Developmental Milestones

Rebecca J. Scharf, MD, MPH,* Graham J. Scharf, MA,† Annemarie Stroustrup, MD, MPH‡ *Division of Developmental Pediatrics, Center for Global Health, Department of Pediatrics, University of Virginia, Charlottesville, VA. †Institute for Advanced Studies in Culture, Charlottesville, VA. ‡Division of Newborn Medicine, Departments of Pediatrics and Preventive Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.

Practice Gap

Clinicians should be aware of developmental milestones for children and especially areas of concern that may prompt referral of a child for further evaluation. Pediatric clinicians should carefully monitor developmental progress in children born preterm.

Objectives After completing this article, readers should be able to:

1. Discuss progress in typical development in motor, language, social, and cognitive domains. 2. Note differences in development for children born preterm. 3. Identify delays that warrant referral for further evaluation.

CHILD DEVELOPMENT

The first years of development are crucial for lifelong learning and development. Milestones follow predictable courses in infants and children, and later developmental skills build on previous ones achieved. Understanding normal development can help clinicians to recognize delayed development. Early identification of developmental delays allows for referral to therapeutic services, and children referred for early intervention are more likely to make gains in developmental milestones. Research into outcomes of intervening early in a child’s life has shown a great variety of benefits when a child receives needed speech/language therapy, physical therapy, occupational therapy, or special education services in a language-rich preschool classroom environment. (1)(2)(3)(4) Coordination of these services is often provided by state-based early intervention programs. These services may also be found in health care settings or departments of education. AUTHOR DISCLOSURE Drs Scharf and Manning and associates (5)(6) created a useful summary of some of the positive Stroustrup and Mr Scharf have disclosed no results seen in intervention, which may be considered in economic analyses as fi nancial relationships relevant to this article. well as policy (Table 1). Targeted early intervention services may provide particular This commentary does not contain a fi discussion of an unapproved/investigative bene t for children living in families with access to fewer resources or low use of a commercial product/device. educational status.

Vol. 37 No. 1 JANUARY 2016 25 Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 TABLE 1. The Beneﬁts of Early Childhood Intervention (5)

EDUCATIONAL/ COGNITIVE BEHAVIORAL HEALTH ECONOMIC OTHER POSITIVE OUTCOMES OUTCOMES OUTCOMES OUTCOMES SOCIAL OUTCOMES OUTCOMES

Increase in Improved school Earlier identification Improved living Decrease in teen Improved parent- intellectual readiness of children at risk conditions pregnancies child relationships competence Positive home-school Reduction in juvenile Improved Improved work skills Reduction in child Increased self-respect relationships delinquency knowledge of abuse nutrition Increased parental Increase in child- Increase in medical Increase in family Elimination of infant Acceptance of involvement in a school engagement check-ups income and child homicide personal child’s schooling responsibility Improved literacy Less disruptive Decrease in licit and Increased Development of social Mental health behavior in illicit drug use employment rates support networks benefits; classroom environment with reduced stress Improved school Improved parent-child Improved prenatal Decrease in welfare Increased familiarity Self-efficacy achievement relationships care dependence with local health care/social service support systems Less need for Reduced participation Fewer emergency Improved peer Lower rates of family remedial in criminal activity department visits relationships adversity and assistance conflict Less school failure Reduced social isolation Higher school Improved networks of completion rates support

Reprinted with permission from Homel et al.(6)

SURVEILLANCE AND SCREENING as the Denver Developmental Screening Test and the Ages & Stages Questionnaires, assess milestones across Surveillance is attentiveness to population trends in disease, multiple domains. Other tools, such as the Modified Check- and screening involves administration of specific assess- list for Autism in Toddlers, examine specific areas of concern, ments to detect disease or disorder in individual children at such as autism spectrum disorders. Clinicians should use a a period when intervention would improve developmental tool, such as those recommended by the AAP, for screening trajectories. Screening is not intended for diagnosis but children at routine intervals during health supervision visits. rather for more rapid identification of individuals who These tools and their use are discussed further in several require further evaluation. Children identified via screening useful articles. (7)(8)(9) as positive for a particular disorder can be referred for further evaluation, which usually entails more comprehen- DOMAINS OF DEVELOPMENTAL DELAY sive history, testing, and examination to elucidate diagnoses Specific developmental skills are described within larger more clearly. domains (Table 2). In children, developmental delays are fi fi TOOLS FOR SCREENING classi ed as speci c or global. Children with global developmental delay have delays in multiple domains of devel- Various valid tools are available for standardized screen- opment, while children with specific delay may have a ing of childhood disorders and concerns. The American delay in only one area of development, such as language or Academy of Pediatrics (AAP) recommends that clinicians motor skills. Delays in one domain may affect skills in screen children for general development using standard- another. For example, a child with severe motor delays ized, validated tools at 9, 18,and24or30monthsandfor may not have as many opportunities to play and explore, autism at 18 and 24 months or at any point when a thus affecting the cognitive domain, or a child with caregiver or the clinician has a concern. Some tools, such language impairment may not be able to interact as well

26 Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 TABLE 2. Developmental Domains

DEVELOPMENTAL DOMAIN SKILLS LEARNED BY CHILD

Gross Motor Movements using the large muscles Fine Motor Movements using the hands and smaller muscles, often involving daily living skills Language Receptive and expressive communication, speech, and nonverbal communication Cognitive Reasoning, memory, and problem-solving skills Social-Emotional and Behavioral Attachment, self-regulation, and interaction with others with playmates, thus slowing progress in the social may still exhibit head bobbing when supported in a seated domain. position.

