A 32-month-old girl is brought to the emergency department by her grandmother with a spiral fracture of the humerus. The grandmother, who provides childcare three days per week, reports the child fell from a sofa. The child's mother arrives and gives a different account, saying the injury occurred when the grandmother pulled the child's arm while lifting her. The grandmother appears distressed and admits she may have 'pulled too hard' when the child was having a tantrum. The child is otherwise well with no other injuries and normal development. What is the most appropriate classification and management of this situation?
Q72
A paediatric consultant reviews growth data for a 13-year-old boy referred for short stature. His height has consistently tracked the 2nd centile since age 2 years. Bone age is 11 years. His father's height is 168 cm (10th centile) and mother's height is 152 cm (2nd centile). The mid-parental height calculation places the target centile range between the 2nd and 9th centiles. Pubertal assessment shows Tanner stage 2 pubic hair and testicular volume 6ml. What is the most likely diagnosis?
Q73
A health visitor is concerned about a 10-month-old infant who has had three attendances at the emergency department in the past 2 months with minor injuries: a bruise to the forehead, a small burn to the hand, and now a torn frenulum. The parents are cooperative and have reasonable explanations for each injury. The child is developing normally and appears well-cared for with no other safeguarding concerns identified. What is the most appropriate next step?
Q74
A 5-year-old girl is brought to the GP with a 3-month history of intermittent limp. Her mother reports she sometimes complains of leg pain, particularly at night. There is no history of trauma. Examination reveals she is on the 98th centile for weight and 75th for height. There is some limitation of internal rotation of the left hip but otherwise examination is unremarkable. What is the most likely diagnosis?
Q75
A 7-year-old boy is referred to community paediatrics by his school with concerns about attention and hyperactivity. During the assessment, his mother mentions that he has always been 'difficult' and she sometimes locks him in his room for several hours when he misbehaves. She states this is the only way to manage him and that her own parents did the same with her. The child appears wary of his mother and flinches when she raises her hand to gesture. What is the most appropriate classification of this situation?
Q76
A paediatric registrar is called to the neonatal unit to review a term baby with poor feeding and hypotonia. The baby was born to a 16-year-old mother who had no antenatal care. On examination, the baby has epicanthic folds, upslanting palpebral fissures, and a single palmar crease. Growth parameters show length on 9th centile, weight on 25th centile, and head circumference on 2nd centile. What is the most appropriate interpretation of these growth parameters in the context of the likely diagnosis?
Q77
A 11-year-old girl presents to her GP with a 6-month history of intermittent abdominal pain and headaches. Examination is unremarkable and previous investigations including coeliac screen, inflammatory markers, and urine tests are normal. During the consultation alone with the doctor, she becomes tearful and discloses that her mother's boyfriend has been watching her get changed and making comments about her body development. She begs the doctor not to tell anyone. What is the most appropriate immediate action?
Q78
A 22-month-old boy is reviewed in the developmental clinic. He can walk well and run, but cannot yet jump with both feet off the ground. He can build a tower of 5 cubes and turn pages in a book singly. He uses approximately 15 single words but no two-word combinations. He feeds himself with a spoon but is very messy. Based on these findings, which developmental domain shows delay requiring further assessment?
Q79
A 3-year-old girl is brought to the emergency department by her mother with burns to both feet described as occurring when she stepped into a bath. The burns are symmetrical, involve both feet up to a clear demarcation line at the ankles, with sparing of the soles. There are no splash marks. The child appears withdrawn and makes little eye contact. What is the most appropriate immediate action?
Q80
A health visitor assesses a 15-month-old child at a routine developmental check. The child cannot yet walk independently but cruises around furniture confidently. She uses 3 clear words with meaning, can drink from a cup with help, and points to desired objects. She enjoys peek-a-boo and waves goodbye. What is the most appropriate next step in management?
