The Flat on the Back of the Head in Infancy

The Flat on the Back of the Head in Infancy- It's Safe

In 1992, the American Academy of Pediatrics made it official- all infants should sleep on their backs.

This major change has had a tremendous impact on the lives of all infants and families.

The risk of the outrageous tragedy of SIDS has indeed dropped in half in the US.

But sleeping on your back as a newborn does tend to flatten the back of your head.  Well worth the dramatic reduction in SIDS, but still can be an issue.

The flattening is very common and has a typical look to it.  It is always the back of the head that flattens, sometimes one side or the other, sometimes in the middle.  Sometimes the flattening is very mild, sometimes more pronounced.

The most important thing to keep in mind is that no matter how much flattening occurs, the brain is safe.

Whether the flattening is mild or pronounced, one one side or the other, in the middle, it never has any impact on your child's brain.  It does not slow down brain growth, it has no impact on how your child's development will unfold or progress, and it has no impact on how your child's brain will work over time- no impact on intellegence, coordination, or personality.

The reason is that the reshaping of the bones of the skull, even if very pronounced, simply does not move the brain enough, or cause enough pressure to be applied to the brain, for the brain to notice or be impacted.

The other good news is that once your infant starts sitting, the flattening typically stops getting worse.  So by 5-8 months of age, flattening hits a peak.  At that age, the head still has lots of growing to do, so from that age on, the head growth restores normal roundness and erases much of the flattening.

Occasionally the flattening is so severe that even subsequent growing of the head after age 6-9 months will leave what is seen as an unacceptable amount of shape change.

Again, the only issue that is relevant is appearance, the flattening from lying on your back cannot cause actual harm or dysfunction.

If the flattening is developing to a degree that raises concern for later appearance, there are options.

One option that is not acceptable is to place your infant on his or her stomach to sleep.  That could spare some flattening but puts infants at risk for SIDS, a bad idea.

But one approach that could help would be to see a pediatric plastic surgeon who is able to create a computer generated helmet that fits to the infant's head to reshape the head as it grows to be more round.

This is an intervention that is harmless and painful, but still a major effort involving fitting for a helmet, your infant wearing a helmet, and repeated adjustments.

Given that most flattening is mild, and that it usually resolves well enough to yield a very nice looking head, interventions like the helmet are only rarely a good idea.

BOTTOM LINE

• Being put on your back to sleep is a very powerful way to cut the risk of SIDS dramatically, and it has.
• Being on your back during infancy does cause flattening of the back of the head.
• This flattening has no impact on the brain, its growth, its development, or its function
• Flattening typically reverses once the infant can sit, as the head grows more round subsequently.
• Rarely the flattening can be severe enough to justify creation of a helmet that will adjust head growth for some months.

Dr. Arthur Lavin

---

*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

A New Lab- just for Children

A New Lab- Just for Children

Advanced Pediatrics is very pleased to announce that a new lab has opened near our office.

This the Child Lab.

Child Lab is the only laboratory in our region whose work is limited exclusively to children.

This offers your children some special value when and if it comes time to do lab work.

• First of all, this lab can do an amazing amount of testing on tiny drops of blood.  This means the whole process of blood tests is suddenly so much easier and so much less painful.
• The lab is set up to do the tests we need to do in pediatrics, so if we have a concern about your child, Child Lab will be almost certain to have the test available, and will report normal ranges for children.
• All their technicians only draw blood from babies and children.  Again, this makes the experience a lot less painful.  They will be far more likely than a general lab to get the sample on the first attempt.

This lab is located on Chagrin Boulevard across the street from Eton, in Woodmere Village.

Their info is:

Child Lab

Hours- Open Mon-Fri 8:30 AM to 5:30 PM

28420 Chagrin Boulevard

216-595-1231 (phone)

216-595-1281 (fax)

We have worked with Child Lab for many years and trust them as the premier lab facility for children in our region.  It is actually very exciting to know they are now in our neighborhood, so your children can now experience their expertise if the time for a lab test should ever arise.

Dr. Arthur Lavin

---

*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Tubes in the Ears: Do they Help, Do they Hurt, What's the Long-term Impact?

Tubes in the Ears:  Do they Help, Do they Hurt, What's the Long-term Impact?

Nearly every child will have at least one ear infection, and about 30-40% of children have recurrent ear infections.  

For those children who have many, many ear infections, the choice of whether to place tubes in the eardrums to improve drainage and cut down on the number of ear infections is an option that frequently comes up.

