infants begin
4). stranger anxiety; 6-month-old infants are more likely
to be wary of strangers and be comforted by familiar
Two Months caregivers.
The major milestone of 6 weeks is the social smile,
further endearing the infant to the parents. Around 2 Nine Months
months of age, infants coo and make noises responsively Around 9 months of age, children pull to stand and may
to caregivers. At this age, infants can bring their hands begin creeping or cruising. Infants can play with toys from
together at midline. When in a prone position, infants their seated position and take objects in and out of con-
begin to lift their chests off the table at 2 months, but they tainers, bang toys or blocks together, and hold food to take

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TABLE 3: Developmental Milestones

1 month Chin up in prone Hands sted near Sucks well Gazes at black- Discriminates Startles to voice/ Throaty noises
position face white objects mothers voice sound
Turns head in Follows face Cries out of
supine position distress

2 months Chest up in Hands unsted Opens mouth at Visual threat Reciprocal Alerts to voice/ Coos
prone position 50% of the time sight of breast or present smiling: sound Social smile (6
Head bobs when Retains rattle if bottle Follows large, responds to weeks)
held in sitting placed in hand highly contrast- adult voice and Vowel-like noises
position Holds hands ing objects smile
together Recognizes

3 months Props on fore- Hands unsted Brings hands to Reaches for face Expression of Regards speaker Chuckles
arms in prone 50% of the time mouth Follows objects disgust (sour Vocalizes when
position Inspects ngers in circle (in taste, loud talked to
Rolls to side Bats at objects supine position) sound)
Regards toys Visually follows
person who is
moving across a

4 months Sits with trunk Hands held pre- Briey holds onto Mouths objects Smiles sponta- Orients head in Laughs out
support dominately open breast or bottle Stares longer at neously at plea- direction of a loud
No head lag Clutches at novel faces than surable sight/ voice Vocalizes when
when pulled to clothes familiar sound Stops crying to alone
sit Reaches Shakes rattle Stops crying at soothing voice
Props on wrists persistently Reaches for ring/ parent voice
Rolls front to Plays with rattle rattle To and fro alter-
back nating

5 months Sits with pelvic Palmar grasps Gums/mouths Turns head to Recognizes care- Begins to respond Says Ah-goo
support cube pureed food look for dropped giver visually to name Razzes, squeals
Rolls back to Transfers objects: spoon Forms attach- Expresses anger
front hand-mouth- Regards pellet or ment relation- with sounds
Puts arms out hand small cracker ship to caregiver other than crying
front when Reaches/grasps
falling dangling ring
Sits with arms
supporting trunk

6 months Sits momentarily Transfers hand- Feeds self Touches reec- Stranger anxiety Stops momen- Reduplicative
propped on hand crackers tion and (familiar versus tarily to no babble with
hands Rakes pellet Places hands on vocalizes unfamiliar Gestures for up consonants
Pivots in prone Takes second bottle Removes cloth people) Listens, then
In prone posi- cube and holds on face vocalizes when
tion, bears on to rst Bangs and adult stops
weight on one Reaches with shakes toys Smiles/vocalizes
hand one hand to mirror

7 months Bounces when Radial-palmar Refuses excess Explores different Looks from object Looks toward Increasing
held grasp food aspects of toy to parent and familiar object variety of
Sits without sup- Observes cube in back when when named syllables
port steadily each hand wanting help Attends to music
Lateral Finds partially (eg, with a wind-
protection hidden object up toy)
Puts arms out to
sides for balance

8 months Gets into sitting Bangs spoon Holds own bottle Seeks object after Lets parents Responds to Says Dada
position after Finger feeds it falls silently to know when Come here (nonspecic)
Commando demonstration Cheerios or the oor happy versus Looks for family Echolalia (8 to 30
crawls Scissor grasp of string beans upset members, months)
Pulls to sitting/ cube Engages in gaze Wheres mama? Shakes head for
kneeling position Takes cube out of monitoring: . etc no
cup adult looks away
Pulls out large and child follows
peg adult glance with
own eyes


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TABLE 3. (Continued )



9 months Stands on feet Radial-digital Bites, chews Inspects bell Uses sounds to Enjoys gesture Says Mama
and hands grasp of cube cookie Rings bell get attention games (nonspecic)
Begins creeping Bangs two cubes Pulls string to Separation Orients to name Nonreduplicative
Pulls to stand together obtain ring anxiety well babble
Bear walks (all Follows a point, Orients to bell Imitates sounds
four limbs Oh look at.
straight) Recognizes
familiar people

10 months Creeps well Clumsy release of Drinks from cup Uncovers toy Experiences fear Enjoys peek-a- Says Dada
Cruises around cube held for child under cloth Looks preferen- boo (specic)
furniture using Inferior pincer Pokes at pellet in tially when name Waves bye-bye Waves bye-bye
two hands grasp of pellet bottle is called back
Stands with one Isolates index Tries to put cube
hand held nger and pokes in cup, but may
Walks with two not be able to let
hands held go

