Original Investigation | Pediatrics

Standardization of a Developmental Milestone Scale Using Data

From Children in Israel
Tamar Sudry, MD; Deena R. Zimmerman, MD, MPH; Hadar Yardeni, MD; Adina Joseph, MD; Ravit Baruch, RN, MA; Itamar Grotto, MD, MPH, PhD;
Dan Greenberg, MSc, PhD; Roni Eilenberg, MSc; Guy Amit, PhD; Pinchas Akiva, PhD; Meytal Avgil Tsadok, PhD; Yitzhak Rize, PhD; Hani Zaworbach, BSc;
Moshe Uziel, BSc; Dror Ben Moshe, BSc; Irit Lior Sadaka, RN, MPH; Eitan Bachmat, PhD; Judah Freedman, MPH; Yair Sadaka, MD, PhD, MHA

Abstract Key Points

Question Can accurate developmental
IMPORTANCE Routine developmental screening tests for children are used worldwide for early
norms for children be determined on
detection of developmental delays. However, assessment of developmental milestone norms lacks
the basis of national developmental
strong normative data, and there are inconsistencies among different screening tools.
assessments of a multicultural
population?
OBJECTIVE To establish milestone norms and build an updated developmental scale.
Findings This cross-sectional,
DESIGN, SETTING, AND PARTICIPANTS This is a cross-sectional, population-based study population-based study analyzed
conducted between 2014 and 2020. Developmental assessments were conducted by trained public 3 774 517 developmental assessments of
health nurses, documented in national maternal child health clinics, known as Tipat Halav, which 643 958 children from birth to age 6
serve all children in Israel. Participants included all children born between January 2014 and years, conducted by trained nurses in
September 2020, who were followed at the maternal child health clinics from birth to age 6 years. Maternal Child Health Clinics (known as
Exclusion criteria were preterm birth, missing gestational age, low birth weight (<2.5 kg), abnormal Tipat Halav) in Israel. A contemporary
weight measurement (<3% according to standardized child growth charts), abnormal head developmental scale, the Tipat Halav
circumference measurement (<3% or >97% according to standardized child growth charts), and Israel Screening Developmental Scale,
visits without developmental data or without the child’s age. Data analysis was performed from was built accordingly, presenting the
September 2020 to June 2021. 75%, 90%, and 95% achievement rate
for evaluated milestones.
EXPOSURES In total, 59 milestones in 4 developmental domains were evaluated, and the
Meaning This developmental scale
achievement rate per child’s age was calculated for each milestone.
based on a diverse population in Israel is
recommended for further evaluation
MAIN OUTCOMES AND MEASURES A contemporary developmental scale, the Tipat Halav Israel
worldwide.
Screening (THIS) Developmental Scale, was built, presenting the 75%, 90%, and 95% achievement
rates for each milestone. The THIS scale was compared with other commonly used screening tests,
including the Denver Developmental Screening Test II (Denver II), the Alberta Infant Motor Scale + Supplemental content
(AIMS), and the Centers for Disease Control and Prevention (CDC) Developmental Assessment. Author affiliations and article information are
listed at the end of this article.

RESULTS A total of 839 574 children were followed in the maternal child health clinics between
January 2014 and September 2020 in Israel, and 195 616 children were excluded. A total of 3 774 517
developmental assessments were performed for the remaining 643 958 children aged 0 to 6 years
(319 562 female children [49.6%]), resulting in the establishment of new developmental norms. In
terms of the comparable milestones, THIS milestones had a match of 18 of 27 (67%) with the Denver
II, 7 of 7 (100%) with AIMS, and 10 of 19 (53%) with the CDC Developmental Assessment. The
remaining unmatched milestones were achieved earlier in the THIS scale compared with other
screening tools.

(continued)

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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 JAMA Network Open | Pediatrics Standardization of a Developmental Milestone Scale Using Data From Children in Israel

Abstract (continued)

CONCLUSIONS AND RELEVANCE The THIS developmental scale is based on the largest population
evaluated to date for developmental performance, representing the heterogeneous, multicultural
population comprising this cohort. It is recommended for further evaluation worldwide.

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Introduction
According to recent statistics, in the US as many as 1 in 4 children from birth to age 5 years are at
moderate or high risk for developmental, behavioral, or social delay.1 Early detection of delay is
crucial for determining which children require close surveillance and intervention.2-5 Early
intervention has been proven to be critical in optimizing language, cognitive, motor, socioemotional
development, and educational success, alongside prevention of additional future developmental
delay.6-13
Because of the importance of early intervention, international health organizations recommend
conducting regular developmental surveillance and screening for all children.1,3,14-16 Tools for
assessing child development are of central importance in allocating resources and making decisions
for the benefit of children with or at risk of developmental delay. Therefore, it is important that the
developmental screening tools will most accurately reflect the natural distribution of developmental
stage timing.
Worldwide, there are multiple developmental screening tools in use.3 However, assessment of
developmental milestones lacks strong normative data,17-19 and there are inconsistencies among
different screening tools regarding normative attainment age of commonly evaluated
milestones.18,20-22 On the basis of the importance of milestone norms in any developmental
screening tool, the current study aimed to establish milestones of normative timing and build a
developmental scale accordingly. The new scale is based on developmental assessments of children
conducted by trained public health nurses in a nationwide program. The establishment of normal
attainment age of each milestone and the developmental scale built by this process in a multicultural
country, with a diverse population of multiple ethnicities and languages, may further strengthen
other developmental screening or diagnostic tools.

Methods
All methods were performed in accordance with relevant guidelines and regulations. The study
protocol was approved by the Soroka Medical Center institutional review board and was conducted
in accordance to the principles of the Declaration of Helsinki.23 An exemption of informed consent
was granted by this ethics committee because the data were anonymous. This cross-sectional study
follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
reporting guidelines for cross-sectional studies.

Maternal Child Health Clinics

In Israel, universal, free-of-charge pediatric preventive care for children from birth to age 6 years is
provided in maternal child health clinics (MCHCs) known as Tipat Halav (“drop of milk”).20 The
objectives of the services provided are prevention of infectious diseases by means of immunization,
early detection of health problems by conducting routine growth, physical, and development
examinations, and health education. Parents are instructed to visit the MCHC after hospital discharge
and then at ages 1, 2, 4, 6, 9, 12, 18, 24, 36, 48, and 60 months. Developmental surveillance is
conducted at all of the scheduled routine visits.

