General principles

For DA – correct age for prematurity (before 37 weeks) till 24mth old. Corrected age = chronological
age – [40weeks – gestational age at birth]

For growth monitoring – correct age for prematurity.

For vaccination – Use chronological age.

Presentations

1. Routine developmental surveillance – recognize children at risk of developmental delay (screening

+ evaluation). Components: History (ask for health booklet/Parents’ concerns + developmental
history + risk/protective factors), PE (observe/examine)

Questions to ask

2. Parental/teacher concern

Developmental milestones

Sources health booklet for 90th percentile, DDST Singapore (NUP notes), NUS prep course, NUS
undergrad notes

By domain

By touchpoint

Assessment skills by domain

Approaches to examining different age groups and presentations

Important conditions to look out for – diagnosis, prognosis, management

Cerebral palsy

ASD

Language delay/hearing loss

Intellectual disability

ADHD
Common management
screentime
Sources: NUS 2018, NUP summary of red flags
Normal development (50th centile)
Gross motor. Birth – Significant head lag,
primitive reflexes (Moro, stepping, ATNR)
present. 6wk – Holds head in line with body in
ventral suspension. 3mth - Holds head 45deg
on ventral suspension, props up on forearms.
4mth – No more head lag, rolls over. 6mth –
Sits with rounded back/tripod. 9mth – Sits
without support, crawls, pulls to stand/stands
with support. 12mth – Stands without support,
walks with hand held. 15mth – Walks
independently. 18mth – Stoops and recovers,
walks up stairs with hand held. 2yr – Runs well,
jumps with 2 feet off ground, kicks ball. 3yr –
Walks up/down stairs alternate feet, pedals
tricycle, stands on 1 foot 3s. 4yr – Hops on 1
foot, throws/catches/bounces ball. 5yr – Stands
on 1 foot 10s, skips, rides bicycle.
Fine motor. Birth – Turns eyes to large diffuse
light source, grasp reflex present. 6wk – Fixes
and follows past midline 90deg. 3mth – Fixes
and follows past 180deg, has hand regard,
unfists/grasps objects. 6mth – Reaches for
objects, transfers from 1 hand to other. 9mth –
Immature pincer grasp, bangs 2 cubes. 12mth –
Mature pincer grasp, casts objects. 18mth –
Scribbles, builds tower of 3blocks. 2yr – Copies
vertical line, builds tower of 6cubes. 3yr –
Copies circle, builds tower of 9 blocks. 4yr –
Copies cross/square, builds tower of 12blocks.
5yr – Copies triangle/draws 6-part person.
Hearing. Birth – Startles to sudden loud sounds.
6wk – Quietens to mother’s voice. 3mth –
Turns head to sounds at ear level. 6mth – Turns
head to sounds out of sight. 9mth –
Understands no/bye. 12mth – Follows 1-step
command with gesture. 18mth – Follows 1-step
Singapore health booklet 90th centiles + NUS
50th centiles
Gross motor. Equal movements (1mth) Lifts
head momentarily when prone (1mth) Lifts
head 45 degrees when prone/ventral
suspension + props up on forearms (3mth,
3mth) No more head lag (4mth) Lifts head 90
degrees when prone (5mth) Holds head steady
in sitting position (5mth) Rolls over. Bears
weight on legs for few seconds (6mth) Sits
unsupported (6mth, 7mth) Stands with support
(9mth, 9mth) Pulls to stand (9mth, 10mth)
Stands without support, cruising (10-12mth)
Stoops to recover (15.5mth) Walks
well/independently (15mth, 16mth) Walks up
steps with support/1 hand held (18mth,
21.5mth) Walks up/down stairs 1 step at a
time, Kicks ball forward (24mth, 26mth) Jumps
up both feet off the ground (24mth, 32.5mth)
Walks up/downs stairs alternate feet, runs well
(30mth) Pedals tricycle (36mth, 41.5mth) Hops
(53.5mth) Balances on either foot for 5 seconds
(36mth, 57mth).
Fine motor. Follows object to mid-line (1.5mth)
Follows object past mid-line (1.5mth, 2.5mth)
