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Difficulty: Very hardNormal Growth and Development

A 15-month-old girl is brought to the clinic for a routine well-child visit. She was born at 28 weeks gestation due to severe maternal preeclampsia. She spent two months in the neonatal intensive care unit primarily for respiratory support and feeding optimization, but was discharged without major complications. Her parents are anxious about her development, noting that her 15-month-old cousin is already walking independently and speaking several words.

On examination, the patient is alert and interactive. She can pull herself to a stand and cruises along the examination table, but she does not take independent steps. She uses a neat pincer grasp to pick up a small cereal piece. She says "mama" and "dada" specifically to her parents and points to a toy stethoscope she wants. She readily plays peek-a-boo with the physician. Neurologic examination reveals normal muscle tone, 2+ symmetric deep tendon reflexes, and no cranial nerve deficits. Growth parameters (adjusted for prematurity) are tracking along the 50th percentiles.

Which of the following is the most appropriate next step in management?

  1. A
    Referral for comprehensive audiologic evaluation
  2. Reassurance and routine developmental surveillanceAnswer
  3. C
    Referral to an early intervention program
  4. D
    Magnetic resonance imaging of the brain
  5. E
    Measurement of serum creatine kinase level

Answer

The most appropriate next step is reassurance and routine developmental surveillance, as the patient's milestones are completely normal for her corrected age of 12 months.
The patient was born at 2828 weeks gestation, meaning she was 1212 weeks (or 33 months) premature. When assessing developmental milestones in premature infants, their chronological age must be adjusted by subtracting the weeks of prematurity until they reach 2424 months of age. Her chronological age is 1515 months, so her corrected age is 1212 months (15−3=1215 - 3 = 12). The patient's abilities—cruising along furniture, using a neat pincer grasp, saying "mama" and "dada" specifically, pointing, and playing peek-a-boo—are perfectly normal milestones for a 1212-month-old child. Because her development is entirely age-appropriate when accurately corrected for prematurity, the most appropriate next step is reassurance and routine developmental surveillance.

Step-by-Step Solution

1
Determine the patient's chronological age and weeks of prematurity.
The patient is 1515 months old chronologically and was born at 2828 weeks gestation.
Developmental milestones must be adjusted for prematurity until a child reaches 2424 months of age to avoid falsely diagnosing developmental delay.
2
Calculate the patient's corrected age.
Full term is 4040 weeks. Prematurity is 40−28=1240 - 28 = 12 weeks, which equals 33 months. Corrected age is 15−3=1215 - 3 = 12 months.
Corrected age provides the accurate biological benchmark for evaluating the child's developmental progress.
3
Compare the patient's current abilities to the expected milestones for her corrected age.
Cruising, using a neat pincer grasp, saying 'mama' and 'dada' specifically, and playing peek-a-boo perfectly align with standard 1212-month milestones.
If evaluated against 1515-month milestones, she would appear delayed across multiple domains, but against 1212-month milestones, her development is completely normal.
4
Select the appropriate clinical management based on the developmental assessment.
The correct action is reassurance and routine developmental surveillance.
Because her development is appropriate for her corrected age and her neurologic exam is benign, specialized testing or referrals are unnecessary.

Key Concept

Developmental milestones in children born prematurely must be evaluated using their corrected age (Chronological age minus weeks of prematurity) until they reach 2 years of age.
Estimated Time:1m 30s
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Topics

Normal Growth and Development

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