Thursday, September 20, 2012

How to Learn (Understand and Memorize) Pediatric Developmental Milestones

Developmental Milestones are the skills babies and young children learn as they grow like walking and talking. They are also the bane of many medical students and pediatric residents because there are quite a few different milestones that we are required to memorize and we have to know exactly at what age we should expect each of these to develop. It is a lot of information. When I had to memorize this stuff I memorized it from this chart:


Needless to say none of this stuff ever stuck in my brain much past the day of the test. So after having to re-memorize the milestones I tried to come up with a better, more efficient way to not only commit the information to memory, but also get a deeper understanding of the topic of development in general.

The following is a paper I wrote that gives a broad overview of the concepts at play in assessing childhood development followed by a methodology for learning the milestones in a fast, efficient, and clinically useful way that will hopefully stick in your head better than a series of loosely related facts. I start with a general overview and then get into the details about how to commit this information to memory in a functional way for both standardized tests as well as use in the clinic.


DEVELOPMENTAL MILESTONES

Why learn it?
Development is an integral part of pediatric practice. Knowing and understanding developmental milestones has important diagnostic application, it separates us from adult medicine, and is infinitely pimpable both by attendings and on our licensing exam. In other words, this stuff is important to know.

How does this all fit together/Global Overview?
We will first discuss why this is clinically important, how it is used in practice, why we define development in four discrete categories (gross motor, fine motor/vision, language/hearing, and social), go through an overview of each developmental category, and most importantly, how to memorize this stuff in a way that is clinically/functionally relevant and will serve you when in clinic, when pimped and, eventually, on our licensing exam.

  1. Why is learning/applying developmental milestones important? Why do we use this modality?
We use milestones for two main reasons:

  1. During early childhood (basically until the age of 5), when kids cannot articulate their inner state, developmental milestones are used as clues to what is going on inside and if any pathology is brewing.
  2. By assessing where the child is in each category, we can tell if delays are isolated to one category (speech delay for example) or appears in multiple categories which will change your diagnostic concerns

  1. How do we use developmental milestones in every day clinical practice?
    1. We assess if the child is meeting milestones in each category for his or her particular age. There are ranges of ages when milestones arrive (refer to Denver Scale). A lot of the classic milestones that we memorize are later in the average range, so if a milestone is not seen by this age, this is possibly a problem. We will later go over some big red flags for certain milestones if not seen by a certain age (a child not walking by 15 months is a concern)..
    2. Example of how we evaluate a six month old at a well child check: At six months, a child should be able to sit up (gross motor), pick up things with a raking grasp (vision &fine motor), babble (language), and recognize family members (social). We ask parents if they see this at home, and observe whether the infant is doing these things in clinic.

  1. Why do we use only these particular four categories? It seems kind of limited in scope. Does this really adequately define a child’s development or are there things we are leaving out? And why do we only really memorize these milestones to the age of 5?
    1. We use these four categories because they are the most easily observable behaviors and we have therefore been able to create norms for when we can expect children to do them.
    2. There are absolutely aspects of development not covered in these four categories. How a child plays is very important in how a child develops, but is way too diverse and individual to create any meaningful way to assess/measure it or create norms. So the four categories that we do use, though chosen out of utility, are good enough to diagnose the vast majority of developmental problems that may arise during a child’s first five years of life.
    3. We only memorize up to age 5 because after that, children are better able to communicate to us their thoughts and feelings, and this is about the age that they enter school and any developmental issue will likely become readily apparent when the child is placed with other children who they will have to interact using all four milestone categories. Any deficiencies will be more obvious because things outside the norm will be visible by comparison to other kids. Also, development is no longer as rapid after age 5, and therefore there is less urgency in diagnosing any problems, and more reliance on things to get lagged socially or academically at school.

  1. So how do I learn all this stuff? Should I learn each milestone category individually? Should I learn a milestone across each category for each age? What information is best learned in a conceptual way? What information do I need to just memorize?
    1. The goal is to learn these milestones in a way that we can use them effectively, quickly, and easily when assessing patients (either at well child checks, outpatient urgent care appointments, or when a child is admitted to the hospital), and also be able to answer quickly when we are pimped or when we see it on a boards exam.
    2. I have tried to memorize these milestones many times since Step 1. I never got a good sense of understanding how everything fits. I’ve had to rememorize these things many times (3rd year pediatric exam, Step 2, Step 3, intern year, board exam) which is clearly not efficient and likely not very effective.
    3. So how do we learn this? It is a mix of conceptual understanding and rote memorization. The best way we have been able to figure out is to (1) Generate an overarching understanding of the development categories (2) Learn why each milestone category progresses as it does in children (why do we crawl before we walk?), and (3) use some memory tricks to learn the most clinically important and most tested milestones for each age. This way you create an overall understanding of what is going on (which is actually fascinating in and of itself) but are still able to quickly recall necessary/important milestones for assessing children and getting pimped.

