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TRANSCRIPT
Pediatrics
Kathryn K. Ostermaier M.D.
Assistant Professor
Baylor College of Medicine
Department of Pediatrics
Meyer Center for Developmental Pediatrics
Infant Growth and
Development
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Background
•“Infant” is derived from the Latin word “infans”
which means unable to speak.
•Prior to the 1900’s, most people felt that infants
were a “blank tablet”.
•Because they could not tell us what they were
thinking, it was assumed they were devoid of
intelligence.
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Background
•Gesell in the early 1900’s was the first person to
closely observe infants and establish
developmental norms.
•By mid-century, theories that stressed the
importance of nurture began to prevail by Pavlov
(1930’s), Watson (1950’s), and Skinner (1960’s)
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Background
•During the second half of the century, Piaget was
the first to describe the infant as having
intelligence.
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Background
•Infant development occurs in an orderly and predictable
manner.
•It proceeds from cephalic to caudal and proximal to distal.
•Responses to stimuli proceed from general reflexes
involving the entire body to discreet voluntary actions under
cortical control.
•Progression is from dependence to independence.
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Why is development important?
•Early development lays the foundation for future
learning abilities.
•The goals for those caring for children should be to
maximize a child’s growth and development.
•Formal developmental screening is an important
part of every well-child check.
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What are the major problems we
should be looking for?
•Cerebral Palsy (2-2.5/1000)
•Speech Impairment (10/1000)
•Hearing Impairment (6/1000)
•Visual Impairment (12/1000)
• Intellectual Disability (2-3% of the
population)
•Autism (1/88)
•Learning Disabilities (5% of the
population)
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Why is screening important?
•Early intervention has been shown to maximize a child’s potential.
•What are the early intervention options?
-Early Childhood Intervention
-Head Start Program
-Preschool programs for children with disabilities
-Special education programs through the local school district
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What does one look for when
screening development? •There are four major areas of development:
-Physical Growth
-Gross Motor
-Visual Perception and Fine Motor Skills
-Language
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Physical Growth
•Normal Weight Patterns:
Birth weight is
-regained by 2 weeks of age
-doubled by 5 mo.
-tripled by 12 mo.
-quadrupled by 24 mo
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Physical Growth
•Head Growth
--Measured by Frontal Occipital Circumference (FOC)
--Head growth during first 5-6 months is due to neuronal cell
division.
--Later head growth is due to neuronal cell growth and
support tissue proliferation.
--Head is approx. adult-sized by 5 yrs.
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Physical Growth “RED FLAGS”
•Short stature or poor weight gain
•Small head or microcephaly:
Reflects cerebral pathology and has cognitive implications.
•Large head or macrocephaly:
50% is familial and benign
Watch out for hydrocephalus!!!!
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Physical Growth “RED FLAGS”
•Dysmorphisms: Minor variations or abnormalities
on physical exam
•Greater than 3 dysmorphisms highly associated
with genetic syndromes
•Greater than 75% of these minor variations can be
found by closely examining the face, hands and
skin.
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Gross Motor Development
•Gross motor skills proceed from a sequence of
prone milestones, to sitting, and then through a
standing/ambulating sequence.
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Evolution of Gross Motor Skills
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Gross Motor Development
•Gross motor skills must always be considered in
context of a neurological exam.
•Important to look at postural reactions and primitive
reflexes in addition to a regular neurological exam.
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Infant Neurological Maturation
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Primitive Reflexes
A: Tonic Labyrinthine Reflex C: Positive Support Reflex
B: Asymmetrical Tonic Neck reflex
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Postural Reactions
Parachute Response Righting Postural Reflex
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Gross Motor “RED FLAGS”
•Persistent fisting beyond 3 months
•Spontaneous postures (frog-legging, scissoring)
•Delays in postural reactions
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Gross Motor “RED FLAGS”
•Abnormal movement patterns:
-persistent head lag/ floppy baby
-pulling directly to a stand at 4 months
-W-sitting
-walking without ever crawling
-persistent toe-walking
•Hand dominance prior to 18 months
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Visual Perception and Fine Motor
Skills •As balance improves in the sitting position and as
the infant begins to walk, hands become more
available for manipulation of objects.
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Visual Perception and Fine Motor
Skills •In the first year of life, fine motor development is
highlighted by the evolution of the pincer grasp and
learning to grasp and explore objects.
•The second year of life is highlighted by the hands
using objects as tools.
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Visual Perception and Fine Motor
Skills •Problem-solving in the first year through sensory-motor
play: “LEARNING TO MANIPULATE”
-Visual inspection
-Reaching, grasping, and mouthing
-Refinement of the pincer grasp for closer inspection
•Object Permanence
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Visual Perception and Fine Motor
Skills •Problem-solving in the second year through
functional play: “MANIPULATING TO LEARN”
-Recognition of objects and their functions
through symbolic play
-Matching and categorizing objects
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Visual Perception and Fine Motor
“RED FLAGS” •Failure to alert to environmental stimuli may
indicate sensory impairment
•Failure to reach for objects may indicate motor,
visual and/or cognitive deficit
•Persistent mouthing past approximately 12 months
•Lack of imitation by 16 months
•Absent symbolic play by 24 months
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Language Development
•Delays in language are more common than delays
in other areas.
•Language is the best indicator of future
intelligence.
•Language is the most difficult to screen in the office
therefore history is very important.
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Language Development
•Language is separated into two domains:
-Expressive Language
-Receptive Language
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Language Development
•Language development during infancy can be
divided into 3 periods:
-Prespeech Period (0-10 months)
-Naming Period (10-18 months)
-Word Combination Period (18-24 months)
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Language Development:
Pre-speech Period (0-10 months)
•Sound Localization
•Cooing
•Babbling
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Language Development: Naming
Period (10-18 months)
•The infant realizes that people and objects have labels.
•Word counts are important to measure expressive
language.
•Receptive language reflected in understanding simple
commands.
•Pointing
•Jargoning
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Language Development:
Word Combination Period
(18-24 months)
•Children typically begin to combine words 6-8 months after
they say their first word.
•Giant words
•Holophrases
•Word combinations (usually does not start until the child has
an expressive vocabulary of at least 50 words)
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Language Development
“RED FLAGS” •Inability to localize sound
•Absent babbling or consonant production
•Lack of pointing by 12-18 months
•Low word counts
•Advanced, non-communicative speech
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How is development screened?
Examples of appropriate
tools include:
The Denver Developmental Screen II
The Capute Scales
The Gesell
Various Parent
Questionaires
•Parents' Evaluation of Developmental
Status (PEDS)
•Ages and Stages Questionnaires
(ASQ)
•Child Development Inventories (CDI)
•Modified Checklist for
Autism in Toddlers (MCHAT)
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Screening Tips
•Start with the visual-perceptual/ fine motor section
of the test and end with gross motor.
•Know your screening test well and have your
testing items organized.
•Do not let children play with the testing materials
ahead of time!
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Screening Tips
•Once you are done with an item, put your testing
materials away so they are not a distraction.
•Give a child several tries to complete a task.
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Conclusions •Infant development is determined by nature AND nurture
•Development follows a predictable course
•Watch for red flags and make referrals early rather than employing “watchful waiting”
•Use a reliable screening tool to get reliable information