What are the major growth and developmental milestones by month that the nurse should monitor for when assessing an infant?

The development of a child mostly takes place in the early years of his life. At this stage, parents are still overwhelmed with how fast babies grow and develop. Parents take much time and patience in picking the best resource to understand a child’s development. Therefore, lots of questions are thrown in the air for the nurse to answer. Some questions prove to be challenging, and it is important for nurses to be able to know the normal developmental milestones like the back of their hands.

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General Principles of Developmental Milestones
Domain #1: Normal Motor Development
Domain #2: Normal Language Development
Domain #3: Cognitive Development
Domain #4: Social Development

The first word, smile, and roll over are called developmental milestones. The child can tick off a milestone on his growing list of firsts depending on how he play, speak, move, and learn. While it is always emphasized that children develop at their own pace, developmental milestones are there to shed light on the general changes that should be expected as the child ages.

General Principles of Developmental Milestones

For excellent developmental assessment and surveillance, nurses must know the general principles of developmental milestones. The four key domains that should be periodically assessed include motor development, language development, problem-solving, and psychosocial skills.

Development occurs in an orderly, predictable, and intrinsic manner. For example, development proceeds from head to toe in a proximal to distal fashion. Reactions to stimuli develop from general into more specific and goal-directed reactions. Children gain independence from early years of total dependence.

Lastly, both intrinsic and extrinsic factors can affect development. Some examples of intrinsic factors are physical characteristics, health state, temperament, and genetic attributes. On the other hand, extrinsic factors include personalities of family members, economic status, learning experiences in the environment, and cultural setting to which the child is born.

Domain #1: Normal Motor Development

Motor milestones can both be assessed through history interview and observation. Evaluating gross motor development usually involves neuro maturational markers like primitive reflexes and postural reactions.

For example, Moro reflex is one primitive reflex that is present at birth and disappears usually between 3-6 months of age. If the baby has stronger and more sustained primitive reflexes, a CNS injury might be considered. On the other hand, parachute reaction is one postural reaction that is acquired. This actually helps the body become oriented in space through an interplay of visual, proprioceptive, and vestibular adjustment done by cerebral and cerebellar brain structures. Delayed development of postural reactions can signify CNS damage.

On the other hand, fine motor skills involve the use of small muscles of the hands. The control progresses from the use of proximal muscles to the distal muscles. As the baby improves on balance during sitting and moving, the hands become more focused on manipulation of objects.

Here is a table of motor development milestones:

Age	Milestone
Gross Motor Milestones
Birth	Turns head side to side
2 months	Lifts head when lying prone Head lags when pulled from supine position
4 months	Rolls over No head lad when pulled from supine position Pushes chest up with arms
6 months	Sits alone Leads with head when pulled from supine position
9 months	Pulls to stand Cruises
12 months	Walks
Fine Motor Milestones
Birth	Keeps hands tightly fisted
3-4 months	Brings hands together to midline and then to mouth
4-5 months	Reaches for objects
6-7 months	Rakes objects with whole hand Transfers object from hand to hand
9 months	Uses immature pincer (ability to hold small object between thumb and index finger)
12 months	Uses mature pincer (ability to hold small object between thumb and the index finger)

Red flags in motor development include: 1) persistent fisting beyond 3 months which indicate neuromotor problems; 2) early rolling over, early pulling to stand instead of sitting, and persistent toe walking which may all indicate spasticity; and 3) early hand dominance (before 18 months of age), which may signify weakness of the opposite upper extremity associated with hemiparesis.

Domain #2: Normal Language Development

Language is the single best indicator of intellectual potential. Language is the ability to communicate with symbols. It is often mistaken as synonymous with speech, the latter being defined as a vocal expression of language. This is the domain with the most number of delays.

It is also interesting to note that a child can usually understand 10 times (receptive language) as many words as he or she can speak (expressive language). The first two (2) years of life is the time for optimal language acquisition.

Here is a table of basic language milestones:

Age	Milestone
Birth	Attunes to human voice Develops differential recognition of parents’ voices
2-3 months	Cooing (runs of vowels), musical sounds (e.g. ooh-ooh, aah-aah)
6 months	Babbling (mixing vowels with mixed consonants) [e.g. ba-ba-ba]
9-12 months	Jargoning (e.g. babbling with mixed consonants, inflection, and cadence) Begins using mama, dada (nonspecific)
12 months	1-3 words, mama and dada (specific)
18 months	20-50 words Beginning to use two-word phrases
2 years	Two-word telegraphic sentences (e.g. mommy come) 25-50% of child’s speech should be intelligible
3 years	Three-word sentences More than 75% of the child’s speech should be intelligible

Domain #3: Cognitive Development

This domain talks about thinking, memory, learning, and problem-solving. By evaluating problem solving and language milestones, infant intelligence can be estimated. There is a poor correlation between gross motor skills and cognitive potential.

Here is a table of cognitive concepts:

Age	Concept
9 months	Object permanence (people and objects continue to exist even when an infant cannot see them). This ability to maintain an image of a person is the reason why separation anxiety (6-18 months) develops when a loved one leaves the room.
9-15 months	Cause and effect (understanding which actions cause certain results).
1-3 years	Magical thinking

It refers to the ability to interact with people and the environment. It is dependent on cultural and environmental factors. Here is a table of social milestones:

Age	Concept
12-36 months	Attachment (bonding with a primary caregiver begins at birth and empathy development is critical during this period).
15 months	A sense of self and independence (process of separation and individuation begins).
12-24 months	Social play (exhibit parallel play during the first 2 years of life).

In the grand scheme of things, it is essential for nurses to understand normal development as well as the variations that are considered acceptable so nurses can recognize pathologic patterns and developmental delays. Prompt planning and intervention will then be instituted for children who may benefit from referral to early intervention programs.

What other milestones can you add to the list? Share this to co-nurses and families that could benefit from this!

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