Growth, Development & Safeguarding UK Medical PG Practice Questions and MCQs
Question 71: A 32-month-old girl is brought to the emergency department by her grandmother with a spiral fracture of the humerus. The grandmother, who provides childcare three days per week, reports the child fell from a sofa. The child's mother arrives and gives a different account, saying the injury occurred when the grandmother pulled the child's arm while lifting her. The grandmother appears distressed and admits she may have 'pulled too hard' when the child was having a tantrum. The child is otherwise well with no other injuries and normal development. What is the most appropriate classification and management of this situation?
A. Accidental injury from a fall - treat the fracture and provide safety advice about furniture climbing
B. Physical abuse by the grandmother - make immediate child protection referral and consider police involvement
C. Accidental injury from excessive force during handling - treat fracture, document carefully, and ensure parents are aware of safe handling techniques
D. Unclear mechanism requiring child protection medical assessment before determining if accidental or non-accidental (Correct Answer)
E. Physical abuse by the grandmother - ensure grandmother has no unsupervised contact and arrange safeguarding assessment within 48 hours
Explanation: ***Unclear mechanism requiring child protection medical assessment before determining if accidental or non-accidental***
- A **spiral fracture** of the humerus in a toddler, especially with **inconsistent histories** from caregivers, is a major red flag for potential **non-accidental injury (NAI)** and mandates a formal **child protection medical assessment**.
- The discrepancy in accounts (fall vs. pulled arm, and the grandmother's admission of excessive force) means the true mechanism of injury is **unverified**, necessitating specialist evaluation to determine if it is accidental or non-accidental.
*Accidental injury from a fall - treat the fracture and provide safety advice about furniture climbing*
- This option **prematurely accepts** an initial, unverified history and disregards the **contradictory accounts** and the suspicious nature of the injury.
- A simple fall from a sofa is unlikely to generate the **torsional force** typically required to produce a **spiral fracture** of the humerus in a young child.
*Physical abuse by the grandmother - make immediate child protection referral and consider police involvement*
- While **physical abuse** is strongly suspected, jumping directly to this conclusion without a **comprehensive medical assessment** to confirm the injury mechanism is premature.
- The immediate priority in the emergency setting is a **thorough medical evaluation** of the child and the injury, which then guides the subsequent child protection actions and police involvement.
*Accidental injury from excessive force during handling - treat fracture, document carefully, and ensure parents are aware of safe handling techniques*
- This assumes the grandmother's second explanation is entirely truthful, ignoring the possibility of an attempt to **downplay or conceal abuse**, particularly given the initial inconsistent history.
- Such a conclusion bypasses the critical need for a **child protection investigation** when the mechanism of a suspicious injury is not clearly established as accidental.
*Physical abuse by the grandmother - ensure grandmother has no unsupervised contact and arrange safeguarding assessment within 48 hours*
- This option makes a definitive judgment of **culpability** before a full **medical and social investigation** has been completed to confirm the nature of the injury.
- Waiting **48 hours** for a safeguarding assessment for a significant injury like a **spiral fracture** with highly suspicious circumstances is an unacceptable delay; an immediate assessment is required.
Question 72: A paediatric consultant reviews growth data for a 13-year-old boy referred for short stature. His height has consistently tracked the 2nd centile since age 2 years. Bone age is 11 years. His father's height is 168 cm (10th centile) and mother's height is 152 cm (2nd centile). The mid-parental height calculation places the target centile range between the 2nd and 9th centiles. Pubertal assessment shows Tanner stage 2 pubic hair and testicular volume 6ml. What is the most likely diagnosis?
A. Familial short stature
B. Constitutional delay of growth and puberty
C. Growth hormone deficiency
D. Combined familial short stature and constitutional delay (Correct Answer)
E. Hypogonadotropic hypogonadism
Explanation: ***Combined familial short stature and constitutional delay***
- This diagnosis is indicated by a height tracking the **2nd centile**, which matches the **mid-parental height** range, combined with a **delayed bone age** (11 vs 13 years).
- The presence of early puberty (Tanner 2, **6ml testicular volume**) at age 13 suggests a late start compared to peers, fitting the pattern of **constitutional delay** superimposed on genetic potential.