Brings hands together/hand regard (3mth,
3.5mth) Unfists/Grasps rattle in hand (3mth,
4mth) Follows object 180 degrees (4.5mth)
Regards small object like raisin (5.5mth)
Reaches for object (6mth, 6mth) Looks for
fallen object (7mth) Transfers objects from
hand to hand (6mth, 7.5mth) Finger-Thumb
grasp/immature pincer grasp (9mth, 10mth)
Bangs 2 cubes held in hands (9mth, 10.5mth)
Mature pincer grasp (12mth, 13.5mth)
Scribbles (16mth) Builds tower of 2-3 cubes
(17mth) Builds tower of 4-6 cubes (24mth,
command without gesture. 2yr – Follows 2-step
command. 3yr – Follows 3-step command. 4yr –
Understands what/where questions. 5yr – Can
follow rules.
Speech. Birth – Cries when
hungry/uncomfortable. 6wk – Coos. 3mth –
Laughs. 6mth – Babbles non-specific. 9mth –
Mama/papa non-specific. 12mth – Mama/papa
specific + 3 words with meaning. 18mth – 10
words with meaning. 2yr – 2-3word phrases,
50-word vocabulary. 3yr – 3-4word phrases,
shapes, count to 3, match colours. 4yr – Correct
grammar/pronouns/plurals/prepositions, count
to 4, 4 colours. 5yr – Fluent speech/stories,
counts to 10, letters by rote.
Social. Birth – Calms when comforted. 6wk –
Social smile in response to caregiver. 3mth –
Spontaneous smile, excites to familiar pleasant
situation (feeding/bathing). 6mth – Stranger
anxiety. 7mth – Responds to name. 9mth –
Waves bye/claps, plays peek-a-boo, eye contact
with familiar persons. 12mth – Points to
indicate wants/joint attention, imitates
gestures, drinks from cup. 18mth – Parallel
play, pretend play/copies simple actions and
words, eats with spoon. 2yr – Copies others,
defiant behavior. 3yr – Interactive play,
dresses/undresses with help, toilet-trained. 4yr
– Role play. 5yr – Follows games with rules, has
group of friends.
29mth) Builds tower of 8-9 cubes (35.5mth)
Copies straight vertical line (24mth, 38.5mth)
Picks longer line (46.5mth) Copies a circle
(36mth, 47mth) Copies a cross (48mth, 50mth)
Copies a square (48mth, 56mth) Draws person
with 3 parts (57.5mth) Copies triangle (60mth).
Hearing. Responds to bell/Alerts to sound
(1mth) Turns head to sound at ear level (3mth)
Turns to sound that is out of sight (6mth,
7.5mth) Follows 1-step command with gesture
(12mth) Follows 1-step command without
gesture (18mth) Follows 2-step command
(24mth) Follows 3-step command (36mth)
Understands what/where questions (48mth)
Can follow rules (60mth).
Speech. Vocalises/Coos (1.5mth, 1.5mth)
Laughs (3mth, 4.5mth) Babbles non-
specifically/Says single syllables e.g. Ba, da, ga,
ma/Imitates speech sounds (6mth, 10mth)
Papa/mama non-specifi (9mth) Indicates wants
by gestures (13.5mth) Says papa/mama
specifically (12mth, 14.5mth) Points to 2 parts
of own body (19mth) Says 3 words other than
Papa/Mama (12mth, 21mth) 10 words with
meaning (18mth) 2-3 word phrases (24mth,
27mth) 50-word vocabulary (24mth) Points to
2-4 pictures correctly (28.5mth) Names 2
pictures correctly (30mth) Names 4 pictures
correctly (37mth) Knows age/name/sex
(40mth) Names a friend (45.5mth) Rote counts
to 10 (52mth) Knows functions of objects
(55.5mth) 3-4 word phrases (36mth) Correct
grammar/pronouns/plurals/prepositions,
Names 3-4 colours (48mth, 63.5mth) Fluent
speech/stories (60mth) Places and counts
blocks (64mth).
Social. Face regard (1mth) Spontaneous social
smile (1mth) Excites at a toy/familiar pleasant
situation(feeding/bathing) (3mth, 5.5mth)
Reacts to stranger/stranger anxiety (6mth,
10mth) Waves bye bye (9mth, 10.5mth) Claps
hands (9mth, 11mth) Indicates wants by
gestures/pointing, has joint attention (12mth,
13.5mth) Imitates household activities (16mth)
Drinks from a cup (12mth, 18.5mth) Uses
spoon (18mth, 22mth) Removes clothing
(24mth) Pretend/Imaginative play e.g. e.g.
Drive cars/action figures/cooking/Comb doll’s