11 months Pivots in sitting Throws objects Cooperates with Finds toy under Gives objects to Stops activity Says rst word
position Stirs with spoon dressing cup adult for action when told no Vocalizes to
Cruises furniture Looks at pictures after Bounces to songs
using one hand in book demonstration music
Stands for a few (lets adult know
seconds he or she needs
Walks with one help)
hand held

12 months Stands well with Scribbles after Finger feeds part Rattles spoon in Shows objects to Follows one-step Points to get
arms high, legs demonstration of meal cup parent to share command with desired object
splayed Fine pincer grasp Takes off hat Lifts box lid to interest gesture (proto-impera-
Posterior of pellet nd toy Points to Recognizes tive pointing)
protection Holds crayon get desired names of two Uses several
Independent Attempts tower object (proto- objects and looks gestures with
steps of two cubes imperative when named vocalizing (eg,
pointing) waving,

13 months Walks with arms Attempts to Drinks from cup Dangles ring by Shows desire to Looks Uses three
high and out release pellet in with some string please caregiver appropriately words
(high guard) bottle spilling Reaches around Solitary play when asked, Immature jar-
clear barrier to Functional play Wheres the goning: inec-
obtain object ball? tion without real
Unwraps toy in words

14 months Stands without Imitates back and Removes socks/ Dumps pellet out Points at object Follows one-step Names one
pulling up forth scribble shoes of bottle after to express inter- command object
Falls by collapse Adds third cube Chews well demonstration est (proto- without gesture Points at object
Walks well to a two-cube Puts spoon in declarative to express inter-
tower mouth (turns pointing) est (proto-
Puts round peg over) Purposeful declarative
in and out of exploration of pointing)
hole toys through trial
and error

15 months Stoops to pick up Builds three-to Uses spoon with Turns pages in Shows empathy Points to one Uses three to
toy four-cube tower some spilling book (someone else body part ve words
Creeps up stairs Places 10 cubes Attempts to Places circle in cries, child looks Points to one Mature jargoning
Runs stiff-legged in cup brush own hair single-shape sad) object of three with real words
Walks carrying Releases pellet Fusses to be puzzle Hugs adult in when named
toy into bottle changed reciprocation Gets object from
Climbs on Recognizes another room
furniture without a dem- upon demand
onstration that a
toy requires acti-
vation; hands it
to adult if cant


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TABLE 3. (Continued )



16 months Stands on one Puts several Picks up and Dumps pellet out Kisses by touch- Understands Uses 5 to 10
foot with slight round pegs in drinks from cup without ing lips to skin simple com- words
support board with Fetches and car- demonstration Periodically visu- mands, Bring to
Walks backwards urging ries objects Finds toy ally relocates mommy
Walks up stairs Scribbles (same room) observed to be caregiver Points to one
with one hand spontaneously hidden under Self-conscious; picture when
held layers of covers embarrassed named
Places circle in when aware of
form board people

18 months Creeps down Makes four-cube Removes Matches pairs of Passes M-CHAT Points to two of Uses 10 to 25
stairs tower garment objects Engages in pre- three objects words
Runs well Crudely imitates Gets onto adult Replaces circle in tend play with when named Uses giant words
Seats self in small vertical stroke chair unaided form board after other people (eg, Points to three (all gone, stop
chair Moves about it has been tea party, birth- body parts that)
Throws ball while house without turned around day party) Points to self Imitates environ-
standing adult (usually with trial Begins to show Understands mental sounds
and error) shame (when mine (eg, animals)
does wrong) and Points to familiar Names one pic-
possessiveness people when ture on demand

20 months Squats in play Completes Places only edi- Deduces loca- Begins to have Points to three Holophrases
Carries large round peg board bles in mouth tion of hidden thoughts about pictures (Mommy?
object without urging Feeds self with object feelings Begins to under- and points to
Walks downstairs Makes ve- to six- spoon entire Places square in Engages in tea stand her/him/ keys, meaning:
with one hand cube tower meal form board party with stuf- me These are
held Completes fed animals Mommys
square peg Kisses with keys.)
board pucker Two-word
requests with

22 months Walks up stairs Closes box with Uses spoon well Completes form Watches other Points to four to Uses 25 to 50
holding rail, put- lid Drinks from cup board children ve pictures words
ting both feet on Imitates vertical well intensely when named Asks for more
each step line Unzips zippers Begins to show Points to ve to Adds one to two
Kicks ball with Imitates circular Puts shoes on deant behavior six body parts words/week
demonstration scribble partway Points to four
Walks with one pieces of cloth-
foot on walking ing when named

24 months Walks down Makes a single- Opens door Sorts objects Parallel play Follows two-step Two-word sen-
stairs holding rail, line train of using knob Matches objects Begins to mask command tence (noun
both feet on cubes Sucks through a to pictures emotions for Understands me/ verb)
each step Imitates circle straw Shows use of social etiquette you Telegraphic
Kicks ball without Imitates horizon- Takes off clothes familiar objects Points to 5 to 10 speech
demonstration tal line without buttons pictures Uses 50 words
Throws Pulls off pants 50% intelligibility
overhand Refers to self by
Names three