DEVELOPMENTAL MILESTONES Four Months By 4 months of age, head-lag disappears when infants are Developmental milestones have been established in gross pulled to sitting. The infant is learning to roll from prone and fine motor skills, self-help, problem-solving, social/ to supine positions. However, because of the current emotional, and receptive and expressive language domains recommendation that all infants be put to sleep on their (Table 3). (10)(11)(12) backs to prevent sudden infant death syndrome, rolling from front to back is sometimes delayed. Occasionally, Neonatal infants learn to roll back to front first, despite it being The 4 weeks after birth set the stage for the infant’s first generally easier to roll prone to supine. Infants at this year. Parents are learning to care for their infant, and early age can reach for objects consistently, put them in their patterns of feeding, sleeping, and alert times are set. mouths, and shake a rattle. Interaction with others blossoms Infants learn to look at faces, discriminate parents’ voices and infants laugh out loud. from others’, cry, make noises with their throats, and raise their chins when prone. During this time, as well as Six Months ’ prenatally, infants hear their parents voices, beginning From 5 to 6 months of age, infants learn to roll supine to the attachment process. Infants are learning that their prone and sit with hands propped in front of them. They caregivers meet their needs, initiating a sense of security can sit upright for a brief time, and when sitting is in these early days. All infants should receive hearing supported, they can use their hands to transfer an object screenings in the neonatal period, and older infants or from one hand to the other. They reach for objects and fi young children who do not alert to sounds or visually xate can hold two objects simultaneously. Infants begin to on objects within a few inches of their face should be feedthemselveseasyfoodssuchascrackersandmay referred for further hearing and vision assessments. hold a bottle. At this age, children move from cooing Infants whose muscle tone is too low to allow for adequate (using vowel sounds such as aaah and oooo) to babbling feeding or movement should be referred for evaluation. (using consonants to make duplicating noises with fl Neonatal protective re exes are a useful way for the sounds such as ba, ma, and da). They smile and make clinician to assess neurologic and motor function (Table noises in front of a mirror. At this age, infants begin 4). “stranger anxiety;” 6-month-old infants are more likely to be wary of strangers and be comforted by familiar Two Months caregivers. The major milestone of 6 weeks is the social smile, further endearing the infant to the parents. Around 2 Nine Months months of age, infants coo and make noises responsively Around 9 months of age, children pull to stand and may to caregivers. At this age, infants can bring their hands begin creeping or cruising. Infants can play with toys from together at midline. When in a prone position, infants their seated position and take objects in and out of con- begin to lift their chests off the table at 2 months, but they tainers, bang toys or blocks together, and hold food to take

Vol. 37 No. 1 JANUARY 2016 27 Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 TABLE 3: Developmental Milestones

PROBLEM- SOCIAL/ RECEPTIVE EXPRESSIVE AGE GROSS MOTOR FINE MOTOR SELF-HELP SOLVING EMOTIONAL LANGUAGE LANGUAGE

1 month • Chin up in prone • Hands ﬁsted near • Sucks well • Gazes at black- • Discriminates • Startles to voice/ • Throaty noises position face white objects mother’s voice sound • Turns head in • Follows face • Cries out of supine position distress

2 months • Chest up in • Hands unﬁsted • Opens mouth at • Visual threat • Reciprocal • Alerts to voice/ • Coos prone position 50% of the time sight of breast or present smiling: sound • Social smile (6 • Head bobs when • Retains rattle if bottle • Follows large, responds to weeks) held in sitting placed in hand highly contrast- adult voice and • Vowel-like noises position • Holds hands ing objects smile together • Recognizes mother

3 months • Props on fore- • Hands unﬁsted • Brings hands to • Reaches for face • Expression of • Regards speaker • Chuckles arms in prone 50% of the time mouth • Follows objects disgust (sour • Vocalizes when position • Inspects ﬁngers in circle (in taste, loud talked to • Rolls to side • Bats at objects supine position) sound) • Regards toys • Visually follows person who is moving across a room

4 months • Sits with trunk • Hands held pre- • Brieﬂy holds onto • Mouths objects • Smiles sponta- • Orients head in • Laughs out support dominately open breast or bottle • Stares longer at neously at plea- direction of a loud • No head lag • Clutches at novel faces than surable sight/ voice • Vocalizes when when pulled to clothes familiar sound • Stops crying to alone sit • Reaches • Shakes rattle • Stops crying at soothing voice • Props on wrists persistently • Reaches for ring/ parent voice • Rolls front to • Plays with rattle rattle • To and fro alter- back nating vocalizations

5 months • Sits with pelvic • Palmar grasps • Gums/mouths • Turns head to • Recognizes care- • Begins to respond • Says “Ah-goo” support cube pureed food look for dropped giver visually to name • Razzes, squeals • Rolls back to • Transfers objects: spoon • Forms attach- • Expresses anger front hand-mouth- • Regards pellet or ment relation- with sounds • Puts arms out hand small cracker ship to caregiver other than crying front when • Reaches/grasps falling dangling ring • Sits with arms supporting trunk

6 months • Sits momentarily • Transfers hand- • Feeds self • Touches reﬂec- • Stranger anxiety • Stops momen- • Reduplicative propped on hand crackers tion and (familiar versus tarily to “no” babble with hands • Rakes pellet • Places hands on vocalizes unfamiliar • Gestures for “up” consonants • Pivots in prone • Takes second bottle • Removes cloth people) • Listens, then • In prone posi- cube and holds on face vocalizes when tion, bears on to ﬁrst • Bangs and adult stops weight on one • Reaches with shakes toys • Smiles/vocalizes hand one hand to mirror

7 months • Bounces when • Radial-palmar • Refuses excess • Explores different • Looks from object • Looks toward • Increasing held grasp food aspects of toy to parent and familiar object variety of • Sits without sup- • Observes cube in back when when named syllables port steadily each hand wanting help • Attends to music • Lateral • Finds partially (eg, with a wind- protection hidden object up toy) • Puts arms out to sides for balance

8 months • Gets into sitting • Bangs spoon • Holds own bottle • Seeks object after • Lets parents • Responds to • Says “Dada” position after • Finger feeds it falls silently to know when “Come here” (nonspeciﬁc) • Commando demonstration Cheerios or the ﬂoor happy versus • Looks for family • Echolalia (8 to 30 crawls • Scissor grasp of string beans upset members, months) • Pulls to sitting/ cube • Engages in gaze “Where’s mama? • Shakes head for kneeling position • Takes cube out of monitoring: ”. etc “no” cup adult looks away • Pulls out large and child follows peg adult glance with own eyes Continued

28 Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 TABLE 3. (Continued)

PROBLEM- SOCIAL/ RECEPTIVE EXPRESSIVE AGE GROSS MOTOR FINE MOTOR SELF-HELP SOLVING EMOTIONAL LANGUAGE LANGUAGE

9 months • ”Stands” on feet • Radial-digital • Bites, chews • Inspects bell • Uses sounds to • Enjoys gesture • Says “Mama” and hands grasp of cube cookie • Rings bell get attention games (nonspeciﬁc) • Begins creeping • Bangs two cubes • Pulls string to • Separation • Orients to name • Nonreduplicative • Pulls to stand together obtain ring anxiety well babble • Bear walks (all • Follows a point, • Orients to bell • Imitates sounds four limbs “Oh look at.” straight) • Recognizes familiar people visually