*Familial short stature*
- In isolated familial short stature, the **bone age** should be equal to the **chronological age**, but it is delayed in this patient.
- Children with this condition typically undergo **puberty** at the normal expected time, rather than showing a delay.
*Constitutional delay of growth and puberty*
- While the **delayed bone age** and late puberty fit this diagnosis, the height would usually be significantly below the **mid-parental target range** if acting alone.
- This patient's height is perfectly consistent with his parents' centiles, indicating a **familial component** is also present.
*Growth hormone deficiency*
- This condition is characterized by **growth velocity failure**, where the child's height **crosses centiles** downwards rather than tracking consistently.
- **Bone age** is often much more severely delayed than what is observed in this clinical scenario.
*Hypogonadotropic hypogonadism*
- This would typically present with **absent puberty** and prepubertal testicular volumes (less than **4ml**) by age 14.
- This boy has already entered puberty (6ml testes), which rules out a complete lack of **gonadotropins**.
Question 73: A health visitor is concerned about a 10-month-old infant who has had three attendances at the emergency department in the past 2 months with minor injuries: a bruise to the forehead, a small burn to the hand, and now a torn frenulum. The parents are cooperative and have reasonable explanations for each injury. The child is developing normally and appears well-cared for with no other safeguarding concerns identified. What is the most appropriate next step?
A. Continue routine health visiting as the injuries have plausible explanations and the child appears well-cared for
B. Arrange a multi-agency meeting to share information and determine if the pattern of injuries raises safeguarding concerns (Correct Answer)
C. Make an immediate child protection referral to social services as three injuries in 2 months indicates abuse
D. Offer the family support through parenting classes and home safety assessment
E. Document concerns and monitor the situation, making a referral only if further injuries occur
Explanation: ***Arrange a multi-agency meeting to share information and determine if the pattern of injuries raises safeguarding concerns***
- A **torn frenulum** in a non-ambulatory or minimally mobile 10-month-old is a highly suspicious injury, often indicative of **non-accidental injury (NAI)**, such as forceful feeding or a blow to the mouth.
- The **frequency and pattern** of three minor injuries in two months, even with parental explanations, necessitate a **collaborative multi-agency assessment** to holistically evaluate the child's safety and risk.
*Continue routine health visiting as the injuries have plausible explanations and the child appears well-cared for*
- Relying solely on **parental explanations** or the child's general well-being can lead to overlooking subtle indicators of **cumulative harm** or abuse.
- Health professionals have a duty to actively investigate **suspicious patterns of injury**, irrespective of the child's outward appearance or parental cooperation.
*Make an immediate child protection referral to social services as three injuries in 2 months indicates abuse*
- While concerns are high, an **immediate child protection referral** may be premature without first gathering and sharing information among all involved agencies (e.g., GP, ED, health visitor) to establish a comprehensive picture.
- The initial step should typically be a **multi-agency discussion** to assess the nature and consistency of injuries with the child's development before escalating to formal child protection proceedings.
*Offer the family support through parenting classes and home safety assessment*
- This approach focuses primarily on **accidental injury prevention** and may dangerously overlook the strong possibility of **physical abuse** suggested by the nature of a torn frenulum.
- Support services should only be considered after a thorough **multi-agency risk assessment** has confirmed that there are no immediate safeguarding concerns regarding non-accidental harm.
*Document concerns and monitor the situation, making a referral only if further injuries occur*
- A **"wait-and-see" approach** is inappropriate and unsafe in child safeguarding, particularly when highly suspicious injuries like a **torn frenulum** are present.
- Failing to act on current **red flags** places the child at significant risk of experiencing **more severe or repeated harm** in the future.
Question 74: A 5-year-old girl is brought to the GP with a 3-month history of intermittent limp. Her mother reports she sometimes complains of leg pain, particularly at night. There is no history of trauma. Examination reveals she is on the 98th centile for weight and 75th for height. There is some limitation of internal rotation of the left hip but otherwise examination is unremarkable. What is the most likely diagnosis?