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 JAMA Network Open | Pediatrics Standardization of a Developmental Milestone Scale Using Data From Children in Israel

There are approximately 1000 MCHCs distributed throughout the country, managed by the
Ministry of Health (MoH), 2 municipalities (Tel Aviv and Jerusalem), or 1 of the 4 Israeli health
maintenance organizations. All clinics work according to the same national care protocols.24 This
study is based on the database of all visits to the clinics run by the MoH, the municipalities, and 1
health maintenance organization (Leumit), all of which use the same electronic medical record. This
group of children represent approximately 70% of the nation’s children in the age group of birth to
6 years.

Developmental Screening and Documentation

One of the standardized protocols of MCHC refers to age-based developmental screening. The
current protocol25 uses developmental milestones in 4 domains: gross motor, fine motor, language,
and personal-social. The protocol has adapted milestones from other scales, including the Sally
Provence Developmental Profile,26 Denver Developmental Scale,17,27 and Gesell Developmental
Schedule,28 and was developed by an MoH task force consisting of pediatricians, nurses, physical
therapists, speech pathologists, occupational therapists, and child psychologists. Description of
these milestones can be found in eTable 1 in the Supplement.
Developmental assessment is performed by the MCHC nursing staff at each routine visit from
birth to 6 years. The MCHC nursing staff includes certified public health nurses who are qualified to
assess the child’s health, growth, and development. Each nurse has been trained specifically to
conduct the developmental assessment protocol, and their training is evaluated and monitored at
the beginning of their clinical practice. At each visit, a predefined group of age-related milestones is
evaluated, according to the expected development at that age, as described in eTable 1 in the
Supplement. However, some of the children arrive to the clinics for developmental assessment at a
later age than expected. In these cases, previous milestones that were not yet evaluated are
examined during the later visit.
The child’s performance of each milestone is reported as observed in the clinic. In cases of
objective difficulty in appropriate evaluation, milestone achievements are documented according to
the parent’s report. If the evaluated milestone was not achieved by observation or parental report,
it is documented as unachieved. All results are documented within an electronic medical
record (EMR).

Electronic Medical Records

The clinical and demographic data collected by the clinic’s staff (nurses and physicians) are entered
into an EMR system, specially developed for the MCHC. The demographic data contain parent-
reported ethnicity, which is included in this study to emphasize the multicultural and multilingual
nature of this database. The EMR system Machshava Briah (“Healthy Thought”)24 is used at the
MCHCs. An anonymized version of the EMR database, with data from 2014 to 2020, was constructed
by the Israel MoH Big Data Department for the current study.

Tipat Halav Israel Screening Developmental Scale Study Cohort

The current study included all children born between January 1, 2014, and September 1, 2020, who
were followed at the MCHCs and who had at least 1 developmental evaluation recorded during the
study period. To assess the developmental norms for a healthy, low-risk population, exclusion criteria
were defined to identify children with potential of abnormal development. The exclusion criteria
included preterm birth (gestational age of <37 weeks), low birth weight (<2.5 kg), abnormal weight
measurement (<3% according to standardized child growth charts), abnormal head circumference
measurement (microcephaly [<3%] or macrocephaly [>97%] according to standardized child growth
charts), missing gestational age at delivery, and visits without developmental data or without the
child’s age.

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 JAMA Network Open | Pediatrics Standardization of a Developmental Milestone Scale Using Data From Children in Israel

Statistical Analysis
There were 59 developmental milestones, grouped into 9 age groups, as shown in Figure 1. For each
developmental milestone, the first evaluation of the milestone for each child was extracted.
Repeated evaluations that may have been performed for the same milestone were excluded to
analyze a population undergoing initial screening and, thus, to avoid a potential bias toward children
with developmental delays. For example, if a child aged 6 to 9 months had failed to crawl in the first
evaluation and then succeeded at the following visit between the ages of 9 to 12 months, only the
first failed evaluation was included in data analysis. Because the exact timing of the evaluation visits
varied, we grouped children by their age on the date of the milestone evaluation and calculated the
achievement rate for each age range. The time ranges that were used for grouping the children were
1 week for young age milestones (birth to 2 years) and 1 month for the older age milestones (2-6
years). Children were considered as achievers of the milestone if they were either observed in the
clinic or reported by their parent to have accomplished the milestone. To determine success rates of
75%, 90%, and 95% of the children for each milestone, the achievement rate was calculated by
dividing the number of achieving children by the total number of children examined at each age
group, resulting in a series of success rates per age group. The final curve of a milestone’s
achievement rate by age (eFigure 1, eFigure 2, eFigure 3, eFigure 4, eFigure 5, eFigure 6, eFigure 7,
eFigure 8, and eFigure 9 in the Supplement) was obtained from this series by averaging adjacent
values using a window of size 5 weeks or 3 months for the early age and older age, respectively. We
applied linear interpolation to increase the temporal resolution of the trends and calculated the ages
at which the success rate surpassed 75%, 90%, and 95% for the first time. To assess potential biases
caused by the timing of the screening, we divided the visit time into quartiles and examined, within
each age, the differences between the children with early and late screening time.

Figure 1. Participant Enrollment Flowchart

839 574 All children born from January 1,

2014, to September 1, 2020
4 943 465 Total developmental visits

81 274 Children excluded

63 151 Gestational age <37 wk
18 123 Missing gestational age

758 300 Children born in-term

4 464 569 Total visits

26 255 Children excluded

24 068 Birth weight <2.5 kg
2187 Missing birth weight
1757 Visits without development data,
missing age, or duplicates

88 087 Children excluded

42 381 Any weight percentile <3%
41 532 Any head circumference
percentile <3% or >97%
4174 Missing weight or head
circumference measures

643 958 Children with 3 774 517 visits

Age 0 to ≤3 mo: 582 926 children with 715 423 visits
Age >3 to ≤6 mo: 572 091 children with 693 336 visits
Age >6 to ≤9 mo: 542 507 children with 755 866 visits
Age >9 to ≤12 mo: 412 909 children with 620 767 visits
Age >12 to ≤18 mo: 507 791 children with 710 752 visits
Age >18 to ≤24 mo: 436 454 children with 643 647 visits
Age >24 to ≤36 mo: 367 003 children with 443 091 visits Overview of the study population, including the
Age >36 to ≤48 mo: 122 237 children with 135 055 visits exclusion criteria and total developmental
Age >48 to ≤72 mo: 28 054 children with 29 802 visits
assessments at each age group.

