Changes to CDC Milestones

With the recent changes to the CDC’s milestone checklists, we know that some parents have had questions about what changed, why they changed them, and what it means for their family. We will give you the overview here, but check out our bonus podcast episode to get more in-depth answers and information!

What happened?

• In 2004, the CDC’s Learn the Signs. Act Early. program developed free milestone checklists that included developmental warning signs, messaging to “act early” to addressing concerns; and developmental tips/activities. These materials were developed to help parents recognize typical development, improve conversations between parents and professionals about a child’s development, and support developmental screening at recommended ages and additional screenings when there are concerns. 
• In early 2022, the Center for Disease Control released changes to these long-standing Developmental Milestone Checklists. The purpose of these checklists has always been to help doctors and parents keep an eye on children’s development and to facilitate ongoing conversations between doctor and the families they serve. It’s not an official screening tool that would be used to help determine if a child would qualify for additional services or therapies – it’s a starting point for a conversation between doctors and families!
• The changes made to these checklists were based on research and recommendations of an expert working group from the American Academy of Pediatrics. According to the article that group published in the peer-reviewed journal, Pediatrics, “The goals of the group were to identify evidence-informed milestones to include in CDC checklists, clarify when most children can be expected to reach a milestone (to discourage a wait-and-see approach), and support clinical judgment regarding screening between recommended ages”

What are the changes/updates?

• The updated checklists no longer list a milestone at more the one age (this caused a lot of confusion before)
• Eliminated vague terms like “children may begin to…”
• Removed the “warning signs” section on each checklist
• Direct citations to research studies that support them (yay!)
• Based on more studies that look at development from more diverse and cross-cultural groups
• Added a checklist specifically for the 15- and 30-month ages (as these are common ages for well-child checks in America that previously did not have a milestone list associated with them)
• Suggestions for open-ended questions for doctors to use with families
• Finally, the biggest change – moving the milestones to the age where 75% of children would be expected to achieve the skill. This was a change from the previous standard of 50%. In most cases, this meant moving milestones back to a slightly older age.

Why did they make these changes?

• The change from 50% to 75% has some people confused or frustrated, so let’s start with some of the reasoning provided for this change. According to the article in Pediatrics, there were several justifications for it.

• When the milestone was listed at the age when 50% of kids could do a task, doctors often would tell concerned parents to just wait and see because some kids simply had to be in the later half. This experience often left parents unsure and unheard. On the flip side, pediatricians knew that waiting until the age where 90% of children could do the task would likely delay the opportunity for children who do have a developmental concerns to get a diagnosis or support services. Therefore, the team landed on 75% as a benchmark to balance these two things.
• These new checklists can also prevent worry for children older than the average age of attainment of a milestone but not likely to be at risk for delays (aka late bloomers)
• In a direct quote from the article, authors said “[the previous checklists provided] insight into typical development but [did] not provide clarity for parents, pediatricians, and other early childhood professionals  about when to be concerned or when additional screening might be helpful”

• Another change that people had a lot of questions about was why crawling was removed from the checklists. According to the article in Pediatrics, the age range varies greatly for this milestone, and some typically-developing children never crawl at all.
• A common misconception was that this move was related to the pandemic, but the criticisms, the thought process, and the planning were underway to make these changes long before the COVID-19 pandemic occurred. (Fun fact: I actually wrote a paper in graduate school on developmental milestones, and I read papers criticizing the original milestone checklists that were published in 2007, 2013, and 2019.)

What’s this mean for you and your family?

• Continue to have conversations with your family doctor about your child’s development. If you have concerns, share them with your doctor. Keep trusting your parenting instincts when things don’t feel right. If necessary, build your skills for assertive communication and advocating for your child!
• Download the CDC’s Milestone Tracker app, and answer the questions related to your child’s age. You will answer Yes/Not Sure/Not Yet to specific questions about your child, and then you’ll get follow-up feedback. You can use this tool to communicate with healthcare professionals or therapists you may work with.
• Keep engaging with your child in through conversations, play, and simple daily routines!

The majority of the content referenced in this episode can be found in this American Academy of Pediatrics journal article – they also have a short video abstract from one of the authors you can watch. https://publications.aap.org/pediatrics/article/149/3/e2021052138/184748/Evidence-Informed-Milestones-for-Developmental