A 15-month-old boy is brought to the office for a well-child visit. His parents are concerned that he is not yet walking. He can pull himself up to stand and take steps while holding on to furniture but has not yet taken any steps unassisted. The patient says 5 words and can follow simple commands, such as "Clap your hands!" or "Wave bye-bye!" He is also able to pick up small items and food with his thumb and pointer finger and tries to use a spoon when feeding. The boy is up to date with all vaccinations. He has no known allergies and takes no medications. He was born via uncomplicated vaginal delivery at 37 weeks gestation. The patient was breastfed exclusively, with vitamin D supplementation, until age 6 months and has since had a varied diet. Gross motor milestones include rolling over at age 6 months and sitting unassisted at age 8 months. Height and weight are at the 40th percentile. Physical examination shows a nondysmorphic and active boy. He pulls himself up to stand and cruises around the examination room while holding on to chairs or his mother. During the examination, he cries and clings to his mother. The remainder of the examination is unremarkable. What is the best next step in management of this patient?

Question

A 15-month-old boy is brought to the office for a well-child visit.  His parents are concerned that he is not yet walking.  He can pull himself up to stand and take steps while holding on to furniture but has not yet taken any steps unassisted.  The patient says 5 words and can follow simple commands, such as "Clap your hands!" or "Wave bye-bye!"  He is also able to pick up small items and food with his thumb and pointer finger and tries to use a spoon when feeding.  The boy is up to date with all vaccinations.  He has no known allergies and takes no medications.  He was born via uncomplicated vaginal delivery at 37 weeks gestation.  The patient was breastfed exclusively, with vitamin D supplementation, until age 6 months and has since had a varied diet.  Gross motor milestones include rolling over at age 6 months and sitting unassisted at age 8 months.  Height and weight are at the 40th percentile.  Physical examination shows a nondysmorphic and active boy.  He pulls himself up to stand and cruises around the examination room while holding on to chairs or his mother.  During the examination, he cries and clings to his mother.  The remainder of the examination is unremarkable.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Developmental milestones are typically described by a mean age at which most children achieve them. All milestones, however, have an age range of normal acquisition. Walking is typically acquired around age 12 months but is considered normal at age 9-16 months. If no other delays (eg, fine motor, language, social) are present and physical examination is otherwise normal, close follow-up is appropriate until age 16 months. In addition to achieving previous gross motor milestones at appropriate ages (eg, rolling over by 6 months), this patient is showing appropriate fine motor coordination (eg, feeding with a spoon) and social interaction (eg, stranger anxiety). Reassurance should be provided, and follow-up in a month is recommended. (Choices A and B) Duchenne muscular dystrophy is an X-linked disorder characterized by proximal muscle weakness and cardiomyopathy. Although delayed walking can be a presenting sign, almost all patients also have cognitive delays, which this child does not have. Screening with a creatine kinase level, which is elevated in this condition, would be reasonable if the child were not walking by age 16 months. If evaluation and examination are otherwise normal, referral to early intervention services and physical therapy would be appropriate. (Choice C) In vitamin D-dependent rickets, patients have decreased vitamin D and calcium levels; the disease can present with delayed gross motor milestones. Physical examination would reveal bowing of the radius/ulna and tibia, delayed closure of fontanelles, and frontal bossing. This child has a varied diet and examination is normal. (Choice D) Bilateral hip radiographs are obtained for suspected developmental dysplasia of the hip in older infants and toddlers. Clinical findings include limited hip abduction and asymmetric leg creases but no delays in motor milestones. This condition is also less likely in nonbreech boys. Educational objective: Walking is a gross motor milestone that normally occurs at age 9-16 months. Evaluation and treatment should be considered if a child is not walking by age 16 months or delays are present in multiple developmental categories. References: Evidence-based milestone ages as a framework for developmental surveillance. (http://www.ncbi.nlm.nih.gov/pubmed/24294064)

A 15-Month-Old Boy Is Brought to the Office for a Well-Child