In the February 2014 issue of Pediatrics, the question of how the tubes work was reviewed.  Over 40 research papers that did a quality job of assessing what the tubes do and do not do were reviewed.

Several themes emerged from this comprehensive review.

Placing tubes in the eardrums does reduce the number of ear infections a child has

The studies were in agreement that if you have tubes in your eardrums, you will have fewer infections.

This supports what we consider the best reason to place these tubes: if the pain of constant or recurring ear infections is too much to bear, ear tubes will help and make sense to have.

Placing tubes in the eardrums has no impact on a child's development of language, cognitive, or academic skills.

Much has been made of the fact that while you have an ear infection, or even just fluid in the ear, your hearing is not as good.  This of course makes sense, put your thumbs in your ears and your hearing gets dramatically worse.  The question is, if your hearing is reduced for a few months or years in early childhood, will that have an impact on your language development?     It is well known that when the ear infection heals and the fluid clears, hearing returns to normal, so the impact of infection or fluid in the ear is always temporary.

What this careful review found was if you took a group of kids with lots of ear infections or fluid and some got tubes and some did not, there was no difference in the cognitive, language, or academic function of the two groups over time.  

So yes, if you have lots of fluid in your ears when quite young, you may not learn as many words as someone without fluid, at the time the fluid is present.  But if you check in some years later, well after the fluid has dried up, say around 7-10 years of age or beyond, the vocabulary, language level, cognitive level, and academic performance level is the same whether you had fluid or not.

This finding supports the notion that the impact of lower hearing while fluid is present disappears once the fluid clears.

Placement of tubes in the eardrums increases the chance that there will be drainage and/or scarring in the ears

The studies also found that kids who got tubes in the eardrums experienced an increase chance of draining fluid from the ear and later on, of scarring on the drum.

BOTTOM LINES

• Ear infections are a very common event in childhood, and many children get many of them.
• Placing tubes in the ears can offer real relief from very frequent, painful ear infections.
• Placing tubes in the ears may offer no change in ultimate levels of language, cognitive, or academic performance
• Placing tubes in the ears does increase the chance of scarring of the eardrum and drainage from it.
• Our recommendation is to place tubes in the ears mainly for relief of excessive and relentless pain, not simply in response to a certain number of ear infections.

Dr. Arthur Lavin

---

*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

How Long do Cold Symptoms Last?

How Long do Cold Symptoms Last?

Everyone gets colds, everyone.   

And we all have a sense of how long we think it's normal for them to last, but do we really know?

Well, now we do.   A major study was published by scientists from Oxford and Bristol in the UK and from Portland, OR in the US.   http://www.bmj.com/content/347/bmj.f7027.pdf%2Bhtml

In this paper, the medical literature was examined and 48 studies identified that gave good data on how long a runny nose, a cough, a sore throat, and an earache last when you get a cold or the flu.

What follows is what they found out.  But first a word on how they reported the results.

The Technique of Describing How long the Symptom Lasts

What they did was take a group of kids with colds and ask two questions, for each symptom:

1. How many days need to go by for half the kids to no longer have that symptom?
2. How many days need to go by for nearly all (90% to be exact) of the kids to no longer have that symptom?

For all the results, keep in mind the number of days is how long it took otherwise healthy kids with colds to get better.   This information does not include any children who developed complications such as pneumonia or asthma, just simple colds that healed without any complications or lasting problems.

The Results:  How long does each Symptom Last?

So here we go, this is how long each of these 4 symptoms typically last in a simple, uncomplicated cold that heals completely without any complication:

Runny Nose, Feeling Sick

50% of kids stopped having a runny nose or feeling sick by Day 10 of the cold

90% of kids stopped having a runny nose or feeling sick by Day 16 of the cold

Range: Looking at all the kids, the range of how long kids had a runny nose or felt sick was 4-16 days.

Sore Throat

This symptom did not have enough people studies to give 50 and 90 percentile duration numbers, but the study did cite that:

Looking at all the kids, sore throats lasted in a range from 2-6.7 days.

Interestingly, how long you were suffering from a sore throat was the same if you had a cold or strep throat.

Fever

Again, not enough kids studied to give exact percentile ranges, but the following trends were reported:

Most typically, fever lasted 2-3 days (44% of kids with a cold)

But fever often lasted more than 3 days (28% of kids with a cold)

Many kids were lucky to have a fever for less than a day (17% of kids with a cold)

And a few had a fever for the 1-2 day  duration (11% of kids with a cold)

Ear Infection

50% of kids stopped having an earache by Day 3 of the cold

90% of kids stopped having an earache by Day 7-8 of the cold

Range: Looking at all the kids, the range of how long kids had an earache was 1/2-9 days.

