Normal Child Growth and Development

Mark H. Deis

Roberta E. Bauer

Pediatricians at well-child visits are the first and most consistent screeners of development, and they along with parents monitor growth and gross motor, fine motor, problem-solving, language, and social skills of the child during the first 2 years of life. Knowledge of the functions expected at the time of the customarily scheduled immunization visits enables the pediatrician to estimate the age from an examination description of a typically developing child, or to refer children not achieving expected milestones for additional assessment. This chapter addresses normal growth and development of the child in regard to:

Parameters of physical growth
Gross motor milestones
Fine motor milestones
Speech and language milestones
Cognitive and social-emotional milestones

PARAMETERS OF PHYSICAL GROWTH

Physical growth data (Table 38.1) are valuable for providing general trends. The head circumference should grow at an average of:

2.0 cm/month during the first 3 months of life
1.0 cm/month during months 3 through 6 of life
0.5 cm/month from months 6 through 12

The median head circumference for a 3-year-old child would be 50.8 cm. Lengths increase from approximately 50 to 87 cm from birth to the age of 2 years, and then approximately 7 cm a year. Doubling the 2-year-old height provides a reasonable estimate of adult height. Weights double by 5 months of life, triple by 1 year, and quadruple by 2 years.

Points to consider regarding physical growth are the following:

Large or small heads warrant close assessment to detect treatable problems (hydrocephalus, metabolic disturbances or syndromes, anatomic problems, congenital infections) and monitor development.
Large or small stature can be associated with a number of syndromes, including developmental delays (Soto syndrome and various chromosomal abnormalities).

Careful examination for dysmorphic features can yield diagnostic clues. One should become familiar with the linear growth patterns in various common childhood conditions that inhibit growth, in addition to the trends in growth of tissue types during childhood and adolescence. These patterns are shown in Figures 38.1 and 38.2.

GROSS MOTOR MILESTONES

Gross motor milestones are listed in Table 38.2.

Monitoring progress in motor development makes it possible to identify underlying muscle, peripheral nerve, anterior horn cell, spinal cord, or central nervous system injuries that present in the first 2 years of life with gross motor changes. Findings that are a cause of concern include:

Rolling before 3 months
Poor head control at 5 months
Lack of sitting by 9 months
Persistence of Moro reflex, asymmetric tonic neck reflex, and tonic labyrinthine reflex past 6 months
Lack of development of protective supportive reactions (e.g., lack of parachute response by 12 months)
Hand dominance before 18 months
Inability to walk independently by 18 months

TABLE 38.1 AVERAGE VALUES FOR PHYSICAL GROWTH PARAMETERS IN THE FIRST 2 YEARS OF LIFE

	Head Circumference (cm)	Height (cm)	Weight (kg)
Birth	35	50.8	3-3.5
1 year	47	76	10
2 years	49	88	12-12.5

Rolling before 3 months may occur with hypertonicity. Poor head control in the pull-to-sit maneuver by 5 months may suggest muscle weakness or slowed progress of cephalic-caudal control over the body caused by injury or changes in the central nervous system. Likewise, persistence of primitive reflexes that should have been integrated may indicate a neuromotor disorder. Lack of independent sitting by 7 months or altered sitting in a W position may be caused by hip adductor spasticity or muscle hypotonia. Lack of emergence of an anterior protective response in sitting by 5 months, lateral protective responses in sitting by 7 months, or parachute protective responses by 12 months may indicate neuromotor disorders. The developmental sequence of locomotion beyond 1 year of age changes as improved balance and coordination allow a narrower base of support in the gait. Likewise, time sequences of use of muscle groups allow more complex motor patterns. Running efficiently by 2 years is followed by jumping on two feet, balancing on one foot (36 months), and hopping (48 months), and skipping. Early motor control should be symmetric with strong hand dominance expected at 18 months or after. Throwing a ball overhand is present by 23 months but catching requires more integration of eye–hand coordination and is present by 5 years.

Figure 38.1 Growth patterns of various systems. (From Bickley LS, Hoekelman RA. Bates’s guide to physical examination and history taking, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 1999:621, with permission.)

FINE MOTOR MILESTONES

Fine motor milestones are listed in Table 38.3.

