engleski

Developmental milestones

“Through knowledge of the normal child should be just as much the basis of the study of children as is physiology and anatomy for medicine in general” (Illingworth RS, 1987.)1. • Primitive (developmental) reflexes. Myriad reflexes in newborn can be evaluated, but detailed neurologic evaluation is not needed. Retention of primitive reflexes is an important finding, because these reflexes interfere with the motor control necessary to walk. o Palmar grasp reflex (normally present up to 4 months of age) o Symmetrical tonic neck reflex (often diminishes by 14 months of age) o Asymmetrical tonic neck reflex (disappears by 6 months of age) o Neck-righting reflex (disappears by 10 months of age) o Moro reflex (disappears by about 4 month of age) o Postural o Parachute reaction (normal response is found after 6 months of age) o Foot placement reaction (persist in some fashion until 3 or 4 y. of age) ● Gross and fine motor skills Gross motor skills include the larger movements of arms, legs, feet, or the entire body. Fine motor skills refer to the small movements of the hands, wrists, fingers, feet, toes, lips, and tongue. Because the development of fine motor skills plays a crucial role in school readiness and cognitive development it is considered an important part of the preschool curriculum. o 2 month = holds head in rise up position when prone o 6 months = sits without support o 12 months = starts to walk o 6-7 years = child walks on an adult mode ; hops on one leg ; walks down the stair alternatively on each leg and without support o Hand-eye coordination begins to develop between the ages of two and four months. o At four or five months, most infants can grasp an object that is within reach, looking only at the object and not at their hands ("top-level reaching"). This achievement is considered an important milestone in fine motor development. o One of the most significant fine motor accomplishments is the pincer grip, which typically appears at about 12 months. o In toddler age child develops the ability to manipulate objects using their fingers to twist dials, pull strings, push levers, turn book pages, and use crayons to produce crude scribbles. o Dominance of either the right or left hand usually emerges during this period, as well. ● Height and weight development The height is important global marker of child’s growth and index for orthopaedic specialist. Between birth and maturity child will grow approximately 1, 20 to 1, 30 meter. o Measurement of standing and sitting height o The sitting height is composed of the head and trunk together o Measurement of sub-ischial height or the lower limbs growth o Those two regions often grow at different rate at different times o Height growth is brisk before the age of 5 years then slows until the onset of puberty o Measurement of segmental bone length could be used for prediction of body height o Children should always have weight evaluation on each consultation o Weight doubles for boys between 10 and 17 years of age o Weight can explain delayed menarche. Girls generally need to reach 40 kg. for menarche to occur o Obesity aggravates orthopaedic clinical problem e.g. Perthes, , Blount, SCFE. ● Appearance and closure of secondary ossification centres (SOC) In the epiphyses of the bone SOC appear, during the first years of postnatal life. Growth takes place on the diaphyseal side of the epiphyseal plate, only. SOC development is autonomous and is influenced by genetic, nutritional and hormonal factors. Distal femoral epiphysis is normaly apparent in full-term newborn, but SOC have only limited value in estimating gestational age/maturity because of the wide range at any one period of gestation. o Timing of appearance and closure of particular SOC could be found in respective books2 o Elbow ossification occurs at the six elbow ossification centres in a reproducible order. o CRITOE (Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon, External epicondyle) o Order is reliable but there is variability in timing. o Girls are sowing earlier ossification of elbow SOC – up to 2 years more advancing. o Being familiar with the order of ossification of the elbow is important in not mistaking a normal ossification centre for an epicodylar fracture. ● Determination of skeletal maturity is important for correlation the timing of peak height velocity to skeletal maturity which will give opportunity to modify treatment based on the amount of growth remaining e.g. idiopathic scoliosis, treatment of lower leg discrepancy, remodelling potential of mild mal-united long bone fracture. o Greulich and Pyle (GP)3 method is comparing standard positioning of child’s left hand-wrist radiograph with standard templates (31 for males and 27 for female) of radiographs. o Risser4 method is based on six stages (from 0 to 5) iliac crest apophysis development o Sauvergrain5 – is using semi-annual series of A.-P. and lateral elbow radiographs (ossification centres of lateral condyle, trochlea, olecranon apophysis and proximal radial epiphysis) during the 2 years of the pubertal growth spurt. Method is based on a twenty-seven point scoring system. ● Secondary sexual characteristics (Tanner’s stages or scale)6 James M. Tanner, a British paediatrician, is author of a scale of physical development in children, adolescents and adults. The scale defines physical measurements of development based on external primary and secondary sex characteristics, such as the size of the breasts, genitals, testicular volume and development of pubic hair. o Stages of pubic hair and genital development in the male. G-1: pre-pubertal ; G-2: the testis and scrotum enlarge, and the skin of the scrotum shows some reddening and change in the texture. Sparse growth of pigmented hair usually slightly curly mainly at the base of the penis (Ph-2) ; G-3: Testis and scrotum enlarge further, the penis grows mainly in length but also in breadth. The hair is darker, coarser and curlier and spreads over the junction of the pubes (Ph-3) ; G-4: Scrotum, testis and penis grow further with development of the glans and further darkening of the scrotal skin. The hair spreads covering the pubes ; G-5: adult stage with spreading of the hair to the medial surface of the thighs. o Tanner Staging – Females Stages of breast development. B-1: pre-pubertal ; B-2: breast bud ; B-3: enlargement of beast and areola with no separation of the contours ; B-4: projection of areola and papilla to form a secondary mound above the level of the breast ; B-5: recession of the areola to the general contour of the breast with projection of the papilla only. Stages of pubic hair development in females. Ph-1: pre-pubertal ; Ph-2: sparse growth of long slightly pigmented hair usually slightly curly mainly along the labia ; Ph-3: the hair is darker, coarser and curlier and spreads over the junction of the pubes ; Ph-4: the hair spreads covering the pubes ; Ph-5 the hair extends to the medial surface of the thighs and is distributed as an inverse triangle. Literature 1. Feingold, David. “Pediatric Endocrinology” In Atlas of Pediatric Physical Diagnosis, Second Edition, Philadelphia. W.B. Saunders, 1992 ; 9:16-19. 2. Hensinger RN. Standard in Pediatric Orthopaedics. Tables, Charts and Graphs Illustrating Growth. New York, Raven Press, 1986. p.142, p.230. 3. Greulitch WW, Pyle SI. Radiograph atlas of skeletal development of the hand and wrist. 2nd ed. Stanford, California, USA, Stanford University press, 1959. 4. Risser JC. The iliac apophysis: an invaluable sign in the management of scoliosis. Clin Orthop 1958 ; 11:111-9. 5. Hans SA, Sanders JO, Cooperman DR. Using the Sauvegrain method to predict peak height velocity in boys and girls. J Orthop Pediatr 2008 ; 28(8):836-9. 6. Tanner JM, Davies PS. Clinical longitudinal standards for height and height velocity for North American children. J Pediatr. 1985 ; 107(3):317-29.

infancy ; school age ; adolescence ; developmental milestones

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