Understanding the revised benchmarks for child development

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Pediatricians use a checklist of developmental milestones to help identify delays in babies and young children. Recently, those milestones got an update from the Centers for Disease Control and Prevention together with the American Academy of Pediatrics. Here with me to explain the changes is Upstate pediatrician, Dr. Jenica O'Malley. Welcome to "The Informed Patient," Dr. O'Malley.

Jenica O'Malley, DO: Hi. I'm happy to be here.

Host Amber Smith: I'd like to start by having you explain what developmental benchmarks are and why they're important to pediatricians and parents and caregivers.

Jenica O'Malley, DO: When we talk about developmental benchmarks or developmental milestones, what we're really talking about is what are those key skills that children develop over time that sort of follow a predictable pattern? So, knowing that a child does a certain thing at a certain age, that's something we've known about for a long, long time that parents and pediatricians have observed. And when we think about them, what's really important about them is they tell us, how is this child doing? How is this child growing, developing, and thriving in their environment?

So if we start to see that a child isn't doing the things we expect them to, that allows us to kind of say, "hey, something's going on here. What do we need to do about it?" Sometimes it's education. And sometimes it's a referral to a service, like early intervention, where a child can get different types of therapy to help them make progress toward meeting those milestones. And what we're really thinking about is the long-term trajectory of the child. It's not even just about childhood. It's really about how do they do when they get to kindergarten? From there, how do they do when they get to middle school, high school? What level of education can they attain? And the earlier you can identify a potential problem, the earlier you can intervene, and the better that trajectory's going to be long term.

Host Amber Smith: So it sounds like benchmarks are part of modern medicine. They didn't use these centuries ago, did they?

Jenica O'Malley, DO: Well, I'm not so sure. I think that as long as there's been parents, they've been aware of what their kids are doing. So I think maybe not formally. Around, in the early 1920s is when people started to really pay attention to the science behind development. That's when one of the first books about child development was published. And they really looked at babies in nurseries. So they would just watch the babies. They wrote down what they did, and they tried to come up with what is normal, what are we seeing? And it was very observational. And at that same time was really the development of the field of child psychiatry and a lot of interest in how do babies and children's brains develop. And most of what was documented at that time was all based on observation and just looking at sets of babies, often in nurseries, because at those times, there was big nurseries where all the babies were brought after they were born, and they just watched them and wrote down and started to establish some normals.

Host Amber Smith: So, do you have parents who come to you worried because their baby isn't talking like all the other babies in the daycare, or walking at a certain stage? I mean, are parents concerned about this?

Jenica O'Malley, DO: Oh yeah, absolutely. I think it's one of the No. 1 things we see and what parents want to ask about. And what they really want to know about is how is my baby doing, compared to other babies? And parents are very astute, right? Many of them have multiple babies, so they know, "oh, you know, Joe did this when he was 3, but Tim, he hasn't done that at all. What's going on here?" Or they get together with their friends and they see their kids playing together and they say, "well, I noticed, you know, my friend down the street, their 2-year-old is saying sentences, and mine only says one word at a time. So what's going on with that?" It's something people are very concerned about. And luckily we have some great community resources, and we have a lot of resources out there for parents to kind of get an idea of where do their kids fall compared to other kids.

Host Amber Smith: How do you advise parents if they have a concern about their child's development?

Jenica O'Malley, DO: Of course, they can always reach out to their pediatrician, but we do have an excellent community resource called Help Me Grow. Parents can reach it by dialing 211. So you just dial 211 and you ask to speak to Help Me Grow. And they can help with all kinds of things, but if you're particularly interested about your child's development, they can assist you with completing a developmental screening tool, and giving you the results and connecting you to some resources to help sort of promote your child's development, things like story times at the library, activities that are going on in the community. And they're just a really amazing resource. So it's 211 and ask for Help Me Grow.

Host Amber Smith: Are the benchmarks in say Central New York, the same as the benchmarks in California or Florida or Mexico or Canada? Are we all on the same playing field or are things different geographically?

Jenica O'Malley, DO: So essentially, nationally the benchmarks are the same. We kind of have the same milestones for a 2-month-old, no matter where they live in the country. It really can't be generalized internationally, mostly becausethe studies just haven't been done. There's a big acknowledgement of what difference does culture make in terms of development because different cultures raise babies differently, and how does that impact the overall development? People are actually starting to look into that. And so I think maybe five or 10 years from now, we'll have a better idea globally what is the difference between different cultures? But overall I'd say kids tend to follow a certain pattern no matter where they live.

Host Amber Smith: Did the COVID pandemic have any impact on benchmarks? There was some concern if kids aren't interacting with one another, that it could cause some harm. Have you seen that?

Jenica O'Malley, DO: It's very hard to say. There's several things sort of working against us in this situation. So yes, some kids lost out on their interactions because either their parents weren't working, so they just kept them home with them. Or their parents didn't feel like it was safe to send their kids into program-based care, or they weren't getting together with other people. So there was definitely some loss of social interaction. At the same time, we had lots of those services that helped to provide therapy stop. So we had kids who weren't getting the help that they really needed to continue to improve their developmental trajectories. So I think that definitely will make an in impact, but I don't think we can say yet for certain. I don't think we'll know for years until the kids who were infants and toddlers during this time are really school aged and older, that we really know what the long term impact has been.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Upstate pediatrician, Dr. Jenica O'Malley about developmental milestones in children.