A. Transient synovitis
B. Septic arthritis
C. Perthes disease (Correct Answer)
D. Slipped upper femoral epiphysis
E. Growing pains
Explanation: ***Perthes disease***- **Perthes disease** (Legg-Calvé-Perthes) typically affects children aged **4–8 years** and presents with an insidious, chronic history of limping and hip pain.- Findings of **limited internal rotation** and abduction are classic signs of **avascular necrosis** of the femoral head occurring at this age.*Transient synovitis*- This condition has an **acute onset** (hours to days) and usually resolves within 1–2 weeks, whereas this patient has a **3-month history**.- It often follows a recent **viral upper respiratory tract infection**, which is not mentioned in this clinical scenario.*Septic arthritis*- Presents as an **acute emergency** with high fever, systemic illness, and a complete **refusal to weight-bear**.- The **intermittent, long-term** nature of this child's symptoms and the lack of systemic features exclude a septic joint.*Slipped upper femoral epiphysis*- Typically occurs in **older children/adolescents** (aged 10–15 years) during the growth spurt, making it less likely in a **5-year-old**.- While the patient's **high weight centile** is a risk factor for SUFE, the age and chronic presentation point more strongly toward Perthes disease.*Growing pains*- These are a diagnosis of exclusion that should have a **completely normal physical examination**, with no limitation of joint movement or limp.- Symptoms are typically **bilateral** and occur in the evening or at night, whereas this patient has **unilateral hip pathology** on examination.
Question 75: A 7-year-old boy is referred to community paediatrics by his school with concerns about attention and hyperactivity. During the assessment, his mother mentions that he has always been 'difficult' and she sometimes locks him in his room for several hours when he misbehaves. She states this is the only way to manage him and that her own parents did the same with her. The child appears wary of his mother and flinches when she raises her hand to gesture. What is the most appropriate classification of this situation?
A. Physical abuse only, requiring immediate child protection referral
B. Emotional abuse and physical abuse, requiring immediate child protection referral (Correct Answer)
C. Emotional abuse only, requiring referral to social services for support
D. Appropriate parenting of a challenging child with ADHD, requiring behaviour management support
E. Concerning parenting requiring referral to parenting support services before considering safeguarding
Explanation: ***Emotional abuse and physical abuse, requiring immediate child protection referral***
- Locking a child in a room for several hours as a form of discipline constitutes **inappropriate physical restraint** and promotes an atmosphere of **fear and isolation**, meeting criteria for both abuse types.
- The child's **wariness** and **flinching** response are clinical indicators of significant emotional harm and the potential threat of physical violence, necessitating an immediate **safeguarding referral**.
*Physical abuse only, requiring immediate child protection referral*
- This option ignores the significant **psychological impact** and persistent emotional maltreatment inherent in the child's fear and the mother's punitive isolation tactics.
- **Emotional abuse** is clearly present through the creation of a fearful environment and the deprivation of normal social interaction for hours.
*Emotional abuse only, requiring referral to social services for support*
- This fails to recognize that **prolonged isolation/restraint** is categorized as a form of physical abuse and underestimates the severity of the situation.
- A simple referral for "support" is insufficient when there is evidence of **significant harm**, which requires a formal **child protection investigation**.
*Appropriate parenting of a challenging child with ADHD, requiring behaviour management support*
- Locking a child away for hours and inducing a **flinch response** are never considered appropriate discipline, regardless of a child's underlying behavioral conditions like **ADHD**.
- This view neglects the **legal and ethical duty** to protect children from harmful parenting practices that stem from intergenerational cycles of abuse.
*Concerning parenting requiring referral to parenting support services before considering safeguarding*
- Delaying a safeguarding referral in the presence of **active abuse signals** (flinching, restraint) places the child at continued risk of physical and psychological injury.
- **Safeguarding** must be the immediate priority to assess the child's safety before or alongside secondary interventions like parenting support.