28 months Jumps from bot- Strings large Holds self and Matches shapes Reduction in Understands just Repeats two
tom step with beads awkwardly verbalizes toilet Matches colors separation one digits
one foot leading Unscrews jar lid needs anxiety Begins to use
Walks on toes Turns paper pa- Pulls pants up pronouns (I, me,
after ges (often several with assistance you)
demonstration at once) Names 10 to 15
Walks backward pictures
10 steps


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TABLE 3. (Continued )



30 months Walks up stairs Makes eight- Washes hands Replaces circle in Imitates adult Follows two Echolalia and
with rail, alter- cube tower Puts things away form board after activities (eg, prepositions: jargoning gone
nating feet Makes a train of Brushes teeth it has been sweeping, put block Names objects
Jumps in place cubes and with assistance turned around talking on in.on box by use
Stands with both includes a stack (little or no trial phone) Understands Refers to self with
feet on balance and error) actions words: correct pronoun
beam Points to small playing . Recites parts of
Walks with one details in pictures washing . well-known
foot on balance blowing story/ lls in
beam words

33 months Walks swinging Makes 9- to 10- Toilet trained Points to self in Begins to take Understands Gives rst and
arms opposite of cube tower Puts on coat photos turns three last name
legs Puts six square unassisted Points to body Tries to help with prepositions Counts to 3
(synchronous pegs in parts based on household tasks Understands Begins to use
gait) pegboard function (What dirty, wet past tense
Imitates cross do you hear Points to objects Enjoys being
with?) by use: ride read to (short
in.put on books)
feet.write with

3 years Balances on one Copies circle Independent Draws a two- to Starts to share Points to parts of Uses 200
foot for 3 Cuts with scis- eating three-part with/without pictures (nose of words
seconds sors: side-to-side Pours liquid from person prompt cow, door of car) Three-word
Goes up stairs, (awkwardly) one container to Understands Fears imaginary Names body sentences
alternating feet, Strings small another long/short, big/ things parts with Uses pronouns
no rail beads well Puts on shoes small, more/less Imaginative play function correctly
Pedals tricycle Imitates bridge without laces Knows own Uses words to Understands 75% intelligibility
Walks heel to toe of cubes Unbuttons gender describe what negatives Uses plurals
Catches ball with Knows own age someone else is Groups objects Names body
stiff arms Matches letters/ thinking (Mom (foods, toys) parts by use
numerals thought I was Asks to be read
asleep) to

4 years Balances on one Copies square Goes to toilet Draws a four- to Deception: inter- Follows three- Uses 300 to
foot 4 to 8 Ties single knot alone six-part person ested in tricking step commands 1,000 words
seconds Cuts 5-inch circle Wipes after Can give others and con- Points to things Tells stories
Hops on one foot Uses tongs to bowel amounts (usually cerned about that are the same 100%
two to three transfer movement less than 5) being tricked by versus different intelligibility
times Writes part of rst Washes face/ correctly others Names things Uses feeling
Standing broad name hands Simple analogies: Has a preferred when actions are words
jump: 1 to 2 feet Imitates gate Brushes teeth dad/boy: friend described (eg, Uses words that
Gallops with cubes alone mother/??? Labels happiness swims in water, tell about time
Throws ball Buttons ice/cold: sadness, fear, and you cut with it,
overhand 10 feet Uses fork well re/??? anger in self its something
Catches ceiling/up: Group play you read, it tells
bounced ball (4 oor/??? time.)
yrs) Points to ve to Understands
six colors adjectives: bushy,
Points to letters/ long, thin,
numerals when pointed
Rote counts to 4
Reads several
common signs/
store names


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TABLE 3. (Continued )



5 years Walks down Copies triangle Spreads with Draws an 8- to Has group of Knows right and Repeats six- to
stairs with rail, Puts paper clip knife 10-part person friends left on self eight-word
alternating feet on paper Independent Gives amounts Apologizes for Points to differ- sentence
Balances on one Can use clothes- dressing (<10) mistakes ent one in a Denes simple
foot > 8 seconds pins to transfer Bathes Identies coins Responds ver- series words
Hops on one foot small objects independently Names letters/ bally to good Understands er Uses 2,000 words
15 times Cuts with scissors numerals out of fortune of others endings (eg, Knows tele-
Skips Writes rst name order batter, skater) phone number
Running broad Builds stairs from Rote counts to 10 Understands Responds to
jump 2 to 3 feet model Names 10 colors adjectives: busy, why questions
Walks backward Uses letter long, thin, Retells story with
heel-toe names as sounds pointed clear beginning,
Jumps backward to invent spelling Enjoys rhyming middle, end
Knows sounds of words and
consonants and alliterations
short vowels by Produces words
end of that rhyme
kindergarten Points correctly
Reads 25 words to side, mid-
dle, corner

