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Difficulty: MediumNormal Growth and Development

A 6-month-old boy is brought to the clinic for a routine well-child visit. He was born at 28 weeks gestation via emergency cesarean delivery due to severe maternal preeclampsia. He spent 6 weeks in the neonatal intensive care unit before being discharged home. His parents are concerned about his motor development because he does not roll over from his stomach to his back and cannot sit up, even with support. On physical examination, his weight, length, and head circumference are tracking appropriately on the premature infant growth chart. When placed in a prone position, he holds his head up steadily at a 45-degree angle. He consistently brings both hands to the midline and tracks objects past the midline. He coos and exhibits a social smile when interacting with the examiner but does not babble or transfer objects from hand to hand. Neurological examination reveals normal muscle tone and symmetric reflexes. Which of the following is the most appropriate next step in management?

  1. Reassurance and routine follow-upAnswer
  2. B
    Referral for early intervention physical therapy
  3. C
    Referral to a pediatric neurologist
  4. D
    Screening cranial ultrasonography
  5. E
    Measurement of serum creatine kinase level

Answer

Reassurance and routine follow-up
The correct action is reassurance and routine follow-up. This patient was born at 28 weeks gestation, which is 12 weeks (or 3 months) premature. For premature infants, developmental milestones should be assessed based on their corrected age until they reach 2 years of chronological age. The corrected age is calculated by subtracting the degree of prematurity from the chronological age. Therefore, this 6-month-old infant has a corrected age of 3 months (6 months - 3 months). The milestones described in the vignette—holding the head up at 45 degrees prone (gross motor), bringing hands to the midline (fine motor), cooing (language), and demonstrating a social smile (social)—are perfectly age-appropriate for a 3-month-old. The parents are expecting 6-month milestones (such as rolling over and sitting with support), but the infant is not yet expected to reach these. Given the normal neurological examination and appropriate milestone acquisition for his corrected age, the child is developing normally, and no intervention is required.

Step-by-Step Solution

1
Calculate the degree of prematurity.
The infant was born at 28 weeks, which is 12 weeks (approximately 3 months) premature compared to a full-term 40-week gestation.
Milestone expectations for premature infants must be adjusted for their gestational age until they reach 2 years of chronological age.
2
Calculate the corrected age.
Chronological age (6 months) minus prematurity (3 months) equals a corrected age of 3 months.
Corrected age determines which developmental milestones the child should currently be demonstrating.
3
Evaluate the patient's current milestones against normal 3-month expectations.
The infant holds his head up at 45 degrees, brings hands to midline, coos, and smiles socially. These align perfectly with 3-month milestones.
Rolling over and sitting with support (the parents' expectations) are 4- to 6-month milestones, which are not yet expected for this infant.
4
Determine the appropriate clinical intervention.
Reassurance and routine follow-up.
Because the infant's development is entirely normal for his corrected age and his neurological examination is reassuring, no further diagnostic workup or referral is indicated.

Key Concept

Premature infants must have their chronological age corrected for their degree of prematurity when assessing developmental milestones until they reach 24 months of age.
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Topics

Normal Growth and Development

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