Singapore Med J 2019; 60(3): 119-123

Practice Integration & Lifelong Learning

https://doi.org/10.11622/smedj.2019025

CMEArticle
Developmental delay: identification and management at
primary care level
Ying Ying Choo1, MD, Pratibha Agarwal2, MD, MMed, Choon How How3,4, MMed, FCFP,
Sita Padmini Yeleswarapu2, MBBS, FRCPCH

Jason, a three-year-old boy, was brought by his mother to your clinic to seek advice regarding
his speech delay. She was concerned because his preschool teachers had told her that he
seemed to be slow in speech compared to his classmates. Jason had a vocabulary of about
10–12 words and had not started speaking in phrases. He could respond to his name and
followed simple instructions well. A physical examination found that he had no dysmorphic
facial features and was in good health. He had attained all other developmental milestones
appropriate to his age except for expressive language.

WHAT IS DEVELOPMENTAL DELAY? Variations in patterns of development

Developmental delay occurs when a child does not achieve Some children may not follow the normal pattern of development.
developmental milestones in comparison to peers of the same These variants include ‘bottom shufflers’, who do not crawl but
age range. The degree of developmental delay can be further shuffle around. These children tend to walk late and may be
classified as mild (functional age < 33% below chronological age), mildly hypotonic, especially in the lower limbs. Some ‘commando
moderate (functional age 34%–66% of chronological age) and crawl’, while others do not go through the crawling phase at
severe (functional age < 66% of chronological age).(1) A significant all. Children may exhibit variation in their rate of acquisition of
delay is defined as performance that is two or more standard language, social skills, play and behaviour, as they may follow a
deviations below the mean on age-appropriate standardised familial pattern (e.g. family history of speech delay) or be affected
norm-referenced testing (usually conducted in secondary or by environmental influences (e.g.  not attending a preschool).
tertiary care settings).(2) There is a general belief that boys tend to acquire language later
than girls, which has not been proven true.(4) Children coming
The delay can be in a single domain (i.e.  isolated
from bilingual families may seem to have delayed acquisition of
developmental delay) or more than one domain. A significant
one language, but they eventually catch up in the absence of any
delay in two or more developmental domains affecting children
risk factors. Nevertheless, physicians should be aware of the red
under the age of five years is termed global developmental
flags in the context of the child’s development when determining
delay (GDD). (3) Other patterns of abnormal development
a further management plan.
include: developmental disorder; developmental arrest and
regression; and developmental disability. In developmental
HOW RELEVANT IS THIS TO MY
disorders, development does not follow the normal pattern,
PRACTICE?
such as in a child with autism who has language abilities but
Singapore does not have a national database to track the
is unable to use it for social interaction and communication
prevalence of developmental delays or disability. However, based
purposes. Developmental arrest and regression refers to a on data from other developed countries, developmental delays
normal developmental phase in a child that is followed by a are reported to occur in 10%–15%(5) and GDD in 1%–3%(1,3) of
failure to develop new skills or even loss of previously acquired children under the age of five years. Various factors determine the
skills. Regression is an unequivocal red flag and warrants prognosis or eventual outcome of children with developmental
an urgent referral to a specialist for further assessment and delay. These include the cause of the delay (i.e. is it a treatable
management. Not all children with developmental delay will cause, such as nutritional deficiencies), areas in which the child
have a developmental disability, which refers to severe, lifelong is delayed, how significant the delay is, the age at which the
impairment in areas of development that affects learning, self- child commenced an intervention, and the extent of parental
sufficiency and adaptive skills. Developmental delays can and caregiver involvement. If developmental delays are detected
be transient, such as during a phase of prolonged illness, or late, opportunities for early intervention are lost, resulting in
persistent. poor outcomes such as learning difficulties, behaviour problems

SingHealth Polyclinics – Sengkang, 2Department of Paediatrics, Child Developmental Service, KK Women’s and Children’s Hospital, 3Care and Health Integration, Changi General
1

Hospital, 4Family Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
Correspondence: Dr Choo Ying Ying, Family Medicine Resident, Singhealth Polyclinics – Sengkang, 2 Sengkang Square, Sengkang Community Hub, #01-06, Singapore 545025.
yingying.choo@mohh.com.sg