General Understanding of Each Domain/Domain Overview
The Categories: We use four categories for assessing child development- Don’t memorize the rest of this section, it is only for getting a conceptual overview of the categories, so when we start memorizing details we have a framework to understand the progression of kids’ acquisition of skills.

Gross Motor: this category is the use of all muscles in a way that does not involve hand/eye coordination, which ends up being essentially everything except eye/finger movements: head control, rolling over, sitting, walking, running, throwing (overhand, from the shoulder), stairs, riding bikes, etc.

Fine Motor/Vision: this group is called “fine motor” but should be called hand/eye coordination. Initial milestones involve fixating and following objects with their eyes, and eventually manipulating objects with hands and fingers. Both dexterity and vision are necessary to achieve many of these milestones (block stacking) so that is why these abilities are grouped together.

Language/Hearing: like “fine motor,” “language” should include hearing as the two are intertwined. If you can’t hear, your language is going to be delayed or nonexistent. Language is divided into two categories; the distinction is clinically important. How someone speaks and how many words they know are often the most obvious milestones, and are examples of expressive language (remember Broca). But language is also receptive (does a child understand what is being said; think Wernicke) and this may be less obvious initially. Receptive language deficits are rarer but more concerning, assuming hearing is intact, as it then implies a brain/cognitive problem, as opposed to expressive language deficits which are more likely to be secondary to mechanical issues. For example, kids with Cerebral Palsy may be intelligent and fully aware of their surroundings, but often the initial erroneous assumption on the part of the provider is that they have poor cognition.

Social: This is how a child interacts with other people. Does a child respond to other people’s behavior and show recognition that other people are sentient beings? For example, do they attempt to draw another person’s attention to an object, indicating that they understand other people even have attention to redirect? Kids with Autism can have trouble with this kind of understanding.

General Overview of Milestones for Each Category
It is very helpful to understand the general progression of each milestone category so you can conceptually understand the progression of each category and why most children develop in a predictable manner. This is most helpful in gross motor development, which we will use as a base on which to memorize the milestones of all the other categories for a particular age. Also, we choose which months to assess a child based on when they have well-child visits (because we most commonly won’t see these kids except at these times)

Gross motor Development: Children develop their gross motor skills from head to toe because myelination of nerves happens from head to toe during the first year of life. You first lift your head up (neck), then you roll (using arms), then you sit (waist), then you crawl (knees), then you stand, and then you walk. The goal of the first year is to walk.

Fine Motor Overview: since children don’t use their hands until a few months old, early on we focus on whether the child appears to be able to see things (track objects with their eyes for example). Around four months the fingers come in to play. The goal of the first year is to have a controlled “pincer grasp,” which is the infant being able to pick up small things using the tips of their thumb and index finger. So you look for vision until 4 months, then the kid can grasp objects with all fingers, then discovers their thumb, then learns to use the thumb and fingers together in a controlled way.

Language Overview: just as we watch for vision first in fine motor, a child has to be able to hear to learn to speak. Thus evidence that the child can hear is an important part of the early milestones. The goal of the first year is to be able to say one word (with meaning—i.e. the child says the word with intent and it means the same thing every time). After the first year, we start looking for increased vocabulary, better pronunciation, and combining words into phrases and sentences.

Social Overview: this covers how children relate to other people. We start by looking for how they react to people, initially with a smile, laughs, and then whether they can discriminate parents vs strangers. After that we we assess when a child develops the insight that other people are thinking beings (and thus different from other objects). They will show this by pointing to draw attention, peekaboo, and more advanced ways of playing and interacting). A child with autism will not be attracted to people, faces and language as distinct from objects.

How to Commit This Stuff to Memory
1. First memorize the months of the well child checks. This is important for creating a framework for memorizing the milestones and will also help when you start memorizing vaccine schedules. The timing of both milestones and vaccines is based on this well child check schedule. The visits are 2 days, 2 weeks, 2 months, then add 2 months twice (4 months, 6 months) then space it out as we get less anxious and the rate of expected milestone acquisition declines. So 2d, 2w, 2m, 4m, 6m, 9, 12, 15, 18, 24m, 3y, 4y, 5y.
-So initially think “2,” 2 days, 2 weeks, 2 months, 4 months, 6 months
-after month 6, it is by 3 for four visits, so 9, 12, 15, 18
-after this it is by full years, 2, 3, 4, 5

2. Once this is down, we memorize the gross motor milestones for each visit. This will be the only milestone category that we have to rotely associate with months. We will use it as a memory base and hook the other milestones in to it.
A good way to memorize motor is to divide these milestones into two categories: birth to 1 year, and 15 months to 5 years.


