Developmental Milestones and Normal Growth

Developmental milestones are the skills or abilities that most children are able to perform when they reach a certain age. Understanding the appropriate milestones and at what age they are reached helps clinicians identify symptoms of delayed development. Developmental milestones are divided into 5 important domains: gross motor, fine motor, language, social, and cognitive. These milestones should be monitored by pediatricians at each well-child check. Early identification of developmental delays can prevent future complications and permits timely referral to appropriate supportive services.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Developmental milestones are a set of benchmarks in gross motor, fine motor, language, cognition, social/emotional, and behavior patterns expected by a certain age.

Assessment of developmental disorders must take into account gestational age at birth; e.g., a premature baby should be expected to reach their milestones appropriately for their chronological age.

Pediatricians assess developmental milestones at every well-child visit for:

  • Screening
  • Surveillance

Developmental Milestones: 0–12 Months

Growth parameters during the 1st year:

By the end of the 1st year, a child’s weight should be triple their birth weight, and their height should increase by 50% from their height at birth.

Table: Developmental milestones during the 1st year of life
Age Gross motor Fine motor Language Social/cognitive
1 month
  • Turns head while supine
  • Lift heads up in prone position
Hands clenched in fists brought near face most of the time Makes sounds
  • Responds differently to caregiver’s voice
  • Startled by loud noise
2 months
  • Holds head and chest up while prone
  • Has very brief head control while sitting up
  • Hands unfisted half of the time
  • Clasps hands
  • Coos
  • Vowel sounds
  • Social smile
  • Recognizes caregiver
4 months
  • Sits with trunk support
  • Rolls (prone to supine)
  • Pushes up on wrists
  • Loss of head lag when pulled from prone position
  • Hands open most of the time
  • Reaches and clutches consistently
  • Grasps items
  • Laughs loudly
  • Turns to voice
  • Stops crying to soothing voice
  • Looks around
  • Mouths objects
  • Spends more time looking at strange faces than familiar ones
5 months
  • Sits with pelvic support
  • Rolls back to front (supine to prone)
  • Palmar grasp
  • Can transfer objects ( hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand to mouth to hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand)
  • Says “ah-goo”
  • Razzes, squeals
  • Begins to respond to name
  • Expresses anger in different way than crying
  • Recognizes caregiver visually
  • Can turn head to look for dropped objects
  • Forms attachment to caregiver
6 months Sits for brief moment propped on hands
  • Transfers objects ( hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand to hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand)
  • While holding object in 1 hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand, takes 2nd object in other hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand
  • Rakes small items
  • Babbles with consonants
  • Stops momentarily to “no”
  • May gesture to be picked up
Stranger anxiety develops
7 months Sits steadily without support Grasps using side of hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand (radial-palmar grasp)
  • Looks toward familiar object when named
  • Increased syllable variety when babbling
  • Explores different aspects of a toy
  • Finds partially hidden objects
9 months
  • Pulls to stand
  • Crawls on 4 straightened limbs
Grasps with 2 fingers and thumb below (radial-digital or 3-finger grasp)
  • Says “mama” (nonspecific)
  • Nonreduplicate babble
  • Imitates sounds
  • Can use sound to get attention
  • Object permanence
10 months
  • Cruises around furniture with 2 hands
  • Stands with 1 hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand held
  • Walks with both hands held
Grasps pellet with side of index finger and thumb (inferior pincer grasp) Says “dada” (specific)
  • Waves “bye-bye”
  • Plays peekaboo
12 months Takes 1st independent steps (walking may be delayed up to 18 months)
  • Fine pincer grasp
  • Builds tower of 2 cubes*
  • Throws objects
Says at least 1 word other than “dada” or “mama”
  • Comes when called
  • Follows 1-step command with gestures
*Number of cube towers a child can build = child age / 2