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 JAMA Network Open | Pediatrics Standardization of a Developmental Milestone Scale Using Data From Children in Israel

The Tipat Halav Israel Screening (THIS) Developmental Scale was compared with milestone
attainment age of 3 other commonly used developmental tests: the Denver Developmental
Screening Test II (Denver II), the Alberta Infant Motor Scale (AIMS), and the Centers for Disease
Control and Prevention (CDC) Developmental Assessment.15,17,29 Because the exact definition of the
evaluated milestones varies among these scales, we compared specific milestones that bear enough
resemblance among the screening tests. For the THIS developmental scale, Denver II, and AIMS,
failing to achieve a milestone was defined as not achieving the milestone at an age in which a 90%
success rate was accomplished. For the CDC scale, it was defined as the age at which failure to
achieve a milestone requires further medical evaluation. A meaningful clinical difference in milestone
achievement among screening scales was defined as more than 1 month within the first 6 months of
the child’s life, more than 2 months between ages 6 and 12 months, more than 3 months within the
second and third year of life, and more than 6 months at age 3 to 6 years.
Data analysis was performed from September 2020 to June 2021. Data analysis was performed
using Python programming language version 3.6 (Python Software Foundation).

Results
The electronic medical records of 839 574 children who visited the study MCHCs between January
2014 and September 2020 were available for analysis. Preterm children (gestational age <37 weeks;
63 151 children), infants with low birth weight (<2.5 kg; 24 068 infants) or missing birth weight (2187
infants), children with abnormal weight measurement (<3% according to standardized child growth
charts; 42 381 children), abnormal head circumference measurement (<3% or >97% according to
standardized child growth charts; 41 532 children), and children with missing gestational age (18 123
children) or missing weight or head circumference measures (4174 children) were excluded from the
analysis. Visits without developmental data or with missing age were removed (1757 children). Thus,
195 616 children were excluded. A total of 643 958 children (319 562 female children [49.6%]) with
3 774 517 developmental evaluations were included in the analysis (Figure 1). The mean (SD) number
of developmental evaluation visits per child was 5.9 (2.4) visits.
To assess a potential selection bias, the study cohort was compared with the Israeli population
documented by the Israeli Central Bureau of Statistics.30 The study cohort represents approximately
70% of the children born in Israel within the study period, without meaningful changes throughout
the years 2014 to 2019. The distributions of child’s sex and mother’s age in the cohort were similar to
the national statistics, whereas the subpopulation of Arab children was slightly overrepresented
compared with the Jewish population (76%-80% of the Israeli-Arab population vs 59%-68% of the
Israeli-Jewish population).
The main demographic, birth, and maternal characteristics for each age group evaluated are
summarized in the Table. The child population was composed of a nearly equal distribution of male
(324 396 children [50.4%]) and female (319 562 children [49.6%]) children. The study cohort
demonstrates the diverse population attending the MCHCs in Israel, with multiple ethnic groups,
including Jewish, Arab, Druze, and others. Most mothers were Israel-born (528 861 mothers [82.1%])
and married (566 747 mothers [88.0%]), whereas maternal education varied, with less than
one-third of the population having an academic degree (195 799 mothers [30.4%]) and
approximately one-quarter having a high school education (171 411 mothers [26.6%]).

Comparison of Age Groups

The number of children examined at each of the 9 groups of age-related milestones ranged from
582 926 children at 0- to 3-month milestones to 28 054 children at 4- to 6-year milestones. The 9
age groups were defined according to the recommended time for evaluation of the milestones.
Because the visit time varied and children who were not evaluated during the recommended time
frame were evaluated later, during their actual visit, we performed a sensitivity analysis in which
within each group of milestones we examined potential differences between the children with early

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 Table. Study Population Characteristics by Age Group

Participants, No. (%)

Total 0 to ≤3 mo >3 to ≤6 mo >6 to ≤9 mo >9 to ≤12 mo >12 to ≤18 mo >18 to ≤24 mo >2 to ≤3 y >3 to ≤4 y >4 to ≤6 y
Cohort characteristics (N = 643 958) (n = 582 926) (n = 572 091) (n = 542 507) (n = 412 909) (n = 507 791) (n = 436 454) (n = 367 003) (n = 122 237) (n = 28 054)
Child sex
Female 319 562 (49.6) 289 559 (49.7) 284 256 (49.7) 270 017 (49.8) 205 273 (49.7) 252 684 (49.8) 217 267 (49.8) 182 435 (49.7) 61 344 (50.2) 13 930 (49.7)
Male 324 396 (50.4) 293 367 (50.3) 287 835 (50.3) 272 490 (50.2) 207 636 (50.3) 255 107 (50.2) 219 187 (50.2) 184 568 (50.3) 60 893 (49.8) 14 124 (50.3)
Ethnic group
Arab 140 525 (21.8) 133 418 (22.9) 130 810 (22.9) 125 257 (23.1) 102 498 (24.8) 117 197 (23.1) 103 101 (23.6) 88 740 (24.2) 34 949 (28.6) 7082 (25.2)
Druse 11 796 (1.8) 11 475 (2.0) 11 206 (2.0) 10 890 (2.0) 9423 (2.3) 10 176 (2.0) 9233 (2.1) 7971 (2.2) 4319 (3.5) 538 (1.9)
JAMA Network Open | Pediatrics

Jewish 392 634 (61.0) 349 441 (59.9) 342 307 (59.8) 322 634 (59.5) 236 543 (57.3) 300 667 (59.2) 254 959 (58.4) 211 728 (57.7) 64 854 (53.1) 16 360 (58.3)
Missing 76 333 (11.9) 67 281 (11.5) 66 715 (11.7) 63 333 (11.7) 47 142 (11.4) 60 846 (12.0) 52 313 (12.0) 44 317 (12.1) 11 836 (9.7) 2921 (10.4)
Othera 22 670 (3.5) 21 311 (3.7) 21 053 (3.7) 20 393 (3.8) 17 303 (4.2) 18 905 (3.7) 16 848 (3.9) 14 247 (3.9) 6279 (5.1) 1153 (4.1)
Mother’s birth country