Birth to 1 Year: Remember that the goal of the first year is to be able to walk (walk at 12 months). At six months you are halfway there (remember “sit at six”). Just with these two milestones you can pretty much fill in everything else. Remember that everything is from head to toe. So 2 months (the first time we really check milestones) you check for head lifting (neck control). You roll at 4 months (at level of shoulders and chest). Then, again, at six you sit. You crawl at 9 months and pull to stand (crawl, pull to stand at 9 months) which makes sense as being between sitting and walking.
In Review:
2 months: lift head 45 degrees
4 months: roll over (front to back first, then back to front, easier if you can push off with hands)
6 months: sit (halfway to goal, halfway through year, “sit at six”)
9 months: crawl, stand (halfway between sitting and goal)
12 months: walk (the goal)


15 months – 5 years: Memorize these milestones in a story as they are harder to associate with particular months like the first year. Using this progression story may help you.
15 months: walks well
18 months: throws objects
24 months/2 years: up and down stairs (one foot at a time); run
3 years: Tricycle (3 wheels, 3 years), jump in place
4 years: up and down stairs alternating feet (2 feet x up/down = 4), balance on 1 foot for 4 seconds (legs look like a 4 when on 1 foot), hop
5 years: skip (5 looks like an “S”kips)
Story: a child on the 1st floor of her house sits up, crawls, cruises, then 1) WALKS to stairs, 1.5) THROWS object up stairs, 2) CLIMBS up the stairs and RUNS to his trike, 3) RIDES a trike upstairs, JUMPS off, 4) RUNS down the stairs, HOPS off the stairs and 5) SKIPS away
3. Once you’ve memorized the months of well child checks and corresponding gross motor milestones, begin to memorize the archetype babies for each age group. These little stories incorporate all the other milestones into a single image which is much easier than trying to memorize many unrelated facts. There are some ways to conceptually link milestones across categories, but they are not frequent enough to be useful for fast recall and the salient milestones and timing which is what happens on tests and during morning report. 


Here are all the babies with milestones listed:

2 months: lift head 45 degrees (when laying on face), turns to sound, follows objects past midline, social smile
Parent’s Little Baby: looks up to sound, smiles because he sees both his parents, one on either side of midline

4 months: lift head 90 degrees/raise up to chest, roll over, find midline, reach for objects, puts objects in mouth, coos (these are vowel sounds), and laughs
Fat Happy Baby: baby is rolling and laughing and cooing because he just discovered midline and is reaching for cake that he will cram into his mouth

6 months: sit up with no head lag, raking grasp, transfer objects between hands, babbles (consonants), recognizes familiar faces
Street-Corner Baby: sitting up on sidewalk, transferring a rake from hand to hand while babbling at people he thinks he recognizes

9 months: Crawl, pull to stand, point, specific babbling (mama, dada), stranger anxiety
Watch Dog Baby: crawls to window, pulls to stand to see out, points at stranger in yard and says “mama” to get attention of parents.

12 months: Walk, pincer grasp, 1 word, patacake, bye bye, peekaboo
Playful Zombie Baby: walking at you, snapping pincers, repeating one word over and over (brrraaaaains), and just wants to play patacake and peekaboo before waving bye bye.

15 months: walks well, imitates, controlled release of blocks (can stack 2)
Little Sister Baby: wants to be just like big sister, walks confidently to the blocks and imitates making a 2 block tower

18 months: Throw, scribble, 4 block tower, 1 step command, uses spoon/cup, points to parts of body
Sir Charming Baby: needs to get note to Rapunzel so scribbles note on paper to throw into high 4 block tower, catapult has cup on end, shoves note in with spoon, and throws note at tower, hitting Rapunzel in the face

2 years:  Run, stairs (1 foot at a time), 20-50 words, 2 step command, parallel play
Bad Twins: mom gives two commands to twin boys to run to the stairs, then walk up the 25 stairs. Each walks up the 25 stairs not helping the other.

3 years: Jump, Tricycle, dresses self (shirt, pants, shoes), full name, “you, me, I”
James Bond Baby: springs into action . . . jumps into 3-piece suit, stands in front of mirror and says full name, jumps on tricycle. “You.Me. I,” is his pickup line.

4 years: Stairs (alternating feet), hop, undresses, 1 foot (4 seconds), 4 word phrases (complete sentences), cooperative play
Bedtime Story Baby: really wants story time, so runs up stairs, hops on one foot to undress, so she and mom can read a story together. A Wrinkle in Time.

