NeuroDev Guidance

Growth charts and neurodevelopmental surveillance with a cited, level-based recommendation for specialist assessment

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Why use it

The AAP supports developmental surveillance at every health supervision visit and standardised screening at 9, 18 and 30 months, with autism-specific screening at 18 and 24 months; concerns raised at any visit should be followed by standardised screening or direct referral (Lipkin & Macias 2020; Hyman et al. 2020). Each step depends on many separate thresholds: milestone ages, corrected age, instrument cut-offs, growth z-scores and red flags that call for priority referral. NeuroDev Guidance applies these published thresholds consistently and shows, for each finding, the source and the verbatim text that supports it, so the recommendation can be checked and documented in the clinical record.

About

NeuroDev Guidance brings together the elements of developmental surveillance described in the AAP algorithm (Lipkin & Macias, Pediatrics 2020): the child's age (with corrected age for children born preterm), growth, developmental milestones, red flags and regression, the results of validated screening and assessment instruments, and associated physical and family-history findings. Its output is always one of four levels of specialist assessment (0 Typical development; 1 Enhanced surveillance; 2 Specialist assessment recommended; 3 Priority specialist assessment), each with the reasons that produced it and the citation behind each reason. It supports detection and referral; it does not diagnose or establish aetiology, does not choose between specialties and does not suggest investigations. Growth is assessed with the WHO Child Growth Standards (2006) and WHO Growth Reference (2007), with the CDC 2000 charts (and CDC extended BMI-for-age) as an alternative profile following the CDC recommendation to use WHO charts under 24 months (Grummer-Strawn et al., MMWR 2010), with the Down syndrome charts of Zemel et al. (Pediatrics 2015), and, for preterm infants, with the INTERGROWTH-21st postnatal standards up to 64 weeks' postmenstrual age (Villar et al., Lancet Glob Health 2015). All reference values are read from the official files. Validated instruments (for example M-CHAT-R/F, SWYC, ASQ-3, PEDS-R, Denver II, Bayley-4) are applied by the clinician on the official forms; only the result is entered, and the instrument's published interpretation rule is applied. Items are never reproduced.

When to use

Health supervision visits from birth to 5 years (milestone surveillance and growth review)
A parent, caregiver or clinician raises a concern about development
Recording the result of a developmental or autism screening instrument and deciding on the next step
Follow-up of a child born preterm (corrected age, preterm growth charts)
Children with risk factors for developmental disorders (perinatal, environmental, family history, consanguinity)
Preparing a referral summary with the reasons and citations for specialist assessment

Method

1. Age: chronological age; corrected age = chronological age − (40 − GA) weeks if GA < 37 weeks, used until 24 months of chronological age (36 months if GA < 28 weeks). 2. Growth: z = ((value/M)^L − 1)/(L·S) on the selected reference table (LMS method); percentile = 100·Φ(z). WHO restricted rule beyond ±3 SD for weight-based indicators. 3. Milestones: status from threshold age and tolerance band: achieved → typical · age < threshold → not yet expected threshold ≤ age ≤ band end → within reference variation (level 1) age > band end → beyond all reference ages (level 2) 4. Instruments: published interpretation rule of each instrument applied to the entered result. 5. Standard scores: z = (score − mean)/SD; z ≤ −2 = significant delay. 6. Conclusion: level = maximum level among the rules that fired (0–3); each rule cites its source.

Pearls & pitfalls

Loss of previously acquired skills at any age is a reason for priority assessment (Filipek 2000; NICE CG128; Noritz 2013). Saving each visit and re-opening the file at the next visit lets the tool detect a milestone recorded as achieved that is now not yet achieved.
For children born before 37 weeks, milestones are judged against corrected age until 24 months of chronological age, or 36 months if born before 28 weeks (Caderneta da Criança 2025).
Each milestone has a single threshold age: the WHO Motor Development Study 99th percentile for six gross-motor milestones and the CDC/AAP 2022 age by which at least 75% of children show the milestone for all others (Zubler et al. 2022). A milestone not achieved after its threshold but within the ages at which other references place it is read as reference variation; beyond all references, as a reason for specialist assessment. This threshold-plus-tolerance rule is a methodological decision of the tool, not a published recommendation, and is stated in every report.
Hands-and-knees crawling is informative only: the WHO study reports that 4.3% of children did not exhibit it.
Parental concern alone justifies additional standardised screening as soon as possible (Lipkin & Macias 2020).
Concern about autism from the clinician or parent warrants referral regardless of the M-CHAT-R/F score (official M-CHAT-R/F instructions).
GSED results are recorded as information only: WHO publishes no individual-level threshold for the D-score or DAZ.
A change of growth chart (for example from INTERGROWTH-21st to WHO at 64 weeks' postmenstrual age) can change a z-score without any change in growth; the tool shows the z-score on both charts at the switch and does not count line crossings across a chart change.
Fenton 2025 preterm charts are not included because their LMS parameters are not publicly released; measurements in that phase are reported as not applicable rather than plotted on a substitute chart.
No data leave the browser: the assessment is kept only in the current tab and is saved by downloading a file.

Next steps

Level 0: continue routine surveillance at every visit and standardised screening at the recommended ages. Level 1: re-assess or screen with a validated instrument within the time frame given by the cited source. Level 2: refer for specialist assessment. Level 3: refer for priority specialist assessment (for example developmental regression, suspected infantile spasms or seizures, an M-CHAT-R total of 8–20, or the absolute indications of Filipek et al. 2000). Audiologic evaluation is recommended for any child with a developmental concern (Lipkin & Macias 2020). The referral summary can be copied into the record or downloaded as text or PDF.