Key issues in hand function include loss of obligatory fisting by 3 months, transferring a toy from one hand to the other across the midline by 6 months, and isolating the index finger, which allows pointing by 10 months. Fine motor functioning impacts both communication and selfcare independence. Neat pincer function is expected for picking up small objects by 1 year and aids self-feeding; and at that age children can voluntarily release a cube into a cup. Building towers of 1-inch cube blocks improve with two blocks expected at 15 months, four blocks at 18 months, and six blocks at 2 years. By 15 months, children should drink from a cup, by 18 months use a spoon, and by 24 months remove simple clothing, potentially allowing early efforts at toileting. Early vertical, horizontal, and general circular scribbling can be imitated from the examiner’s model at 2 years. A practical way to assess fine motor skills is to ask a child to copy a drawn figure:

3-year-old: circle
4-year-old: cross
4.5-year-old: square
5-year-old: triangle

Fine motor development may be sensitive to the same delaying factors as gross motor development. In general, the development of fine motor skills proceeds in a proximal-to-distal direction. In children with visual impairment, it may be more efficient to explore with the whole hand rather than just the index finger. Similarly, children with a lack of depth perception or visual acuity may have difficulty with stacking activities. As the use of tools becomes more complex, cognitive delays may be reflected in the fine motor function.

SPEECH AND LANGUAGE MILESTONES

Speech and language milestones are listed in Table 38.4.

Language development is one of the most important parameters of cognitive and emotional development. In infancy, language development is categorized as prespeech (birth-10 months); at this time, the skills needed to understand
language (receptive) are acquired by learning to localize sound. Expressive skills begin with cooing (vowel sounds) and differentiated crying when the baby is hungry, hurt, or in need of attention. At 3 months, babies begin vocalizing when they see an adult, and at 5 months, they take turns vocalizing with adults, quieting when the other speaks, and mimicking tone changes, although not actual words. At 6 months, babies add consonants (babbling), and when their parents respond to “mama” and “dada” with smiles and hugs, the baby eventually connects meaning to those sounds. When babies attach meaning to gestures or vocalizations, they have developed true words and initiated the naming period (10-18 months). Usually, “mama,” “dada,” the infant’s name, and “no” are the first recognized labels. Once begun, the growth of receptive language is rapid, and by 12 months, 100 words may be understood. One-step commands associated with a gesture can be understood by the child at 1 year of age, and the need for a gesture is lost in a few months. The development of expressive skills progresses more slowly, with most children having at least one true
word before their first birthday and most of their verbalization consisting of complicated multisyllabic consonant and vowel sounds with intonation changes, called jargon. By the end of the naming period, 18-month-old children use approximately 25 meaningful words spontaneously.

Figure 38.2 Growth patterns in children with short stature associated with six different causes. (From Kaplan SA. Clinical pediatric endocrinology, 2nd ed. Philadelphia: Saunders, 1990:51, with permission.)

TABLE 38.2 GROSS MOTOR MILESTONES

Age	Gross Motor Skill	Mobility
Newborn	Moves symmetrically	Lies down
2 months	Lifts shoulders up in prone position Head bobs in supported sitting position	Head up in prone position
3-4 months	Up on forearms in prone position Rolls from front to back Steady head control while sitting Bears weight on legs when standing	Puppy prop Extended arms
5-6 months	Tripod sitting (propped by hands)	Rolls back to front Tripod sitting
	No head lag on pulling to sit from supine position Sits with support
7 months	Bounces in supported standing	Free sitting
	Supports weight in standing with assistance for balance
	Feet to mouth
	Commando crawls
8 months	Gets to sitting position	Reaches
	Reaches with one hand from four-point kneeling from quad
9 months	Sits without support
11 months	Stands
12 months	Independent steps	Steps Pulls to stand
	Creeps	Cruises
15 months	Walks well independently Plays ball with examiner Gives and takes a toy Stoops to floor and recovers to standing position
16 months	Creeps up stairs Stoops and recovers Walks backward
18 months	Walks fast, seldom falls Runs stiffly Walks up stairs with one hand held Pushes/pulls large objects Throws ball while standing Seats self in small chair Climbs onto an adult chair
24 months	Kicks ball Jumps in place (both feet off floor) Throws a ball overhand Walks up stairs by placing both feet on same step
36 months	Walks up stairs by alternating feet Walks well on toes Stands on one foot for 1-2 seconds Broad jumps Jumps from a step Hops two or three times Pedals tricycle
4 years	Dresses without help Walks up and down stairs by alternating feet Balances on one foot for 3 seconds Hops on one foot
5 years	Tandem walks backward Skips by alternating feet Hops ten times
6 years	Rides a bicycle