Reasoning GP · Algorithm · 1-page summary
Developmental and speech delay in children
For: children with motor, speech and language, social or global developmental concerns in primary care, mainly 0–5 years. Not for: the acutely unwell child (acute pathways), established epilepsy or autism management (their own protocols). Use corrected age to 2 years.
Core rule: loss of skills is never normal — route it by speed, age and type. For any speech delay, refer to audiology and SALT (and autism or paediatric services) in parallel, never one after the other.
0Stop — act today — before any milestone check
- Infantile spasms: clusters of head drops, salaam attacks, brief flexor or extensor spasms → Same-day specialist. Do not treat in primary care.
- Rapidly progressive regression, or regression with seizures, altered consciousness, focal signs, acute gait change or suspected raised ICP → Same-day paediatrics
- New neurological signs (hypotonia, hyperreflexia, abnormal movements) or rapidly progressive weakness → Same-day paediatrics / neurology
- Seizure over 5 minutes, cannot be woken, struggling to breathe → 999. Serious safeguarding risk → Same-day paediatrics + safeguarding referral.
1Triage by pattern — corrected age
| Pattern | Route |
|---|---|
| Regression, under 3 | Language or social → autism team directly (judge medical causes) |
| Regression, other | Language over 3, or motor → Urgent paediatrics / neurology first |
| Motor milestones | Not sitting by 8 mo; not walking by 15 mo (girls) or 18 mo (boys); hand preference <1 year → Urgent child development (NG127) |
| Global delay | Two or more domains → Urgent child development / paediatrics |
2Screen — one row is enough
- Boy with Gowers', calf hypertrophy or proximal weakness → consider CK (NG127); Urgent paediatrics
- Progressive weakness, faltered growth, chest infections → Urgent neurology / genetics
- Dysmorphism, anomalies or abnormal head growth with delay → Urgent paediatrics ± genetics
- First suspected seizure → Urgent, seen within 2 weeks (NG217)
- Severe or profound hearing loss suspected → Urgent audiology; if none → Same-day paediatrics
- Unexplained injury, inconsistent history, failure to thrive → local safeguarding pathway.
3Assess — all four domains
☐ Gestation, corrected age, trajectory, Red Book ☐ Height, weight, head circumference plotted ☐ Dysmorphism, skin (ash-leaf, café-au-lait, port-wine) ☐ Tone, reflexes, gait, Gowers' ☐ Red reflex, squint, visual behaviour ☐ Otoscopy; newborn hearing and bloodspot results ☐ Joint attention, pointing
TFTs only if clinical features or newborn result uncertain. No routine bloods for isolated speech delay. Genetic, metabolic, MRI and EEG: specialist-led.
4Classify — only if the screen is negative
- Expressive delay — understands well, gestures and points → SALT + audiology; prognosis varies.
- Receptive or mixed delay — poor comprehension, more concerning → SALT, audiology, community paediatrics.
- Autism features — reduced joint attention, no pointing, repetitive behaviour → local multidisciplinary autism pathway. M-CHAT-R/F (16–30 months) is a screen, not a diagnosis.
- Glue ear — dull, retracted drum → audiology; bilateral with hearing loss, reassess at 3 months (NG233). SALT regardless.
- Motor-only delay — suspected cerebral palsy or muscle disease → child development service; physiotherapy.
- Uncertain — say so and refer in parallel; name who reviews and when.
5Treat today — only these
- Refer in parallel today: audiology + SALT (+ autism or paediatrics). Do not wait for one before another.
- Language-rich home: talk, read, sing; less background TV. Keep the home language.
- Glue ear: no antibiotics, oral or nasal steroids, antihistamines or decongestants.
- Family: ask about parental mental health (NHS Talking Therapies); carer's assessment, DLA, support organisations.
6Refer routinely
- Isolated speech concern → local Children's SALT, current route/form (confirm whether parent/carer self-referral or professional referral is needed). Over 2 with abnormal speech → consider SALT (NG127).
- Gross motor → physiotherapy; fine motor or coordination (DCD) → OT.
- Selective mutism → child mental health / psychology with school.
- Family history of intellectual disability, or consanguinity → clinical genetics. School needs → SENCo, local SEND team (EHCP).
7Never reassure by
- Bilingualism — assess all languages; delay across all of them matters.
- A passed newborn hearing screen.
- A negative M-CHAT-R/F, good eye contact or smiling.
- "Late talker" with good comprehension — still refer to SALT.
- Slow loss of skills as "a phase" — regression is never normal.
- Waiting for audiology before SALT or autism referral.
8Safety-net — say it, then document it
999 “Call 999 if a seizure lasts more than 5 minutes, your child cannot be woken, or is struggling to breathe.” Same-day “Contact us or NHS 111 the same day if your child loses skills they had, has fits or switching-off episodes, becomes weak or unsteady, has persistent vomiting, headache, odd eye movements, a fast-growing head, new swallowing or breathing problems, or becomes unwell.”
Follow-up: no fixed interval — document the next review. Check growth, medicines, safeguarding and parental wellbeing; at 3 years confirm SALT and hearing assessment done. Not attending with significant delay is a safeguarding concern.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies; any regression routed by age and type
Corrected age, domains and head circumference recorded
Audiology and SALT referred in parallel
Safeguarding considered and recorded
Safety-net given; review date and referral owner set
Summary of the full Reasoning GP developmental and speech delay algorithm, which holds the milestones, history, examination and evidence. Sources: NICE NG127, CG128, CG170, NG62, NG233, NG217; Working Together to Safeguard Children 2026; RCPCH growth charts. Clinical reference — follow local child development, SALT, audiology and safeguarding pathways; check medicines in the current BNFC.