5 years:  Skip, Tie shoes, Difference between reality/fantasy
Oz Baby: ties ruby shoes, skips down Yellow Brick Road back to Kansas

Review of Approach to Memorization
1. Learn ages of well child checks from birth to 5 years. It’s not important to memorize in and of itself, but will really help you keep milestones and vaccine schedules straight:
-be able to rattle off all the checks (2, 4, 6 . . . remember 2-5 years are only annual checks so you really only have to memorize up to 2 years old)
-a flash card is helpful for this, just know it cold.
2. Learn associated gross motor milestones for each visit (make sure you understand the physiologic basis for the gross motor milestone progression as it will help you figure things out if you ever forget a particular milestone for a given month and can only remember the milestones around that month)
-flashcards helpful
3. Learn the archetype baby for each age (make sure you can visualize everything that baby is doing, the more vivid the picture, the faster you learn it, the easier it is to retain, and the faster you will be able to recall the milestones)
-again, flashcards helpful
That should do it! Knock this stuff out early in residency so you can move on to learning more conceptually difficult stuff. Here is a few examples of how you’ll see it during your education.

Example of questions you will see on boards:
You are seeing a 6 month old boy for his well child check. He is smiling at you, very talkative (no intelligible words), is able to pick up a block and change it from hand to hand, and has just started rolling over. At this time is he developmentally appropriate?

Example of how attendings will pimp you:
1. Can a baby roll off the bed at 3 months old and hit head of floor like mom is saying? (assessing for abuse) – no, this milestone only comes in at 4 months, a 3 month old should not be able to do this so your concern for non-accidental trauma is increased (though not definitive as some kids mature faster)
2. What would you expect this 9 month old to be able to do?

How this is used in clinic?
A mother brings her 11 month old concerned that he has not started talking at all and still cannot walk. What do you tell her?

Hope this helps.


82 comments:

  1. thank you very much this was very helpful! God bless you!

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  2. really thanks a lot for this helpful stuff ..helped me a lot

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  3. I am in NP school doing my ped rotation and I would like to print this for my records. Where did you find this chart?

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  4. Also and FNP student doing my pedi rotation...THANK YOU>>>TEST TOMORROW!

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  5. This is GREAT stuff, THANK YOU! Although your 'midline' information may be backwards--tracking up to midline comes first, tracking past midline comes later (says that in all the resources I've seen except yours and one other). In fact, the chart image you linked to also says tracking up to midline comes first and past midline comes later.

    Also, one more thing, you wrote "4) RUNS down the stairs, HOPS off the stairs". You listed the child as 'running' again at 4, which you already had at 2. And why are you specifying "down the stairs" in particular (instead of just "HOPS off the stairs" which does make sense)?

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  6. A developmental pediatric fellow once explained the method to the madness of milestones.It is head to toe, back to front, extensor before flexor, large to small.
    also it would be a good idea to add the reflexes to the chart as they form a integral part of dev assessment.

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  7. I think it is very important to know how your child is progressing. That is why they have so many doctors visits when they are young. Though being able to look for the sign from home could be a good preventative measure.
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  8. showed this to my friends at med school and now we all use it, thanks!

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  9. Yup it was very helpful......thanks ...:):)

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  10. Thanks helped a lot.was a headache.many thanks

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  11. Thank you so much! Super helpful. I will share this with other folks who, like me, are studying for the exam for IBCLC (international board certified lactation consultant).

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  13. Thank you so much for this easy to understand explanation of the milestones and the helpful hints in memorizing/understanding it. I am starting my peds rotation as an FNP student and this will really help me! :)

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  14. Thank you so much. This was brilliant. What a nightmare solved.

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  15. Dear CTS MED

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  19. Thank you so so much. Amazing techniques to study

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  20. thanks!! this is very useful to me!

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  22. Can you share the excel sheet of the chart if there is one?

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  23. That was so helpful for exam studying! Those without kids of their don't recall the order of events as easily. Breaking it down was so useful. Thank you!

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  33. I know I'm a bit late to the game but this is fantastic, extremely helpful for someone like me who can reason things out fairly easily but struggles remembering anything by heart. Thank you very much, and I hope you have a wonderful day/week/year/life.

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  35. Hve been thinking over ways to get acquainted with milestones.......... Well this is a very helpful article.....loved the way of memeorising

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  39. Hello,
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  42. Please cross check some of these milestones with what is published on UpToDate. Thanks.
    https://www.uptodate.com/contents/developmental-behavioral-surveillance-and-screening-in-primary-care

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  43. I do appreciate this outline and guideline very much. Very helpful. And, when I double checked on UpToDate, I got some milestones that were slightly different. Please cross check. The imagery was fun, and helpful.

