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Difficulty: HardNormal Growth and Development

A 13-month-old boy is evaluated in the pediatric clinic for a routine well-child visit. His parents express significant anxiety regarding his motor progression. They note that their older daughter took her first independent steps at 10 months of age, but their son only pulls to a stand and cruises along the living room furniture. He has just started standing without support for a few seconds. Furthermore, the father reports that the boy's toes spread outward when the soles of his feet are tickled during bath time. The parents read online that this foot reflex indicates brain damage. The patient was born at term following an uncomplicated pregnancy. He easily picks up small pieces of cereal using the tips of his thumb and index finger. His vocabulary includes "mama", "dada", "ball", and "no", which he uses appropriately. He enjoys playing interactive games like peek-a-boo. Neurologic examination demonstrates symmetric muscle tone. Plantar stimulation yields bilateral dorsiflexion of the great toe and fanning of the lesser toes. Which of the following is the most appropriate next step in the care of this patient?

  1. A
    Comprehensive neurological evaluation
  2. B
    Magnetic resonance imaging of the brain
  3. C
    Pediatric physical therapy consultation
  4. Reassurance and routine pediatric careAnswer
  5. E
    Serum thyroid-stimulating hormone measurement

Answer

Reassurance and routine pediatric care
The patient's development is entirely age-appropriate for a 13-month-old. Independent walking is typically achieved between 12 and 15 months of age; therefore, a 13-month-old who is cruising and standing momentarily without support is demonstrating normal gross motor progression. His fine motor skills (mature pincer grasp using finger tips), language development (four contextual words), and social skills (playing peek-a-boo) all meet expectations for his age. Additionally, the extensor plantar (Babinski) response is a normal physiological finding in infants. The corticospinal tracts are not fully myelinated at birth, and this reflex typically disappears between 12 and 24 months of age. Because his history and physical examination findings represent normal growth and development, reassurance and routine care without further testing is the correct management.

Step-by-Step Solution

1
Evaluate the patient's gross motor milestones compared to expected age norms.
At 13 months, pulling to stand, cruising, and momentary standing are completely normal; independent walking is not strictly expected until 15 to 18 months of age.
To determine if the patient has a true gross motor delay warranting physical therapy or further evaluation.
2
Assess the clinical significance of the bilateral extensor plantar (Babinski) response.
The reflex is a normal physiologic finding in children under 2 years of age due to incomplete myelination of the corticospinal tracts.
To differentiate a normal infantile reflex from a pathological upper motor neuron lesion.
3
Synthesize the findings to select the most appropriate management step.
Because all historical and examination findings represent normal growth and development, reassurance is the correct approach.
Unnecessary diagnostic testing or specialist referrals should be avoided in patients demonstrating normal developmental variations.

Key Concept

Normal motor milestone acquisition timelines and the physiological persistence of primitive reflexes in toddlers.
Estimated Time:1m 15s
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Topics

Normal Growth and Development

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