Croup

50% of kids stopped having croupy cough by Day 1 of the illness

80% of kids stopped having croupy cough by Day 2 of the illness

Range: Looking at all the kids, the range of how long kids had a croupy cough was 1-3 days.

COUGH

50% of kids stopped having a cough by Day 10 of the cold

90% of kids stopped having a cough by Day 25 of the cold

Range: Looking at all the kids, the range of how long kids had a cough was 1-25 days.

What these Observations Mean

This was a very, very interesting study, finally answering a question we get asked as much as any other question:

How long does a cold symptom last, and if the symptom is still present does that mean it's no longer just a cold, but some complication has developed?

Now we have the answers.

As noted above, the most striking finding for me was that a child with a plain old cold, no complications, who is going to be fine, can easily have a cough for 25 days!

This is what we see, it does fit with actual experience, but how incredible that a simple cold can make you cough for a month, easily.   And it fits with our experience that the fever, ear ache, sore throat, runny nose, and even feeling sick can all go away long before the cough ceases.

Bottom Line

• The one day cold is a great hope, but rarely seen.
• Colds tend to last 1-2 weeks.
• The cough from a cold is the symptom that takes the longest to heal, and typically can go on for a month, even if no complications are present.
• Overall, colds cause a lot more suffering than we imagine, but they do heal, they ultimately cause no lasting harm or damage, it takes a long time to heal, but we do heal, and completely.

Dr. Arthur Lavin

---

*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Time to Choose a Pharmacy that Does not Sell Tobacco

Time to Choose a Pharmacy that Does not Sell Tobacco 

Normally we do not endorse any particular store or brand, but the CVS drugstores announced a decision on February 5, 2014 that truly deserves our admiration and calls for our support.

For many years, I have been rather amazed at the fact that at the back of all the major pharmacies, life-giving medications are made available for a full range of serious medical conditions.  The pharmacies are places where lives are saved and improved.

But at the front of every one of these stores, a huge rack of goods are sold that kill more people than any single disease, tobacco.  And on February 5, 2014, the CVS corporation decided it would empty all its stores of all tobacco products this year.  This is the first major national pharmacy chain to take this action.   It will cost this company $2 billion in revenue every year.

I am sure there are reasons it took this step that make good business sense, there are no illusions about the extent of this altruism.  But the point is that they have taken this step.

An American pharmacy chain has decided to no longer sell any tobacco products.

This is so important, because tobacco alone causes 1/3 of all cancer.   About 2 million Americans die every year, and tobacco causes about 400,000 of those 2 million deaths.

Of course, not all death is preventable, but about 1 million deaths a year don’t need to happen that year, and tobacco is the cause of 40% of those needless deaths.

It has long seemed most cruel that we sell tobacco, knowing how much suffering, illness, and death it causes.   So it is very heartening to see the medical world really step up to eliminate tobacco from our lives.  Most hospitals are completely tobacco free campuses.

And now, CVS will no longer sell it.

With this step, we now recommend that if you can choose where to get your prescriptions, you do them all at a CVS, until the other chains (e.g., Walgreen’s, Rite-Aide), and big box store pharmacies (e.g., WalMart, Target) follow suit and also stop selling the deadly tobacco products.

Today, I happened to need a photo frame, and changed where I went to be sure it was a CVS store.  I mentioned to the staff present that I thought the decision to end sales of all tobacco products was a powerful and life-giving decision, and that I would be recommending that all pharmacy business go to CVS until the others stop selling tobacco.

The staff were, justifiably, quite proud.

Bottom Line:

• Tobacco causes nearly half of all the preventable deaths in the US each year, and fully 1/3 of all cancer.
• On February 5, 2014, CVS made history, committing at great cost to end sales of all tobacco products by October.
• Our recommendation is that all pharmacy commerce be now directed to only stores that have committed to stop all sales of all tobacco products.  At this time that is only CVS.
• Let your pharmacy know if you hope that they will no longer sell tobacco, and if you plan to only purchase goods at pharmacies committed to ceasing all sales of all tobacco products.
• This is an issue beyond politics and the varying fads in health.  Tobacco is a very serious, very addictive, and very deadly product.  It is very powerful to be able to help all our pharmacies to follow the lead of CVS.

Dr. Arthur Lavin

---

*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Antibiotics: What are they, Who do they help, Where do they not work?

