Developmental Milestones — SAQ

Stem

An 18-month-old boy is brought by his parents because he is not yet walking independently and says only 3 words. He sits, pulls to stand, and cruises along furniture. He makes good eye contact, points to objects, and follows simple commands.

Questions

a) Classify the developmental status. (2 marks)

Gross motor delay: not walking at 18 months (normal range 9-18 months; 18 months is the upper limit). He is at the cruising stage (9-12 month level). Language delay: only 3 words at 18 months (expected 10-20 words; normal range is 3-50 words — borderline). Social/cognitive: age-appropriate (good eye contact, pointing = joint attention, follows commands).

b) What are the red flags? (2 marks)

1. Not walking by 18 months — upper limit of normal; requires evaluation
2. Expressive language delay — 3 words is at the lower limit of normal at 18 months
3. No regression, good social interaction (reassuring — makes autism less likely)

c) What is the initial workup? (3 marks)

1. Detailed history: birth history, milestone trajectory, family history
2. Physical examination: tone, reflexes, joint mobility (exclude DDH, muscular dystrophy), head circumference, dysmorphic features
3. Hip examination: Ortolani/Barlow (developmental dysplasia of the hip can delay walking)
4. Creatine kinase (CK): exclude muscular dystrophy (Duchenne)
5. TFTs: exclude hypothyroidism
6. Hearing assessment: exclude hearing loss contributing to language delay
7. Refer to developmental paediatrics if delay confirmed

d) What advice and management would you provide? (3 marks)

1. Reassurance: social development is normal; motor delay may be constitutional (late walker) or mild neurological
2. Referral: community paediatrician for assessment and physiotherapy
3. Speech and language therapy assessment for expressive language delay
4. Monitor: repeat assessment at 2 years; if still not walking, MRI brain and further investigations
5. Early intervention services: developmental play, stimulation programmes