Evidence

Levels follow the structure of the AAP surveillance and screening algorithm (Lipkin & Macias, Pediatrics 2020;145:e20193449). The final level is the most severe rule that fires; no points are summed. Rules and their sources include: developmental regression (Filipek et al., Neurology 2000; NICE CG128; Noritz et al., Pediatrics 2013; Hyman et al., Pediatrics 2020); infantile spasms and suspected seizures (NICE NG217, 2022); neuromotor red flags for prompt referral (Noritz et al. 2013, Table 3); absolute indications for immediate evaluation — no babbling or gesture by 12 months, no single words by 16 months, no two-word spontaneous phrases by 24 months (Filipek et al. 2000); M-CHAT-R/F scoring algorithm (official form, March 2025; validation by Robins et al., Pediatrics 2014); significant delay defined as ≥ 2 SD below the mean on standardised testing and global developmental delay as significant delay in two or more domains (Shevell et al., Neurology 2003; Moeschler & Shevell, Pediatrics 2014); head circumference below −2 or above +2 z-scores (Caderneta da Criança 2025; microcephaly definition, Ashwal et al., Neurology 2009); growth-line crossing (Caderneta da Criança 2025); faltering growth and length relative to mid-parental height (NICE NG75, 2017); early red flags of autism (Hyman et al. 2020); and developmental risk factors (Caderneta da Criança 2025; Lipkin & Macias 2020). Milestone thresholds come from the WHO Multicentre Growth Reference Study Motor Development Study (Acta Paediatr Suppl 2006;450:86-95) and from Zubler et al. (Pediatrics 2022;149:e2021052138); tolerance ages come from the same two sources, the Caderneta da Criança 2025 (Brazil) and the DGS Programa Nacional de Saúde Infantil e Juvenil 2013 (Portugal). These are guideline, consensus and normative sources; the tool itself has not been validated as a diagnostic or screening instrument.

References

Lipkin PH, Macias MM; AAP Council on Children with Disabilities, Section on Developmental and Behavioral Pediatrics. Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening. Pediatrics. 2020;145(1):e20193449. — link
Zubler JM, Wiggins LD, Macias MM, et al. Evidence-Informed Milestones for Developmental Surveillance Tools. Pediatrics. 2022;149(3):e2021052138. — link
WHO Multicentre Growth Reference Study Group. WHO Motor Development Study: Windows of achievement for six gross motor development milestones. Acta Paediatr Suppl. 2006;450:86-95. — link
Hyman SL, Levy SE, Myers SM; AAP Council on Children with Disabilities. Identification, Evaluation, and Management of Children With Autism Spectrum Disorder. Pediatrics. 2020;145(1):e20193447. — link
Filipek PA, Accardo PJ, Ashwal S, et al. Practice parameter: screening and diagnosis of autism. Neurology. 2000;55(4):468-479. — link
Noritz GH, Murphy NA; Neuromotor Screening Expert Panel. Motor delays: early identification and evaluation. Pediatrics. 2013;131(6):e2016-e2027. — link
Shevell M, Ashwal S, Donley D, et al. Practice parameter: evaluation of the child with global developmental delay. Neurology. 2003;60(3):367-380. — link
Moeschler JB, Shevell M; AAP Committee on Genetics. Comprehensive evaluation of the child with intellectual disability or global developmental delays. Pediatrics. 2014;134(3):e903-e918. — link
Robins DL, Casagrande K, Barton M, et al. Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F). Pediatrics. 2014;133(1):37-45. — link
Ashwal S, Michelson D, Plawner L, Dobyns WB. Practice parameter: Evaluation of the child with microcephaly. Neurology. 2009;73(11):887-897. — link
National Institute for Health and Care Excellence. Epilepsies in children, young people and adults. NICE guideline NG217. 2022. — link
National Institute for Health and Care Excellence. Autism spectrum disorder in under 19s: recognition, referral and diagnosis. Clinical guideline CG128. 2011. — link
National Institute for Health and Care Excellence. Faltering growth: recognition and management of faltering growth in children. NICE guideline NG75. 2017. — link
Brasil. Ministério da Saúde. Caderneta da Criança: Passaporte da Cidadania. 7ª edição revisada. Brasília; 2025. — link
Direção-Geral da Saúde. Programa Nacional de Saúde Infantil e Juvenil. Norma n.º 010/2013. Lisboa: DGS; 2013. — link
WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards: Methods and development. Geneva: WHO; 2006. — link
Grummer-Strawn LM, Reinold C, Krebs NF. Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States. MMWR Recomm Rep. 2010;59(RR-9):1-15. — link
Villar J, et al. Postnatal growth standards for preterm infants: the Preterm Postnatal Follow-up Study of the INTERGROWTH-21st Project. Lancet Glob Health. 2015;3(11):e681-e691. — link
Zemel BS, Pipan M, Stallings VA, et al. Growth charts for children with Down syndrome in the United States. Pediatrics. 2015;136(5):e1204-e1211. — link
Tanner JM, Goldstein H, Whitehouse RH. Standards for children's height at ages 2-9 years allowing for heights of parents. Arch Dis Child. 1970;45:755-762. — link