Developmental milestones at the age of 2 months are as follows:Social and Emotional:- Begins to smile at people – Can briefly calm herself (may bring hands to mouth and suck on hand)- Tries to look at the parents Language/Communication:- Coos, makes gurgling sounds – Turns head toward sounds Cognitive (learning, thinking, problem-solving):- Pays attention to faces – Begins to follow things with eyes and recognize people at a distance – Begins to act bored (cries, fussy) if an activity doesn’t changeMovement/Physical Development:- Can hold head up and begins to push up when lying on tummy – Makes smoother movements with arms and legs

In a child with an age of 12 months – pincer grasp should be well developed. It is essential to have a good grasp of important milestones. Most 12-month-old children will be mobile, by standing holding onto a support, lifting one foot and moving it sideways (‘cruising’ around the furniture). They will demonstrate a neat pincer grasp, e.g. picking up a raisin or piece of paper between the tip of the index finger and the thumb. Words (or meaningful word-like utterances) are produced, but words are not usually chosen and put together deliberately by a child until after the second birthday (typically around the age of 30 months). Word combinations used earlier than this are likely to be an echo of a learnt phrase which may be understood by the child to be one single word even though they are a combination of more than one word (e.g. daddy, home). Building a tower of three cubes and following a one-step command such as ‘take off your socks’, is expected at 18 months.

Among the given options a 2-year-old child with normal developmental milestones will be able to pull and push large wheeled toys and squat to play with toys on the floor.Other options:- Bouncing and catching a ball is learnt by the age of 5.- The ability to pedal a tricycle should be attained by 3 years of age, not 2.- A child can walk on tip-toe by 2.5 and run on tip-toe by (option D) 3 years of age, not 2.- The ability to momentarily maintain balance using one leg (option E) should be attained by 3 years.

Primitive reflexes are central nervous system responses, many of which disappear as a child matures. Retention of these reflexes may point to atypical neurology such as in cerebral palsy or stroke. However, some persist into adulthood. The stepping reflex is present from birth and normally disappears by 6 weeks, while the moro reflex is present from birth to about 4 months. The asymmetrical tonic neck reflex disappears by about 6 months. Reflexes that persist include the head righting reflex which develops at 6 months, and the parachute reflex which develops at 9 months.

By the age of three months a child should become more fascinated with their hands and fingers| they can bring their hand to their mouth, open and close their hand, and shake and grab at dangling objects and toys. Their ability to roll over will come by the time the child is 6 months, at which time they will also be able to sit with support. Soon, at 8-9 months, attempts will be made to crawl and as they approach 12 months they will be able to pull on objects to stand.

From the given clinical scenario, the peroxisomal disorder in question is Refsum’s disease.It is characterised by anosmia, early-onset retinitis pigmentosa (night blindness), chronic ataxia, variable neuropathy, deafness and ichthyosis. It is an inherited disorder of fatty acid oxidation with phytanic acid accumulation in the blood and tissues. This leads to the motor and sensory neuropathy. Other options:- Loss of sensation in extremities, dysarthria and diabetes is suggestive of Friedrich’s Ataxia. It is the most common autosomal recessive cause of ataxia. Associated features include dysarthria, scoliosis, diabetes and hypertrophic cardiomyopathy. – Numbness of the limbs, seizures and developmental delay suggests mitochondrial cytopathy such as NARP (Neuropathy, Ataxia and Retinitis Pigmentosa). Learning difficulties, developmental delays and convulsions are not uncommon, as with many mitochondrial disorders. – Rapid, chaotic eye movements, behaviour change and irritability, suggest opsoclonus-myoclonus syndrome. It is thought to be a Para infectious or paraneoplastic condition (secondary to neuroblastoma) linked to an abnormal immune response. Children present unwell with altered behaviour, irritability, ataxia, random chaotic eye movements and later myoclonus. – Sweet-smelling urine, lethargy and seizures suggest Maple Syrup Urine Disease (MSUD). It is an autosomal recessive organic acidaemia. There is a distinct sweet odour to the urine of affected individuals, particularly at times of acute illness. Without treatment, MSUD can lead to seizures, brain damage, coma and death. The most common and classic form affects babies shortly after birth, but variant forms may not be evident until later childhood.

Fine motor development involves greater use of the hands to perform more precise tasks. By 6 -12 months children should be able to reach for small objects and pass an object from one hand to the other. From 1 -2 years they can perform more complex tasks such a building a tower of blocks, feeding themselves, and turning knobs. In terms of pencil skills, they should be able to imitate scribbles and then spontaneously scribble. By the age of 2 years they can draw a line, and by three they can draw a circle. From the age of 3.5 they can draw a cross, 4.5 – a square, 5 – a triangle, and 6 a diamond.

Toe walking refers to a pattern of walking in which the infants walk on the balls of their feet, without putting the heel of the feet on the ground. It is considered normal under the age of 2 years, but if it continues beyond that, it can signify some underlying pathology. The diseases that can be associated with toe walking include unilateral hip dislocation, Spinal tumours, Duchenne muscular dystrophy, prematurity, and cerebral palsy. Waardenburg’s syndrome is an autosomal dominant disorder, causing sensorineural deafness, and heterochromatic irises. Toe walking is not a feature.

PARACHUTE REFLEX: This reflex occurs in slightly older infants when the child is held upright and the baby’s body is rotated quickly to face forward (as in falling). The baby will extend his arms forward as if to break a fall, even though this reflex appears long before the baby walks.Newborn reflexes are:Rooting reflex:This reflex starts when the corner of the baby’s mouth is stroked or touched. The baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This helps the baby find the breast or bottle to start feeding. This reflex lasts about 4 months.Suck reflex:Moro reflex:The Moro reflex is often called a startle reflex. That’s because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his or her head, extends out his or her arms and legs, cries, then pulls the arms and legs back in. This reflex lasts until the baby is about 2 months old.Tonic neck reflex:When a baby’s head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. This is often called the fencing position. This reflex lasts until the baby is about 5 to 7 months old.Grasp reflex:Stroking the palm of a baby’s hand causes the baby to close his or her fingers in a grasp. The grasp reflex lasts until the baby is about 5 to 6 months old. A similar reflex in the toes lasts until 9 to 12 months.Stepping reflex:This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his or her feet touching a solid surface. This reflex lasts about 2 months.

Generally, bed-wetting before age 7 isn’t a concern as the child may still be developing night-time bladder control. The child is less than 5 years and most children will outgrow bed-wetting on their own. Therefore only reassurance and behavioural therapy are suggested at this stage.