6 years Tandem walks Builds stairs from Ties shoes Draws a 12- to Has best friend of Asks what un- Repeats 8- to
memory Combs hair 14-part person same sex familiar words 10-word
Draws diamond Looks both ways Number con- Plays board mean sentences
Writes rst and at street cepts to 20 games Can tell which Describes events
last name Remembers to Simple addition/ Distinguishes words do not in order
Creates and bring belongings subtraction fantasy from belong in a Knows days of
writes short Understands reality group the week
sentences seasons Wants to be like 10,000 word
Forms letters Sounds out reg- friends and vocabulary
with down- ularly spelled please them
going and coun- words Enjoys school
terclockwise Reads 250 words
strokes by end of rst
Copies drawing grade
of ag

bites. At this age, gaze monitoring (following the adult desired object, an action that becomes very useful for emerg-
glance with the childs own eyes) begins. Nine-month-olds ing toddlers discovering their own wishes. These children
are interested in what others around them nd interesting understand and respond to no (even if they dont always
and are eager to engage. These infants respond to simple obey) and they begin using words.
commands and may begin using dada/papa and mama
nonspecically in babble.
Fifteen Months
As children pass their rst birthday, many new skills con-
Twelve Months tinue to emerge. Early toddlers are beginning to learn more
The 1 year old mark hails numerous changes in a childs words; many combine babbling, jargon, and words for a
life. Children begin to walk and talk around this age. delightful language all their own. The children begin to
Increased communication and mobility have cascading point to body parts or objects in books upon request and
effects for learning in all domains. By 12 months, many retrieve an object when sent (eg, when asked to go get their
infants can stand well, with legs apart and arms out or shoes so they will be ready to go to the park). In addition,
overhead. They can walk, either independently or while they can turn pages in a book (important for early reading
holding the hand of a caregiver. They have learned to throw development) and place 10 cubes in a cup, a pellet in a small
objects and can enjoy the wonders of gravity by dropping bottle, and a circle in a shape puzzle. A key skill by this age is
objects over the side of the high chair or stroller. One-year-olds proto-declarative pointing or pointing to express interest.
cooperate with dressing, remove hats and socks, and nger Fifteen-month-olds scribble on paper with a crayon and
feed themselves using a mature pincer grasp. They look for build a three-cube tower. At this age, empathy begins to
hidden toys and can let adults know when they need help. develop and children can feel happy or sad alongside a peer
Proto-imperative pointing involves pointing to obtain a or family member.

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Eighteen Months hands and face, and use a fork. During the year, four-year-
At 18 months of age, children can run, seat themselves in a olds often develop a preference for certain friends, can
chair, make a four-cube tower with blocks, and imitate identify emotions they may feel, and are learning to play
vertical strokes with a crayon. They pretend to talk on the in groups.
phone, drive a car, or have a tea party. Children now begin
to understand the concept of mine, and this often
Five Years
becomes a favorite word as children learn possessiveness.
At the 5-year birthday, children enter the school-age
Shame, guilt, or sadness after wrongdoing emerge at this
years. Their balance improves to more than 8 seconds per
age and may affect a childs choice of actions. Children at
foot, they can hop on one foot 15 times in a row, and they
18 months often use 10 to 25 words (or more!) and point to
learn to skip. They can copy a triangle, cut out shapes with
pictures, people, and body parts as well as name a familiar
scissors, write their names, and use blocks to build stairs.
object when requested.
They can dress themselves in the morning and are often
able to bathe independently. Children draw a person with
Twenty-four Months 8 to 10 parts, identify coins, recite the alphabet, and count
Here begins the wonderful world of two-year-olds. Children out loud. At this age, children sometimes skip letters or
who are 24 months can kick a ball, throw overhand, and give numbers out of order, and they may still write some
begin to learn to jump. They can imitate circles and hori- letters or numbers reversed. The ability to hear and
zontal lines. They are beginning to take clothes off inde- produce rhyming words is an important predictor of
pendently (a key step to potty-training) and can turn door early phonemic awareness and literacy skills. By the
knobs. Socially, they often play in parallel, ie, side-by-side end of kindergarten, children usually know the sounds
but often without signicant cooperation. They can dem- that consonants and short vowels make and can often
onstrate deant behavior as well as mask certain feelings read 25 words (or more). Socially, children in kindergar-
when socially appropriate. At 2 years of age, children are ten usually have a group of friends and are able to be glad
using between 50 and 200 words, putting two words for their friends when good things happen. During this
together in sentences with a noun and verb, and calling year, children learn right from left (from their own
themselves by name. perspective) and can identify locations. At this age, chil-
dren have more than 2,000 words and can dene simple
Thirty-six Months words, use sentences competently, and memorize their
Three years is the magical year of pretend play, socialization, telephone number or address. They can answer why
and developing creativity. By 3 years, most children can questions. Children often love to be read to and can repeat
identify their own gender as well as the gender of their stories, retelling the beginning, middle, and end of the plot.
friends. Children learn to draw a circle, are able to climb on a Creativity and unique interests begin to emerge in this
jungle gym, and run much more quickly than before. delightful age.
Sentences develop into paragraphs and children begin to
take part in back and forth conversation. A three-year-old can Six to Twelve Years
fear imaginary things and describe what others might be The school years are devoted to gaining and rening skills.
thinking. Children develop greater motor skills and proceed from
learning to run, hop, and skip to more complex skills such
Four Years as soccer, swimming, or dancing. By 6 years, many chil-
At 4 years, children are gaining greater balance and learn dren have mastered riding a bicycle without training
to hop on one foot a few times in a row. They can balance wheels. Fine motor skills progress to improved handwrit-
on each foot for 4 to 8 seconds, jump 1 to 2 feet forward, ing and then more complex tasks such as ngering on the
and gallop. Four-year-olds learn to copy a cross and a violin, drawing and painting, woodworking, or typing.
square with a crayon, tie a knot, and cut paper. Four-year- Children are able to speak in paragraphs, hold conversa-
olds can also draw a four- to six-part person. They can tions, and recount stories with detail. Around the third
point to ve to six colors, identify many numbers and grade, children progress from learning to read and begin
letters, count to 4 by rote, and possibly recognize signs reading to learn, thus opening a world of knowledge. The
(such as a Stop sign) or favorite stores or brands. They are elementary years are an enjoyable time of learning, grow-
able to use the restroom independently, brush teeth, wash ing, and exploring.