10 months • Creeps well • Clumsy release of • Drinks from cup • Uncovers toy • Experiences fear • Enjoys peek-a- • Says “Dada” • Cruises around cube held for child under cloth • Looks preferen- boo (speciﬁc) furniture using • Inferior pincer • Pokes at pellet in tially when name • Waves “bye-bye” • Waves “bye-bye” two hands grasp of pellet bottle is called back • Stands with one • Isolates index • Tries to put cube hand held ﬁnger and pokes in cup, but may • Walks with two not be able to let hands held go

11 months • Pivots in sitting • Throws objects • Cooperates with • Finds toy under • Gives objects to • Stops activity • Says ﬁrst word position • Stirs with spoon dressing cup adult for action when told “no” • Vocalizes to • Cruises furniture • Looks at pictures after • Bounces to songs using one hand in book demonstration music • Stands for a few (lets adult know seconds he or she needs • Walks with one help) hand held

12 months • Stands well with • Scribbles after • Finger feeds part • Rattles spoon in • Shows objects to • Follows one-step • Points to get arms high, legs demonstration of meal cup parent to share command with desired object splayed • Fine pincer grasp • Takes off hat • Lifts box lid to interest gesture (proto-impera- • Posterior of pellet ﬁnd toy • Points to • Recognizes tive pointing) protection • Holds crayon get desired names of two • Uses several • Independent • Attempts tower object (proto- objects and looks gestures with steps of two cubes imperative when named vocalizing (eg, pointing) waving, reaching)

13 months • Walks with arms • Attempts to • Drinks from cup • Dangles ring by • Shows desire to • Looks • Uses three high and out release pellet in with some string please caregiver appropriately words (high guard) bottle spilling • Reaches around • Solitary play when asked, • Immature jar- clear barrier to • Functional play “Where’sthe goning: inﬂec- obtain object ball?” tion without real • Unwraps toy in words cloth

14 months • Stands without • Imitates back and • Removes socks/ • Dumps pellet out • Points at object • Follows one-step • Names one pulling up forth scribble shoes of bottle after to express inter- command object • Falls by collapse • Adds third cube • Chews well demonstration est (proto- without gesture • Points at object • Walks well to a two-cube • Puts spoon in declarative to express inter- tower mouth (turns pointing) est (proto- • Puts round peg over) • Purposeful declarative in and out of exploration of pointing) hole toys through trial and error

15 months • Stoops to pick up • Builds three-to • Uses spoon with • Turns pages in • Shows empathy • Points to one • Uses three to toy four-cube tower some spilling book (someone else body part ﬁve words • Creeps up stairs • Places 10 cubes • Attempts to • Places circle in cries, child looks • Points to one • Mature jargoning • Runs stiff-legged in cup brush own hair single-shape sad) object of three with real words • Walks carrying • Releases pellet • Fusses to be puzzle • Hugs adult in when named toy into bottle changed reciprocation • Gets object from • Climbs on • Recognizes another room furniture without a dem- upon demand onstration that a toy requires acti- vation; hands it to adult if can’t operate Continued

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PROBLEM- SOCIAL/ RECEPTIVE EXPRESSIVE AGE GROSS MOTOR FINE MOTOR SELF-HELP SOLVING EMOTIONAL LANGUAGE LANGUAGE

16 months • Stands on one • Puts several • Picks up and • Dumps pellet out • Kisses by touch- • Understands • Uses 5 to 10 foot with slight round pegs in drinks from cup without ing lips to skin simple com- words support board with • Fetches and car- demonstration • Periodically visu- mands, “Bring to • Walks backwards urging ries objects • Finds toy ally relocates mommy” • Walks up stairs • Scribbles (same room) observed to be caregiver • Points to one with one hand spontaneously hidden under • Self-conscious; picture when held layers of covers embarrassed named • Places circle in when aware of form board people observing

18 months • Creeps down • Makes four-cube • Removes • Matches pairs of • Passes M-CHAT • Points to two of • Uses 10 to 25 stairs tower garment objects • Engages in pre- three objects words • Runs well • Crudely imitates • Gets onto adult • Replaces circle in tend play with when named • Uses giant words • Seats self in small vertical stroke chair unaided form board after other people (eg, • Points to three (all gone, stop chair • Moves about it has been tea party, birth- body parts that) • Throws ball while house without turned around day party) • Points to self • Imitates environ- standing adult (usually with trial • Begins to show • Understands mental sounds and error) shame (when “mine” (eg, animals) does wrong) and • Points to familiar • Names one pic- possessiveness people when ture on demand named

20 months • Squats in play • Completes • Places only edi- • Deduces loca- • Begins to have • Points to three • Holophrases • Carries large round peg board bles in mouth tion of hidden thoughts about pictures (”Mommy?” object without urging • Feeds self with object feelings • Begins to under- and points to • Walks downstairs • Makes ﬁve- to six- spoon entire • Places square in • Engages in tea stand her/him/ keys, meaning: with one hand cube tower meal form board party with stuf- me “These are held • Completes fed animals Mommy’s square peg • Kisses with keys.”) board pucker • Two-word combinations • Answers requests with “no”

22 months • Walks up stairs • Closes box with • Uses spoon well • Completes form • Watches other • Points to four to • Uses 25 to 50 holding rail, put- lid • Drinks from cup board children five pictures words ting both feet on • Imitates vertical well intensely when named • Asks for more each step line • Unzips zippers • Begins to show • Points to five to • Adds one to two • Kicks ball with • Imitates circular • Puts shoes on defiant behavior six body parts words/week demonstration scribble partway • Points to four • Walks with one pieces of cloth- foot on walking ing when named board

24 months • Walks down • Makes a single- • Opens door • Sorts objects • Parallel play • Follows two-step • Two-word sen- stairs holding rail, line “train” of using knob • Matches objects • Begins to mask command tence (noun þ both feet on cubes • Sucks through a to pictures emotions for • Understands me/ verb) each step • Imitates circle straw • Shows use of social etiquette you • Telegraphic • Kicks ball without • Imitates horizon- • Takes off clothes familiar objects • Points to 5 to 10 speech demonstration tal line without buttons pictures • Uses 50þ words • Throws • Pulls off pants • 50% intelligibility overhand • Refers to self by name • Names three pictures

