Paediatrics chapters
Developmental milestones, developmental delay and counselling
The key milestones from birth to 5 years in gross motor, fine motor and vision, hearing and speech, and social skills, plus primitive reflexes, red flags of delay and how to counsel parents.
In 30 seconds
- Development is assessed in four domains: gross motor, fine motor and vision, hearing and speech, and social behaviour; it proceeds head to toe (cephalocaudal) and from centre to periphery.
- Anchor ages: social smile 6 weeks, head control 3 months, sits 6-8 months, pincer grasp 9-10 months, walks 12-15 months, two-word phrases 2 years, tricycle and circle 3 years.
- Red flags: loss of skills at any age, no sitting by 12 months, no walking by 18 months, fewer than 6 words at 18 months, primitive reflexes after 6 months, early hand preference, and any parental concern about vision or hearing.
On this page
Overview
Development is the gain of skills as the nervous system matures. It is checked in four domains:
- Gross motor (posture and movement)
- Fine motor and vision (hand use and seeing)
- Hearing, speech and language
- Social behaviour (play, self-care, interaction)
Milestones are average ages; normal children vary. What matters is the sequence, the pattern across domains, and whether a child is progressing or losing skills. Use corrected age for preterm babies until about 2 years.
Principles of development
- Cephalocaudal: head control comes before arms, and arms before legs.
- Proximal to distal: trunk and shoulder control before finger skills.
- General to specific: whole-body movements give way to precise ones (palmar grasp → pincer grasp).
- Primitive reflexes must fade before voluntary skills take over.
- Development is continuous but not steady; illness, hunger or tiredness affect performance on the day.
High-yield
Delay means skills come late. Regression means the child loses skills already gained. Regression always needs urgent assessment for a neurodegenerative or metabolic disease (and autism in language and social skills).
Milestones by age
Neonate
- Gross motor: flexed posture; marked head lag on pull to sit; in ventral suspension the head and limbs hang down.
- Vision and hearing: pupils react to light; turns towards diffuse light; startles to loud noise; quietens to voice.
- Reflexes: Moro, rooting, sucking, grasp, stepping present.
6 weeks to 3 months
| Domain | 6 weeks | 3 months |
|---|---|---|
| Gross motor | Lifts head briefly prone | Holds head steady; little or no head lag (little at 2, none at 3 months); lifts head and chest on forearms |
| Fine motor and vision | Follows a face or light | Follows through 180°; hands mostly open; holds a rattle briefly; watches own hands |
| Hearing and speech | Startles, quietens to voice | Coos, vocalises when spoken to, turns to a nearby voice |
| Social | Social smile (about 6 weeks) | Laughs; happy response to mother's face |
6 months
- Gross motor: sits with support (back straight); rolls front to back (about 5 months) and back to front (6 months); bears weight on legs when held; lifts chest on extended arms; grasps feet.
- Fine motor: reaches with one hand; palmar grasp; transfers objects hand to hand; takes everything to the mouth.
- Speech: babbles monosyllables ("ba", "da"), squeals, turns to sound at ear level.
- Social: enjoys active play; still friendly with strangers.
- Sits alone (without support) at 6-8 months.
9-10 months
- Gross motor: sits steadily and pivots; crawls (9-10 months); pulls to stand holding furniture (about 10 months); forward parachute from about 7 months.
- Fine motor: pincer grasp (index finger and thumb; mature pincer about 10 months, scissor grasp first); pokes with index finger; looks for a fallen or hidden toy (object permanence).
- Speech: babbles bisyllables ("mama", "dada" without meaning); shouts for attention.
- Social: stranger anxiety (from about 7-9 months); plays peek-a-boo; waves bye-bye; chews a biscuit.
12 months
- Gross motor: cruises round furniture (11 months); walks with one hand held; may stand alone.
- Fine motor: neat pincer; releases a cube into a cup; clicks two cubes together.
- Speech: 2-3 words with meaning; knows own name; follows a one-step command with a gesture ("give it to me").
- Social: drinks from a cup with help; helps with dressing (holds out an arm); waves and plays pat-a-cake.
15-18 months
| Domain | 15 months | 18 months |
|---|---|---|
| Gross motor | Walks alone, broad-based, uneven steps | Walks steadily, runs stiffly, climbs stairs with one hand held, pulls a toy |
| Fine motor | Tower of 2 cubes; scribbles | Tower of 3 cubes; turns several pages at once |
| Speech | Several single words | 6-20 words; points to body parts and named objects |
| Social | Feeds with fingers | Uses a spoon; takes off shoes and socks; imitates housework |
2 years
- Gross motor: runs well; up and down stairs two feet per step; kicks a ball.
- Fine motor: tower of 6 cubes; turns pages singly; copies a vertical line; holds a pencil.
- Speech: two- to three-word phrases; 50 or more words; refers to self by name.