Vol. 37 No. 1 JANUARY 2016 33

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TABLE 4. Neonatal Reexes

Rooting The infants head turns toward the side, the cheek is Present in utero at 24 weeks, disappears at 3-4 months,
touched, and the mouth opens. although may persist in sleep until 1 year.
Sucking Placing something in the mouth causes infant to suck Sucking appears in utero early in gestation. Sucking and
and draw liquid into the mouth. swallowing may not mature until 32-36 weeks
gestation. Sucking may disappear around 3 months of
age, although it persists longer in sleep.
Moro/Startle A sudden change in position or loud noise causes the In utero at 28 weeks gestation, disappears at 3-6 months
infants arms/ngers to extend and then come of age.
Withdrawal The infant moves the hand or foot from painful Present at birth and remains for life.
Palmar/Plantar Grasp Placing a small object or nger in palm or beneath toe Present at 32 weeks gestation. Palmar disappears at 3-4
causes ngers or toes to curl around object. months and is replaced by voluntary grasp at 4-5
months. Plantar disappears at 9-12 months.
Asymmetric Tonic Neck When supine and head turned to one side, the arm Present at birth and disappears at approximately 3-4
(ATNR) and leg on that side extend while opposite limbs months (and allows for rolling).
are exed.
Babinski Stroking bottom of foot causes big toe to raise while Present at birth and disappears at 9-10 months. If found
other toes fan out and foot twists in. when child is older, may indicate neurologic disease.
Landau When infant is suspended horizontally and prone, if Appears at 3 months and disappears between 1 and 2
head is exed against the trunk, the legs ex against years.
the trunk.
Parachute Suddenly moving the infant downward when Appears at 7-9 months and persists indenitely.
horizontal causes hands and ngers to extend
forward and spread to protect from fall.
Knee Jerk A tap on the tendon below the patella causes the leg Becomes more pronounced at postnatal day 2 and
to extend quickly. remains throughout life.

RED FLAGS have challenges promoting their childs growth and

development and may benet from aid in providing
Clinicians may note red ags in developmental mile-
developmental stimulation and opportunities for play
stones that are cause for concern, further monitoring,
and learning. Parents with low educational attainment
or referral (Table 5). In children, certain absent mile-
or fewer community resources may require additional
stones may indicate a developmental delay that is more
likely to be long-lasting or to require earlier intervention. support services. (14)
The pediatrician is often the primary support for fam-
Areas that benet from intervention are particularly
ilies in identifying red ags and guiding interventions.
important to identify and treat to allow the child the
Children with unexplained early motor delays or hypotonia
greatest likelihood of healthy development. Studies show
that beginning intervention earlier in a childs develop- may benet from further evaluation for conditions such as
mental course leads to improved outcomes and can cerebral palsy, muscular dystrophy, or other neuromuscu-
improve engagement of a family in the childs develop- lar disorders. A recent AAP Guideline for Early Identi-
mental progress (Table 1). (5) cation of Motor Delay provides a helpful algorithm for
Parents may also exhibit patterns that are red ags for a motor evaluation at routine periods. The algorithm sug-
childs development. If a parent is frequently insensitive to gests obtaining creatinine kinase measurements and thy-
an infants communication, is unable to recognize the roid studies when hypotonia is found and ordering
infants cues, is easily angered by the infant, or ignores the magnetic resonance imaging of the brain in specic set-
infant, this may be a sign of difculty with attachment and tings of persistent, unexplained hypertonia. (15) Children
family support may be warranted. (13) Furthermore, par- who exhibit red ags in the areas of social communica-
ents struggling with depression or substance abuse may tion can be referred for evaluation for autism spectrum

