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The common cause of mental impairment and the wide range of physical abnormalities is balanced chromosome rearrangement. As such, it is difficult to interpret, posing as a diagnostic challenge in human development. We present a unique case report with a denovo autosomal-balanced reciprocal translocation involving chromosomal regions 4q and 20q.The etiology of the translocation, i.e. 46,XX,t (4;20)(q28;q11) was detected by conventional high-resolution Giemsa-Trypsin-Giemsabanding technique. Parents non-consanguineous, with 2 healthy children. To the best of our knowledge this is the first case reported so far with the balanced reciprocal translocation involving 4q and 20q associated with the delayed milestone development.