- Social: dry by day; plays alongside others (parallel play); asks for toilet.
3 years
- Gross motor: climbs stairs with alternating feet (comes down two feet per step); rides a tricycle; stands on one foot briefly.
- Fine motor: tower of 9 cubes; builds a bridge of 3 cubes; copies a circle.
- Speech: short sentences; gives full name, age and sex; counts 3 objects; knows rhymes.
- Social: dry by night; plays with others and starts to share; dresses with help.
4 years
- Gross motor: comes downstairs with alternating feet; hops on one foot; stands on one foot for a few seconds.
- Fine motor: copies a cross; draws a person with head, body and legs; uses scissors.
- Speech: speech grammatical and understandable; tells stories; gives address.
- Social: goes to the toilet alone; plays cooperatively with other children.
5 years
- Gross motor: skips; walks a straight line; catches a ball.
- Fine motor: copies a square and a triangle; builds steps with cubes.
- Speech: names 4 colours; gives full name, age and birthday.
- Social: dresses and undresses alone; washes face and hands.
Memory hook
Shapes by birthday: 3 circle, 4 cross, 5 square and triangle. Cubes: 18 months 3, 2 years 6, 3 years 9 ("three times age in years" from age 2 onwards is close).
Gross motor summary table
| Milestone | Usual age | Refer if not achieved by |
|---|---|---|
| Head control | 3 months | 4-6 months |
| Sits without support | 6-8 months | 12 months |
| Crawls | 9-10 months | - |
| Pulls to stand | 10 months | - |
| Walks alone | 12-15 months | 18 months |
| Runs | 18 months-2 years | 2.5 years |
| Tricycle, stairs alternating feet | 3 years | - |
| Hops | 4 years | - |
| Skips | 5 years | - |
Primitive reflexes
| Reflex | Appears | Disappears |
|---|---|---|
| Moro (startle; arms abduct and extend, then come together) | Present at birth (from about 28 weeks' gestation) | 4-6 months |
| Palmar and plantar grasp | Birth | 4-6 months (plantar later) |
| Rooting and sucking | Birth | 3-4 months (rooting) |
| Stepping and placing | Birth | 4-6 months |
| Asymmetric tonic neck (fencing posture) | Birth | 4-6 months |
| Galant (trunk curves to stroked side) | Birth | 6-9 months |
| Landau | 6-8 months | Between 15 months and 2 years |
| Parachute | 6-8 months | Persists for life |
| Glabellar tap | Birth | Persists |
- Absent or reduced Moro: hypotonia, severe brain injury.
- Asymmetrical Moro: Erb palsy, fractured clavicle or humerus, hemiplegia.
- Persistence of primitive reflexes after 6 months (especially the tonic neck reflex) suggests cerebral palsy.
- The plantar response is often extensor in infancy; an extensor plantar after about 2 years indicates an upper motor neurone lesion.
Red flags of development
Act at any age:
- Loss of skills already gained.
- Parental or professional concern about vision (not fixing or following) or hearing.
- Persistent floppiness or stiffness; asymmetry of movement.
- Hand preference before about 12-18 months (suggests hemiplegic cerebral palsy).
- Persistent toe walking.
- Head circumference above the 99.6th or below the 0.4th centile.
Age-specific:
| By this age | Red flag |
|---|---|
| 6 weeks-3 months | No social smile (smiling at 3 months or later is slow) |
| 5-6 months | Does not hold an object or reach for it; no turning to voice |
| 9 months | No babbling |
| 10-12 months | Does not respond to own name (Nelson: by 10 months); cannot sit unsupported by 12 months |
| 18 months | No speech or fewer than 6 words with meaning; not walking |
| 2 years | Not combining words into phrases; fewer than about 10-25 words; does not point to share interest |
| 2.5 years | Not running |
| 3 years | Speech not understood by strangers; no 3-word sentences |
High-yield
In any speech delay, test hearing first. Deafness is a common, treatable cause and is easy to miss.
Exam trap
A child who smiled, babbled and then stopped talking and playing at 18 months to 2 years is not simply "late"; think of autism spectrum disorder or a neurodegenerative disorder.
Developmental delay
Types
| Type | Meaning | Typical causes |
|---|---|---|
| Global developmental delay | Significant delay in two or more domains (under 5 years) | Chromosomal (Down), brain malformation, HIE, congenital infection, hypothyroidism, metabolic disease |
| Motor delay | Gross motor mainly | Cerebral palsy, neuromuscular disease (Duchenne, spinal muscular atrophy), hypotonia |
| Speech and language delay | Language mainly | Hearing loss, autism, lack of stimulation, global delay |
| Social and communication | Poor eye contact, joint attention, play | Autism spectrum disorder |
| Regression | Loss of skills | Neurodegenerative (leukodystrophies, storage diseases), Rett syndrome, SSPE, uncontrolled epilepsy |
Developmental quotient (DQ) = developmental age ÷ chronological age × 100. A DQ below about 70 suggests significant delay.