34 Pediatrics in Review
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disorders or language concerns. Children with receptive or intervention before intrauterine demise. (18) Long-term
expressive language delays benet from a thorough eval- survival of infants born preterm has also risen dramati-
uation and treatment by a speech/language pathologist. cally. Preterm birth is now a leading cause of neuro-
Children with developmental delay not explained by the developmental disabilities in children, (19) and the
medical history may benet from evaluation by a pediatric degree of neurodevelopmental disability is inversely cor-
genetics team. (16) related with gestational age at birth. Although previously
believed to be at low risk for developmental delay, even
children born in the late preterm period (34-0/7 to 36-6/7
weeks gestation) have a signicantly increased risk of
Each year, approximately 12% of infants in the United behavioral disorders and learning delay compared with
States almost 500,000 are born preterm (before the children born at term. (20) Delays associated with pre-
37th postmenstrual week). (17) Although stable in the maturity include cognitive, language, motor, social-
recent past, the preterm birth rate rose dramatically emotional, and learning domains. (21) Risk factors for delay
between 1980 and 2006, due both to the development can manifest before or after preterm birth (Table 6). Many
and increased use of assisted reproductive technologies of the most signicant contributors to developmental chal-
and to advances in obstetric management that allowed lenges are social and may need to be addressed using

TABLE 5. Developmental Red Flags


Neonatal period Infant does not respond to loud Muscle tone too low to feed. Caregiver shows indifference or
sounds. disinterest in infant.
2 months Does not alert to voice. Cannot raise head when prone. Lack of looking at faces/lack of xation.
4 months No cooing or gurgling sounds. Unable to bring hands to midline. Lack of smiling.
6 months Lack of turning toward voices. Does not pass object from one hand No smiling, laughing, or expression.
to another.
9 months Lack of babbling with consonants. Inability to sit. Lack of rolling. Absence of back-and-forth smiles and
vocalizations in conversation.
12 months Child does not respond to name. Does Does not stand or bear weight on legs Indifferent or resistant attachment to
not understand no. when supported. caregiver. Does not look where
caregiver points.
15 months Does not use words such as mama No pincer grasp. Absence of proto-imperative pointing
and papa/dada. (point to desired object).
18 months Not using at least 6 words. Inability to walk independently. Absence of proto-declarative pointing
(point to show interest) or showing
24 months Lack of words and two-word Inability to walk well. Does not imitate actions or words of
meaningful sentences. Inability to caregivers. Poor eye contact.
follow simple commands.
36 months Inability to use three-word sentences. Frequent falling or difculty with stairs. Lack of pretend play.
4 years Unclear speech. Does not answer Does not jump in place. Ignores other children.
simple questions. Inability to use
5 years Inability to rhyme. Inability to Does not draw pictures, a square, or a Unusually fearful, sad, shy, angry. Does
recognize shapes, letters, colors. cross. Poor balance. not distinguish between real and
Resists dressing, sleeping, using the make-believe.
6-12 years Cannot retell or summarize a story Does not skip or hop on one foot. Does not name friends. Cannot
with beginning, middle, and end. Does not write name. recognize feelings in others.
Any age Loss of previously acquired skill.

Vol. 37 No. 1 JANUARY 2016 35

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community support services addressing the entire familys entrance for many children, and because school entrance is
needs or concerns. based on chronologic rather than corrected age, reverting
Screening tests and treatment algorithms for devel- to chronologic age allows the provision of appropriate
opmental delay in children born at term can be used for services for preterm children cared for alongside their
preterm children. When comparing performance of term peers.
preterm children to developmental norms, corrected Besides age-adjustment, clinicians should pay specic
age or age from due date rather than birth date is attention to sensory function in children born preterm. The
generally used. (22)(23) There is no consensus among incidence of visual and hearing impairments is higher in
experts in perinatal care regarding the specic duration preterm than term children due to increased risk for reti-
of time that gestational age correction should be per- nopathy of prematurity, jaundice, cortical hemorrhages,
formed. Both the AAP and Centers for Disease Control infections, and extended hospitalization. Unrecognized
and Prevention support gestational age correction, as do visual or hearing impairment can distort performance on
most researchers focused on neurodevelopmental out- cognitive and behavioral testing. Children born preterm are
comes, although formal policy guidelines for when and also at greater risk than their term peers for intraventricular
how to apply gestational age correction have not been hemorrhage and possible cerebral palsy, particularly spastic
formulated. (24) As a result, some developmental cen- diplegia, which can also affect performance on assessments
ters do not correct for prematurity, while others con- of motor function.
tinue correcting until a child is attending school. Many Language delays are more common in infants born
screening tools have specic guidelines for gestational preterm due to distinct or compounded difculties with
age correction; in those cases, the recommended tool- processing auditory and visual information, learning and
specic correction should be used. In the absence of conceptualizing verbal language, and producing speech
formal guidelines, most developmental clinicians and sounds. (23) As they reach school age, children born
researchers correct for prematurity for the rst 24 preterm are at particular risk for learning delays, both
months after birth. (23) When children are delayed those related to spoken and written language production
beyond their corrected age, this is a red ag for concern. and those related to behavioral problems that make class-
Pediatric clinicians should be aware that correcting for room learning challenging. Both externalizing and inter-
gestational age may overcorrect for milestones in the nalized behaviors, as well as social difculties, are more
social and language domains, and these may need closer common in preterm than term children. (22)(26)(27)(28)
attention. By age 2 or 3 years, most children with Due to the elevated risk of sometimes subtle cognitive and
transient delays related to prematurity have caught behavioral disabilities, pediatric clinicians caring for chil-
up with their term peers, and chronologic age can be dren born preterm must be particularly vigilant when
used. (25) This time point also corresponds to preschool performing developmental assessments to engage the