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and functional impairments later on in life.(6) There is strong Box 1. Common aetiologies of developmental delay:(2,8)
research evidence suggesting that effective early identification of Prenatal
developmental delays and timely early intervention can positively • Genetic disorders: Down syndrome, fragile X syndrome,
alter a child’s long-term trajectory.(7) chromosomal microdeletion or duplication
Primary care physicians play a significant role in early • Cerebral dysgenesis: microcephaly, absent corpus callosum,
identification of developmental delays, both through hydrocephalus, neuronal migration disorder
developmental screening and routine developmental surveillance. • Vascular: occlusion, haemorrhage
• Drugs: cytotoxic, anti‑epileptic
Hence, it is essential that they have the knowledge and skills
• Toxins: alcohol, smoking
to identify developmental delays and provide an appropriate • Early maternal infections: rubella, cytomegalovirus,
management plan to the family, including counselling the parents toxoplasmosis
if necessary. • Late maternal infection: varicella, malaria, HIV
Perinatal
WHAT CAUSES DEVELOPMENTAL DELAY? • Prematurity, intrauterine growth retardation, intraventricular
Multiple causes or illnesses can contribute to developmental haemorrhage, periventricular leucomalacia
• Perinatal asphyxia: hypoxic‑ischaemic encephalopathy
delay. The causes listed in Box 1 are not exhaustive but cover most
• Metabolic: symptomatic hypoglycaemia, bilirubin‑induced
of the common aetiologies. These can be broadly divided into
neurological dysfunction
four categories: prenatal; perinatal; postnatal; and other causes. Postnatal
Studies evaluating the causes of GDD have indicated that • Infections: meningitis, encephalitis
in one-third of the cases, the cause can be established through • Metabolic: hypernatraemia, hyponatraemia, hypoglycaemia,
history and examination alone, and in another one-third, through dehydration
a thorough clinical evaluation prompting investigations. The • Anoxia: suffocation, near‑drowning, seizure
remaining cases can be identified through investigations alone.(9) • Trauma: head injury, either accidental or non‑accidental
• Vascular: stroke
Others
HOW DO I IDENTIFY DEVELOPMENTAL • Social: severe understimulation, maltreatment,
DELAY? malnutrition (deficiency of iron, folate and vitamin D)
In primary care settings, children with developmental delays • Maternal mental health disorder
are normally identified through three major channels: during • Unknown
routine developmental surveillance or screening; following
parental concern; and after third parties such as preschool
teachers or nursery care professionals raise concerns. The child’s be made to review again, refer further or discharge. For children
health booklet is a useful resource that should be wisely utilised presenting with mild developmental delay, in the absence of any
by parents and clinicians to monitor a child’s development. red flags and no abnormality detected on clinical examination,
An important step to improve the early identification of parents can be advised about appropriate stimulation activities
developmental delay is educating the parent to make use of the and a review conducted in three months’ time, especially if
health booklet’s developmental checklist. Other details regarding earlier milestones were achieved. For example, an 18-month-old
developmental surveillance and screening have been discussed child may present with concerns of expressive language delay,
in our previous article on developmental assessment.(10) as he has only started saying a few single words with meaning.
In the absence of any other concerns (e.g. the child has good
Common barriers to early identification eye contact and joint attention, with no behaviour concerns),
Apart from the aforementioned barriers of lack of time, resources advice on language stimulation activities could be given. In
and training, the primary care physician’s referral to a specialist children presenting with significant developmental delays or
for further assessment and management may not be activated with a history of regression in development, and those at risk for
by the parent. This could be due to parents disagreeing with developmental delays, a prompt referral should be made to a
the referral, denial, lack of understanding of the significance developmental paediatrician.
of the referral or the family’s social circumstances (e.g.  single In cases where delays have been identified, but there is
parenthood, lack of financial resources), preventing the children parental denial, consider arranging a follow-up appointment
from accessing further care. to conduct a more detailed developmental assessment. The
functional impact of the child’s developmental delay should
WHAT CAN I DO IN MY PRACTICE? be explained to the parents. For example, if a child is identified
During each consultation, the primary care physician should with a fine motor delay, the possible impact on adaptive skills
encourage the parents to share any concerns they might have should be explored. When a consultation is pitched at the
about their child’s development or behaviour, conduct an parental level of understanding, there is a better chance of
opportunistic evaluation (developmental surveillance) and ensure acceptance. A lower referral threshold is advisable for children
that the child has attended developmental screening at the who are at high risk for developmental problems, such as
prescribed touch points. Based on the consultation, a decision can preterm children (without follow-up), children with chronic