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Israel 528 861 (82.1) 479 985 (82.3) 470 756 (82.3) 446 192 (82.2) 338 327 (81.9) 418 073 (82.3) 360 165 (82.5) 304 631 (83.0) 103 045 (84.3) 23 264 (82.9)
Otherb 58 983 (9.2) 51 603 (8.9) 50 793 (8.9) 47 829 (8.8) 35 485 (8.6) 45 024 (8.9) 37 766 (8.7) 30 250 (8.2) 7920 (6.5) 1983 (7.1)
Europe 25 180 (3.9) 22 462 (3.9) 22 123 (3.9) 21 066 (3.9) 16 110 (3.9) 19 346 (3.8) 16 324 (3.7) 13 946 (3.8) 4756 (3.9) 1213 (4.3)
Former Soviet Union 22 240 (3.5) 20 748 (3.6) 20 510 (3.6) 19 846 (3.7) 16 885 (4.1) 18 347 (3.6) 16 139 (3.7) 13 241 (3.6) 4645 (3.8) 1101 (3.9)
Ethiopia 8644 (1.3) 8081 (1.4) 7866 (1.4) 7535 (1.4) 6069 (1.5) 6964 (1.4) 6027 (1.4) 4905 (1.3) 1861 (1.5) 492 (1.8)
Missing 50 (<0.1) 47 (<0.1) 43 (<0.1) 39 (<0.1) 33 (<0.1) 37 (<0.1) 33 (<0.1) 30 (<0.1) 10 (<0.1) <5 (<0.1)
Employment status
Missing 199 544 (31.0) 178 338 (30.6) 176 036 (30.8) 167 653 (30.9) 126 114 (30.5) 159 720 (31.5) 138 090 (31.6) 118 748 (32.4) 38 743 (31.7) 9322 (33.2)
Not working 131 703 (20.5) 119 167 (20.4) 117 947 (20.6) 112 276 (20.7) 88 922 (21.5) 106 306 (20.9) 92 686 (21.2) 78 824 (21.5) 28 558 (23.4) 6265 (22.3)
Student 28 514 (4.4) 26 065 (4.5) 25 427 (4.4) 24 008 (4.4) 18 101 (4.4) 22 249 (4.4) 19 050 (4.4) 15 948 (4.3) 5423 (4.4) 1146 (4.1)

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Working 284 197 (44.1) 259 356 (44.5) 252 681 (44.2) 238 570 (44.0) 179 772 (43.5) 219 516 (43.2) 186 628 (42.8) 153 483 (41.8) 49 513 (40.5) 11 321 (40.4)
Mother’s education level
Academic degree 195 799 (30.4) 180 889 (31.0) 178 087 (31.1) 170 057 (31.3) 136 364 (33.0) 158 102 (31.1) 137 449 (31.5) 115 961 (31.6) 42 643 (34.9) 9083 (32.4)
Elementary school 13 442 (2.1) 12 208 (2.1) 12 046 (2.1) 11 300 (2.1) 9152 (2.2) 10 732 (2.1) 9235 (2.1) 7784 (2.1) 2493 (2.0) 688 (2.5)
High school 171 411 (26.6) 158 223 (27.1) 155 430 (27.2) 148 418 (27.4) 116 353 (28.2) 139 077 (27.4) 121 002 (27.7) 102 192 (27.8) 37 027 (30.3) 8272 (29.5)
Missing 199 021 (30.9) 174 040 (29.9) 171 094 (29.9) 160 972 (29.7) 114 971 (27.8) 152 122 (30.0) 128 663 (29.5) 108 483 (29.6) 30 739 (25.1) 7835 (27.9)
Tertiary education 64 285 (10.0) 57 566 (9.9) 55 434 (9.7) 51 760 (9.5) 36 069 (8.7) 47 758 (9.4) 40 105 (9.2) 32 583 (8.9) 9335 (7.6) 2176 (7.8)
Mother’s family status
Married 566 747 (88.0) 513 990 (88.2) 504 205 (88.1) 478 649 (88.2) 364 300 (88.2) 448 556 (88.3) 386 976 (88.7) 326 829 (89.1) 110 505 (90.4) 25 175 (89.7)
Missing 43 380 (6.7) 37 999 (6.5) 37 191 (6.5) 34 593 (6.4) 24 872 (6.0) 32 096 (6.3) 26 217 (6.0) 20 914 (5.7) 5286 (4.3) 1291 (4.6)
Unmarried 20 005 (3.1) 18 354 (3.1) 18 174 (3.2) 17 244 (3.2) 13 975 (3.4) 15 814 (3.1) 13 428 (3.1) 10 931 (3.0) 3494 (2.9) 855 (3.0)
Other 7160 (1.1) 6449 (1.1) 6430 (1.1) 6147 (1.1) 4985 (1.2) 5761 (1.1) 4940 (1.1) 4112 (1.1) 1370 (1.1) 319 (1.1)
Divorced 6343 (1.0) 5828 (1.0) 5795 (1.0) 5576 (1.0) 4544 (1.1) 5296 (1.0) 4656 (1.1) 4005 (1.1) 1505 (1.2) 391 (1.4)
Widowed 323 (0.1) 306 (0.1) 296 (0.1) 298 (0.1) 233 (0.1) 268 (0.1) 237 (0.1) 212 (0.1) 77 (0.1) 23 (0.1)
Consanguinity
No 606 227 (94.1) 547 578 (93.9) 537 525 (94.0) 509 570 (93.9) 386 126 (93.5) 476 956 (93.9) 409 582 (93.8) 344 240 (93.8) 114 342 (93.5) 26 439 (94.2)
Yes 37 731 (5.9) 35 348 (6.1) 34 566 (6.0) 32 937 (6.1) 26 783 (6.5) 30 835 (6.1) 26 872 (6.2) 22 763 (6.2) 7895 (6.5) 1615 (5.8)

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Standardization of a Developmental Milestone Scale Using Data From Children in Israel

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 Table. Study Population Characteristics by Age Group (continued)