And now I'd like to ask you why and how these benchmarks were updated. Do you know what the process was?

Jenica O'Malley, DO: So, I'll go back just a little bit to explain what we're discussing, which is specifically the CDC's milestone checklist. They first came out in 2004, and they were really developed as a tool for parents, pediatricians, educators, other people working with children, daycare workers, to have a quick, easy-to-access checklist for various ages of childhood to look at and say, "okay, at two months you should be able to smile, you should be able to lift your head up," and quickly kind of look and see if the kids that they were around were meeting those milestones. And it also included some warning signs. So it would have red flags. If your baby is 2 years old and they're not talking, call your pediatrician, or call early intervention, things like that. They mostly were established from a book. So they looked at a book that is published by the AAP (American Academy of Pediatrics), and that had included milestones, and they put those into lists, and that was kind of the first iteration.

So this was the first update. And what they really wanted to do was make a few changes. So 1., they wanted to make sure that the milestones that they were including had evidence behind them. So they didn't want to just say that at 2 months, a baby should smile. They wanted to make sure that there was evidence that showed that was the normal age for a baby to smile. So they looked at each milestone first to see if it met criteria based on what's, the evidence that that's appropriate. And that has to do with, going through lots of articles. They looked at over 1,000 articles to include, to find their evidence base, so to find the evidence to say that these are the right milestones for the right age. And they actually were only able to include about 30. I think it was 34 articles that they used to collect their evidence.

And the other thing they wanted to do was make it easier for parents and really anyone to understand the milestones. So they wanted to simplify them. And the big thing that they did was to adjust basically the percentile that the children were falling into. So the original milestones that they were using from 2004 was based on what we call the 50th percentile. So that means if a milestone was that at 12 months you walk, it would mean that 50% of kids were walking at 12 months. But it also means that 50% are not walking independently at 12 months. And it kind of they felt like, encouraged people to take more of what's called a "wait and see" approach because they were like, "half of kids walk at this time. You're not. Let's give it a few more months and see what happens," instead of doing intervention.

So for this iteration, what they decided to do was adjust it to the 75th percentile. So for example, walking is one of the ones that they changed. So, it changed from 12 months to 15 months because by 15 months, 75% of kids should be walking. So most kids should be walking. And if your child's not walking at that age, that would be more worrisome than if they weren't walking at 12 months. They wanted to make it so people weren't waiting as long. So you would see someone at 15 months, you would say, "oh, they're not walking. This is a worrisome finding. We should do more evaluation, do a referral," something like that. And that was the really big change. They did not necessarily change the science of how kids develop. You know, They didn't say, oh, kids are developing in a different way now. They adjusted their messaging to have a different public health approach, I would say.

Host Amber Smith: So, if you do have that child that is in the 25%, that's not walking at 15 months, you as a pediatrician, you then have to think about why that might be. What do you do?

Jenica O'Malley, DO: The first thing you want to do is we always want to ask more questions. We wanna look globally at the child. We want to say, "well, what are the things they are doing in other domains?" So when we think about development, specifically with these milestone checklists from the CDC, they look at four different domains of development. So there's cognitive development, which is problem solving, how do they learn? There is language and speech development, communication. Social emotional, and then physical skills. Some people may be familiar with the terms gross motor and fine motor. They lumped it all together into sort of physical development. So that's the first thing we're going to do.

We're going to look and see, is this something that, across the board, the child is not meeting milestones in multiple areas? Or is this isolated to just not walking? And then we're going to say, well, what are some possible reasons for this, and where are they in the development? Because it's a continuum. So it starts with being able to lift your head up when you're on your belly, and then you're rolling, and then you're sitting, pulling yourself up to stand. So how far have they made it? And then we're going to think about, OK, are there medical problems, like physical medical problems, something like a muscular dystrophy or a neurologic disease that just causes them to have an isolated problem with their motor development? And if we're really not finding anything, some people just have a different timeline for development, and it could be in a month or two, that child is going to be walking and running and doing all the things that they're supposed to be. Because as you said, they're in that 25%, so they may still just be falling behind a little bit, but we're probably also going to think about making a referral to something like early intervention.

Host Amber Smith: So even if you do identify a child who isn't walking at 15 months, what do you find if you fast forward 20 years from now? What difference will that make, possibly, in that person's life?

Jenica O'Malley, DO: Well, that is a very complicated question. So, you may find that it made no difference. You may find that they didn't get the help they needed, and then they weren't really ready to succeed in kindergarten, and so they then -- we know that kids who don't succeed as early as kindergarten have lower educational attainment -- so it may be that they don't go on to the best college they could, or something like that. But there's so many other influences on people's lives, right? So this is one thing. And then there could be several other things that push them up or down in a certain direction on their trajectory. Maybe they're a family that's also impacted by poverty, and that is pushing their trajectory lower than someone who's not impacted by poverty. Maybe there's a really, really strong family bond between everyone, and they work really hard to get through things together, and that pushes their trajectory in a different direction. So it's really hard to say just based on one area of development what the long term trajectory of a person's life will be just because of how many different influences there are.