TABLE 6. Risk Factors for Developmental/Behavioral Concerns Following

Preterm Birth (23)
Prenatal Very low birthweight (<1500 g)
Extremely low gestational age (birth <28 weeks gestation)
Intrauterine growth restriction
Male gender
Postnatal Neonatal seizures (before 28 days of age)
Abnormal brain imaging (white matter injury/periventricular leukomalacia, grade 3 or 4 intraventricular hemorrhage)
Chronic lung disease/bronchopulmonary dysplasia
Prolonged mechanical ventilation (>96 hours)
Bacteremia, meningitis, or sepsis
Necrotizing enterocolitis
Feeding problems beyond 36 weeks postmenstrual age
Extracorporeal membrane oxygenation
Social Low socioeconomic status
Low parental educational achievement
Language barrier with family
Parental depression

36 Pediatrics in Review
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appropriate therapeutic services as early as possible. (3)
Available dedicated early intervention programs should Summary
be used because they may have a lasting benet on
On the basis of observational studies (level C), preterm birth is a
cognitive outcome and educational achievement. (29) leading cause of neurodevelopmental disabilities in children, (19)
(30) In addition, counseling and parent support groups and the degree of neurodevelopmental disability is inversely
may have benet for families seeking to provide behav- correlated with gestational age at birth. When comparing
ioral and emotional support to their children born pre- performance of preterm children to developmental norms,
corrected age or age from due date rather than birth date
term. (31)(32)
should be used for the rst 24 to 36 months. (22)(23)
On the basis of observational studies (level C), clinicians should
CONCLUSION pay specic attention to sensory function in children born
preterm because the incidence of visual and hearing impairments
The rst years of development are crucial for lifelong is higher in preterm than term children. Due to the elevated risk of
learning and development. Milestones follow predictable cognitive and behavioral disabilities, clinicians caring for children
born preterm should be vigilant when performing
courses in infants and children, and later developmental
developmental assessments to improve outcomes. (3)
skills build on previous ones achieved. Understanding
On the basis of observational studies (level C), early identication
normal development is important for the pediatrician to
of developmental delays allows for referral to therapeutic
be able to recognize delayed development. (1)(5)(33) De- services, and children referred for early intervention are more
velopmental screening identies developmental delays likely to make gains in developmental milestones. (1)(5)(33)(34)
at a time period in which formal evaluation and interven-
tion would be benecial. Children with global develop-
mental delay have delays in multiple domains of development, CME quiz and references for this article are at http://pedsinreview.
while children with specic delay may have a delay in aappublications.org/content/37/1/25. Access this and all other PIR
only one area of development such as language or motor CME quizzes available for credit at: http://www.aappublications.
skills. org/content/pediatrics-review-quizzes.

Parent Resources from the AAP at HealthyChildren.org

Developmental Milestones: 1 Month: https://www.healthychildren.org/English/ages-stages/baby/Pages/Developmental-Milestones-1-Month.aspx
Developmental Milestones: 3 Months: https://www.healthychildren.org/English/ages-stages/baby/Pages/Developmental-Milestones-3-Months.aspx
Developmental Milestones: 7 Months: https://www.healthychildren.org/English/ages-stages/baby/Pages/Developmental-Milestones-7-Months.aspx
Developmental Milestones: 12 Months: https://www.healthychildren.org/English/ages-stages/baby/Pages/Developmental-Milestones-12-Months.aspx
Developmental Milestones: 2 Year Olds: https://www.healthychildren.org/English/ages-stages/toddler/Pages/Developmental-Milestones-2-Year-Olds.aspx
Developmental Milestones: 3 to 4 Year Olds: https://www.healthychildren.org/English/ages-stages/toddler/Pages/Developmental-Milestones-3-to-4-Years-Old.aspx
Developmental Milestones: 4 to 5 Year Olds: https://www.healthychildren.org/English/ages-stages/toddler/Pages/Developmental-Milestones-4-to-5-Years-Old.

CME Quiz Correction

In the November 2015 article Otitis Media: To Treat, To Refer, To Do Nothing: A Review for the Practitioner, (Rosa-
Olivares J, Porro A, Rodriguez-Varela M, Riefkohl G, Niroomand-Rad I. Pediatrics in Review. 2015;36(11):480, DOI:
10.1542/pir.36-11-480), there were errors in CME quiz question 4. In the question body, the following sentence should
have been omitted: You refer her to the audiologist, who documents a 30-dB hearing loss. In addition, the correct
answer option should be C. Referral to audiology. The online version of the quiz and the article have been corrected.
The journal regrets the error.

Vol. 37 No. 1 JANUARY 2016 37

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PIR Quiz
There are two ways to access the journal CME quizzes:
1. Individual CME quizzes are available via a handy blue CME link in the Table of Contents of any issue.
2. To access all CME articles, click Journal CME from Gateways orange main menu or go directly to: http://www.