Participants, No. (%)

Total 0 to ≤3 mo >3 to ≤6 mo >6 to ≤9 mo >9 to ≤12 mo >12 to ≤18 mo >18 to ≤24 mo >2 to ≤3 y >3 to ≤4 y >4 to ≤6 y
Cohort characteristics (N = 643 958) (n = 582 926) (n = 572 091) (n = 542 507) (n = 412 909) (n = 507 791) (n = 436 454) (n = 367 003) (n = 122 237) (n = 28 054)
Pregnancy week, median (IQR) 39.5 39.5 39.5 39.5 39.5 39.5 39.5 39.5 39.5 39.5
(38.6-40.3) (38.6-40.3) (38.6-40.3) (38.6-40.3) (38.6-40.3) (38.6-40.3) (38.6-40.3) (38.6-40.3) (38.6-40.2) (38.6-40.1)
Birth weight, mean (SD), kg 3.3 (0.4) 3.3 (0.4) 3.3 (0.4) 3.3 (0.4) 3.3 (0.4) 3.3 (0.4) 3.3 (0.4) 3.3 (0.4) 3.3 (0.4) 3.3 (0.4)
Apgar score 1 min
<8 18 862 (2.9) 17 220 (3.0) 16 945 (3.0) 16 123 (3.0) 12 848 (3.1) 14 980 (3.0) 13 042 (3.0) 11 070 (3.0) 3643 (3.0) 973 (3.5)
≥8 613 747 (95.3) 557 743 (95.7) 547 015 (95.6) 518 649 (95.6) 394 298 (95.5) 485 059 (95.5) 416 868 (95.5) 350 700 (95.6) 117 018 (95.7) 26 714 (95.2)
Missing 11 349 (1.8) 7963 (1.4) 8131 (1.4) 7735 (1.4) 5763 (1.4) 7752 (1.5) 6544 (1.5) 5233 (1.4) 1576 (1.3) 367 (1.3)
JAMA Network Open | Pediatrics

Apgar score 5 min

<8 4112 (0.6) 3696 (0.6) 3655 (0.6) 3465 (0.6) 2863 (0.7) 3304 (0.7) 2910 (0.7) 2616 (0.7) 872 (0.7) 307 (1.1)
≥8 624 688 (97.0) 567 884 (97.4) 556 979 (97.4) 528 208 (97.4) 402 143 (97.4) 493 971 (97.3) 424 724 (97.3) 357 280 (97.4) 119 260 (97.6) 27 280 (97.2)

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Missing 15 158 (2.4) 11 346 (1.9) 11 457 (2.0) 10 834 (2.0) 7903 (1.9) 10 516 (2.1) 8820 (2.0) 7107 (1.9) 2105 (1.7) 467 (1.7)
Head circumference, mean (SD), cm 34.5 (1.3) 34.5 (1.3) 34.5 (1.3) 34.5 (1.3) 34.5 (1.3) 34.5 (1.3) 34.5 (1.3) 34.5 (1.3) 34.5 (1.4) 34.5 (1.4)
Type of birth
Cesarean delivery 92 540 (15.1) 85 191 (15.4) 84 181 (15.5) 80 263 (15.6) 62 285 (16.2) 73 949 (15.4) 63 792 (15.6) 53 317 (15.7) 18 152 (16.6) 3455 (16.3)
Instrumental 34 008 (5.6) 31 221 (5.6) 30 690 (5.7) 29 262 (5.7) 22 619 (5.9) 27 031 (5.6) 23 299 (5.7) 19 239 (5.7) 6782 (6.2) 1249 (5.9)
Spontaneous 485 464 (79.3) 436 337 (78.9) 427 590 (78.8) 404 393 (78.7) 299 370 (77.9) 377 874 (78.9) 321 920 (78.7) 267 567 (78.7) 84 259 (77.2) 16 549 (77.9)
Newborn position
Breech 14 532 (2.3) 13 392 (2.3) 13 299 (2.3) 12 732 (2.3) 9931 (2.4) 11 815 (2.3) 10 227 (2.3) 8655 (2.4) 2909 (2.4) 543 (1.9)
Head 540 304 (83.9) 489 661 (84.0) 479 778 (83.9) 454 322 (83.7) 339 875 (82.3) 422 414 (83.2) 360 035 (82.5) 297 751 (81.1) 94 340 (77.2) 17 526 (62.5)
Missing 82 832 (12.9) 74 287 (12.7) 73 467 (12.8) 70 333 (13.0) 59 464 (14.4) 68 902 (13.6) 62 267 (14.3) 57 423 (15.6) 24 088 (19.7) 9836 (35.1)

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Other 6290 (1.0) 5586 (1.0) 5547 (1.0) 5120 (0.9) 3639 (0.9) 4660 (0.9) 3925 (0.9) 3174 (0.9) 900 (0.7) 149 (0.5)
Mother’s age, y
≤20 7101 (1.1) 6372 (1.1) 6469 (1.1) 6239 (1.2) 4900 (1.2) 6125 (1.2) 5764 (1.3) 5560 (1.5) 1919 (1.6) 232 (0.8)
>20 to ≤40 584 833 (90.8) 530 281 (91.0) 520 093 (90.9) 493 521 (91.0) 376 257 (91.1) 462 003 (91.0) 398 357 (91.3) 336 816 (91.8) 114 187 (93.4) 26 109 (93.1)
>40 45 095 (7.0) 40 517 (7.0) 40 153 (7.0) 37 956 (7.0) 29 207 (7.1) 35 585 (7.0) 29 572 (6.8) 23 022 (6.3) 5934 (4.9) 1667 (5.9)
Missing 6929 (1.1) 5756 (1.0) 5376 (0.9) 4791 (0.9) 2545 (0.6) 4078 (0.8) 2761 (0.6) 1605 (0.4) 197 (0.2) 46 (0.2)
a b
Refers to Circassians, other Christians (non-Arab), and unknown. Refers to North America, South and Central America, Asia, Africa, Australia, and Oceania.