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Box 2. Additional tests for children referred to a Child Services for children presenting with developmental
Development Unit: delays
Genetic evaluation Following further specialist assessment, children can be
• Child appears syndromic referred to appropriate therapies, such as speech language
• Clinical findings suggestive of any genetic condition therapy, physiotherapy, occupational therapy and behavioural
• Family history of developmental delay/intellectual disability intervention (e.g.  psychologist). Children who could benefit
Creatine phosphokinase test from intensive and long-term interventions, such as those
• Gross motor delay, especially in boys
presenting with GDD, are referred to EIPIC (Early Intervention
Screening for inborn errors of metabolism
Programme for Infants and Children) centres during their
• Unexplained global developmental delay and a history of
regression preschool years. Some children with developmental delays
TORCH (toxoplasmosis, rubella cytomegalovirus, herpes may require cognitive testing (e.g. IQ testing) and assessment
simplex and HIV) screen of adaptive functioning at about six years of age. This would
• Macrocephaly/microcephaly guide appropriate school placement if they are deemed more
Neuroimaging suitable for a special education school. Children in mainstream
• Focal neurological deficits/abnormal neurological findings schools who continue to present with developmental delays
Electroencephalography
may need ongoing therapy services provided in a hospital or
• History suggestive of seizures/regression
private setting.

medical conditions, and children in challenging circumstances TAKE HOME MESSAGES

(e.g. being in the care system or having a main caregiver with 1. Developmental delays are common and can involve
mental health problems). Primary care physicians should follow either a single domain or multiple domains of the child’s
up with the parents at the next visit to ensure that the referral functioning.
has been activated. 2. Early identification of developmental delays and appropriate
Furthermore, consistent long-term emotional and practical management can positively alter the child’s developmental
support should be provided to the families of children with trajectory.
special needs. As this group is at high risk for caregiver stress, 3. Primary care physicians play a pivotal role in early
consider evaluating stress levels at each opportunistic visit, identification of developmental delays through
as well-being has an impact on their capability to look after developmental screening and surveillance.
their children.(11) The family can be referred to a Family Service 4. For children presenting with mild developmental delays
Centre for further support if necessary. Other assessments and and in the absence of any red flags, appropriate stimulation
investigations include: activities can be suggested, with close monitoring of the
• Head-to-toe examination, including plotting the child’s child.
weight, height and occipitofrontal circumference; 5. There should be a low threshold for specialist referral for
• Hearing assessment if there are concerns about hearing children at high risk for developmental problems, such as
(e.g.  poor response to name when called) and language those who are in care, have an underlying chronic medical
delay; condition, or have a primary caregiver with a mental health
• Vision assessment if the child (≥ 6 weeks) is not fixing and problem.
following, has a history of frequent bumping into objects
(for a mobile child), or may have delayed fine motor skills;
and You obtained more relevant history from Jason’s
• Full blood count (possible iron deficiency), bone mineral mother. She said he was full term and had an
profile and vitamin D levels (if rickets are suggested), thyroid uneventful neonatal period. Jason had passed
function tests (especially for children with GDD and growth his newborn hearing test and developmental
problems), urea levels and electrolyte levels. screening at the previous touch points. He had
For preschoolers in Singapore, the two main Child never been hospitalised or exposed to any ototoxic
Developmental Units (CDUs) are the Department of Child agents, and had no history of any significant
Development at KK Women’s and Children’s Hospital and the infections such as meningitis. You explained
Child Development Unit at National University Hospital. If a child
that Jason’s expressive language seemed to be
delayed. At three years of age, he should be able
is referred to a CDU, a developmental assessment is conducted,
to speak in three- to four-word sentences and have
and investigations are tailored based on the clinical evaluation.
speech that is intelligible to strangers. Because of
Apart from the aforementioned tests, these could include: the expressive language delay, you recommended
genetic evaluation; creatine phosphokinase test; screening for a referral to a Child Developmental Unit for a
inborn errors of metabolism; TORCH (toxoplasmosis, rubella hearing assessment as well as further evaluation
cytomegalovirus, herpes simplex and HIV) screen; neuroimaging; of speech and language.
and electroencephalography (Box 2).

