What is the appropriate intervention for a 19‑month‑old girl who is near the gross‑motor developmental cutoff but otherwise age‑appropriate in all other screening domains?

Management of a 19-Month-Old with Borderline Gross Motor Skills

For a 19-month-old girl who is near but not below the gross motor cutoff and age-appropriate in all other domains, the appropriate intervention is enhanced developmental surveillance with scheduled follow-up at the next well-child visit (typically 24 months), combined with parental education about motor-promoting activities, rather than immediate referral to early intervention or subspecialty evaluation. 1

Rationale for Watchful Waiting with Enhanced Surveillance

The American Academy of Pediatrics recommends continuous developmental surveillance with scheduled follow-up rather than immediate extensive evaluation when milestones fall within expected ranges, emphasizing the importance of ongoing monitoring for children with potential motor concerns. 2 This approach is appropriate because:

• The child has not crossed the threshold into definitive delay (she is "near" but not "below" the cutoff) 1
• All other developmental domains are age-appropriate, making isolated severe pathology less likely 1
• Normal variation exists in motor milestone achievement, and some children attain typical milestones at a later age without underlying pathology 1

Expected Gross Motor Milestones at 19 Months

At this age, you should verify the child can perform:

• Independent walking (should be well-established by 15-18 months) 2, 3
• Standing without support 2, 3
• Walking backward (emerging around 18 months) 3
• Beginning to run (emerging around 18 months) 3
• Walking up steps with hand held (emerging around 18 months) 3

Critical Red Flags That Would Change Management

If any of the following are present, immediate referral to early intervention and pediatric neurology is warranted, regardless of screening scores: 1, 2

• Regression or loss of any previously acquired motor skills (suggests progressive neuromuscular disorder) 1, 2
• Marked asymmetry in movement patterns (suggests unilateral cerebral palsy) 1, 2
• Abnormal muscle tone on examination (hypertonia or hypotonia with weakness) 4
• Absence of independent walking by 18 months (major delay requiring evaluation) 2
• Systemic symptoms such as feeding difficulties, respiratory concerns, or dysmorphic features 2, 4

Specific Follow-Up Plan

At the Current Visit:

• Perform a focused neurologic examination assessing muscle tone, deep tendon reflexes, symmetry of movement, and spontaneous motor function during play 1
• Elicit detailed parental concerns using open-ended questions about what the child is or is not doing compared to peers 1
• Correct for prematurity if the child was born before 36 weeks' gestation (adjust age for at least the first 24 months) 1, 3
• Provide anticipatory guidance on motor-promoting activities, including supervised play that encourages climbing, running, and navigating obstacles 5

Parental Instructions:

Instruct parents to return immediately if: 2

• The child loses any motor skills she currently has
• New concerns about strength, coordination, or endurance emerge
• Feeding, swallowing, or respiratory difficulties develop
• Asymmetry in movement becomes apparent

Scheduled Follow-Up:

• Reassess at the 24-month well-child visit (approximately 5 months away) with formal standardized developmental screening using a validated tool such as the Ages and Stages Questionnaire (ASQ-3) 3, 4
• At 24 months, expected gross motor skills include riding a toy without pedals and jumping up 3
• If the child remains near the cutoff or falls below it at 24 months, proceed with immediate referral to early intervention and consider pediatric physical therapy evaluation 2, 4

Common Pitfalls to Avoid

• Do not rely on informal milestone checklists alone, as they contribute to underdetection of delays; use validated screening tools at recommended intervals 3
• Do not dismiss parental concerns even when clinical observations seem reassuring; parent concern is a valid trigger for formal evaluation 2
• Do not delay evaluation if regression occurs at any point; this is a major red flag requiring immediate action 1, 2
• Do not wait for a specific diagnosis before referring to early intervention if the child crosses into definitive delay at follow-up; therapy should begin while diagnostic workup proceeds 2, 4

When to Escalate Care

Immediate referral to early intervention and pediatric subspecialists is indicated if: 2, 4, 5

• The child demonstrates definitive delay (falls below cutoff) on repeat screening
• Any red-flag features emerge during surveillance
• The child fails to achieve independent walking by 24 months
• Parental anxiety is high and reassurance alone is insufficient

This surveillance-based approach balances the risk of over-referral for normal variation against the critical need to identify true pathology early, when intervention is most effective. 1, 5