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Difficulty: MediumNormal Growth and Development

During a routine health maintenance visit, the parents of a 2-year-old male toddler report anxiety regarding his speech progression. While his peers are beginning to combine words, he currently relies on a vocabulary of approximately 10 to 12 isolated words. He does not yet link words together. He frequently communicates his desires by pointing and grunting, though he readily responds when his name is called and follows simple verbal instructions like "give me the block."

His birth history and past medical history are unremarkable. A parental autism screening questionnaire administered today is negative for behavioral red flags.

Physical examination reveals an alert, socially engaging child who makes appropriate eye contact. He runs steadily, kicks a small ball without falling, and can build a tower using six wooden blocks. He assists his parents in taking off his jacket. Tympanic membranes are translucent with a normal light reflex bilaterally. Which of the following is the most appropriate next step in the evaluation of this patient?

  1. Comprehensive audiologic evaluationAnswer
  2. B
    Reassurance and follow-up at age 3 years
  3. C
    Referral for speech-language therapy
  4. D
    Brain magnetic resonance imaging
  5. E
    Chromosomal microarray analysis

Answer

Comprehensive audiologic evaluation
The correct answer is a comprehensive audiologic evaluation. This patient presents with an isolated expressive language delay. By 24 months of age, a child should have a vocabulary of at least 50 words and be able to combine them into 2-word phrases. The most common cause of language delay in an otherwise normally developing toddler is hearing impairment. Even if a child appears to respond to noises, follow simple commands, or has normal-appearing tympanic membranes on physical examination, a formal hearing test is mandatory. Subjective parental or physician assessments of hearing are insufficient to rule out mild or high-frequency hearing loss, which can severely impact speech development.

Step-by-Step Solution

1
Assess the patient's developmental milestones based on age.
The 24-month-old patient has normal motor and social skills but demonstrates an expressive vocabulary of only 10-12 words without two-word phrases.
Comparing expected milestones with the patient's presentation identifies areas of delay. A 24-month-old is expected to have a vocabulary of ≥50 words and use 2-word phrases.
2
Categorize the type of developmental delay.
The patient has an isolated expressive language delay.
Motor skills, social interaction, and receptive language (following commands) are intact, ruling out global developmental delay or severe autism spectrum disorder.
3
Determine the most appropriate initial management step for isolated language delay.
Formal audiologic evaluation is required.
Hearing loss is a common, reversible cause of language delay and must be excluded before initiating speech therapy, even if the child appears to hear normally.

Key Concept

All children presenting with a language delay should undergo a formal audiologic evaluation as the initial diagnostic step, regardless of whether they appear to respond to sound or follow commands.
Estimated Time:1m 0s
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Topics

Normal Growth and Development

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