FFinalistSouthampton · 2027
Child health
AKT · Child health/Growth, GI & MSK

Developmental milestones & red flags

Four domains — gross motor · fine motor/vision · speech/hearing/language · social

Overview

Development is assessed across four domains; delay can be global (all domains — think genetic/metabolic/antenatal insult) or specific (one domain). The exam tests the limit ages (the age by which a skill should be present) and the regression/asymmetry red flags, NOT the median ages.

Recognise

  • Gross motor: head control 3–4mo · sits unsupported 6–8mo · crawls ~9mo · cruises 10–12mo · walks 13–15mo · runs ~2y · stairs ~2.5y
  • Fine motor/vision: fixes & follows 6wk · palmar grasp 6mo · transfers 6–7mo · pincer grip 9–12mo · tower of 2 bricks 15mo, 6 bricks 2y · scribbles 18mo
  • Speech/hearing/language: coos 3mo · babbles 6–9mo · first words ~12mo · 2-word phrases 2y · 3-word sentences 3y
  • Social/behaviour: social smile 6wk · stranger awareness 9mo · waves bye 9–12mo · symbolic play 18–24mo · parallel play 2y · interactive/sharing play 3y

Red flags

  • Loss of skills (REGRESSION) at any age → neurodegenerative/metabolic or ASD — urgent
  • Hand preference before 12 months → possible cerebral palsy (hemiplegia)
  • Not smiling by 10 weeks; not sitting by 9 months; not walking by 18 months (check creatine kinase in boys — Duchenne); no words by 18 months; no 2-word phrases by 2 years
  • Persistent primitive reflexes, asymmetry of movement/tone

Differentials & how to tell them apart

Global developmental delay≥2 domains delayed → genetic (Down, Fragile X), antenatal/perinatal insult, metabolic
Cerebral palsymotor-predominant + abnormal tone/posture, early hand preference, non-progressive
Autism spectrum disordersocial-communication + restricted/repetitive behaviour; may show regression of social skills ~18–24mo
Duchenne muscular dystrophyboys, gross-motor delay/late walking, calf pseudohypertrophy, Gowers — raised CK
Hearing impairmentisolated speech/language delay — always test hearing

Investigations

Structured developmental history + examination against the limit ages; hearing test and vision check; growth/head circumference. Targeted work-up by pattern: CK (boys, motor delay → Duchenne), karyotype/array-CGH + Fragile-X, TFTs, metabolic screen if regression; refer to community paediatrics.

Management

Assess against limit ages; refer to community paediatrics + targeted investigation by pattern

  1. 1Screen at the Healthy Child Programme reviews (e.g. 6–8wk, 12mo, 2–2.5y). Map the delay: global vs specific domain.Gate: Any LOSS of previously-acquired skills (regression) → urgent referral for neurodegenerative/metabolic cause or ASD
  2. 2Specific motor delay in a boy / late walking → check creatine kinase before attributing to simple delay (Duchenne).
  3. 3Refer to community paediatrics; multidisciplinary early intervention (SALT, physio, OT, portage).
No drug — surveillance & early intervention — Healthy Child Programme reviews; portage, SALT, physio/OT

Key points

Always correct for prematurity until 2 years. Isolated speech delay = test hearing first. The exam gives a limit age being missed (e.g. not walking at 18mo) — the missed limit age is the answer, not the median.

Monitor & prognosis

Serial developmental review; re-assess against limit ages; track head circumference and growth.

Depends on cause; early intervention improves outcomes.

Source: RCPCH developmental milestones; NICE NG (developmental follow-up); Healthy Child Programme