Touchpoints 50th centile NUS and red flags NUP
1mth-6wk. Gross motor - Holds head in line
with body in ventral suspension.; RF - Not
moving arms/legs equally when lying on back.
Fine motor - Fixes and follows past midline
90deg; RF – Cannot follow to midline. Hearing
– Startle response to loud noises, quietens to
mother’s voice; RF no startle response to
sudden loud sounds. Speech – Coos. Social –
Social smile in response to caregiver. Focus:
Congenital cataracts (bilateral red reflex),
cardiac murmurs, hip dysplasia; prolonged
jaundice, feeding issues (breastfeeding,
vomiting/reflux), abnormal growth (good
weight gain).
4mth. Gross motor - Holds head 45deg on
ventral suspension, props up on forearms, No
more head lag, rolls over.; RF – Significant head
lag on pull-to-sit. Fine motor - Fixes and follows
past 180deg, brings hands together/has hand
regard, unfists/grasps objects e.g. rattle; RF –
No fix and follow, persisting fisting/grasp
reflex. Hearing - Turns head to sounds at ear
level (Bell response); RF – No bell response.
Speech – Laughs; RF – No cooing/sounds. Social
- Spontaneous smile, excites to familiar
pleasant situation (feeding/bathing); RF – Does
not regard face, No social/spontaneous smile.
12mth. Gross motor – Sits/Stands without
support, walks with hand held; RF – No sitting
with head steady, standing with support. Fine
motor – Mature pincer grasp, casts objects; RF
– no reaching for toys, no pincer grasp.
Hearing – Turns head to sounds out of sight,
Follows 1-step command with gesture; RF – No
turning to sound out of sight (normal 7.5mth).
Speech – Mama/papa specific + 3 words with
meaning; RF – No babbling/speech sounds.
Social – Points to indicate wants/joint
attention, imitates gestures, drinks from cup;
RF – No waving bye/clapping hands, no
hair (18mth, 24.5mth) Walks up and down
steps (24.5mth) Puts on clothing with help
(34mth) Toilet-trained (36mth) Brushes teeth
with help (51mth) Dresses with no help (54mth)
Brushes teeth with no help (69mth).
Touchpoints 90th centile and red flags NUP
1mth (4-8wk). Gross motor - Equal movements
(1) Lifts head momentarily when prone (1) Fine
motor - Follows object to mid-line (1.5) Follows
object past mid-line (2.5) Grasp reflex present.
Hearing – Responds to bell/Alerts to sound (1)
Speech – Vocalises (1.5) Social – Face Regard
(1) Spontaneous social smile (1)
4mth (3-5mth). Gross motor - Lifts head 45
degrees when prone, props up on forearms (3)
No head lag. Fine motor - Hand regard/inspects
fingers/hands to mouth/Brings hands together
(3.5) Unfists mostly, Grasps rattle in hand (4)
Hearing – Turns to sound. Speech – Vocalises
when talked to. Social –
6mth. Gross motor - Lifts head 90 degrees
when prone (5) Holds head steady in sitting
position (5) Bears weight on legs for few
seconds (6). Fine motor - Follows object 180
degrees (4.5) Regards small object like raisin
(5.5) Reaches for object (6). Hearing? Speech –
Laughs (4.5). Social – Excites at a toy (5.5).
12mth (6-12mth). Gross motor - Crawls/Sits
unsupported (7) Stands with support (9) Pulls
to stand (10). Fine motor - Transfers objects
from hand to hand (7.5) Finger-Thumb grasp
(10) Bangs 2 cubes held in hands (10.5). Hearing
– Turns to sound that is out of sight (7.5).
Speech –Says single syllables eg. Ba, da, ga, ma
(10) Imitates speech sounds (10). Social – Looks
for fallen object (7) Reacts to stranger (10)
Waves bye bye (10.5) Claps hands (11).
