Pediatric Primary Care (19 page)

F.  Ask about plans for returning to work. Discuss guidelines for selecting sitter/ daycare.

G.  May have “fussy” time of 1–2 hours/day, often in evening. Use “fussy” time as interaction time, not extra feeding. Cry gradually decreases by 3 months of age. Baby may have symptoms of “colic” (starts 2–3 weeks of age, ceases by 12 weeks). Infant cries for prolonged periods, no specific cause or etiology identified. Infant continues to grow well. Infant is alert and playful at other times. Infant may require additional comfort measures to quiet and settle and should be accepted as expected for age.

H.  Should have some supervised, “tummy” play time while awake.

I.  Encourage parent to actively talk, play with infant. Select age-appropriate toys.

VII. IMMUNIZATIONS (SEE
APPENDIX A
)

A.  Infant will receive first set of immunizations today. Combinations are available that decrease number of injections. Parents trust providers to guide them in their decision to immunize their children. Need to discuss risks and benefits of immunizations and have parent sign consent. The following immunizations are best practice for 2-month-old infants.

1.  Hepatitis B 2: After the birth dose, the hepatitis B series can be completed with either monovalent HepB or a combination vaccine containing HepB. Administer 4 doses of HepB to infants if combination vaccines with HepB are given after the birth dose.

2.  DTaP #1 (diphtheria-tetanus-acellular pertussis). Minimum age of 6 weeks.

3.  IPV #1 (inactivated poliovirus). Minimum age of 6 weeks.

4.  Hib #1 (Haemophilus influenzae type b). Minimum age of 6 weeks.

5.  PCV #1 (pneumococcal conjugate). Minimum age of 6 weeks.

6.  RV (rotavirus vaccine). Minimum age of 6 weeks. Maximum age of 14 weeks and 6 days to start series.

B.  Giving acetaminophen prophylactically after immunizations may decrease the response to the vaccine. Few infants run fevers after immunizations.

VIII. SAFETY/ANTICIPATORY GUIDANCE

A.  Needs safe sleep position “back to sleep.”

1.  Not safe for baby to sleep in adult bed.

2.  Discuss temperature of room, temperature of water, bathing safety guidelines.

3.  Discuss appropriate amount of clothing to keep baby comfortable in varied environments.

B.  Never leave baby unattended near pet or sibling.

C.  Keep hand on baby when on changing tables, sofas, avoid risk of falling.

D.  Review need for car seat that is Federal Motor Vehicle Safety tested and approved, installed properly in backseat, facing backward in automobile. Contact local hospital, fire department, or March of Dimes chapter for car seat rental program.

E.  No smoking around infant.

F.  To treat constipation, advise giving extra water (no more than 1 oz/day).

G.  No solids should be offered. Offer pacifier if acting “hungry” or going to nap.

H.  Make sure smoke detectors are installed and functioning in home. Home should have working fire detectors, a fire evacuation plan, and periodic drills to ensure preparedness.

I.  Limit sun exposure, use sunscreen with SPF rating of at least 15 if out for even 15 minutes of direct sun exposure. Protect babies by using hats and long sleeve shirts and pants.

J.  Baby will be seen for regular appointment again at 4 months. Discuss skills infant will acquire and how to work with baby to learn them: babbling, cooing, trying to roll over, and more. Discuss second set of immunizations, similar to what baby had at this visit.

K.  Remind parents of when and how to call the healthcare provider.

1.  Breathing difficulties.

2.  Seizures.

3.  Irritability.

4.  Poor feeding, vomiting.

5.  No urine output in 12 hours, black/decreased bowel movements.

6.  Any fever.

7.  Praise the parents for all that they are doing for the infant.

BIBLIOGRAPHY

Back to Sleep, Tummy to Play. Healthy Child Care America; 2009:
http://www.healthychildcare.org/pdf/SIDStummytime.pdf
. Accessed June 2, 2011.

Car Safety Seats: A Guide For Families 2011. American Academy of Pediatrics Healthy Children website:
http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx
. Accessed July 20, 2011.