Question 76: A paediatric registrar is called to the neonatal unit to review a term baby with poor feeding and hypotonia. The baby was born to a 16-year-old mother who had no antenatal care. On examination, the baby has epicanthic folds, upslanting palpebral fissures, and a single palmar crease. Growth parameters show length on 9th centile, weight on 25th centile, and head circumference on 2nd centile. What is the most appropriate interpretation of these growth parameters in the context of the likely diagnosis?
A. The growth parameters are typical for Down syndrome and require no specific intervention beyond routine monitoring
B. The relative microcephaly suggests an additional diagnosis such as fetal alcohol syndrome should be considered (Correct Answer)
C. The low head circumference indicates probable birth asphyxia and requires neuroimaging
D. The growth parameters indicate intrauterine growth restriction requiring investigation for placental insufficiency
E. The discrepancy between length and weight suggests a chromosomal disorder other than Down syndrome
Explanation: ***The relative microcephaly suggests an additional diagnosis such as fetal alcohol syndrome should be considered***
- While the baby presents with classic features of **Down syndrome** (epicanthic folds, upslanting palpebral fissures, single palmar crease, hypotonia), the head circumference on the 2nd centile is disproportionately low compared to the length (9th centile) and weight (25th centile.
- This **relative microcephaly**, coupled with the high-risk maternal history (16-year-old, no antenatal care), strongly suggests considering an additional diagnosis like **Fetal Alcohol Syndrome (FAS)**, which is a leading cause of **microcephaly** and developmental delays.
*The growth parameters are typical for Down syndrome and require no specific intervention beyond routine monitoring*
- Although infants with **Down syndrome** often have smaller overall growth, the **disproportionate microcephaly** (head circumference at 2nd centile) is not typical for uncomplicated Down syndrome and warrants further investigation.
- Dismissing this discrepancy would mean missing a potential co-morbidity such as **Fetal Alcohol Syndrome**, which requires specific management and profoundly impacts neurodevelopmental prognosis.
*The low head circumference indicates probable birth asphyxia and requires neuroimaging*
- **Birth asphyxia** primarily presents with acute neurological symptoms (e.g., poor Apgar scores, neonatal encephalopathy, seizures) at birth, not typically with isolated **microcephaly** as a sole presenting feature.
- While neuroimaging might be considered, the chronic nature of the observed **microcephaly** points more towards a congenital or prenatal insult rather than an acute intrapartum event.
*The growth parameters indicate intrauterine growth restriction requiring investigation for placental insufficiency*
- **Placental insufficiency** typically causes **asymmetric IUGR**, characterized by head sparing, meaning the head circumference is relatively preserved while weight and length are more significantly reduced.
- In this case, the **head circumference is disproportionately small** relative to other growth parameters, suggesting a primary issue with brain development rather than generalized IUGR from placental problems.
*The discrepancy between length and weight suggests a chromosomal disorder other than Down syndrome*
- The specific facial dysmorphism and **hypotonia** are highly indicative of **Down syndrome**, making a different primary chromosomal disorder less likely.
- The most significant growth discrepancy is the **microcephaly**, which points towards an **additional or secondary condition** rather than suggesting a completely different primary chromosomal anomaly.
Question 77: A 11-year-old girl presents to her GP with a 6-month history of intermittent abdominal pain and headaches. Examination is unremarkable and previous investigations including coeliac screen, inflammatory markers, and urine tests are normal. During the consultation alone with the doctor, she becomes tearful and discloses that her mother's boyfriend has been watching her get changed and making comments about her body development. She begs the doctor not to tell anyone. What is the most appropriate immediate action?
A. Respect her confidentiality as she is Gillick competent and arrange a follow-up appointment to discuss further
B. Explain that you need to share this information to keep her safe, and make an immediate safeguarding referral (Correct Answer)
C. Arrange for her to speak with a counsellor first before deciding on further action
D. Speak with her mother to get more information about the situation at home
E. Document the disclosure clearly in the notes and arrange review in 2 weeks to see if she will consent to referral
Explanation: ***Explain that you need to share this information to keep her safe, and make an immediate safeguarding referral***
- In cases of potential **child sexual abuse**, such as voyeurism or inappropriate comments, a clinician's **safeguarding duty** overrides the duty of confidentiality to ensure the patient's protection.
