Pediatric Primary Care (20 page)

2.  Sleeping surface should be firm; avoid pillows, comforters. Slats 2 3/8 in. apart; corner posts 1/16 in. high.

3.  Smoke-free environment.

4.  Remove mobiles, Venetian blind cords, other hanging toys before infant learns to pull up in crib.

V.  GROWTH AND DEVELOPMENT

A.  Growth.

1.  Infants should gain 0.5-1 oz/day or about 2 lbs/month; doubles birth weight between 4 and 6 months.

2.  Infants grow, on average, 1 in./month.

3.  Head circumference increases 0.5 cm/month.

B.  Development.

1.  Grasps objects, begins with raking motion.

2.  Brings hands together.

3.  Follows objects with eyes to 180°.

4.  Good head control. Lifts head and chest when prone.

5.  Bears weight on legs.

6.  Rolls from front to back.

7.  Rooting and palmar grasp disappear.

8.  Moro, Babinski, and tonic neck no longer as prominent, may disappear by 4 months.

9.  Begins to link event with action such as quieting when put in nursing position.

10.  Ability to wait begins to develop as infant learns to anticipate response from caregiver.

11.  Cooing, laughing, squealing. Vocalizes in variety of ways to initiate and sustain interaction.

12.  Beginning to listen when others speak.

VI.  SOCIAL DEVELOPMENT

A.  Relationships.

1.  Recognizes primary caregiver.

2.  Variety of facial expressions such as smiling, surprise, fear.

3.  Enjoys being cuddled.

B.  Environment: conditions that foster trust, positive psychosocial feelings, development.

1.  Learning to trust caretakers.

2.  Responsiveness to infant's needs and cues reinforces trust and does not result in spoiling.

3.  Smiles are purposeful.

VII.  IMMUNIZATIONS (SEE
APPENDIX A
)

A.  Review immunization schedule: DTaP #2, Hib #2, IPV #2, PCV #2, RV #2, hepatitis B if not previously started.

B.  Review immunization reactions.

VIII.  SAFETY/ANTICIPATORY GUIDANCE

A.  Always check bathwater temperature.

B.  Never leave infant alone in tub or on changing table.

C.  Use sunscreen of at least SPF 15 and avoid prolonged sun exposure.

D.  Use car seat consistently. Never leave infant alone in car.

E.  Avoid use of walkers.

F.  Begin “baby proofing”: outlet covers, door and drawer latches, safety gates. Remove cords, wires, string, plastic bags from baby's environment.

G.  Maintain smoke-free environment.

H.  If mother is returning to work, plan strategies for breastfeeding.

I.  No honey or corn syrup (Karo).

J.  Do not prop bottles. Do not put cereal in bottles.

K.  Allow infant to self-regulate amount eaten: Watch for cues, e.g., turning head away.

L.  Secure infant in highchair. Never leave infant alone in highchair. M. Encourage floor “tummy” time so infant can begin to explore surroundings.

N.  Talk, read, sing to infant.

O.  Use variety of toys/other household objects to stimulate infant. Introduce infant to different textures in toys, objects.

P.  Discuss infant's temperament and how it relates to sleep/wake activities.

Q.  Begin exploring parental ideas about discipline.

R.  Cleanse gums with soft cloth after feeding.

S.  Increased drooling indicates functional salivary glands, not teething.

T.  Stress handwashing by all caregivers.

U.  Use of cool mist vaporizers for upper respiratory illness.

V.  Review guidelines for calling healthcare provider, illness signs (i.e., fever, vomiting, diarrhea).

BIBLIOGRAPHY

Burns CE, et al.
Pediatric Primary Care: A Handbook for Nurse Practitioners.
4th ed. Philadelphia, PA: W.B. Saunders; 2009.

Centers for Disease Control and Prevention.
2011 Recommendations and Guidelines: Childhood & Adolescent Immunization Schedules.
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm
. Accessed June 2, 2011.

Dixon SD, Stein MT.
Encounters with Children: Pediatric Behavior and Development.
4th ed. St. Louis, MO: Mosby; 2006.

Hagan JF, Shaw JS, Duncan P (eds).
Bright Futures: Guidelines for Health Supervision of Infants, Children, and
Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Marcdante KJ, Kliegman RM, Jenson HB et al. (eds). Nelson Essentials of Pediatrics. 6th ed. Philadelphia, PA: Saunders; 2011.

Mindell JA, Owens JA.
A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems.
2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

Ontario Society of Nutrition Professionals in Public Health. Pediatric Nutrition Guidelines for Primary Care Providers. Ontario, CA; 2008:
http://www.osnpph.on.ca/pdfs/Improving0ddsJune-08.pdf
. Accessed June 2, 2011.

Porter RS, Kaplan JL. The Merck Manual Online:
http://www.merck.com/mmpe/index.html
. Accessed June 2, 2011.

Samour PQ, King K.
Handbook of Pediatric Nutrition.
3rd ed. Sudbury, MA: Jones and Bartlett Publishers; 2005.

CHAPTER 10

Six-Month Visit

Patricia Clinton

I.  GENERAL IMPRESSION

A.  Six-month-old infant is active, social person in family and with others although new people may be cause for some anxiety.

B.  Parents are comfortable in their role, look forward to infant's new achievements.

II.  NUTRITION

A.  Caloric and nutrient needs.

1.  95-105 kcal/kg/ day.

2.  Iron stores may not meet needs; encourage iron-fortified cereals and formulas.

3.  Nutrient needs generally cannot be met from breastmilk or formula alone.

B.  Breastfeeding.

1.  Continue to encourage breastfeeding through first year.

C.  Formula feeding.

1.  Continue with iron-fortified formula.

2.  No cow's milk until after first birthday.

D.  Solid foods.

1.  Should be offering solid foods by 6 months 2-3 times/day.

2.  Goal is to accustom infant to new textures and tastes.

3.  Introduce solids with spoon; do not put cereal in bottle.

4.  Begin with iron-fortified rice cereal; prepare with either breastmilk or formula.

5.  Progress from iron-fortified cereals to fruits and vegetables.

6.  Add new foods one at a time and start with 1-2 teaspoons.

7.  Meat not added until later in first year.

8.  Avoid feeding as a comfort measure.

E.  Eating habits/safety.

1.  No bottles in bed.

2.  Infants with strong family history of allergies avoid foods with high allergy potential (strawberries, eggs, etc.) until end of first year.

3.  No honey until after first year.

4.  Vary textures from pureed to fine grind.

5.  Eating is social time; include infant in family meals. Introduce cup. As infant's pincer grasp develops, may offer finger foods.

III.  ELIMINATION

A.  Continues to have 6 wet diapers/day.

B.  Stool consistency and color change with intake of solid foods.

IV.  SLEEP

A.  Should be sleeping through night; 9-12 hours.

B.  Naps in morning and afternoon from 30 minutes to 2 hours.

C.  Regular patterns are established although there may be occasional lapses.

D.  Continue to put to bed drowsy but awake. Encourage consistent bedtime rituals.

E.  Transitional objects continue to be important.

F.  Night feedings not needed.

V.  GROWTH AND DEVELOPMENT

A.  Doubles birth weight between 5 and 6 months. Length increases 0.5 in./ month. Growth may occur in spurts; always plot.

B.  Anterior fontanel still open, no overriding sutures palpated. Head circumference increases about 1 cm/month.

C.  Rakes objects. Grasps objects with hands. Transfers objects between hands.

D.  “Plays” with objects: drops, shakes, bangs.

E.  Sits alone or with minimal support and no head lag.