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  44. Picmonic is cute too. There seem to be some inconsistencies between them and UpToDate too.

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  45. Picmonic: https://www.picmonic.com/learn/age-2-months-developmental-milestones_5759

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  46. Yeah the textbook we were told to use in my school doesn't match UpToDate either and when I look online there seems to be little consensus on these :(
    However, +1 for using Picmonic to remember these, it sure gets close enough and I'll NEVER forget all of them that I learned in under an hour :)

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    I got married 2 years ago and it just seemed that there was no excitement in my sex life. My dysfunction to perform to the best of my abilities in bed made it harder for my wife and me to have a good time during sex. And i was having the feelings that she may decide to get a divorce one day. I knew something had to be done in order to improve my sex life and to save my marriage because my marriage was already falling apart, so when i was on my Facebook page i came across a story of how Dr Aziba helped him enlarged his penis to 8ins better.so i Immediately copied the Email address of the Dr and explained to him my problem,he gave me some simply instruction which i must follow and i did easily and my friends Today, i am the happiest man on Earth, All Thanks to Dr Aziba for saving my marriage and making me a real man today.i asked him about some purpular diseases like HERPES,HIV AIDS,HEPATITES,DIABETIS, CANCERS, WART, Get Ex back ,etc....... which are affecting most people he said there is no disease without a cure , he has it all...You can as well reach the Dr below for help on your problem, for he has the solution to all...
    Email:[ PRIESTAZIBASOLUTIONCENTER@GMAIL COM ]
    WhatsAPP DR [ +2348100368288 ]

    ReplyDelete
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  55. My name is Eric form USA taxes, I want to share a testimony of how Dr ORAL herbal mixture cream saves me from shame and disgrace, my penis was a big problem to me as the size was really so embarrassing,and i was also having weak erection problem. I can't make love to my wife and my penis was just too small a full grown man like me having 4 inches penis and to worsen it i don't last in sex i cant even last two minutes it was really a thing of shame to me. My wife was really tired of me because my sex life was very poor,she never enjoyed sex,i was always thinking and searching for solutions everywhere until when i saw a testimony of how Dr ORAL herbal mixture cream have been helping people regarding their sex life, so i decided to give him a try and to my greatest surprise in less than one week of taking the herbs my penis grow to 8 inches i couldn't believe my eyes and as i speak now my penis is now 8 inches and i do not have week erection again. I can make love to my wife longer in bed. And my marriage is now stable,my wife now enjoy me very well in bed. can contact him droralherbalhome@gmail.com call or what-apps him through +2349031111198

    ReplyDelete
  56. HOW DR IMOLOA HERBAL MEDICINE HELPED ME GET RID OF MY 3 YEARS HERPES SIMPLEX VIRUS. Hello everyone my name is DONALD am from the united states i have been suffering from (HERPES) disease since 2016 and had constant pain, especially in my knees. During the first year,I had faith in God that i would be healed someday.This disease started circulate all over my body and i have been taking treatment from my doctor, few weeks ago i came on search on the internet if i could get any information concerning the prevention of this disease, on my search i saw a testimony of someone who has been healed from (Hepatitis B and Cancer) by this Man Dr Imoloa and she also gave the email address of this man and advise we should contact him for any sickness that he would be of help, so i wrote to Dr imoloa telling him about my (HERPES Virus) he told me not to worry that i was going to be cured!! hmm i never believed it,, well after all the procedures and remedy given to me by this man few weeks later i started experiencing changes all over me as the Doctor assured me that i have been cured,after some time i went to my doctor to confirmed if i have been finally healed behold it was TRUE, So friends my advise is, if you have such sickness or any other at all like hepatitis A,B,C,CANCER,HPV,HIV/AIDS,DIABETES 1 AND 2,SMALL PENIS PROBLEM ,HIGH BLOOD PRESSURE SYPHILIS, WEAK ERECTION,BREAST ENLARGEMENT AND many more ....... you can email him on drimolaherbalmademedicine@gmail.com) or whatsapp him on +2347081986098. Sir, i am indeed grateful for the help i will forever be grateful for the good work.