- The practitioner must explain the **necessity of disclosure** to the child and proceed with an **immediate referral** to social services or the police to prevent further harm.
*Respect her confidentiality as she is Gillick competent and arrange a follow-up appointment to discuss further*
- **Gillick competence** applies to a child's ability to consent to medical treatment, but it does not allow a doctor to withhold information regarding **significant harm** or abuse.
- Maintaining confidentiality in this scenario places the child at an **ongoing risk** of abuse, which is a breach of medical and legal safeguarding protocols.
*Arrange for her to speak with a counsellor first before deciding on further action*
- Delaying the referral for counseling inhibits the **prompt investigation** required by local authorities to ensure the child's home environment is safe.
- **Child protection** actions must be initiated as soon as a disclosure is made, rather than waiting for psychological intervention.
*Speak with her mother to get more information about the situation at home*
- Contacting the mother or household members may inadvertently tip off the perpetrator, potentially putting the child at **increased risk of harm** or intimidation.
- In instances of intra-familial or household-based abuse, the **local safeguarding lead** or social services should manage how family members are informed.
*Document the disclosure clearly in the notes and arrange review in 2 weeks to see if she will consent to referral*
- A two-week delay is inappropriate and dangerous as it leaves the child in an environment where **sexual grooming or abuse** is actively occurring.
- Consent for a **safeguarding referral** is not required when there is a risk of significant harm to a minor; the safety of the child is the paramount concern.
Question 78: A 22-month-old boy is reviewed in the developmental clinic. He can walk well and run, but cannot yet jump with both feet off the ground. He can build a tower of 5 cubes and turn pages in a book singly. He uses approximately 15 single words but no two-word combinations. He feeds himself with a spoon but is very messy. Based on these findings, which developmental domain shows delay requiring further assessment?
A. Gross motor skills
B. Fine motor and vision
C. Speech and language (Correct Answer)
D. Social and self-care skills
E. No developmental delay is present
Explanation: ***Speech and language***
- By **22 months**, a child is typically expected to use **50+ individual words** and begin forming **two-word combinations**; this child’s use of only 15 single words is significantly below milestones.
- A delay in this domain warrants further investigation, including a **hearing test** and referral for **speech and language therapy** to rule out underlying sensory or developmental issues.
*Gross motor skills*
- This child can **walk and run well**, which are appropriate milestones for a child under 2 years of age.
- **Jumping with both feet** is a milestone typically achieved between **2.5 to 3 years**, so his inability to do so at 22 months is not considered a delay.
*Fine motor and vision*
- Building a **tower of 5 cubes** is appropriate, as the 18-month milestone is 3-4 cubes and the 24-month milestone is 6-7 cubes.
- **Turning pages singly** in a book is a skill usually mastered by **24 months**, indicating this child's fine motor progress is well within the normal limit.
*Social and self-care skills*
- **Feeding with a spoon** (even if messy) is a development typically expected around **18-24 months**, demonstrating age-appropriate autonomy.
- The "messiness" is developmentally normal at this stage as **fine motor coordination** for self-feeding is still maturing.
*No developmental delay is present*
- This is incorrect because the absence of **word joining** and a limited vocabulary by nearly 2 years of age constitute a clear **language delay**.
- Standard developmental screening protocols require intervention or further assessment if a child is not using **two-word phrases** by age 2.
Question 79: A 3-year-old girl is brought to the emergency department by her mother with burns to both feet described as occurring when she stepped into a bath. The burns are symmetrical, involve both feet up to a clear demarcation line at the ankles, with sparing of the soles. There are no splash marks. The child appears withdrawn and makes little eye contact. What is the most appropriate immediate action?