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and late screening time. As presented in eTable 2, eTable 3, eTable 4, eTable 5, eTable 6, eTable 7,
eTable 8, eTable 9, and eTable 10 in the Supplement, some minor differences were observed;
however, these differences do not appear to have clear clinical importance.
High parental compliance with MCHC visits was observed at early ages when visits include
vaccine administration, as described in the Table. A comparison between the populations examined
at age 0 to 3 years and 3 to 6 years, presented in eTable 11 in the Supplement, showed some minor
differences between these groups. The main difference was the lower percentage of Jewish children
in the older age group (72 830 children [54.2%] in the older age group vs 392 621 children [61.0%]
in the younger age group). This is consistent with the greater overall compliance of the Jewish
population in Israel with preventative health programs, which is also evidenced by their routine
immunization coverage rates.31 In addition, the mother’s education level was lower in the older
age group.

Establishment of Milestone Norms and Building the THIS Developmental Scale

The curves of success rate by age for each milestone are presented in eFigure 1, eFigure 2, eFigure 3,
eFigure 4, eFigure 5, eFigure 6, eFigure 7, eFigure 8, and eFigure 9 in the Supplement. For 18 of the
59 milestones evaluated, the achievement rate already exceeded 95% at the earliest screening time.
Thus, the 95% achievement rate might have been reached at an earlier age. For 3 of the milestones,
success rates did not exceed 95%; therefore, they were evaluated up to an achievement rate of 90%
to 95%.
Because achievement of a milestone was defined as either clinical observation or parental
report (in cases where observation was impossible), we compared this definition with the alternative
of defining achievement only by clinical observation. The overall percentage of milestone
achievement reported by parents (of all achieved milestones) was 8.7%. Per milestone, the mean
(SD) percentage was 9.3% (10.3%) (median [IQR], 5.7% [2.3%-11.55%]). As shown in eFigure 10 in
the Supplement, there is good overall agreement between the 2 percentages. Differences were
observed in individual tasks related to language expression assessment and daily functions, such as
getting dressed independently, which are difficult to assess in the clinical setting. The thresholds of
95% milestone achievement when including the parental report preceded those obtained using
clinical observation alone by a mean (SD) of 2.0 (4.4) weeks (median [IQR] difference, 0.6 [0.2-1.2]
weeks). Figure 2 presents the final THIS developmental scale, including all evaluated milestones, the
ages at which they were screened, and the observed success rate per task.

Comparison Between THIS Developmental Scale and Milestone Norms

of Other Screening Tools
The THIS Developmental Scale was compared with milestones norms of 3 other commonly used
developmental tests: Denver II, AIMS, and the CDC Developmental Assessment.15,17,29 Figure 3
presents a comparison of the equivalent milestones from the 4 scales, demonstrating a match of 18
of 27 milestones (67%) with the Denver II scale, 7 of 7 (100%) with the AIMS scale, and 10 of 19 (53%)
with the CDC Developmental Assessment. The remaining unmatched milestones were achieved
earlier in the THIS scale compared with the other screening tools.15,17,29

Discussion
This cross-sectional study describes the establishment of milestones norms and building of THIS, an
evidence-based developmental scale from birth to the age of 6 years. Updated performance norms
were established according to a large national database of standardized developmental milestone
assessments in the domains of gross motor, fine motor, language, and social skills. The THIS
developmental scale represents the heterogeneous population comprising this cohort.
To the best of our knowledge, the current study is based on the largest population evaluated for
developmental performance to date, including approximately 3.8 million evaluations conducted over

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Figure 2. Tipat Halav Israel Screening Developmental Scale

Developmental domain Achievement rate

Personal-social Language Gross motor Fine motor <75% 75%-90% 90%-95% >95%

Milestone/age (mo)
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Visually follows a moving object horizontally
Vocalizes in response to human voice
Smiles responsively
Raises head
Visually follows a moving object vertically
Responds to rattling sound
Makes various sounds including constants (ie, Mm rr gg)
Hands together, manipulates fingers
Grasps an object
Head and chest up in prone position
Transfers an object from one hand to the other
Makes repetitive syllables-constant or vowels
Rolls over from abdomen to back and back to abdomen
Taps 2 objects playfully
Crawls
Vocalizes in a dialogue
Responds when addressed by name
Responds differently to familiar and stranger
Feeds self
Uses thumb-fingers grasp
Understands simple instructions
Gets to sit without support
Says 1 word or pronounces meaningful sounds
Expresses will vocally or with gestures
Makes eye contact and expresses reciprocity during joint game
Walks with assistance
Points at familiar objects to request
Pulls to stand
Says 2-3 words
Climbs upstairs with assistance
Walks without assistance
Eats independently with a spoon
Familiar with at least 1 body part
Builds a tower of cubes
Has a vocabulary of over 10 words
Squeezes and sticks out lips to give a kiss
Composes a sentence of at least 2 words

Milestone/age (y)
2 2.5 3 3.5 4 4.5 5 5.5 6
24 25 26 27 28 29 30 31 32 33 34 35 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72
Runs well without falling
Climbs up and down the stairs without an adult’s assistance
Squeezes and sticks out lips to give a kiss
Has a vocabulary of over 10 words
Recognizes familiar objects and pronounces them by name
Composes a sentence of at least 2 words
Participates in a dialogue
Understands actions and speech without gestures
Imitates horizontal, vertical, and circle lines
Expresses freely
Jumps from a stair
Puts on shoes and dresses independently without buttoning
Imitates patterns (+) and copies circles
Stands up on 1 leg for 3 seconds
Counts 3 cubes
Familiar with at least 3 prepositions
Plays with peer group
Dresses independently
Understandable speech
Uses correct verbs and tense to describe a picture
Answers orientation questions such as name or age
Jumps on 1 leg
Walks heel to toe
Draws a human figure
Copies geometrical shapes such as X and triangle

The rows represent the evaluated milestones, the columns represent the age by month (top panel) and year (bottom panel). Each milestone is colored according to the relevant field,
as shown in the key (fine motor, gross motor, personal-social, and language). For each milestone the success rate is shown, each indicating a success threshold of less than 75% to
90%, 90% to 95%, and greater than 95%. For example, the milestone “vocalizes in response to human voice” is achieved by less than 75% of children at the age of 0 months, 75% to
90% of children at the age of 1 month, and more than 95% of children at the age of 2 months.

