What is the best approach to help a 14-month-old child who is not standing or balancing on their own?

Approach to a 14-Month-Old Not Standing or Balancing Independently

At 14 months, inability to stand independently warrants immediate referral to early intervention services and pediatric physical therapy while simultaneously pursuing diagnostic evaluation—do not wait for a definitive diagnosis to initiate therapy. 1

Understanding Normal Development and Red Flags

• Independent standing typically emerges between 12-15 months, but failure to stand with support or bear weight on legs at 14 months represents a significant motor delay requiring evaluation 1, 2
• The American Academy of Pediatrics emphasizes that children benefit from educationally and medically based therapies even when a specific neuromotor diagnosis has not been identified 1, 2

Immediate Actions Required

Refer to early intervention services immediately without waiting for subspecialist appointments or diagnostic confirmation 1, 2

Initiate physical therapy evaluation while diagnostic investigations proceed in parallel 1, 3

Schedule pediatric neurology consultation with direct physician-to-physician communication to expedite the evaluation 1, 2

Critical Historical Elements to Obtain

• Prenatal and perinatal complications: Birth asphyxia, prematurity, NICU stay suggest risk for cerebral palsy 3
• Regression of motor skills: Any loss of previously achieved milestones is a major red flag requiring immediate evaluation for progressive neuromuscular disorders 1, 3
• Family history: Developmental delays, recurrent pregnancy loss, stillbirth, or infant death may indicate genetic etiology 3

Essential Physical Examination Components

Assess muscle tone carefully as this determines the diagnostic pathway 3:

• Increased tone suggests upper motor neuron problems like cerebral palsy and requires brain MRI 3
• Low/normal tone with weakness suggests lower motor neuron or muscle disease and requires creatine kinase (CK) and thyroid function tests 3

Evaluate for specific red flags 1, 3, 2:

• Asymmetric movements or posturing (suggests unilateral cerebral palsy) 1, 2
• Tongue fasciculations (indicates spinal muscular atrophy requiring immediate referral) 3
• Dysmorphic facial features (suggests genetic syndromes) 3, 2
• Organomegaly or signs of heart failure (may indicate metabolic diseases like Pompe disease) 3
• Respiratory insufficiency with weakness (high-risk for respiratory failure) 3

Perform standardized developmental screening using validated tools like the Ages and Stages Questionnaire 3

Initial Laboratory Testing Based on Examination

If low/normal tone with weakness 3:

• Order creatine phosphokinase (CK) and thyroid function tests (TSH and T4)
• Elevated CK may suggest muscular dystrophy

If increased tone 3:

• Brain MRI is the preferred imaging modality for suspected cerebral palsy
• Review newborn screening results to exclude metabolic disorders

Additional testing to consider 2:

• Chromosomal microarray as first-line test if dysmorphic features or multiple anomalies present
• Fragile X testing for both boys and girls with motor delays
• Metabolic screening including serum glucose, calcium, magnesium

Ongoing Monitoring and Follow-Up

Schedule early return visit within 2-4 weeks for 1, 2:

• Serial measurements of weight, length, and head circumference
• Reassessment of developmental concerns
• Review of therapy progress and subspecialist findings

Instruct parents to return immediately if 1:

• Child loses any additional motor skills
• New concerns about strength, respiration, or swallowing emerge
• Feeding difficulties develop

Identify as child with special health care needs to initiate chronic condition management and care coordination, even without a specific diagnosis 2

Common Pitfalls to Avoid

• Do not adopt a "wait and see" approach—early intervention services should be activated within weeks, not months 1
• Do not wait for subspecialist appointments to initiate therapy services—refer to physical therapy immediately while diagnostic workup proceeds 1, 3
• Do not use vague terms like "at risk of developmental delay"—if motor dysfunction is present but diagnosis cannot be confirmed immediately, use the interim clinical diagnosis of "high risk of cerebral palsy" 1
• Parent concern is valid—trigger formal diagnostic investigations even when clinical observations seem reassuring 1