What is the best course of action for a 6-month-old infant who is not rolling over?

Immediate Referral for 6-Month-Old Not Rolling

A 6-month-old infant who is not rolling over requires immediate referral to early intervention services and concurrent referral to pediatric physical therapy and pediatric neurology for comprehensive neuromotor evaluation. 1, 2

Why This Is Urgent

Rolling is typically established by 6 months of age, and absence at this milestone represents a significant motor delay requiring prompt evaluation. 2 The concern is heightened because:

• Cerebral palsy can now be accurately diagnosed before 6 months' corrected age using validated tools with 86-98% sensitivity, making early identification and intervention critical for optimizing long-term outcomes. 1
• Motor delays at 6 months may signal serious underlying neuromuscular disorders including cerebral palsy, spinal muscular atrophy, or other progressive conditions that benefit from early diagnosis and intervention. 1, 3

Specific Red Flags to Assess Immediately

Before referral, evaluate for these concerning features that indicate higher urgency:

• Regression of any previously acquired motor skills (major red flag for progressive neuromuscular disorders requiring immediate evaluation) 2
• Hypotonia (floppiness or decreased muscle tone) 1, 3
• Asymmetry in movement patterns or persistent one-handed activities (suggests unilateral cerebral palsy) 2
• Feeding difficulties, tongue fasciculations, or respiratory abnormalities (may indicate spinal muscular atrophy or other serious conditions) 3
• Inconsistent or poor head control in prone position at this age (suggests weakness or abnormal tone) 2
• Dysmorphic features (warrant earlier subspecialist referral) 1

Immediate Action Steps

Step 1: Refer to Early Intervention Services

• All children with suspected motor delay should be referred to early intervention or special education resources immediately, even before a specific diagnosis is established. 1
• Children with motor delays benefit from educationally and medically based therapies regardless of whether a specific neuromotor diagnosis has been identified. 1

Step 2: Concurrent Referral to Physical Therapy

• Refer to pediatric physical therapy while diagnostic investigations proceed. 1, 2
• Do not wait for subspecialist appointments to initiate therapy services. 1

Step 3: Refer to Pediatric Neurology

• Direct physician-to-physician communication is recommended when motor delays are identified. 1
• The neurologist will conduct comprehensive neuromotor examination and may utilize validated assessment tools including the Hammersmith Infant Neurological Examination (HINE) with 90% sensitivity for detecting cerebral palsy risk. 1

Step 4: Consider MRI if Available

• Neonatal or infant MRI has 86-89% sensitivity for detecting cerebral palsy when safe and feasible. 1
• This decision should be made in consultation with pediatric neurology. 1

Interim Diagnosis While Awaiting Evaluation

If motor dysfunction is present but diagnosis cannot be confirmed immediately, use the interim clinical diagnosis of "high risk of cerebral palsy" rather than vague terms like "at risk of developmental delay." 1 This ensures:

• The infant receives cerebral palsy-specific early interventions that differ from general developmental interventions. 1
• Regular medical, neurological, and developmental monitoring continues. 1

Common Pitfalls to Avoid

• Do not adopt a "wait and see" approach. The outdated concept of a "silent period" before 12-24 months where cerebral palsy cannot be identified is no longer valid. 1
• Do not delay referral waiting for other milestones to clarify the picture. Early intervention improves outcomes, and therapy should begin while diagnostic workup proceeds. 1, 2
• Do not dismiss parental concern. Parent concern is a valid reason to trigger formal diagnostic investigations even when clinical observations seem reassuring. 2
• Do not confuse motor milestones with intellectual capacity. Motor delays indicate motor dysfunction but do not necessarily predict cognitive outcomes. 4

Follow-Up Instructions for Parents

Instruct parents to return immediately if the child: 2

• Loses any additional motor skills (regression)
• Develops feeding, swallowing, or respiratory concerns
• Shows worsening weakness or decreased movement

Timeline Expectations

While awaiting subspecialist evaluation (which may have long wait times in some areas), ensure: 1

• Early intervention services are activated within weeks, not months
• Physical therapy evaluation occurs promptly
• Close developmental monitoring continues with frequent return visits 1