Host Amber Smith: Well, can I ask you about some of the other major milestones that you look for? When should a baby start making eye contact?

Jenica O'Malley, DO: Eye contact is interesting. We start to see eye contact very early. It's one of the earliest social type of development you see. So as young as a few weeks of age, some babies will be making eye contact during feedings, a very close distance because their vision is very poor in the first few months of life. So, you will really see that eye contact as early as a few weeks of age, and then you'll start to see it more and more sustained, for longer periods of time around 2 months of age, and then increasing at 4 months of age. And that's when you're really starting to get a lot of what we call social reciprocation. So I say something, the baby says something back to me. They don't say a word, but you know they understand that queuing of like, oh, it's called serve and return. I serve something and I make a funny face and smile, and the baby smiles and coos, and we go back and forth.And that's all sort of part of a similar line of development, which is really social development.

Host Amber Smith: What about talking or, or saying words?

Jenica O'Malley, DO: I think that development starts earlier than people realize sometimes too. We are going to start to see some sounds very early on, 1 to 2 months, where they're making some soft, cooing sounds. And then a lot of cooing, we call cooing, around 4 months of age, which is all of those sort of soft vowels, oohs and ahs. And by 6 months, we start to see more babbling, where we are starting to hear some consonant sounds. And that's really, you know, 6 to 9 months, where we're starting to hear the bu, bu, bu, du, du, du, cu, cu, cu, and around 12 months, you might start to hear meaningful words. Most often that's caregivers, so mama or dada, with the intention of labeling a person.

Host Amber Smith: What developmental milestones happen during the "terrible twos?" And I'm just wondering if there's any developmental milestones during that time period that are not so terrible.

Jenica O'Malley, DO: Well, yes, there's lots of them. So, I think a lot of what gets labeled as the terrible twos is really a lot of that cognitive and problem solving development that you see. So they're starting to figure out the ways that they can sort of manipulate the world around them. And I don't mean, like, manipulate the way I behave, but just the way that they know their action causes a reaction. And they're really starting to come to terms with that. At the same time, you start to see that their language is emerging, but it's not fully there. So there's a lot of big feelings they're starting to develop. So they're starting to show this wide range of frustration and anger and sadness and silliness and loveliness and all of these different things, but they don't always have the language to kind of say, "I feel really angry right now," or "I feel really sad." So it comes out the only ways that they know how, which is outbursts or tantrums that we call those things. And those things are not necessarily problem behaviors. They're just the ways that children are kind of trying to figure out how to cope with what's going on around them. And you see just, that is such an age of social development. So learning how to play together. So up until really around 2 years of age, you see kids playing together, but they don't do a lot of interacting together. They do a lot of playing side by side. They do a lot of taking this toy from someone to because they want to use it. They don't do so much of that back and forth of I'm pretending to be grandma, and you're the child. After the age of 2 and going into 3 and 4, they have this huge bloom in their imaginative skills. And that's a developmental milestone really, is starting to have that really strong, imaginative play, where they can just carry on a whole scenario without, really, any toys and go back and forth with other kids. I think that's one of the most wonderful things about that "terrible" time of their toddlerhood.

Host Amber Smith: Now parents like to talk about different phases that their child may be in, all the way up to teenage years where a teenager is going through a phase. But I wonder if that's another way of describing benchmarks.

Jenica O'Malley, DO: I'm sure in some ways it is definitely. The development of memory is a big thing. So, at 6 months of age, we think what we understand is that there's maybe about a 24-hour memory.And it obviously gets progressively longer. So as kids get older, they start to have longer memory, and so they do start to get more attached to certain things, or really latch onto certain ideas. And personality is developing, right? We think babies have almost some innate personality, right? We talk about kids who are more colicky, or what we will say is they're more spirited, and some kids that are just really more relaxed, and some of those personality traits really do carry on throughout almost their whole life. So I think some of it is that kind of development, the development of your personality and preferences, and not necessarily just straight developmental milestones, but just their overall developmental trajectory.

Host Amber Smith: At what age do the pediatricians stop tracking developmental milestones?

Jenica O'Malley, DO: Right now I would say it's very standard that people are going to pay very close attention to how kids are developing through the age of 3. But it's becoming more and more recognized to continue to really follow closely up until about age 5 that we're really looking at those domains closely and that we have a strong recall in our own pediatrician minds of what are the milestones for these ages? Certainly there are kids beyond the age of 5 who are not caught up to their peers that may have a we refer to as a developmental age that is younger than their chronologic age, their age in years. And at that time, we start to think like, OK, is this something that's going to be with them forever versus this is something that's gonna be completely amenable to physical therapy during the first couple years of life, or something like that.

Host Amber Smith: Well, Dr. O'Malley, I really appreciate you making time for this interview.

Jenica O'Malley, DO: Great. Thank you so much for having me.

Host Amber Smith: My guest has been Upstate pediatrician, Dr. Jenica O'Malley. "The Informed Patient" is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.