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REFERENCES
ABSTRACT Developmental delays are common in 1. Mithyantha R, Kneen R, McCann E, Gladstone M. Current evidence-based
recommendations on investigating children with global developmental delay.
childhood, occurring in 10%–15% of preschool children.
Arch Dis Child 2017; 102:1071-6.
Global developmental delays are less common, occurring 2. Bellman M, Byrne O, Sege R. Developmental assessment of children. BMJ 2013;
in 1%–3% of preschool children. Developmental delays 346:e8687.
are identified during routine checks by the primary care 3. Shevell M, Ashwal S, Donley D, et al; Quality Standards Subcommittee of the
American Academy of Neurology; Practice Committee of the Child Neurology
physician or when the parent or preschool raises concerns. Society. Practice parameter: evaluation of the child with global developmental
Assessment for developmental delay in primary care delay: report of the Quality Standards Subcommittee of the American Academy
settings should include a general and systemic examination, of Neurology and The Practice Committee of the Child Neurology Society.
Neurology 2003; 60:367-80.
including plotting growth centiles, hearing and vision
4. Hyde JS, Linn MC. Gender differences in verbal ability: a meta-analysis. Psychol
assessment, baseline blood tests if deemed necessary, Bull 1988; 104:53-69.
referral to a developmental paediatrician, and counselling 5. Vitrikas K, Savard D, Bucaj M. Developmental delay: when and how to screen.
the parents. It is important to follow up with the parents Am Fam Physician 2017; 96:36-43.
6. Shevell M, Majnemer A, Platt RW, Webster R, Birnbaum R. Developmental
at the earliest opportunity to ensure that the referral has and functional outcomes at school age of preschool children with global
been activated. For children with mild developmental developmental delay. J Child Neurol 2005; 20:648-53.
delays, in the absence of any red flags for development 7. Scherzer AL, Chagan M, Kauchali S, Susser E. Global perspective on early
diagnosis and intervention for children with developmental delays and
and no abnormal findings on clinical examination, advice
disabilities. Dev Med Child Neurol 2012; 54:1079-84.
on appropriate stimulation activities can be provided and 8. Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 4th Edition. Missouri:
a review conducted in three months’ time. Mosby, 2012:51.
9. van Karnebeek CD, Scheper FY, Abeling NG, et al. Etiology of mental retardation
in children referred to a tertiary care center: a prospective study. Am J Ment
Keywords: developmental assessment, developmental delay, primary care, red flags
Retard 2005; 110:253-67.
10. Choo YY, Yeleswarapu SP, How CH, Agarwal P. Developmental assessment:
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11. Valicenti-McDermott M, Lawson K, Hottinger K, et al. Parental stress in families
of children with autism and other developmental disabilities. J Child Neurol
2015; 30:1728-35.

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SINGAPORE MEDICAL COUNCIL CATEGORY 3B CME PROGRAMME

(Code SMJ 201903A)
  True   False
1. Developmental delays are common, occurring in approximately 20% of preschool children.   □   □
2. During a phase of prolonged illness, a child may have a plateau or even a delay in development,   □   □
which is usually transient.
3. Children who have a variant crawl pattern, such as ‘commando crawlers’, are likely to walk late.   □   □
Hence, they need to be referred early for intervention.
4. A majority of children with developmental delay have a developmental disability.   □   □
5. A significant delay refers to performance of two or more standard deviations below the mean on age-   □   □
appropriate norm-referenced standardised testing.
6. The cause of global developmental delay (GDD) can always be identified through investigations alone.   □   □
7. Developmental regression is an unequivocal red flag that warrants an urgent referral for further   □   □
assessment and management.
8. All children presenting with developmental delays, irrespective of the degree of delay, should be   □   □
promptly referred for further specialist assessment.
9. Children from socially disadvantaged backgrounds are at higher risk for developmental delays.   □   □
10. A boy presenting with gross motor delay should have his serum creatine phosphokinase checked.   □   □
11. All children with a diagnosis of GDD need cognitive testing to assess their intellectual functioning at   □   □
the age of about six years.
12. The majority of children with GDD have a degree of intellectual disability.   □   □
13. Nutritional deficiencies such as iron deficiency are a treatable cause of developmental delays.   □   □
14. In children presenting with significant development delays (e.g. language delay) or with a history of   □   □
regression, a prompt referral to a developmental paediatrician is warranted.
15. Vision assessment should be part of the evaluation, especially for a child presenting with fine motor   □   □
delay.
16. Children should be discouraged from exposure to many languages, as they will have persistent difficulties   □   □
with language acquisition.
17. Baseline investigations for a child presenting with GDD would not include thyroid function tests if   □   □
they were already done in the newborn period as part of the newborn metabolic screen.
18. Hearing assessment should be part of the developmental evaluation for a child presenting with   □   □
language delay.
19. Children needing intensive and long-term interventions are usually referred to EIPIC (Early Intervention   □   □
Programme for Infants and Children) centres.
20. Baseline blood tests, such as a full blood count, should be performed for all children presenting with   □   □
developmental delays.

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