28 months • Jumps from bot- • Strings large • Holds self and • Matches shapes • Reduction in • Understands “just • Repeats two tom step with beads awkwardly verbalizes toilet • Matches colors separation one” digits one foot leading • Unscrews jar lid needs anxiety • Begins to use • Walks on toes • Turns paper pa- • Pulls pants up pronouns (I, me, after ges (often several with assistance you) demonstration at once) • Names 10 to 15 • Walks backward pictures 10 steps Continued

30 Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 TABLE 3. (Continued)

PROBLEM- SOCIAL/ RECEPTIVE EXPRESSIVE AGE GROSS MOTOR FINE MOTOR SELF-HELP SOLVING EMOTIONAL LANGUAGE LANGUAGE

30 months • Walks up stairs • Makes eight- • Washes hands • Replaces circle in • Imitates adult • Follows two • Echolalia and with rail, alter- cube tower • Puts things away form board after activities (eg, prepositions: jargoning gone nating feet • Makes a “train” of • Brushes teeth it has been sweeping, “put block • Names objects • Jumps in place cubes and with assistance turned around talking on in.on box” by use • Stands with both includes a stack (little or no trial phone) • Understands • Refers to self with feet on balance and error) actions words: correct pronoun beam • Points to small “playing . • Recites parts of • Walks with one details in pictures washing . well-known foot on balance blowing” story/ ﬁlls in beam words

33 months • Walks swinging • Makes 9- to 10- • Toilet trained • Points to self in • Begins to take • Understands • Gives ﬁrst and arms opposite of cube tower • Puts on coat photos turns three last name legs • Puts six square unassisted • Points to body • Tries to help with prepositions • Counts to 3 (synchronous pegs in parts based on household tasks • Understands • Begins to use gait) pegboard function (”What dirty, wet past tense • Imitates cross do you hear • Points to objects • Enjoys being with?”) by use: “ride read to (short in.put on books) feet.write with”

3 years • Balances on one • Copies circle • Independent • Draws a two- to • Starts to share • Points to parts of • Uses 200þ foot for 3 • Cuts with scis- eating three-part with/without pictures (nose of words seconds sors: side-to-side • Pours liquid from person prompt cow, door of car) • Three-word • Goes up stairs, (awkwardly) one container to • Understands • Fears imaginary • Names body sentences alternating feet, • Strings small another long/short, big/ things parts with • Uses pronouns no rail beads well • Puts on shoes small, more/less • Imaginative play function correctly • Pedals tricycle • Imitates bridge without laces • Knows own • Uses words to • Understands • 75% intelligibility • Walks heel to toe of cubes • Unbuttons gender describe what negatives • Uses plurals • Catches ball with • Knows own age someone else is • Groups objects • Names body stiff arms • Matches letters/ thinking (”Mom (foods, toys) parts by use numerals thought I was • Asks to be read asleep”) to

4 years • Balances on one • Copies square • Goes to toilet • Draws a four- to • Deception: inter- • Follows three- • Uses 300 to foot 4 to 8 • Ties single knot alone six-part person ested in “tricking” step commands 1,000 words seconds • Cuts 5-inch circle • Wipes after • Can give others and con- • Points to things • Tells stories • Hops on one foot • Uses tongs to bowel amounts (usually cerned about that are the same • 100% two to three transfer movement less than 5) being tricked by versus different intelligibility times • Writes part of first • Washes face/ correctly others • Names things • Uses “feeling” • Standing broad name hands • Simple analogies: • Has a preferred when actions are words jump: 1 to 2 feet • Imitates gate • Brushes teeth • dad/boy: friend described (eg, • Uses words that • Gallops with cubes alone mother/??? • Labels happiness swims in water, tell about time • Throws ball • Buttons • ice/cold: sadness, fear, and you cut with it, overhand 10 feet • Uses fork well fire/??? anger in self it’s something • Catches • ceiling/up: • Group play you read, it tells bounced ball (4½ floor/??? time.) yrs) • Points to five to • Understands six colors adjectives: bushy, • Points to letters/ long, thin, numerals when pointed named • Rote counts to 4 • ”Reads” several common signs/ store names Continued

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PROBLEM- SOCIAL/ RECEPTIVE EXPRESSIVE AGE GROSS MOTOR FINE MOTOR SELF-HELP SOLVING EMOTIONAL LANGUAGE LANGUAGE

5 years • Walks down • Copies triangle • Spreads with • Draws an 8- to • Has group of • Knows right and • Repeats six- to stairs with rail, • Puts paper clip knife 10-part person friends left on self eight-word alternating feet on paper • Independent • Gives amounts • Apologizes for • Points to differ- sentence • Balances on one • Can use clothes- dressing (<10) mistakes ent one in a • Defines simple foot > 8 seconds pins to transfer • Bathes • Identifies coins • Responds ver- series words • Hops on one foot small objects independently • Names letters/ bally to good • Understands “er” • Uses 2,000 words 15 times • Cuts with scissors numerals out of fortune of others endings (eg, • Knows tele- • Skips • Writes first name order batter, skater) phone number • Running broad • Builds stairs from • Rote counts to 10 • Understands • Responds to jump 2 to 3 feet model • Names 10 colors adjectives: busy, “why” questions • Walks backward • Uses letter long, thin, • Retells story with heel-toe names as sounds pointed clear beginning, • Jumps backward to invent spelling • Enjoys rhyming middle, end • Knows sounds of words and consonants and alliterations short vowels by • Produces words end of that rhyme kindergarten • Points correctly • Reads 25 words to “side,”“middle,”“corner”