    ReplyDelete
  57. Dr. Imoloa has really made me so much believe in him by getting me cured with his herbal treatment. i really appreciate you Dr.imoloa for bringing back happiness to my life again. thank you so much,friends join me to thank him for what he has actually done for me i pray to you all for a good life and good health, and most especially to you Dr. imoloa Thanks

    I have been suffering from (HERPES SIMPLEX VIRUS) disease for the past four years and had constant pain, especially in my knees. During the first year,I had faith in God that i would be healed someday.This disease started circulating all over my body and i have been taking treatment from my doctors, few months ago i came on search on the internet if i could get any information concerning the cure of this disease, on my search i saw a testimony of someone who has been healed from (HERPES SIMPLEX VIRUS) by this Man Dr imoloa and she drop the email address of this man and advise we should contact him for any sickness that he would be of help, so i wrote to Dr. imoloa telling him about my (HERPES Virus) well after all the procedures and remedy given to me by this man few weeks later i started experiencing changes all over me. I am now here to testify that i am no longer a herpes patient, I have experience a total transformation in my life,for all herpes patients get your herbal medicine to cure your sickness. And there has being rapid improvement in my health, I no longer feel pains and I wake up each morning feeling revived. So friends my advise is if you have such sickness or any other at all,you can contact him on drimolaherbalmademedicine@gmail.com, you can still reach him on whatssap- +2347081986098
    CANCER
    EPILEPSY.
    GENPILENCIN.
    HIV AIDS.
    DIABETICS
    STROKE.
    BREAST ENLARGEMENT...PENIS ENLARGEMENT, H.P.V TYPE 1 TYPE 2 TYPE 3 AND TYPE 4. TYPE HUMAN PAPAILOMA VIRUS HERPES. SYPHILIS. HEPATITIS A B and C.

    ReplyDelete
  58. My name is john Rooney am from U.S.A. I want to share a testimony of how Dr.Imoloa herbal mixture cream saves me from shame and disgrace, my penis was a big problem to me as the size was really so embarrassing,and i was also having weak erection problem. I can't make love to my wife and my penis was just too small a full grown man like me having 4 inches penis and to worsen it i don't last in sex i cant even last two minutes it was really a thing of shame to me. My wife was really tired of me because my sex life was very poor,she never enjoyed sex,i was always thinking and searching for solutions everywhere until when i saw a testimony of how Dr.imoloa herbal mixture cream have been helping people regarding their sex life, so i decided to give him a try and to my greatest surprise in less than two weeks of taking the herbs my penis grow to 8 inches i couldn't believe my eyes and as i speak now my penis is now 8 inches and i do not have week erection again. I can make love to my wife longer in bed. And my marriage is now stable,my wife now enjoy me very well in bed. u can contact him drimolaherbalmademedicine@gmail.com . call or whats-apps him through +2347081986098 . he is also specialize on.... GETTING YOUR VIRGINITY BACK.

    Thanks for the Enlarging my penis sir, you indeed save my marriage...I am really grateful sir.

    ReplyDelete
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    ReplyDelete
  60. I'm Karem really happy that I have been cured of (HERPES SIMPLEX VIRUS 2) with the herbal medicine of DR. AKHIGBE HERBAL CENTER, I have been suffering from this disease for the past four years without solution until i came across this email (drrealakhigbe@gmail.com) on the internet of a herbal doctor who have cure so many people of herpes virus with his herbal medicine, I also choose to give him a chance to help me, he told me what to do and i kindly did it, and he sent me his herbal medicine through Dhl courier services delivery and direct me on how to use it, I also follows his instruction for use and he ask me to go for a check up after three weeks and which i did, to my greatest surprise my result came out as negative, I am really happy that there is someone like this DR. AKHIGBE HERBAL CENTER who is ready to help people anytime any day. to all the readers and viewers that is doubting this testimony stop doubting it and contact this DR. AKHIGBE HERBAL CENTER and see if he will not actually help you. I am not a stupid person that I will come out to the public and start saying what someone have not done for me. he is really a great man contact him now. with this email: (drrealakhigbe@gmail.com) or you can contact him +2348142454860

    ReplyDelete
  61. I'm Karem really happy that I have been cured of (HERPES SIMPLEX VIRUS 2) with the herbal medicine of DR. AKHIGBE HERBAL CENTER, I have been suffering from this disease for the past four years without solution until i came across this email (drrealakhigbe@gmail.com) on the internet of a herbal doctor who have cure so many people of herpes virus with his herbal medicine, I also choose to give him a chance to help me, he told me what to do and i kindly did it, and he sent me his herbal medicine through Dhl courier services delivery and direct me on how to use it, I also follows his instruction for use and he ask me to go for a check up after three weeks and which i did, to my greatest surprise my result came out as negative, I am really happy that there is someone like this DR. AKHIGBE HERBAL CENTER who is ready to help people anytime any day. to all the readers and viewers that is doubting this testimony stop doubting it and contact this DR. AKHIGBE HERBAL CENTER and see if he will not actually help you. I am not a stupid person that I will come out to the public and start saying what someone have not done for me. he is really a great man contact him now. with this email: (drrealakhigbe@gmail.com) or you can contact him +2348142454860