18mth (15-22mth). Gross motor - Stoops to
recover (15.5) Walks well independently (16)
Walks up steps with support (21.5) Fine motor -
Pincer grasp (13.5) Scribbles (16) Builds tower
of 2 cubes (17). Hearing – Understands simple
pointing/gestures for needs; No response to
name, No eye contact with familiar people.
18mth. Gross motor – Stoops and recovers,
walks up stairs with hand held; RF – Not
walking independently. Fine Motor – Scribbles,
builds tower of 3blocks; RF – No scribbling.
Hearing – Follows 1-step command without
gesture. Speech – 10 words with meaning; RF –
No mama/papa specific (14.5mth), no other
single words. Social – Parallel play, pretend
play/copies simple actions and words, eats with
spoon; RF – No joint attention, no response to
affection/interaction.
30mth/2.5yr. Gross motor – Runs well, jumps
with 2 feet off ground, kicks ball; RF – Cannot
walk up/down stairs independently, cannot
kick ball. Fine Motor – Copies vertical line,
builds tower of 6cubes; RF – Cannot stack
tower of 6 blocks. Hearing – Follows 2-step
command; RF – Cannot follow 1-step
command without gestures. Speech – 2-3word
phrases, 50-word vocabulary; RF - No
spontaneous 2-word phrases. Social – Copies
others, defiant behavior; RF – No pretend play
(comb doll’s hair, feed animal).
4yr. Gross motor – Hops on 1 foot,
throws/catches/bounces ball; RF – cannot walk
up/down stairs alternating feet, cannot
throw/catch ball. Fine Motor – Copies
cross/square, builds tower of 12blocks; RF –
Can’t copy circle. Hearing – Follows 3-step
command, Understands what/where questions;
RF - Can’t follow 2-step command (go to
kitchen + bring me a plate). Speech – Correct
grammar/pronouns/plurals/prepositions, count
to 4, 4 colours; RF – No 4-5word sentences,
answer 2 of 3 name/age/sex. Social –
Interactive play, dresses/undresses with help,
toilet-trained, Role play; RF – No pretend play,
unable to follow instructions/take turns, not
interested in others. Focus – Visual acuity and
stereopsis test.
instructions. Speech - Indicates wants by
gestures/pointing (13.5) Says papa/mama
specifically (14.5) Points to 2 parts of own body
(19) Says 3 words other than Papa/Mama (21)
Social – Indicates wants by gestures/pointing
(13.5) Imitates household activities (16) Drinks
from a cup (18.5).
30mth (2-3yr). Gross motor - Walks up and
down steps (24.5) Kicks ball forward (26). Fine
motor - Builds tower of 4-6 cubes (29). Hearing
– Speech – Two word phrases (27) Points to 2-4
pictures correctly (28.5) Names 2 pictures
correctly (30). Social – Uses spoon (22)
Removes clothing (24) Imaginative play e.g. e.g.
Drive cars/action figures/cooking/Comb doll’s
hair (24.5).
4yr (4-5yr). Gross motor - Jumps up (32.5)
Pedals tricycle (41.5) Hops (53.5) Balances on
either foot for 5 seconds (57). Fine motor -
Builds tower of 8 cubes (35.5) Copies straight
line (38.5) Picks longer line (46.5) Copies a circle
(47) Copies a cross (50) Copies a square (56)
Draws person with 3 parts (57.5). Hearing –
Follows 3-step instructions. Speech – Speaks 4-
5 word full sentences. Names 4 pictures
correctly (37) Knows age/name/sex (40) Names
a friend (45.5) Rote counts to 10 (52) Knows
functions of objects (55.5) Names 3 colours
(63.5) Places and counts blocks (64). Social –
Bladder control by day. Plays with friends.
Follows 3-step instructions. Puts on clothing
(34) Brushes teeth (51) Dresses with no help
(54) Brushes teeth with no help (69).