Child’s developmental skills described within 4 domains:

• Gross motor skills

• Fine motor skills and vision

• Language and Hearing

• Social & Self-Help

5-10% children have developmental delay in at least one domain.
Speech delay affects 15-20% of children. Consider referral to paediatric audiology as well as SALT (speech and language therapy)

Global developmental delay: significant functional delay in two or more domains. GDD affects 1-3% of children

Development coordinator disorder (DCD): impairment of motor coordination (dyspraxia), affects 10% of children.
If mild, and not limiting the child’s academic achievement or daily living, and no other domains impaired, then paediatric referral is not often required.

Autism: combination of repetitive motor mannerisms, poor language skills, poor social interaction, reduced eye contact, lack of social awareness, preoccupation with interests, and issues with personal space

Regression or delay in social milestones may indicate autism or child abuse

Newborn Hearing test: automated otoacoustic emissions (AOAE) test is offered to all neonates

6w Neonatal review: each child has an early neonatal (6w weeks) medical review with a GP.
Vision: test for red reflex in each eye, ability to fix and follow, response to light
Hearing: test for startle/response to sound

Pre-school visual screen: each child should be screened for visual impairment age 4-5y (orthoptic-led service) to detect amblyopia, refractive error and strabismus.
Testing is carried out by an optometrist or suitably trained school nurse.

Prematurity: need to correct for gestational age if premature; correction required for chronological and ‘biological age’ for up to 1yr-18m.
Significantly premature babies are usually already under child development centre follow up.

Developmental Red Flags (requiring paediatric referral)

Gross motor skills

Unable to hold head on ventral suspension by 3m

Unable to support head when prone by 6m

Unable to sit by 8-9m

No attempt to crawl/bottom shuffle by 12m

Not walking by 18m
(check creatine kinase)

Not running by 2.5y
Persistent toe walking
Persistently low muscle tone or floppiness
Asymmetry of movements +/- increased muscle tone

Fine motor & vision

Not able to fix and follow an object/face or poor eye contact at ANY AGE (+ refer to ophthalmology)

Unable to hold object(palmar grasp) or reach for objects by 6m

Unable to transfer between hands by 9m

Not able to use pincer grip by 12m

Early asymmetry of hand function (hand preference) before 1 year

Language & Hearing

No startle to loud sounds by 6w

Not turning to rattle sound by 6m

No speech by 15-18m (+ refer to paediatric audiology)

Hearing loss (+ refer to paediatric audiology)

Social & Self-help

Not able to smile by 6w

Not able to point a objects to share interest with others by 2y

No interactive play by 3y

Approximate times for the development of some gross motor skills are:

• Head lag evident – when pulled to sitting: 0–6 weeks

• Rolls over: 8–18 weeks

• Sits alone: 18–30 weeks

• Pulls self up to stand: 6–10 months

• Walks holding furniture: 7–13 months

• Walks alone: 11–14 months

• Jumps with both feet together: 12–20 months

• Kicks ball: 14–24 months

• Hops, skips: 34–60 months

• Skip on both feet: 72 months

Assessment

History

• History of complaint: single or multiple domains, duration, pattern of symptoms dependent on home/outside home/school environment, attainment of other developmental milestones

• History of pregnancy and birth and any antenatal/perinatal complications

• Past medical history

• Family history, (any siblings with similar developmental issues)

• Social history (any safeguarding concerns)

Examination

• Ensure child’s weight, height and head circumference is plotted

• Any obvious dysmorphic features or microcephaly

• Conduct full physical examination including cardiac, respiratory, neurological, musculoskeletal and ENT assessment

Differential diagnosis for delayed milestones

• Cerebral palsy

• Muscular dystrophy

• Neuromuscular and neurocutaneous disorder

• Genetic: chromosomal, inborn errors of metabolism, Down’s, Fragile X syndrome

• Prenatal e.g. congenital intrauterine infection or maternal drug/alcohol use

• Prematurity, HIE

• Child abuse, particularly neglect

• Idiopathic (Isolated motor delay- accounts for majority of delay in walking)