    ReplyDelete
  62. My name is Gwen Stacy Wailker , am here to appreciate Dr isiramen for using his herbal medicine to cure my Herpes virus. Is about 3 years and 6 months now I have been living with this virus and it has been a serious problem to me, I was so confused cause i have been taking several drugs to be cured but all of my effort was in vain,one morning I was browsing through the internet then I saw several testimonies about Dr. isiramen curing people from Herpes virus and immediately i contacted Dr. isiramen on his email: oyimeanelisiramen@gmail.com i told him about my troubles and he told me that i must be cured, he gave me some instructions and which i rightly followed. so he prepared a herbal medicine and sent it to me which i used for 2 weeks and i was cured everything was like a dream to me and my Herpes virus was totally gone, dr .isiramen, God bless you and give you more power and ability for more cure.I don't know if there is any one out there suffering for herpes virus or any of these diseases..DIABETES, CANCER, HIV/AIDS, HERPES HEPATITiS A AND B DISEASES etc. why don't you contact dr.isiramen today and be free from your diseases because he is very good and honest Doctor and he is also called the godfather of herbalism contact him via email; oyimeanelisiramen@gmail.com or whatsApp him on +2348117963221

    ReplyDelete
  63. Natural cures for herpes have been in existence before the first Olympian threw a disc or ran a race. Modern Medicine came in like a conquering hero and all the old remedies were soon forgotten and swept under the rug. It wasn't until someone investigated all the possibilities and combinations of ancient remedies that many of the natural cures became popular.I Linda Donna, I was herpes patient for two year and have taken different prescription of drugs or medicine but there was no cure i became very sick and frustrated also, Until my friend saw and read a testimony of a lady on this blog on who was cured of HIV~aids by Dr Akhigbe. With his herbal remedies cure, We contacted him through his email, drrealakhigbe@gmail.com He reply us and told us what to do, He prepared the herbal medicine and send it to me through Dhl courier services, and instructed me how i will be taking it. My grated surprise is getting to three weeks my herpes get cure totally. Brother and sister Dr Akhigbe herbal remedies cure is very powerful. I have to testify him here so that everyone can get the information here.Dr Akhigbe also cure diseases like,. DIABETES,ALS,HIV~AIDS,CANCER, FIBROID,HERPES ,HEPATITIS..In case you are there and you need his help please contact his email, drrealakhigbe@gmail.com or WhatApp HIM ON +2348142454860
    website: https:drrealakhigbe.weebly.com

    ReplyDelete
  64. Natural cures for herpes have been in existence before the first Olympian threw a disc or ran a race. Modern Medicine came in like a conquering hero and all the old remedies were soon forgotten and swept under the rug. It wasn't until someone investigated all the possibilities and combinations of ancient remedies that many of the natural cures became popular.I Linda Donna, I was herpes patient for two year and have taken different prescription of drugs or medicine but there was no cure i became very sick and frustrated also, Until my friend saw and read a testimony of a lady on this blog on who was cured of HIV~aids by Dr Akhigbe. With his herbal remedies cure, We contacted him through his email, drrealakhigbe@gmail.com He reply us and told us what to do, He prepared the herbal medicine and send it to me through Dhl courier services, and instructed me how i will be taking it. My grated surprise is getting to three weeks my herpes get cure totally. Brother and sister Dr Akhigbe herbal remedies cure is very powerful. I have to testify him here so that everyone can get the information here.Dr Akhigbe also cure diseases like,. DIABETES,ALS,HIV~AIDS,CANCER, FIBROID,HERPES ,HEPATITIS..In case you are there and you need his help please contact his email, drrealakhigbe@gmail.com or WhatApp HIM ON +2348142454860
    website: https:drrealakhigbe.weebly.com

    ReplyDelete
  65. i have been diagnosed of herpes disease since 3 years ago and ever since then i have gone through all manners of challenges and so many more,i was very lucky one very day when i was searching the internet on how to get a cure,as i came across a testimony on how Dr PETER has cured so many people of their herpes disease, i had to contact his email address: peterherpescurehome@gmail.com, as i contacted him i told him of how i have been suffering from herpes disease for 3 years, he assured me of a solution that i will be cure of herpes disease,i obeyed his instruction followed all his words and he then prepared a herbal medicine and he told me that once i start using his herbal medicine i will be cure in 2 weeks and all the virus will be flush out, after he has prepared the herbal medicine, he sent the medicine to me which after 2 weeks i was indeed cured totally thank you once again Dr. PETER in case you also need his help contact him now: peterherpescurehome@gmail.com or WhatsApp +971588071205

    ReplyDelete
  66. Very informative blog. Thanks a lot for sharing information.