Worked example: developmental quotient
A child of 24 months functions at the level of 12 months.
DQ = 12 ÷ 24 × 100 = 50 → marked delay
Causes by timing
| Timing | Examples |
|---|---|
| Prenatal | Chromosomal (Down, fragile X, Turner), TORCH infection, drugs and alcohol, brain malformation, congenital hypothyroidism, inborn errors (PKU, galactosaemia) |
| Perinatal | Prematurity, birth asphyxia (HIE), intraventricular haemorrhage, kernicterus, hypoglycaemia |
| Postnatal | Meningitis, encephalitis, head injury, severe malnutrition, iodine deficiency, lead poisoning, psychosocial deprivation |
| Unknown | About a third of cases |
Factors affecting development
- Genetic potential and family pattern.
- Health: prematurity, chronic illness, epilepsy, sensory loss (vision, hearing).
- Nutrition: protein-energy malnutrition, iodine and iron deficiency.
- Environment: stimulation, play, parental education, poverty, neglect, abuse, screen time without interaction.
- Emotional: a secure attachment and responsive caregiving.
Assessment
- History: pregnancy, birth, neonatal problems, milestones, regression, family history, consanguinity, social background.
- Examination: growth, head circumference, dysmorphic features, skin (café-au-lait spots, ash-leaf macules), tone, reflexes, vision and hearing.
- Screening tools such as the Denver Developmental Screening Test.
- Tests guided by findings: hearing assessment, thyroid function, karyotype or genetic tests, TORCH serology, metabolic screen, CK (boys with motor delay), MRI brain, EEG if seizures.
Caregiver counselling
Counselling follows the IMNCI "care for development" approach: play and communicate with the child at every age.
| Age | Advice to parents |
|---|---|
| 0-6 months | Hold and cuddle, skin-to-skin, look into the baby's eyes, talk and sing, respond to cries; tummy time when awake; brightly coloured objects to follow |
| 6-12 months | Name objects, play peek-a-boo, give safe household objects to bang and drop, let the child sit and crawl safely, respond to babbling |
| 1-2 years | Read picture books, name body parts, encourage walking and climbing safely, give stacking toys and crayons, praise attempts to talk |
| 2-5 years | Tell stories, sing rhymes, ask questions, let the child dress and feed self, play with other children, simple chores, drawing and puzzles; limit screens |
Also:
- Keep immunisations and growth monitoring up to date.
- Safety: prevent falls, burns, poisoning and drowning as mobility grows.
- Explain that milestones vary; agree a review date; refer early if a red flag appears. Early intervention (physiotherapy, speech therapy, special education) improves outcome.
- For a child with established delay: honest explanation, support for the family, and a multidisciplinary team.
Exam focus
Expect: the four domains; social smile at 6 weeks; head control at 3 months; sitting at 6-8 months; pincer grasp at 9-10 months; walking at 12-15 months; cubes (3 at 18 months, 6 at 2 years, 9 at 3 years); shapes (circle 3, cross 4, square and triangle 5); tricycle and alternating feet at 3 years; dry by day at 2 and by night at 3; stranger anxiety at about 9 months; primitive reflexes and their disappearance, asymmetric Moro in Erb palsy; red flags (regression, no walking at 18 months, early hand preference); hearing test first in speech delay; causes of global delay; DQ calculation.
Quick revision
- Four domains: gross motor, fine motor and vision, hearing and speech, social.
- Smile 6 weeks; head control 3 months; sits 6-8 months; crawls and pincer 9-10 months; walks 12-15 months.
- Words: 2-3 at 12 months, 6-20 at 18 months, 2-word phrases and 50 words at 2 years.
- Cubes 3-6-9 at 18 months-2-3 years; shapes circle 3, cross 4, square and triangle 5.
- Moro, grasp, rooting and tonic neck reflexes go by 4-6 months; parachute stays.
- Red flags: regression, not sitting at 12 months, not walking at 18 months, early hand preference, persisting primitive reflexes.
- Speech delay: test hearing first; think autism if social skills are also poor.
Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics; Park's Preventive and Social Medicine).
FAQ
What is the earliest social milestone?
The social smile, which appears at about 6 weeks of age.
At what age should a child walk alone?
Most walk alone between 12 and 15 months; a child not walking by 18 months needs assessment.
What does early hand preference mean?
Clear preference for one hand before about 12-18 months suggests weakness of the other hand, usually hemiplegic cerebral palsy.
Why is regression more worrying than delay?
Loss of skills already gained suggests a progressive brain disorder such as a neurodegenerative or metabolic disease, or autism, and needs urgent assessment.