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Figure 3. Comparison of Developmental Milestones Between Different Screening Tools

A Personal-social

Dresses independently THIS

Plays with peer group CDC
Puts on shoes and dresses independently without buttoning AIMS
Eats independently with a spoon DENVER
Makes eye contact and expresses reciprocity during joint game
Smiles responsively

0 10 20 30 40 50 60 70 80
Age, mo

B Language

Uses correct verbs and tense to describe a picture

Understandable speech
Understands actions and speech without gesture
Composes a sentence of at least 2 words
Says 2-3 words
Points at familiar objects to request
Says 1 word or pronounces meaningful sounds
Understands simple instructions
Makes repetitive syllables-constant or vowels
Makes various sounds including constants (ah-goo)
Vocalizes in response to human voice

0 10 20 30 40 50 60 70 80
Age, mo

C Gross motor

Walks heel to toe

Jumps on 1 leg
Stands up on 1 leg for 3 s
Walks without assistance
Walks with assistance
Pulls to stand
Gets to sit without support
Crawls
Rolls over from abdomen to back and back to abdomen
Head and chest up in prone position
Raises head

0 10 20 30 40 50 60 70 80
Age, mo

D Fine motor

Copies geometrical shapes such as X and triangle

Draws a human figure
Imitates patterns (+) and copies circles
Builds a tower of cubes
Uses thumb-fingers grasp
Taps 2 objects playfully
Transfers an object from 1 hand to the other
Grasps an object
Hands together, manipulates fingers
Visually follows a moving object vertically
Visually follows a moving object horizontally

0 10 20 30 40 50 60 70 80
Age, mo

Graphs show comparisons of the milestones at each field (personal-social, language, fine, Denver Developmental Screening Test II [Denver]). The orange symbols represent
and gross motor), between the Tipat Halav Israel Screening (THIS) developmental scale milestones with clinically meaningful differences in achievement age between the
and the different commonly used screening tools (Centers for Disease Control and different screening tools.
Prevention [CDC] Developmental Assessment, Alberta Infant Motor Scale [AIMS], and

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 JAMA Network Open | Pediatrics Standardization of a Developmental Milestone Scale Using Data From Children in Israel

a period of 6 years. Because Israel is a multicultural country, with a diverse population of multiple
ethnicities and languages, we can use our representative data set to define subpopulations of
interest, thereby enabling adapting of the scale for specific populations of interest.
The THIS developmental scale currently enables evaluation of milestone attainment age and
comparison with the population norms, allowing early identification of potential delay and further
guidance, surveillance, and in-depth evaluation when needed. In Israel, the standardized MoH
protocol for MCHCs has been updated to reflect the findings of the current study. Further monitoring
and fine-tuning of the updated scale, as well as validating THIS developmental scale performance as
a screening tool for early detection of developmental delay, will be performed and made accessible
for public use.
The THIS developmental scale was compared with milestone attainment ages for 3 commonly
used developmental tests.15,17,29 The Denver II17 is widely performed by health care practitioners
globally to identify children up to age 6 years with developmental problems, in low-risk populations.
Denver II norms were established using data collected in 1988 to 1989. Among the 27 milestones
that were comparable between THIS and Denver II, 18 were achieved during a similar time frame, and
9 were achieved earlier in the THIS developmental scale. The main discrepancies found were in fine
motor skills, with mismatch of 5 milestones, alongside 2 discrepant milestones in each of gross motor
and language tasks. It is yet to be determined whether these differences originate from nuances of
the milestone evaluation method or from cultural disparities.
The AIMS29 is an observational assessment scale, constructed to specifically measure gross
motor maturation in infants from birth through 18 months. It enables evaluation of motor
developmental delay among high-risk populations. AIMS norms were established using data
collected between 1989 and 1992. All 7 comparable milestones were achieved during a similar time
frame in the THIS scale.
The THIS scale, Denver II, and AIMS all involve comprehensive evaluation based on
developmental testing, structured observations, and interviews with the child’s parents, which
require substantial resources of time and staff. In contrast, the CDC Developmental Assessment15
comprises a brief checklist of social, language, fine motor, and gross motor age-related milestones
completed by the parents, alongside a list of alert signs—that is, milestones that require further
medical evaluation if not accomplished by a certain age. The CDC data were collected between 2004
and 2008. Because using brief questionnaires is easier and more feasible for worldwide use, the THIS
scale was also compared with the CDC Developmental Assessment. Because the CDC Developmental
Assessment differs from the Denver II and AIMS by not providing the exact age in which 90% of
children fail to achieve each milestone, the comparison may hold some discrepancies. Of 19
milestones that were comparable to THIS, only 10 were achieved during a similar time frame,
whereas 9 were achieved earlier in the THIS developmental scale. Because only 53% of the
comparable milestones were achieved during a similar time frame, the CDC Developmental
Assessment might require further fine-tuning. Earlier studies demonstrated inconsistency between
the CDC Developmental Assessment and other screening tools,18 which is in agreement with our
findings. The observed changes between the various scales might be attributed to several factors,
such as possible differences of the populations characteristics, the exact manner in which the
milestones were evaluated, and the gap of 15 to 30 years between the contemporary data presented
in this study and the other tools.
Further study is required to examine the efficacy of the THIS developmental scale in screening
low-risk populations for developmental delays. Furthermore, it is essential to evaluate the effect of
demographic variables, such as cultural ones, maternal education, socioeconomic status, or sex, on
the success rate of the milestones, to enable a better culture-adjusted and personalized
developmental evaluation.

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Limitations
Our study has several limitations. First, the primary objective of this study was to standardize
developmental norms for a healthy population. However, the EMRs on which this study is based do
not include data regarding genetic syndromes or other congenital anomalies that may result in
developmental delay. We have minimized the influence of this gap by excluding children with
abnormal developmental potential, including preterm infants, those with low birth weight, and those
with abnormal weight or head circumference measurements, which may reflect factors associated
with the risk of developmental delay. Second, among 59 evaluated milestones, 18 had already
exceeded 95% success rates during initial assessment. This gap may indicate that these milestones
are normally achieved at an earlier age; however, because they were not screened for earlier, we lack
these normative data. Third, although the new THIS developmental scale includes milestones that
are evaluated at Israeli MCHCs, many additional, potentially important, milestones were excluded
because of the technical difficulty of performing wide developmental screening assessments to the
entire children population regularly. An effort was made to include a balanced set of milestones,
representing 4 developmental domains at each age group.

