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Difficulty: EasyNormal Growth and Development

A 24-month-old boy is brought to the clinic by his parents for a routine well-child visit. His parents express concern regarding his development. They report that he frequently refuses to share toys with his older sister and prefers to play alongside her rather than together. Furthermore, they are worried because he cannot pedal the tricycle he received for his second birthday. On physical examination, the child runs well and walks up and down the examination room steps by placing both feet on each step. He is able to kick a ball forward. During the visit, he stacks 6 wooden blocks to build a tower. His vocabulary consists of approximately 50 words, and he uses 2-word phrases. His speech is roughly 50% intelligible to the physician. Which of the following is the most appropriate next step in management?

  1. A
    Referral for physical therapy
  2. B
    Referral for occupational therapy
  3. C
    Referral for speech-language pathology
  4. Reassurance and routine pediatric careAnswer
  5. E
    Referral for behavioral therapy

Answer

Reassurance and routine pediatric care
The child's developmental milestones across all domains (gross motor, fine motor, language, and social) are completely normal for a 24-month-old (2 years). Because there is no evidence of developmental delay, the most appropriate management is reassurance and continuing routine pediatric care.

Step-by-Step Solution

1
Evaluate the child's gross motor milestones.
Walking up and down stairs placing both feet on each step, running, and kicking a ball are normal for a 24-month-old. Pedaling a tricycle is a 3-year (36-month) milestone.
To determine if the parents' concern about the tricycle warrants physical therapy.
2
Evaluate the child's fine motor milestones.
Building a tower of 6 blocks is the expected milestone for a 24-month-old. (A 3-year-old can typically build a tower of 9 blocks and copy a circle/line).
To rule out fine motor delay.
3
Evaluate the child's language milestones.
Having a vocabulary of 50 words, using 2-word phrases, and being 50% intelligible to strangers are precisely the expected language milestones for age 2.
To assess if speech-language intervention is needed.
4
Evaluate the child's social and cognitive milestones.
Engaging in parallel play (playing alongside others) and not sharing toys is normal behavior for a 2-year-old. Cooperative play and sharing emerge closer to age 4.
To determine if the parents' behavioral concerns are clinically significant.
5
Synthesize the findings.
All domains of development are age-appropriate. No further workup or specialty referral is required.
To select the most appropriate next step in management.

Key Concept

Normal pediatric milestones at 24 months (2 years)
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Topics

Normal Growth and Development

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