Antibiotics:  What are they, Who do they help, Where do they not work?

Antibiotics are a group of medicines that kill germs.

There are three types of germs that can make us ill:

1. Bacteria
2. Viruses
3. Parasites

There are plenty of medicines that kill bacteria and parasites, not so many that kill viruses.

Of course, it makes a big difference if a medicine works or not, so let's take a look at each of these types and whether antibiotics makes sense or not.

Bacteria

Bacteria are like us, living cells that eat food.  They are very small, always one-celled, and when the feed on us they make pus.  Antibiotics were invented to kill bacteria, and do a great job at it.

But, most of the infections we see in childhood, in fact the vast majority, are not caused by bacteria.

The most common infections bacteria cause are: ear infections (about 60% of them), pneumonia (about 20% of them in kids), strep throat, impetigo (a skin infection), and boils.  

Bacteria all have chemistries that are different from our cell's chemistries, so one could create a drug that blocks bacterial chemistry, but leaves our alone.  That's how the antibiotics are able to kill all the bacteria causing our infection, but leave our human cells alone.

If we know your child has an infection caused by bacteria, and the infection needs to go away, antibiotics are always available to kill essentially any bacteria.

Viruses

Viruses are an odd thing.  They are essentially a packet of information.  Every virus is a small snippet of genetic material (DNA or RNA) wrapped in a coat of protein designed to deliver the genes into our cells. Once in place, the genes only job is to force our cell to make more viruses, usually popping the cell in the process.  We get sick from all the cells infected with a virus that get destroyed.

Viruses have very little chemistry inside of them, so there are very, very few ways a drug can be taken to kill a virus.  There are a few antibiotics that kill viruses, but each only kill one very specific type of virus.  Tamiflu kills the influenza virus, but not any other virus, for example.

Viruses cause most of the infections now seen in childhood, and every person alive will have dozens of these infections, every person.

Infections caused be viruses include colds, flus, and stomach flus.

The usual antibiotics have no impact at all on any viral infections, and we have seen many children on antibiotics for a bacterial infection actually develop a viral infection, while on the antibiotic.

For the common cold and all stomach flus, medical science has not yet developed any drug or medicine that could kill or control that virus.

For influenza infections, there is Tamiflu, but this drug is very limited in its ability to help.  It has no impact on the course of the illness if taken 48 hours or more after it starts.  Further, in children, the impact on the course of a case of influenza virus infection is rather small, even if started at the start of the infection.

When it comes to nearly all viruses, antibiotics are ineffective, really very useless.

Parasites and fungi

Parasites are worms and small cellular creatures that cause infections.  This category is an unusual source of serious infection.  The yeast that babies in diapers get is a fungus, as is ringworm, but aside from occassional growths on the skin, fungi and parasites are very unusual sources of infection in American children.

As with bacteria, parasites and fungi can have chemistries that are different than ours, so again there are usually varieties of antibiotics that can kill them and are very useful.

Hazards of antibiotic use

One of the glories of antibiotics is that they do not kill human cells, even though they can kill vast swarms of bacteria completely.

But three hazards of use still exist:

1.  Allergic reaction.  Anyone can develop an allergy to any antibiotic anytime.  Sometimes these reactions can be quite severe, even dangerous.  So no one should take an antibiotic unless it is clear it will help and clearly needed.

2.  Disruption of "good" bacteria.  It turns out that 99%+ of all bacteria are actually helpful, even necessary, for our health and well-being.   It even turns out that for every one of us, we walk around with 10 times as many bacterial cells in and on us as there are human cells.  Antibiotics make no distinction between good and bad bacteria.  Thankfully they kill the bad ones, but unfortunately, they wipe out the good ones, especially in our gut, too.  So no one should take an antibiotic unless it is clear it will help and clearly needed.

3.  Resistance.   All bacteria are smart, so if they see a drug a bunch of times, they will figure out a way to resist being killed by that drug.   Only one bacteria, so far, has failed to find a way from being killed by an antibiotic:  every strep germ we know of is killed by penicillin, even after 70 years of being exposed to penicillin.  But in all other instances, bacteria have evolved to find the once deadly antibiotic harmless to them.  This almost never happens during a 10 day course of one antibiotic in a person.  It usually takes millions of doses across millions of people for the emergence of one resistant bacteria that then survives and spreads.   But the point is that if every doctor prescribes antibiotics for illnesses, such as colds, for which they do not good, then we do have a situation in which hundreds of millions of dosages are given that do go on to breed resistant strains.  This matters because once a strain of bacteria evolves that is resistant to an antibiotic, that antibiotic is then rendered useless against that bacteria.  Over time, even proper use of antibiotic will lead to all bacteria being resistant to all antibiotics, but overuse makes that process go a lot faster.