Conclusions
The current study describes the validation and establishment of new milestones norms, composing
the THIS developmental scale, an evidence-based developmental scale from birth to the age of 6
years. The THIS developmental scale is based on the largest population evaluated to date for
developmental performance, representing the heterogeneous, multicultural population comprising
this cohort. It is recommended for further evaluation worldwide.

ARTICLE INFORMATION
Accepted for Publication: January 11, 2022.
Published: March 14, 2022. doi:10.1001/jamanetworkopen.2022.2184
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Sudry T
et al. JAMA Network Open.
Corresponding Author: Yair Sadaka, MD, PhD, MHA, Neuro-Developmental Research Center, Mental Health
Institute, Hatzadik Meyerushalim 2, Be’er-Sheva 8461144, Israel (yair.sadaka@gmail.com).
Author Affiliations: Neuro-Developmental Research Center, Mental Health Institute, Be’er-Sheva, Israel (Sudry,
Freedman, Sadaka); KI Research Institute, Kfar Malal, Israel (Sudry, Amit, Akiva, Sadaka); Public Health Services,
Israel Ministry of Health, Jerusalem, Israel (Zimmerman, Joseph, Baruch); Department of Child Development and
Rehabilitation, Israel Ministry of Health, Jerusalem, Israel (Yardeni); School of Public Health, Faculty of Health
Sciences, Ben-Gurion University of the Negev, Be’er-Sheva, Israel (Grotto); Department of Health Policy and
Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-
Sheva, Israel (Greenberg, Lior Sadaka); TIMNA Initiative, Big Data Platform, Israel Ministry of Health, Jerusalem,
Israel (Eilenberg, Tsadok, Rize, Zaworbach, Uziel, Ben Moshe); Department of Computer Science, Ben-Gurion
University of the Negev, Be’er-Sheva, Israel (Bachmat); Faculty of Health Sciences, Ben-Gurion University of the
Negev, Be’er-Sheva, Israel (Sadaka).
Author Contributions: Drs Amit and Sadaka had full access to all of the data in the study and take responsibility for
the integrity of the data and the accuracy of the data analysis.
Concept and design: Sudry, Zimmerman, Yardeni, Baruch, Grotto, Greenberg, Akiva, Tsadok, Zaworbach, Uziel,
Bachmat, Freedman, Sadaka.
Acquisition, analysis, or interpretation of data: Sudry, Zimmerman, Joseph, Grotto, Eilenberg, Amit, Akiva, Tsadok,
Rize, Zaworbach, Uziel, Ben Moshe, Lior Sadaka, Sadaka.
Drafting of the manuscript: Sudry, Zimmerman, Yardeni, Joseph, Baruch, Amit, Akiva, Rize, Zaworbach, Ben
Moshe, Freedman, Sadaka.
Critical revision of the manuscript for important intellectual content: Sudry, Zimmerman, Yardeni, Grotto,
Greenberg, Eilenberg, Amit, Tsadok, Uziel, Lior Sadaka, Bachmat, Sadaka.

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Statistical analysis: Eilenberg, Amit, Tsadok, Rize, Zaworbach, Uziel, Ben Moshe.
Administrative, technical, or material support: Sudry, Zimmerman, Yardeni, Baruch, Uziel, Ben Moshe, Bachmat.
Supervision: Sudry, Yardeni, Joseph, Grotto, Akiva, Tsadok, Uziel, Ben Moshe, Bachmat, Sadaka.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank all public health nurses and physicians from the maternal child health clinics
for their dedication, hard work, and meticulous data registration, which enabled the planning and execution of
this study. Nesia Cohen, BCS (Computer and Information Division of the Ministry of Health), and the Machshava
Briah (Healthy Thought) development team assisted in data accessibility and in solving problems that arose during
the work on the database. They were not compensated for this work beyond their normal salaries.
Additional Information: A printable PDF version of the THIS developmental is available at https://www.eng.
linkcaring.com/developmental-scale.

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s40615-019-00658-w

SUPPLEMENT.
eFigure 1. Task Performance Results Over Time at the Age 0-3 Months
eFigure 2. Task Performance Results Over Time at the Age 3-6 Months
eFigure 3. Task Performance Results Over Time at the Age 6-9 Months
eFigure 4. Task Performance Results Over Time at the Age 9-12 Months
eFigure 5. Task Performance Results Over Time at the Age 12-18 Months
eFigure 6. Task Performance Results Over Time at the Age 18-24 Months
eFigure 7. Task Performance Results Over Time at the Age 2-3 Years (24-36 Months)
eFigure 8. Task Performance Results Over Time at the Age 3-4 Years (36-48 Months)
eFigure 9. Task Performance Results Over Time at the Age 4-6 Years (48-72 Months)
eFigure 10. Comparison of Milestone Achievement Threshold by Clinical Observation and Parental Report Versus
Clinical Observation Alone
eTable 1. Israeli Ministry of Health: A Guide to Performing Developmental Assessments for Infants and Toddlers
From Birth up to the Age of Six Years
eTable 2. Population Analysis of Children Evaluated at Each Visit at the Age 0-3 Months
eTable 3. Population Analysis of Children Evaluated at Each Visit at the Age 3-6 Months
eTable 4. Population Analysis of Children Evaluated at Each Visit at the Age 6-9 Months
eTable 5. Population Analysis of Children Evaluated at Each Visit at the Age 9-12 Months
eTable 6. Population Analysis of Children Evaluated at Each Visit at the Age 12-18 Months
eTable 7. Population Analysis of Children Evaluated at Each Visit at the Age 18-24 Months
eTable 8. Population Analysis of Children Evaluated at Each Visit at the Age 2-3 Years (24-36 Months)
eTable 9. Population Analysis of Children Evaluated at Each Visit at the Age 3-4 Years (36-48 Months)
eTable 10. Population Analysis of Children Evaluated at Each Visit at the Age 4-6 Years (48-72 Months)
eTable 11. Comparison of the Characteristics of Evaluated Children Between the Ages 0-3 Years and 3-6 Years

JAMA Network Open. 2022;5(3):e222184. doi:10.1001/jamanetworkopen.2022.2184 (Reprinted) March 14, 2022 14/14

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