Developmental Milestones: 1–5 Years

Table: Developmental milestones: 1–5 years
Age Gross motor Fine motor Language Social/cognitive
15 months
  • Crawls/climbs up stairs
  • Stoops to pick up objects
  • Walks while carrying objects
Builds 3- to 4-cube tower Uses 3–5 words
  • Hugs adult
  • Shows empathy
  • Can turn pages in a book
  • Knows at least 1 body part
  • Retrieves objects in another room when asked
18 months
  • Crawls/climbs down stairs
  • Runs well
  • Throws ball while standing
  • Makes 4-cube tower
  • Removes clothing
  • Uses vocabulary of 10–25 words
  • Names 1 picture on demand
  • Begins to show shame
  • Matches pairs of objects
  • Imitates environmental noises (e.g., animal sounds)
  • Engages in pretend play
24 months
  • Walks up and down stairs, bringing both feet to each step
  • Kicks ball
  • Throws overhand
  • Makes a single-line “train” of cubes
  • Can imitate horizontal line and circle
  • 50+ words in vocabulary
  • Uses 2-word sentences (noun + verb)
  • 50% of speech is clear.
  • Refers to self by name
  • Follows 2-step command
  • Understands “me”/”you”
  • Opens doors
  • Takes clothes off without help
  • Parallel play
3 years
  • Walks up and down stairs, with alternating feet
  • Rides tricycle
  • Balances on 1 foot for 3 seconds
  • Walks heel to toe
  • Copies circle
  • Makes a 9- to 10-cube tower
  • Uses 200+ words
  • Uses 3-word sentences
  • 75% of speech is clear.
  • Uses plurals
  • Understands negatives
  • Understands long/short
  • Fears imaginary things
  • Imaginative play
  • Knows gender and age
4 years
  • Balances on 1 foot for 4–8 seconds
  • Hops on 1 foot (2–3 times)
  • Catches ball
  • Copies a square
  • Ties single knot
  • Identifies colors
  • 100% of speech is clear.
  • Tells stories
  • Can write part of own 1st name
  • Expresses feelings in words
  • Group play
  • Follows 3-step commands
  • Has a preferred friend
  • Can go to toilet by self
  • Basic self-hygiene: face/hands/ teeth Teeth Normally, an adult has 32 teeth: 16 maxillary and 16 mandibular. These teeth are divided into 4 quadrants with 8 teeth each. Each quadrant consists of 2 incisors (dentes incisivi), 1 canine (dens caninus), 2 premolars (dentes premolares), and 3 molars (dentes molares). Teeth are composed of enamel, dentin, and dental cement. Teeth
5 years
  • Skips
  • Walks and jumps backward
  • Copies a triangle
  • Ties shoelaces
  • Writes first name
  • Can bathe and dress self
  • Counts to 10
  • Can speak in 5-word sentences
  • Can give definition of words
  • Identifies coins
  • Has group of friends
  • Apologizes for mistakes
  • Completes toilet training

Screening Recommendations

It is recommended to use standardized screening for early identification of developmental or behavioral problems.

Table: Screening recommendations for identification of developmental and behavioral problems
Age Benefit of screening
9-month visit Might identify motor, vision, hearing, or communication problems
18-month visit Might identify motor delays, language delays, and symptoms of autism spectrum disorders (ASD)
24-month visit Might identify patients with ASD who were missed at the 18-month screening
30-month visit Might identify motor, language, and cognitive delays
4-year-old visit Screen for school readiness (e.g., fine motor, gross motor, handwriting, communication, and self-help skills)

Clinical Relevance

  • Primitive reflexes Primitive Reflexes Primitive reflexes are involuntary motor responses that can be elicited after birth. Although these reflexes are important for survival, they gradually disappear within the 1st year of life due to their inhibition by the developing frontal lobe. Primitive Reflexes: actions mediated by the brainstem or spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord level. Present at birth and disappear during normal childhood development of higher-functioning brain regions ( cerebral cortex Cerebral cortex The cerebral cortex is the largest and most developed part of the human brain and CNS. Occupying the upper part of the cranial cavity, the cerebral cortex has 4 lobes and is divided into 2 hemispheres that are joined centrally by the corpus callosum. Cerebral Cortex). Primitive reflexes Primitive Reflexes Primitive reflexes are involuntary motor responses that can be elicited after birth. Although these reflexes are important for survival, they gradually disappear within the 1st year of life due to their inhibition by the developing frontal lobe. Primitive Reflexes can serve a similar function as developmental milestones in early-age infants to screen for the presence of any central nervous system Nervous system The nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system. General Structure of the Nervous System pathology.
  • Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive: a condition seen in children and toddlers. Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive is defined as weight below the 2nd percentile for age/gender on more than 1 occasion or weight < 80% ideal weight for age. The condition has psychosocial and organic origins and long-lasting repercussions on the general well-being of the affected child. Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive is another benchmark that must be assessed along with developmental milestones. 
  • Stranger anxiety: the fear of being around unfamiliar people. Stranger anxiety begins around 6 months of age and is attributed to a child’s developing ability to distinguish between familiar and unfamiliar persons. The child usually cries when they are approached by strangers, even in the presence of a caregiver. Stranger anxiety revolves around the age of 2 years. 
  • Separation anxiety: the anxiety that a child develops when they are separated from their parents. Separation anxiety is a normal phenomenon that starts around 9 months of age and resolves around 2 years of age when the child develops object permanence. The condition can return at any age during childhood, especially during periods of transition. Separation anxiety doesn’t affect development or cause significant distress.

References

  1. Centers for Disease Control and Prevention. Developmental Disabilities. Retrieved May 17, 2021, from https://www.cdc.gov/ncbddd/developmentaldisabilities/ 
  2. Sadock BJ, Sadock VA, Ruiz P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 31, Child Psychiatry, pages 1086-1090. Philadelphia, PA: Lippincott Williams and Wilkins.
  3. Lipkin PH, Macias MM (2020). Council on Children with Disabilities, Section on Developmental and Behavioral Pediatrics. Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening. Pediatrics.

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