BOTTOM LINES

1.  There is no magic to the word antibiotic, these are simply the category of all drugs that kill germs.

2.  For the most common infections of childhood, such as colds, no antibiotic has any effect.  For two reasons, then, antibiotics should not be used for colds:  they do not work at all, and use of them greatly accelerates the emergence of deadly resistant bacteria.

3.  For bacterial illnesses that require treatment, there are antibiotics that will work, that will cure the infection.  The main risk from use of these drugs are allergic reactions and disruption of the natural and beneficial bacteria in our bodies.  

4.  The disruption caused by use of antibiotics can have unexpected effects, many of which are not understood.  The use of probiotics has been proven to help reduce this disruption and keep our useful bacteria in good balance.

Dr. Arthur Lavin

---

*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Development- How to know if it is fine or a problem?

Development- How to know if it is fine or a problem?

Development is a very hot topic these days, and probably has gripped our attention for a very long time as well.

The reason it's so hot today, is that much is written to push parents to be worried that their infant and toddler is not developing well, might even be "delayed," and should receive "services" to avoid an unfortunate future.

So in this posting, we will take a look at development, some basics on how we develop, and some guideposts that will help you know if your child has a problem, or not.

Basics of Development

All of life develops, meaning that what a life form can do at one moment in time changes, often quite dramatically, over time.  This is quite case for all people.  Everyone of us starts off as a single cell, the fertilized egg, are born rather helpless, and over many years emerge as a fully grown person, capable of a staggering range of imaginative achievements ranging from the athletic, to the intellectual, to the artistic, to the enterprising, and beyond.

For most of us, we can see the transformations we call development starting at birth.  The newborn can see and hear, smell and touch, suck and swallow, cry and look and sleep, and can learn at a dramatic pace.  But a newborn cannot walk or talk, cannot sing or write a poem, cannot grab or smile.  The emergence of all these fabulous human abilities and more is what we mean by development.

There are three key aspects to all human development:

• The timeline.  No one is born able to do all that an adult can do, the emergence of these abilities always follows a timeline.  Time is a fundamental dimension of development.
• A rather predictable progression.  Consider walking, nearly everyone goes through this sequence in developing the ability to walk: can't walk at all, pulls to standing, walks holding on, takes a few steps, toddles in an early form of walking, develops more fluency and ease of walking, walks.  The point here is that everyone tends to follow a certain path to every commonly developed skill.
• There are highly individual patterns to development.  Despite nearly everyone learning to walk in the same sequence, the exact timing of each step, the enthusiasm or fear the progress generates, the age at which each step occurs vary wildly across a group of infants and toddlers.

A word on how misleading the average age is

Before we take a look at how to know when to worry, a word on one value can be potentially quite misleading, the average age any particular achievement in development occurs.

Consider sitting.   The average age infants learn to sit is 7 months old.  The vast majority of blogs, web pages, books, and magazine articles use this item as the key guide to know if everything is OK.  And that would seem to make sense, why not use the average age, after all, if your infant sits by 5 months of age, knowing the average age of attaining that skill is 7 months will prove to all your infant learned to sit in plenty of time- no problem.

The problem is that half of all humanity achieves any single developmental stage after the average age. That's what makes it the average age.  So if you base your sense of how things are going on the average age, you quickly find about half of all humanity being told there is a problem.

A much more helpful piece of reference information is the range of ages children achieve any particular developmental step.  

For sitting that can be anywhere from 4 to 9 months of age.

One last point in the basics:  when your infant or child achieves a milestone tends to have no relationship on how bright they are or how well they will perform in that arena.  

Say some kids walk starting at age 11 months, and others start at age 15 months. The ones who started at 15 months may turn out to be far more skillful track athletes than the ones who started at 11 months. Development is to a large extent the process of different processes in our brain coming together and activating.  When a light switch is turned on says nothing about how bright the light is.

How to Know if your Child's Development is OK or Needs Help

Human development is described in 4 categories:  gross motor (e.g., sitting, walking, and running), fine motor (e.g., grabbing, various grasps, drawing, writing), speech and language, and social.

In each instance, we get concerned if the child's progress establishes that they will struggle or be unable to attain a level of skill in any of these categories that would limit their ability to live their life successfully.