    ReplyDelete
  67. I am very much happy to share to every viewers that is reading this,I want to inform the whole public of how I got help for my herpes, I wanted this since 6 months ago, I have also taken treatment from some doctor,few weeks back I came on the net to see if I will be able to get any information as to cure my herpes, on my search I saw various testimony of people who was helped by a great man called Dr Akhigbe and without any hesitation, I contacted him, I wrote to him and and he guided me, I asked him for solutions and he started the remedies for me and indeed 3 weeks after I started using the medicine, I was completely happy as it worked for me.I went to the hospital for check up and indeed I was declared negative from my disease, and I also waited again for two weeks and went back to another hospital for check up to be fully sure and to my great surprise I was still declared negative, and I decided to share this great opportunity to those people out there fighting this sickness, You can contact him now for your medicine to cure your diseases, contact his Email; drrealakhigbe@gmail.com or Whatsapp +2348142454860. website. hpps:drrealakhigbe.weebly.com

    Dr Akhigbe also cure diseases like..
    HIV
    Herpes
    Cancer
    Chronic Disease
    Asthma
    Als
    Heart Disease
    Diabetes
    Kidney Disease
    Lupus
    Epilepsy
    Stroke
    Eczema
    Eating Disorder
    Back Pain. etc
    contact him for your solution

    ReplyDelete
  68. I really appreciate DR AKHIGBE,my name is LAURIE HUGHES . I will never stop testifying DR AKHIGBE , Happiness is all i see now I never thought that I will be cured from HIV virus again. DR AKHIGBE did it for me I have been suffering from a deadly disease (HIV) for the past 2 years now, I had spent a lot of money going from one place to another, from churches to churches, hospitals have been my home every day residence. Constant checks up have been my hobby not until this faithful day, I saw a testimony on how DR AKHIGBE helped someone in curing his HIV disease in internet quickly I copied his email which is drrealakhigbe@gmail.com just to give him a test I spoke to him, he asked me to do some certain things which I did, he told me that he is going to provide the herbal cure to me, which he did, then he asked me to go for medical checkup after some days, after using the herbal cure and i did, behold I was free from the deadly disease,till now no HIV in me again he only asked me to post the testimony through the whole world, faithfully am doing it now,all the testimony of DR AKHIGBE is true please BROTHER and SISTER, MOTHER and FATHER he is great, I owe him in return. if you are having a similar problem just email him on drrealakhigbe@gmail.com or you can whats App his mobile number on +2348142454860 He can also cure these diseases like HIV and AIDS HERPES,DIABETICS,CANCER, HEPATITIS A&B,CHRONIC DISEASES, ASTHMA, HEART DISEASES, EPILEPSY, STROKE, LUPUS,ECZEMA,BACK PAIN,JOINT PAIN. .ETC .please email drrealakhigbe@gmail.com...or whats APP him ..+2348142454860 he is a real good and honest man.
    website... https:drrealakhigbe.weebly.com

    ReplyDelete
  69. Thanks a lot for sharing this

    ReplyDelete

  70. So is possible that HIV Disease can be cured because I have been scammed so many times not until I came across this great man Dr Akhigbe who helped me at first I never believe all this comment and post about him and I was very sick because I have been infected with HIV/AIDS for the past two year,just last 2 months I keep reading the testimony about this man named Dr Akhigbe they said that the man is so powerful he have cured different type of diseases, I keep monitoring his post of some people about this man and I found out that he was real so I decided to give him a trial I contacted him for help and he said he was going to help me get my cure that all I needed to do was to send him money to prepare the medication after which it will be sent to me via DHL courier delivery services which I did to my greatest surprise the medication was sent to me he gave me instructions to follow on how to drink it that after three weeks I should go for check up,after taking the medicine and follow his instruction after three weeks I went back to the hospital for another test, at first I was shocked when the doctor told me that I was negative I ask the doctor to check again and the result was still the same negative that was how I free from HIV VIRUS at of the shock I decided to come and share my own testimony with you for those who think there is no cure for HIV VIRUS the cure as finally come' out stop doubting and contact Dr Akhigbe via email drrealakhigbe@gmail.com he will help you out you can also whatsApp him via +2348142454860 he is also perfect in curing DIABETICS,HERPES,HIV/AIDS, ;ALS, CANCER ,HEPATITIS A AND B,ASTHMA, HEART DISEASE, CHRONIC DISEASE.,KIDNEY DISEASE, LUPUS, EPILEPSY,STROKE, ECZEMA, EATING DISORDER etc believe me that deadly disease is not longer a deadly sentence because dr akhigbe has the cure.the godfather of herbal root.
    email: drrealakhigbe@gmail.com whatsapp number: +2348142454860
    website: https://drrealakhigbe.weebly.com

    ReplyDelete