Centers for Disease Control and Prevention.
Growth Charts for Birth through 36 Months.
CDC website:
http://www.cdc.gov/growthcharts/clinical_charts.htm
. Accessed June 2, 2011.

Dowshen S.
Choosing Child Care.
KidsHealth from Nemours; 2007:
http://kidshealth.org/parent/positive/amily/child_care.html
. Accessed June 2, 2011.

Hagan JF, Shaw JS, Duncan P, eds.
Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents.
3rd ed. American Academy of Pediatrics;2008:
http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html
. Accessed June 2, 2011.

Oral Health Initiative: Protecting All Children's Teeth: Nonnutritive Sucking, Pacifiers. American Academy of Pediatrics; 2010:
http://www.aap.org/oralhealth/PACT/ch8_sect1b.cfm
. Accessed June 2, 2011.

Port Washington Fire Department.
E.D.I.T.H. Exit Drills in the Home.
http://www.pwfd.com/content/850_fs3.html
. Accessed August 9, 2011.

Recommended Immunization Schedule for Persons Aged 0 through 6 Years–United States 2010. Centers for Disease Control and Prevention website:
http://www.cdc.gov/vaccines/recs/acip
. Accessed June 2, 2011.

Soloway KB.
Prophylactic Acetominophen could lower response to childhood immunizations.
Medscape Today; 2009:
http://www.medscape.com/viewarticle/712540
. Accessed June 2, 2011.

Task Force on Sudden Infant Death Syndrome.
The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk.
American Academy of Pediatrics website:
http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;116/5/1245
. Accessed June 2, 2011.

Tips and Tools: Safety for Your child; Birth to 6 Months. Retrieved from
http://www.healthychildren.org/english/tips-tools/Pages/default.aspx
. Accessed June 2, 2011.

White J.
Overview of Infacnt Colic.
http://baby.about.com/od/healthandsafety/p/infant_colic.htm
. Accessed June 2, 2011.

CHAPTER 9

Four-Month Visit

Patricia Clinton

I.  GENERAL IMPRESSION

A.  Four-month-old infant is generally well integrated into family unit, interacts with family members, is beginning to actively explore environment by making more purposeful movements.

B.  Patterns of sleeping, eating, elimination are fairly well established.

IIs.  NUTRITION

A.  Caloric needs: 98-108 kcal/kg/day.

B.  Breastfeeding.

1.  Recommended as sole source of nutrition.

2.  Infant easily distractible.

3.  Support mother in continuing to nurse throughout first year.

4.  Vitamin D supplementation recommended at 400 IU/day.

C.  Formula feeding.

1.  Iron-fortified only.

2.  No cow's milk of any kind.

D.  Introduction of solids.

1.  May begin after 4-month visit.

2.  Preference is to postpone until 6 months to minimize allergies.

3.  Introduce solids when tongue thrust diminishes, infant has good head control (see
Chapter 10
).

III.  ELIMINATION

A.  Voiding pattern.

1.  Average 6-8 wet diapers/day.

2.  Illness (fever, vomiting, diarrhea) associated with decreased voiding and concerns of dehydration.

B.  Stooling pattern.

1.  Breastfed infants generally have 1 stool/day to 1 stool every 7-10 days.

2.  Consistency more important than frequency.

3.  Stools should be soft, semiformed, odor not offensive.

4.  Formula-fed infants generally have 1 or more stools/day, color varies by formula, may be more odiferous.

IV.  SLEEP

A.  Requirements.

1.  Nighttime 9-12 hours; may still waken for nighttime feedings.

2.  Naps 2-4 times/day; 30 minutes to 2 hours.

B.  Environment.

1.  Begin to establish consistent bedtime routine.

2.  Put to bed drowsy but awake.

3.  Room temperature should be temperate and not excessively warm.

4.  Transitional object such as blanket may be comforting.

5.  Room dim, may use night-light.

6.  Cosleeping is family/culturally determined; encourage discussion, avoid being judgmental; safety should be focus.

7.  Avoid bottles in bed.

C.  Safety.

1.  Put to bed on back. Once he/she rolls over, infant determines position during sleep.