A. Treat the burns, provide safety advice about bath water temperature, and discharge with follow-up
B. Admit for burns management and initiate a child protection medical assessment (Correct Answer)
C. Refer to social services for assessment within 48 hours and arrange outpatient burns follow-up
D. Document concerns in the notes, treat the burns, and discuss with the GP for community follow-up
E. Arrange a strategy discussion with police and social services before treating the burns
Explanation: ***Admit for burns management and initiate a child protection medical assessment***- The symmetrical pattern with **clear demarcation lines** and **absence of splash marks** is highly diagnostic of **forced immersion** and non-accidental injury.- Sparing of the **soles** and the child's **withdrawn behavior** necessitate immediate admission to ensure safety and conduct a formal **safeguarding evaluation**.*Treat the burns, provide safety advice about bath water temperature, and discharge with follow-up*- Discharging the child is unsafe as the clinical presentation strongly contradicts the history and suggests an **unsafe home environment**.- Providing safety advice alone is an inadequate response to suspected **physical abuse** and fails to trigger essential **child protection protocols**.*Refer to social services for assessment within 48 hours and arrange outpatient burns follow-up*- A referral within 48 hours is too slow; suspected **non-accidental injury** requires **immediate action** to ensure the child's safety.- Outpatient follow-up is inappropriate because the child remains at risk of **further harm** if not hospitalized and protected.*Document concerns in the notes, treat the burns, and discuss with the GP for community follow-up*- **GP follow-up** is secondary to the requirement for an immediate **multidisciplinary safeguarding investigation** in a hospital setting.- This approach underestimates the severity of the **red flags for abuse**, such as the **immersion pattern** that cannot be accidental.*Arrange a strategy discussion with police and social services before treating the burns*- While a **strategy discussion** is necessary, **emergency medical treatment** and stabilization of the burns should never be delayed for administrative meetings.- The correct sequence is to stabilize the patient, ensure **immediate hospital safety**, and then proceed with legal and **social services consultations**.
Question 80: A health visitor assesses a 15-month-old child at a routine developmental check. The child cannot yet walk independently but cruises around furniture confidently. She uses 3 clear words with meaning, can drink from a cup with help, and points to desired objects. She enjoys peek-a-boo and waves goodbye. What is the most appropriate next step in management?
A. Reassure the parents that development is normal and arrange routine follow-up at 2 years
B. Refer urgently to community paediatrics for assessment of global developmental delay
C. Arrange physiotherapy assessment for gross motor delay
D. Request hearing assessment and speech and language therapy referral
E. Advise encouraging walking practice and review in 2 months (Correct Answer)
Explanation: ***Advise encouraging walking practice and review in 2 months***
- Independent walking typically occurs between **12 and 18 months**; as the child is only 15 months and is **confidently cruising**, this is considered within the range of normal variation.
- Since development in **fine motor, language, and social domains** is appropriate for her age, watchful waiting with a review before the **18-month limit** is the best clinical approach.
*Reassure the parents that development is normal and arrange routine follow-up at 2 years*
- While the delay is currently minor, a child who is not walking by **18 months** must be formally investigated for underlying pathology.
- Waiting until 2 years is too long, as it misses the **clinical threshold** for specialist referral if independent walking is not achieved soon.
*Refer urgently to community paediatrics for assessment of global developmental delay*
- **Global developmental delay** is defined by significant delay in two or more domains, but this child is only showing a delay in **gross motor** skills.
- There are no **red flags** (such as regression or loss of milestones) to justify an urgent referral at this stage.
*Arrange physiotherapy assessment for gross motor delay*
- A referral to **physiotherapy** is premature as the child is already meeting the preparatory milestone of **cruising furniture**.
- Most children who cruise at 15 months will achieve independent walking by 18 months without requiring **formal intervention**.
*Request hearing assessment and speech and language therapy referral*
- Using **3 clear words with meaning**, pointing, and waving at 15 months indicates that **language and social** development are on track.
- A **hearing assessment** is not indicated as there is no evidence of speech delay or failure to respond to sound.
