Sudden Refusal to Walk in a 21-Month-Old

Clinical Assessment and Diagnosis

The American Academy of Pediatrics recommends determining the onset and progression of refusal to walk, as sudden refusal is associated with serious underlying disease in the majority of cases, and assessing for fever presence, pain localization, and recent trauma or falls 1
A comprehensive history should include questions about systemic symptoms, such as fever, irritability, decreased oral intake, or changes in level of alertness, which may indicate septic arthritis, osteomyelitis, or meningitis 1
The American Academy of Pediatrics suggests that loss of other motor skills, such as regression of previously acquired abilities, would indicate progressive neurologic disease 2, 3
A focused physical examination should include observation of spontaneous movement, watching the child play and move without forced examination, and noting if they move all extremities symmetrically, bear weight when held upright, or demonstrate pain with specific movements 1, 4
The American Academy of Pediatrics recommends a systematic musculoskeletal examination, palpating all long bones, joints, and spine for tenderness, swelling, erythema, or warmth that may indicate infection or fracture 1
A neuromotor assessment should evaluate muscle tone, strength through functional observation, deep tendon reflexes, and presence of Gower maneuver when attempting to stand 1, 4, 5

The American Academy of Pediatrics suggests that for acute presentation with focal findings, laboratory evaluation should include CBC, ESR, and CRP, and imaging should start with plain radiographs of the affected area to evaluate for fracture or bone lesions 1
Advanced imaging, such as bone scan or MRI, should be considered if radiographs are negative but symptoms persist with localized findings, to detect occult fractures, osteomyelitis, or septic arthritis 1
For non-focal presentation without clear etiology, a comprehensive neuromotor examination should assess for hypotonia with weakness, which may indicate neuromuscular disorders 5
Laboratory screening should include measurement of serum creatine phosphokinase (CK) and thyroid-stimulating hormone (TSH) concentrations to screen for muscular dystrophy and hypothyroidism 1, 4, 5

The American Academy of Pediatrics recommends immediate evaluation by pediatric neurology for comprehensive neuromotor evaluation if neuromuscular etiology is suspected, even before diagnostic workup is complete 1, 3
Early intervention services should begin immediately for suspected motor delays, not after subspecialist evaluation is complete 1, 3
The American Academy of Pediatrics suggests that CK and TSH should be obtained as initial screening for common neuromuscular disorders 1, 4, 5
Brain MRI should be considered in consultation with neurology if cerebral palsy or central nervous system pathology is suspected 3

True regression, loss of previously attained motor skills, indicates possible progressive neuromuscular or neurologic disorder and requires urgent subspecialist referral 1, 3
Asymmetric movements, persistent use of only one side of the body, or marked asymmetry suggests unilateral cerebral palsy or focal neurologic lesion and requires urgent subspecialist referral 1, 3
Abnormal muscle tone, either hypertonia or hypotonia with weakness, requires neurologic evaluation 1
The American Academy of Pediatrics recommends maintaining a high index of suspicion and pursuing further diagnostic evaluation if symptoms persist beyond 48-72 hours 1