6 years • Tandem walks • Builds stairs from • Ties shoes • Draws a 12- to • Has best friend of • Asks what un- • Repeats 8- to memory • Combs hair 14-part person same sex familiar words 10-word • Draws diamond • Looks both ways • Number con- • Plays board mean sentences • Writes first and at street cepts to 20 games • Can tell which • Describes events last name • Remembers to • Simple addition/ • Distinguishes words do not in order • Creates and bring belongings subtraction fantasy from belong in a • Knows days of writes short • Understands reality group the week sentences seasons • Wants to be like • 10,000 word • Forms letters • Sounds out reg- friends and vocabulary with down- ularly spelled please them going and coun- words • Enjoys school terclockwise • Reads 250 words strokes by end of first • Copies drawing grade of flag

bites. At this age, gaze monitoring (following the adult desired object, an action that becomes very useful for emerg- glance with the child’s own eyes) begins. Nine-month-olds ing toddlers discovering their own wishes. These children are interested in what others around them find interesting understand and respond to “no” (even if they don’talways and are eager to engage. These infants respond to simple obey) and they begin using words. commands and may begin using dada/papa and mama nonspecifically in babble. Fifteen Months As children pass their first birthday, many new skills con- Twelve Months tinue to emerge. Early toddlers are beginning to learn more The 1 year old mark hails numerous changes in a child’s words; many combine babbling, jargon, and words for a life. Children begin to walk and talk around this age. delightful language all their own. The children begin to Increased communication and mobility have cascading point to body parts or objects in books upon request and effects for learning in all domains. By 12 months, many retrieve an object when sent (eg, when asked to go get their infants can stand well, with legs apart and arms out or shoes so they will be ready to go to the park). In addition, overhead. They can walk, either independently or while they can turn pages in a book (important for early reading holding the hand of a caregiver. They have learned to throw development) and place 10 cubes in a cup, a pellet in a small objects and can enjoy the wonders of gravity by dropping bottle, and a circle in a shape puzzle. A key skill by this age is objects over the side of the high chair or stroller. One-year-olds proto-declarative pointing or pointing to express interest. cooperate with dressing, remove hats and socks, and finger Fifteen-month-olds scribble on paper with a crayon and feed themselves using a mature pincer grasp. They look for build a three-cube tower. At this age, empathy begins to hidden toys and can let adults know when they need help. develop and children can feel happy or sad alongside a peer Proto-imperative pointing involves pointing to obtain a or family member.

32 Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 Eighteen Months hands and face, and use a fork. During the year, four-year- At 18 months of age, children can run, seat themselves in a olds often develop a preference for certain friends, can chair, make a four-cube tower with blocks, and imitate identify emotions they may feel, and are learning to play vertical strokes with a crayon. They pretend to talk on the in groups. phone, drive a car, or have a tea party. Children now begin to understand the concept of “mine,” and this often Five Years becomes a favorite word as children learn possessiveness. At the 5-year birthday, children enter the “school-age” Shame, guilt, or sadness after wrongdoing emerge at this years. Their balance improves to more than 8 seconds per age and may affect a child’s choice of actions. Children at foot, they can hop on one foot 15 times in a row, and they 18 months often use 10 to 25 words (or more!) and point to learn to skip. They can copy a triangle, cut out shapes with pictures, people, and body parts as well as name a familiar scissors, write their names, and use blocks to build stairs. object when requested. They can dress themselves in the morning and are often able to bathe independently. Children draw a person with Twenty-four Months 8 to 10 parts, identify coins, recite the alphabet, and count Here begins the wonderful world of two-year-olds. Children out loud. At this age, children sometimes skip letters or who are 24 months can kick a ball, throw overhand, and give numbers out of order, and they may still write some begin to learn to jump. They can imitate circles and hori- letters or numbers reversed. The ability to hear and zontal lines. They are beginning to take clothes off inde- produce rhyming words is an important predictor of pendently (a key step to potty-training) and can turn door earlyphonemicawarenessandliteracyskills.Bythe knobs. Socially, they often play in parallel, ie, side-by-side end of kindergarten, children usually know the sounds but often without significant cooperation. They can dem- that consonants and short vowels make and can often onstrate defiant behavior as well as mask certain feelings read 25 words (or more). Socially, children in kindergar- when socially appropriate. At 2 years of age, children are ten usually have a group of friends and are able to be glad using between 50 and 200 words, putting two words for their friends when good things happen. During this together in sentences with a noun and verb, and calling year, children learn right from left (from their own themselves by name. perspective) and can identify locations. At this age, children have more than 2,000 words and can define simple Thirty-six Months words, use sentences competently, and memorize their “ ” Three years is the magical year of pretend play, socialization, telephone number or address. They can answer why and developing creativity. By 3 years, most children can questions. Children often love to be read to and can repeat identify their own gender as well as the gender of their stories, retelling the beginning, middle, and end of the plot. friends. Children learn to draw a circle, are able to climb on a Creativity and unique interests begin to emerge in this jungle gym, and run much more quickly than before. delightful age. Sentences develop into paragraphs and children begin to take part in back and forth conversation. Athree-year-old can Six to Twelve Years fear imaginary things and describe what others might be The school years are devoted to gaining and refining skills. thinking. Children develop greater motor skills and proceed from learning to run, hop, and skip to more complex skills such Four Years as soccer, swimming, or dancing. By 6 years, many chil- At 4 years, children are gaining greater balance and learn dren have mastered riding a bicycle without training tohopononefootafewtimesinarow.Theycanbalance wheels. Fine motor skills progress to improved handwrit- on each foot for 4 to 8 seconds, jump 1 to 2 feet forward, ing and then more complex tasks such as fingering on the and gallop. Four-year-olds learn to copy a cross and a violin, drawing and painting, woodworking, or typing. square with a crayon, tie a knot, and cut paper. Four-year- Children are able to speak in paragraphs, hold conversa- olds can also draw a four- to six-part person. They can tions, and recount stories with detail. Around the third point to five to six colors, identify many numbers and grade, children progress from learning to read and begin letters, count to 4 by rote, and possibly recognize signs reading to learn, thus opening a world of knowledge. The (such as a Stop sign) or favorite stores or brands. They are elementary years are an enjoyable time of learning, grow- able to use the restroom independently, brush teeth, wash ing, and exploring.