One approach would be to simply wait until development is completed and see what skills the child needs help improving.  The problem with this approach is that it waits a long time to help, and we do know that helping earlier leads to better results and less frustration.  

Another approach is to look carefully at your infant and toddler, and at the earliest sign of a problem with development, intervene to accelerate or improve their developmental progress.  The advantage of this approach is that you can perhaps change that child's developmental pace and outcome and prevent the impact of a limited ability in the area of concern.  There is one major disadvantage to this approach: inaccuracy.  When you try to identify whose development may be indicating trouble ahead, you cannot avoid the possible error that a child who is going to be fine is told there may be a problem.

Being Accurate

If we do accept the idea that looking carefully at our child to detect early signs of developmental concern, we must also accept the idea this sort of looking calls on us to be accurate.  By accurate we mean doing our best not to consider a child's development of concern unless there really are indications that the development will leave the child with a truly abnormal or limiting outcome.

The chief source of inaccuracy comes from not taking into account the normal variability in development, the third of the three key properties of development noted above.

One way to think about all this could be very helpful.  For any one developmental step, say talking for example, there are three phases of variability:

• Absolute uniformity- no one at this age or prior to it can do this skill, no one.  Everyone is the same.
• Maximal variability- big differences from person to person in the ability to do this skill are seen normally.
• Near uniformity- well after the age that people tend to develop a certain skill, nearly everyone can do that skill, nearly everyone is the same.

Now let's see how this works with talking, which starts with very early steps around 9 months of age and is well in place with most children by about 3 years of age.  So, the ages of 0-6 months are quite uniform- no young infant talks.  And also, well after 3 years of age, there is plenty of uniformity, essentially every healthy 5 year old talks, again lots of uniformity.

But look at a group of 2 year olds, there is no uniformity.  Many 2 year olds speak very well, some sound like grown-ups!  But many 2 year olds only speak in short phrases, and there are plenty of two year olds who will turn out fine who speak barely at all.

Picking out the problems

So the real challenge is picking out the child who needs help, and leaving the child who is going to turn out fine alone.  

Think about our group of 2 year olds.   Say we find 20 of them who aren't using many words yet, will all of them need help?  The answer is no.  Some of these children will turn out to have a problem, and could really use the help and benefit of good speech therapy.  Some of these children will simply be going along their developmental path in their own way and will reach the desired goal of normal speech without any help at all. Again, 50% of all people develop any skill after the average age everyone reaches it.

How to know when to act then?   We suggest some guidelines that can help you be reassured when no problem is present, and know when to act if a problem is present:

1. If the developmental step has not yet occurred, but if your child is still in the normal range of ages for gaining that skill, that is reassuring.   For example, the average age range for normal development of walking could be something like 8-18 months old.  That is, nearly all kids learn to walk by the time they are 18 months old and not many before 8 months of age.  So if your child is not walking yet, and is 14 months old, they are still at an age where normally developing children might not have learned to walk yet.   But, if your child is 26 months old and not walking, the chances of that being a sign that something is wrong is much greater.
2. Progress is reassuring.  If we think about developing the ability to walk again, consider someone who is not walking at 15 months of age.  If that child pulled herself to standing at 12 months, started walking holding on to furniture at 14 months of age, and seems tantalizingly close to letting go and taking a step now, that is more reassuring than the situation where the child can only sit at 15 months of age, cannot pull to standing.   If over several months there is no change noted towards the goal that is a sign worth being concerned about.
3. Losing a skill is always of concern.  Again, in the arena of walking, if someone was walking quite well at 13 months of age, but at 15 months of age cannot walk, that is very worrisome.  Losing a skill is very unusual and always requires evaluation.

BOTTOM LINES

1. Development are the changes that happen to all people that allow them to do certain skills that they could not possibly do earlier in life.
2. All human development follows a timeline, follows a regular pattern of change, but carries with it lots of individual variation.
3. Around the average age people gain any particular skill, there is lots of variability.   So the range of normal ages for gaining a skill says loads more than the actual average age about who to be worried about.
4. If you are in the range of normal ages for gaining a skill and making good progress, there is usually less to be worried about than if that is otherwise.
5. When a variation in development is noted, but all indications are that your child is still progressing along normally and will likely gain that skill and do well, there is less need for help.
6. When a variation in development is noted, and the indications are that progress towards the goal is not so likely, or has actually reversed, help is a very good idea.

Dr. Arthur Lavin

---

*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.