1. What is the purpose of screening for developmental milestones? REQUIREMENTS: Learners

A. Assess the incidence of developmental delays in a clinic population. can take Pediatrics in
B. Diagnose developmental delays. Review quizzes and claim
C. Identify children for referral to special education programs. credit online only at:
D. Identify children who should be referred for further evaluation. http://pedsinreview.org.
E. Plan for treatment of developmental delays.
2. A term 4-month-old male infant is developing normally. Which of the following is the To successfully complete
major milestone for normally developing children at this age? 2016 Pediatrics in Review
A. Bring hands together to midline. articles for AMA PRA
B. Lift head up when prone. Category 1 CreditTM,
C. No head lag when pulled to sit. learners must
D. Social smile. demonstrate a minimum
E. Roll supine to prone. performance level of 60%
or higher on this
3. A child is able to run, make a four-cube tower with blocks, and have a tea party. She
assessment, which
understands mine and she feels badly when she steps on her mothers foot. Given normal
measures achievement of
developmental progress, how old is she?
the educational purpose
A. 15 months. and/or objectives of this
B. 18 months. activity. If you score less
C. 2 years. than 60% on the
D. 2.5 years. assessment, you will be
E. 3 years. given additional
4. A 3-year-old girl is developing normally. Which of the following milestones is consistent opportunities to answer
with her developmental age? questions until an overall
A. Copy a square. 60% or greater score is
B. Identify her own gender. achieved.
C. Imitate a horizontal line.
D. Throw a ball overhand. This journal-based CME
E. Turn door knobs. activity is available
5. How long should you correct for gestational age when evaluating preterm infants? through Dec. 31, 2018,
A. 6 months. however, credit will be
B. 12 months. recorded in the year in
C. 24 months. which the learner
D. Until kindergarten. completes the quiz.
E. Until entry to high school.

38 Pediatrics in Review
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Developmental Milestones
Rebecca J. Scharf, Graham J. Scharf and Annemarie Stroustrup
Pediatrics in Review 2016;37;25
DOI: 10.1542/pir.2014-0103

Updated Information & including high resolution figures, can be found at:
Services http://pedsinreview.aappublications.org/content/37/1/25
References This article cites 31 articles, 12 of which you can access for free at:
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Journal CME
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
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Management 25% to 50% addiction rates. Patients with CHS should
Patients presenting in a hyperemetic phase of CHS often be referred to inpatient or outpatient drug rehabilitation
are volume-depleted and require oral or IV rehydration. If programs.
volume depletion is severe or urine output remains low
after administration of uids, renal function should be Lessons for the Clinician
tested. Because esophagogastroscopy in patients with Recurrent vomiting has a broad differential diagnosis that
CHS has shown gastritis and esophagitis, many clinicians includes gastrointestinal, neurologic, metabolic, urologic,
routinely prescribe acid suppressive therapy. Antiemetics psychiatric, and toxic causes.
typically are unhelpful, although a case report has docu- Cannabinoid hyperemesis syndrome (CHS) presents
mented relief with haloperidol. Pain is usually treated with in chronic daily or almost-daily users of cannabinoids,
nonopioids because of concern that opioids might worsen typically after more than 1 year of use.
nausea. Patients may be encouraged to continue hot bath- Diagnosing CHS is often substantially delayed; one
ing for pain and nausea relief. Curative therapy consists of important diagnostic clue is the learned behavior of hot
cessation of cannabis use, after which pain and emesis bathing to relieve pain and nausea.
typically resolve over 48 hours. Resumption of cannabis In cases of CHS, an extensive or prolonged diagnostic
use leads to relapse. Educating the patient about the cause of evaluation is not necessary.
symptoms is key because many perceive cannabis to be Curative therapy for CHS consists of cessation of can-
helpful for their nausea. nabis use.
Although cannabinoids are believed to be less addictive
than many drugs of abuse, approximately 9% of users Suggested Readings for this article are at http://pedsinreview.
become addicted, and daily users are at higher risk, with aappublications.org/content/37/6/264.

In the January 2016 review Developmental Milestones (Scharf, Scharf, Soustrup. Pediatrics in Review. 2016;37(1):2538,
DOI: 10.1542/pir.2014-0103), a line was duplicated inadvertently. In Table 3: Developmental Milestones, at age 5 months,
ne motor skills should not include Holds hands together. The online version of the article has been corrected. The
journal regrets the error.


Cytomegalovirus and Epstein-Barr Virus Infections: 1. E; 2. E; 3. E; 4. A; 5. C.
Acquired and Congenital Hemolytic Anemia: 1. D; 2. D; 3. A; 4. B; 5. C.
Preventing Infections in Children with Cancer: 1. C; 2. B; 3. E; 4. C; 5. E.

266 Pediatrics in Review

Developmental Milestones
Rebecca J. Scharf, Graham J. Scharf and Annemarie Stroustrup
Pediatrics in Review 2016;37;25
DOI: 10.1542/pir.2014-0103

The online version of this article, along with updated information and services, is
located on the World Wide Web at:

An erratum has been published regarding this article. Please see the attached page for:

Data Supplement at:


Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2016 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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