Vol. 37 No. 1 JANUARY 2016 33 Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 TABLE 4. Neonatal Reﬂexes

REFLEX DESCRIPTION APPEARANCE/DISAPPEARANCE

Rooting The infant’s head turns toward the side, the cheek is Present in utero at 24 weeks, disappears at 3-4 months, touched, and the mouth opens. although may persist in sleep until 1 year. Sucking Placing something in the mouth causes infant to suck Sucking appears in utero early in gestation. Sucking and and draw liquid into the mouth. swallowing may not mature until 32-36 weeks’ gestation. Sucking may disappear around 3 months of age, although it persists longer in sleep. Moro/Startle A sudden change in position or loud noise causes the In utero at 28 weeks’ gestation, disappears at 3-6 months infant’s arms/fingers to extend and then come of age. together. Withdrawal The infant moves the hand or foot from painful Present at birth and remains for life. stimuli. Palmar/Plantar Grasp Placing a small object or finger in palm or beneath toe Present at 32 weeks’ gestation. Palmar disappears at 3-4 causes fingers or toes to curl around object. months and is replaced by voluntary grasp at 4-5 months. Plantar disappears at 9-12 months. Asymmetric Tonic Neck When supine and head turned to one side, the arm Present at birth and disappears at approximately 3-4 (ATNR) and leg on that side extend while opposite limbs months (and allows for rolling). are flexed. Babinski Stroking bottom of foot causes big toe to raise while Present at birth and disappears at 9-10 months. If found other toes fan out and foot twists in. when child is older, may indicate neurologic disease. Landau When infant is suspended horizontally and prone, if Appears at 3 months and disappears between 1 and 2 head is flexed against the trunk, the legs flex against years. the trunk. Parachute Suddenly moving the infant downward when Appears at 7-9 months and persists indefinitely. horizontal causes hands and fingers to extend forward and spread to protect from fall. Knee Jerk A tap on the tendon below the patella causes the leg Becomes more pronounced at postnatal day 2 and to extend quickly. remains throughout life.

RED FLAGS have challenges promoting their child’sgrowthand development and may benefit from aid in providing Clinicians may note red flags in developmental mile- developmental stimulation and opportunities for play stones that are cause for concern, further monitoring, and learning. Parents with low educational attainment or referral (Table 5). In children, certain absent mile- or fewer community resources may require additional stones may indicate a developmental delay that is more likely to be long-lasting or to require earlier intervention. support services. (14) The pediatrician is often the primary support for fam- Areas that benefit from intervention are particularly ilies in identifying red flags and guiding interventions. important to identify and treat to allow the child the Children with unexplained early motor delays or hypotonia greatest likelihood of healthy development. Studies show fi that beginning intervention earlier in a child’s develop- may bene t from further evaluation for conditions such as mental course leads to improved outcomes and can cerebral palsy, muscular dystrophy, or other neuromuscu- fi improve engagement of a family in the child’s develop- lar disorders. A recent AAP Guideline for Early Identi - mental progress (Table 1). (5) cation of Motor Delay provides a helpful algorithm for Parents may also exhibit patterns that are red flags for a motor evaluation at routine periods. The algorithm sug- child’s development. If a parent is frequently insensitive to gests obtaining creatinine kinase measurements and thy- an infant’s communication, is unable to recognize the roid studies when hypotonia is found and ordering infant’s cues, is easily angered by the infant, or ignores the magnetic resonance imaging of the brain in specificset- infant, this may be a sign of difficulty with attachment and tings of persistent, unexplained hypertonia. (15) Children family support may be warranted. (13) Furthermore, par- who exhibit red flags in the areas of social communica- ents struggling with depression or substance abuse may tion can be referred for evaluation for autism spectrum

34 Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 disorders or language concerns. Children with receptive or intervention before intrauterine demise. (18) Long-term expressive language delays benefit from a thorough eval- survival of infants born preterm has also risen dramati- uation and treatment by a speech/language pathologist. cally. Preterm birth is now a leading cause of neuro- Children with developmental delay not explained by the developmental disabilities in children, (19) and the medical history may benefit from evaluation by a pediatric degree of neurodevelopmental disability is inversely cor- genetics team. (16) related with gestational age at birth. Although previously believed to be at low risk for developmental delay, even IMPLICATIONS FOR PRETERM INFANTS children born in the late preterm period (34-0/7 to 36-6/7 weeks’ gestation) have a significantly increased risk of Each year, approximately 12% of infants in the United behavioral disorders and learning delay compared with States – almost 500,000 – are born preterm (before the children born at term. (20) Delays associated with pre- 37th postmenstrual week). (17) Although stable in the maturity include cognitive, language, motor, social- recent past, the preterm birth rate rose dramatically emotional, and learning domains. (21) Risk factors for delay between 1980 and 2006, due both to the development can manifest before or after preterm birth (Table 6). Many and increased use of assisted reproductive technologies of the most significant contributors to developmental chal- and to advances in obstetric management that allowed lenges are social and may need to be addressed using

TABLE 5. Developmental Red Flags

TIME PERIOD LANGUAGE/COGNITIVE MOTOR SOCIAL-EMOTIONAL

Neonatal period Infant does not respond to loud Muscle tone too low to feed. Caregiver shows indifference or sounds. disinterest in infant. 2 months Does not alert to voice. Cannot raise head when prone. Lack of looking at faces/lack of ﬁxation. 4 months No cooing or gurgling sounds. Unable to bring hands to midline. Lack of smiling. 6 months Lack of turning toward voices. Does not pass object from one hand No smiling, laughing, or expression. to another. 9 months Lack of babbling with consonants. Inability to sit. Lack of rolling. Absence of back-and-forth smiles and vocalizations in “conversation.” 12 months Child does not respond to name. Does Does not stand or bear weight on legs Indifferent or resistant attachment to not understand “no”. when supported. caregiver. Does not look where caregiver points. 15 months Does not use words such as mama No pincer grasp. Absence of proto-imperative pointing and papa/dada. (point to desired object). 18 months Not using at least 6 words. Inability to walk independently. Absence of proto-declarative pointing (point to show interest) or showing gestures. 24 months Lack of words and two-word Inability to walk well. Does not imitate actions or words of meaningful sentences. Inability to caregivers. Poor eye contact. follow simple commands. 36 months Inability to use three-word sentences. Frequent falling or difﬁculty with stairs. Lack of pretend play. 4 years Unclear speech. Does not answer Does not jump in place. Ignores other children. simple questions. Inability to use pronouns. 5 years Inability to rhyme. Inability to Does not draw pictures, a square, or a Unusually fearful, sad, shy, angry. Does recognize shapes, letters, colors. cross. Poor balance. not distinguish between real and Resists dressing, sleeping, using the make-believe. toilet. 6-12 years Cannot retell or summarize a story Does not skip or hop on one foot. Does not name friends. Cannot with beginning, middle, and end. Does not write name. recognize feelings in others. Any age Loss of previously acquired skill.

