A 24-month-old boy is brought to the office by his parents for a routine well-child visit. The mother is concerned about his language development. However, his father says, "I started talking late when I was a kid. I used to be shy, so I'm not concerned." The boy lives with his parents and 5-year-old sister, who speak both English and Spanish at home. He can say 5-8 words in Spanish and seems to enjoy playing alongside his older sibling, but he does not play directly with her. The boy can run well and walk up and down stairs without assistance. His diet typically consists of milk, pasta, chicken nuggets, and fruit. Full-term gestation as well as labor and delivery were uncomplicated. Routine newborn screen and hearing screen were normal at birth. He had an episode of otitis media 5 months ago that was treated with antibiotics. Growth has been consistent along the 25th and 60th percentiles for height and weight, respectively. Physical examination shows a nondysmorphic and alert boy. Pneumatic otoscopy shows gray, mobile tympanic membranes. Skin examination reveals two café au lait spots on the lower back. The rest of the examination is unremarkable. During the visit, the boy is observed smiling and shows his parents a line he drew on a piece of paper. Which of the following is the most appropriate response to the parents?

Question

A 24-month-old boy is brought to the office by his parents for a routine well-child visit.  The mother is concerned about his language development.  However, his father says, "I started talking late when I was a kid.  I used to be shy, so I'm not concerned."  The boy lives with his parents and 5-year-old sister, who speak both English and Spanish at home.  He can say 5-8 words in Spanish and seems to enjoy playing alongside his older sibling, but he does not play directly with her.  The boy can run well and walk up and down stairs without assistance.  His diet typically consists of milk, pasta, chicken nuggets, and fruit.  Full-term gestation as well as labor and delivery were uncomplicated.  Routine newborn screen and hearing screen were normal at birth.  He had an episode of otitis media 5 months ago that was treated with antibiotics.  Growth has been consistent along the 25th and 60th percentiles for height and weight, respectively.  Physical examination shows a nondysmorphic and alert boy.  Pneumatic otoscopy shows gray, mobile tympanic membranes.  Skin examination reveals two café au lait spots on the lower back.  The rest of the examination is unremarkable.  During the visit, the boy is observed smiling and shows his parents a line he drew on a piece of paper.  Which of the following is the most appropriate response to the parents?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf54_f895_8f63_b5f4cc6079f0_MD0005_00 11ec2b69_bf54_f896_8f63_3b97480c08c1_MD0005_00 Normal language development at age 2 includes a >50-word vocabulary with use of 2-word phrases. Children at this age with <50 words and few word combinations have language delay. Many children with an initial delay catch up by age 4-5, but some may have a pathologic process that will result in persistent language impairment (ie, language disorder). Early identification and treatment are critical for optimal speech development, social and emotional growth, and academic achievement. Hearing loss, even if mild or unilateral, can affect speech and language development. All children with language delay should therefore undergo an audiology evaluation to assess for underlying hearing impairment. A formal assessment should be obtained as exposure to additional risk factors (eg, meningitis, recurrent/persistent otitis media, ototoxic medications) may have occurred since the newborn test, and in-office evaluations may not detect subtle hearing loss. (Choices A, B, and C) This child's marked language delay cannot be attributed to environmental or genetic causes without further investigation. Moreover, language development in boys and girls is typically similar prior to age 3, although boys are at higher risk for expressive language delay associated with autism spectrum disorder and/or global developmental delay/intellectual disability. Finally, multilingual language exposure has not been shown to affect language acquisition. For example, a bilingual English-Spanish-speaking child should have a >50-word vocabulary consisting of English and Spanish words. (Choice E) Language delay in a 2-year-old also warrants screening for autism, which may require referral to a neurologist if positive. Although lack of cooperative play in an older child can be a sign of autism, this child's engagement in parallel play is normal for a 2-year-old. Additionally, 1-3 isolated café au lait spots can be a normal skin finding and do not require evaluation for neurofibromatosis (NF); evaluation would be recommended if examination reveals >6 café au lait spots or other classic NF findings (eg, axillary freckling, Lisch nodules). Educational objective: Normal language development at age 2 includes a >50-word vocabulary with use of 2-word phrases. Language delay in any child warrants audiologic evaluation. References: Evidence-based milestone ages as a framework for developmental surveillance. (http://www.ncbi.nlm.nih.gov/pubmed/24294064) How vocabulary size in two languages relates to efficiency in spoken word recognition by young Spanish-English bilinguals. (http://www.ncbi.nlm.nih.gov/pubmed/19726000)

A 24-Month-Old Boy Is Brought to the Office by His