Vol. 37 No. 1 JANUARY 2016 35 Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 community support services addressing the entire family’s entrance for many children, and because school entrance is needs or concerns. based on chronologic rather than corrected age, reverting Screening tests and treatment algorithms for devel- to chronologic age allows the provision of appropriate opmental delay in children born at term can be used for services for preterm children cared for alongside their preterm children. When comparing performance of term peers. preterm children to developmental norms, “corrected Besides age-adjustment, clinicians should pay specific age” or age from due date rather than birth date is attention to sensory function in children born preterm. The generally used. (22)(23) There is no consensus among incidence of visual and hearing impairments is higher in experts in perinatal care regarding the specificduration preterm than term children due to increased risk for reti- of time that gestational age correction should be per- nopathy of prematurity, jaundice, cortical hemorrhages, formed. Both the AAP and Centers for Disease Control infections, and extended hospitalization. Unrecognized and Prevention support gestational age correction, as do visual or hearing impairment can distort performance on most researchers focused on neurodevelopmental out- cognitive and behavioral testing. Children born preterm are comes, although formal policy guidelines for when and also at greater risk than their term peers for intraventricular how to apply gestational agecorrectionhavenotbeen hemorrhage and possible cerebral palsy, particularly spastic formulated.(24)Asaresult,somedevelopmentalcen- diplegia, which can also affect performance on assessments ters do not correct for prematurity, while others con- of motor function. tinue correcting until a child is attending school. Many Language delays are more common in infants born screening tools have specificguidelinesforgestational preterm due to distinct or compounded difficulties with age correction; in those cases, the recommended tool- processing auditory and visual information, learning and specific correction should be used. In the absence of conceptualizing verbal language, and producing speech formal guidelines, most developmental clinicians and sounds. (23) As they reach school age, children born researchers correct for prematurity for the first 24 preterm are at particular risk for learning delays, both months after birth. (23) When children are delayed those related to spoken and written language production beyond their corrected age, this is a red flag for concern. and those related to behavioral problems that make class- Pediatric clinicians should be aware that correcting for room learning challenging. Both externalizing and inter- gestationalagemayovercorrectformilestonesinthe nalized behaviors, as well as social difficulties, are more social and language domains, and these may need closer common in preterm than term children. (22)(26)(27)(28) attention. By age 2 or 3 years, most children with Due to the elevated risk of sometimes subtle cognitive and transient delays related to prematurity have “caught behavioral disabilities, pediatric clinicians caring for chil- up” with their term peers, and chronologic age can be dren born preterm must be particularly vigilant when used. (25) This time point also corresponds to preschool performing developmental assessments to engage the

TABLE 6. Risk Factors for Developmental/Behavioral Concerns Following Preterm Birth (23)

Prenatal Very low birthweight (<1500 g) Extremely low gestational age (birth <28 weeks’ gestation) Intrauterine growth restriction Male gender Postnatal Neonatal seizures (before 28 days of age) Abnormal brain imaging (white matter injury/periventricular leukomalacia, grade 3 or 4 intraventricular hemorrhage) Chronic lung disease/bronchopulmonary dysplasia Prolonged mechanical ventilation (>96 hours) Bacteremia, meningitis, or sepsis Necrotizing enterocolitis Feeding problems beyond 36 weeks postmenstrual age Extracorporeal membrane oxygenation Social Low socioeconomic status Low parental educational achievement Language barrier with family Parental depression

36 Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 appropriate therapeutic services as early as possible. (3) Available dedicated early intervention programs should Summary be used because they may have a lasting benefiton • On the basis of observational studies (level C), preterm birth is a cognitive outcome and educational achievement. (29) leading cause of neurodevelopmental disabilities in children, (19) (30) In addition, counseling and parent support groups and the degree of neurodevelopmental disability is inversely may have benefit for families seeking to provide behav- correlated with gestational age at birth. When comparing ioral and emotional support to their children born pre- performance of preterm children to developmental norms, “corrected age” or age from due date rather than birth date term. (31)(32) should be used for the first 24 to 36 months. (22)(23) • On the basis of observational studies (level C), clinicians should CONCLUSION pay specific attention to sensory function in children born preterm because the incidence of visual and hearing impairments The first years of development are crucial for lifelong is higher in preterm than term children. Due to the elevated risk of learning and development. Milestones follow predictable cognitive and behavioral disabilities, clinicians caring for children born preterm should be vigilant when performing courses in infants and children, and later developmental developmental assessments to improve outcomes. (3) skills build on previous ones achieved. Understanding • On the basis of observational studies (level C), early identification normal development is important for the pediatrician to of developmental delays allows for referral to therapeutic be able to recognize delayed development. (1)(5)(33) De- services, and children referred for early intervention are more velopmental screening identifies developmental delays likely to make gains in developmental milestones. (1)(5)(33)(34) at a time period in which formal evaluation and intervention would be beneficial. Children with global developmental delay have delays in multiple domains of development, CME quiz and references for this article are at http://pedsinreview. while children with specificdelaymayhaveadelayin aappublications.org/content/37/1/25. Access this and all other PIR only one area of development such as language or motor CME quizzes available for credit at: http://www.aappublications. skills. org/content/pediatrics-review-quizzes.

Parent Resources from the AAP at HealthyChildren.org • Developmental Milestones: 1 Month: https://www.healthychildren.org/English/ages-stages/baby/Pages/Developmental-Milestones-1-Month.aspx • Developmental Milestones: 3 Months: https://www.healthychildren.org/English/ages-stages/baby/Pages/Developmental-Milestones-3-Months.aspx • Developmental Milestones: 7 Months: https://www.healthychildren.org/English/ages-stages/baby/Pages/Developmental-Milestones-7-Months.aspx • Developmental Milestones: 12 Months: https://www.healthychildren.org/English/ages-stages/baby/Pages/Developmental-Milestones-12-Months.aspx • Developmental Milestones: 2 Year Olds: https://www.healthychildren.org/English/ages-stages/toddler/Pages/Developmental-Milestones-2-Year-Olds.aspx • Developmental Milestones: 3 to 4 Year Olds: https://www.healthychildren.org/English/ages-stages/toddler/Pages/Developmental-Milestones-3-to-4-Years-Old.aspx • Developmental Milestones: 4 to 5 Year Olds: https://www.healthychildren.org/English/ages-stages/toddler/Pages/Developmental-Milestones-4-to-5-Years-Old. aspx

CME Quiz Correction In the November 2015 article “Otitis Media: To Treat, To Refer, To Do Nothing: A Review for the Practitioner,” (Rosa- Olivares J, Porro A, Rodriguez-Varela M, Riefkohl G, Niroomand-Rad I. Pediatrics in Review. 2015;36(11):480, DOI: 10.1542/pir.36-11-480), there were errors in CME quiz question 4. In the question body, the following sentence should have been omitted: “You refer her to the audiologist, who documents a 30-dB hearing loss.” In addition, the correct answer option should be “C. Referral to audiology.” The online version of the quiz and the article have been corrected. The journal regrets the error.

Vol. 37 No. 1 JANUARY 2016 37 Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 PIR Quiz

There are two ways to access the journal CME quizzes: 1. Individual CME quizzes are available via a handy blue CME link in the Table of Contents of any issue. 2. To access all CME articles, click “Journal CME” from Gateway’s orange main menu or go directly to: http://www. aappublications.org/content/journal-cme.

1. What is the purpose of screening for developmental milestones? REQUIREMENTS: Learners A. Assess the incidence of developmental delays in a clinic population. can take Pediatrics in B. Diagnose developmental delays. Review quizzes and claim C. Identify children for referral to special education programs. credit online only at: D. Identify children who should be referred for further evaluation. http://pedsinreview.org. E. Plan for treatment of developmental delays. 2. A term 4-month-old male infant is developing normally. Which of the following is the To successfully complete major milestone for normally developing children at this age? 2016 Pediatrics in Review A. Bring hands together to midline. articles for AMA PRA TM B. Lift head up when prone. Category 1 Credit , C. No head lag when pulled to sit. learners must D. Social smile. demonstrate a minimum E. Roll supine to prone. performance level of 60% or higher on this 3. A child is able to run, make a four-cube tower with blocks, and have a tea party. She assessment, which understands “mine” and she feels badly when she steps on her mother’s foot. Given normal measures achievement of developmental progress, how old is she? the educational purpose A. 15 months. and/or objectives of this B. 18 months. activity. If you score less C. 2 years. than 60% on the D. 2.5 years. assessment, you will be E. 3 years. given additional 4. A 3-year-old girl is developing normally. Which of the following milestones is consistent opportunities to answer with her developmental age? questions until an overall A. Copy a square. 60% or greater score is B. Identify her own gender. achieved. C. Imitate a horizontal line. D. Throw a ball overhand. This journal-based CME E. Turn door knobs. activity is available 5. How long should you correct for gestational age when evaluating preterm infants? through Dec. 31, 2018, A. 6 months. however, credit will be B. 12 months. recorded in the year in C. 24 months. which the learner D. Until kindergarten. completes the quiz. E. Until entry to high school.

38 Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 Developmental Milestones Rebecca J. Scharf, Graham J. Scharf and Annemarie Stroustrup Pediatrics in Review 2016;37;25 DOI: 10.1542/pir.2014-0103

Updated Information & including high resolution figures, can be found at: Services http://pedsinreview.aappublications.org/content/37/1/25 References This article cites 31 articles, 12 of which you can access for free at: http://pedsinreview.aappublications.org/content/37/1/25#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Journal CME http://classic.pedsinreview.aappublications.org/cgi/collection/journal _cme Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://classic.pedsinreview.aappublications.org/site/misc/Permissions .xhtml Reprints Information about ordering reprints can be found online: http://classic.pedsinreview.aappublications.org/site/misc/reprints.xht ml

Downloaded from http://pedsinreview.aappublications.org/ by guest on September 4, 2016 Management 25% to 50% addiction rates. Patients with CHS should Patients presenting in a hyperemetic phase of CHS often be referred to inpatient or outpatient drug rehabilitation are volume-depleted and require oral or IV rehydration. If programs. volume depletion is severe or urine output remains low after administration of ﬂuids, renal function should be Lessons for the Clinician tested. Because esophagogastroscopy in patients with • Recurrent vomiting has a broad differential diagnosis that CHS has shown gastritis and esophagitis, many clinicians includes gastrointestinal, neurologic, metabolic, urologic, routinely prescribe acid suppressive therapy. Antiemetics psychiatric, and toxic causes. typically are unhelpful, although a case report has docu- • Cannabinoid hyperemesis syndrome (CHS) presents mented relief with haloperidol. Pain is usually treated with in chronic daily or almost-daily users of cannabinoids, nonopioids because of concern that opioids might worsen typically after more than 1 year of use. nausea. Patients may be encouraged to continue hot bath- • Diagnosing CHS is often substantially delayed; one ing for pain and nausea relief. Curative therapy consists of important diagnostic clue is the learned behavior of hot cessation of cannabis use, after which pain and emesis bathing to relieve pain and nausea. typically resolve over 48 hours. Resumption of cannabis • In cases of CHS, an extensive or prolonged diagnostic use leads to relapse. Educating the patient about the cause of evaluation is not necessary. symptoms is key because many perceive cannabis to be • Curative therapy for CHS consists of cessation of can- helpful for their nausea. nabis use. Although cannabinoids are believed to be less addictive than many drugs of abuse, approximately 9% of users Suggested Readings for this article are at http://pedsinreview. become addicted, and daily users are at higher risk, with aappublications.org/content/37/6/264.

Correction In the January 2016 review “Developmental Milestones” (Scharf, Scharf, Soustrup. Pediatrics in Review. 2016;37(1):25–38, DOI: 10.1542/pir.2014-0103), a line was duplicated inadvertently. In Table 3: Developmental Milestones, at age 5 months, ﬁne motor skills should not include “Holds hands together.” The online version of the article has been corrected. The journal regrets the error.

ANSWER KEY FOR JUNE 2016 PEDIATRICS IN REVIEW Cytomegalovirus and Epstein-Barr Virus Infections: 1. E; 2. E; 3. E; 4. A; 5. C. Acquired and Congenital Hemolytic Anemia: 1. D; 2. D; 3. A; 4. B; 5. C. Preventing Infections in Children with Cancer: 1. C; 2. B; 3. E; 4. C; 5. E.

266 Pediatrics in Review Developmental Milestones Rebecca J. Scharf, Graham J. Scharf and Annemarie Stroustrup Pediatrics in Review 2016;37;25 DOI: 10.1542/pir.2014-0103

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/37/1/25

An erratum has been published regarding this article. Please see the attached page for: http://pedsinreview.aappublications.org//content/37/6/266.full.pdf

Data Supplement at: http://pedsinreview.aappublications.org/content/suppl/2016/01/18/37.1.25.DC1.html

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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