Well Child Visit Guidelines and Anticipatory Guidance

Well Child Visit Guidelines and Anticipatory Guidance
2-WEEK WELL CHILD VISIT
This is the settling-in period for parents and baby. Adequate physical care and development of emotional ties are the essential factors to be evaluated.
  • Overview
    • Parents
      • Adjustment to new responsibilities and appreciation of continued emotional stress and fatigue
      • Identification of any high-risk factors
    • Mother
      • Physical status
      • Breastfeeding (see Breastfeeding Guidelines, p. 24)
        • Attitude toward new child
        • Identification of postpartum depression. Use Edinburgh Postpartum Depression Scale (EPDS) to screen (http://www.dbpeds. org/media/edinburghscale.pdf)
    • Newborn
      • Physical
        • Quality of care: Consistent caregiver responding to needs of newborn
        • Good color, lusty cry
        • Sleeping and nursing appropriately
        • Physical problems not already under care identified and treated or referred
      • Emotional
        • Quieting easily: Contented newborn
        • Responding to parents by eye contact
      • Intellectual: Searching for eye contact with caregiver
    • Risk factors
      • Apathetic
      • Low weight gain
      • Cannot be comforted
      • No consistent, loving caregiver
      • Postpartum depression in mother
    • See guidelines for specific factors to be noted in physical examination.
  • Injury prevention
    • Review safety protocol.
    • Safe environment
      • Cradle or crib in safe area
      • Back to Sleep: Newborn not placed on soft mattress, couch, bean bag, fluffy blankets
      • Newborn not sleeping in bed with adult
      • Siblings and pets supervised
      • Appropriate car seat. Never hold infant in lap. (See current car seat recommendations, available at: http://www.aap.org/healthtopics/carseatsafety.cfm.)
    • At-risk caregivers
      • Difficult responses to birth and postpartum recovery
      • Inadequate support system, and basic needs not being met
    • Fear of violence or abuse; not all injuries are accidents.
  • Child abuse
    • Physical identification
      • Failure to thrive; physical bruises, burns
      • Any injury with delayed office visit or unreliable history
    • At-risk newborn
      • Cranky newborn
      • Physical abnormalities
      • Premature birth
    • Identify:
      • Siblings and adults near baby who have aggressive behavioral patterns
      • Alcohol and drug abusers and those with history of being physical abusers or being abused
  • Developmental process
    • Parents
      • Energy level and general health adequate for demands of family and baby
      • Expectations of having and caring for baby and expectations of baby’s physical appearance fulfilled and accepted
      • Acceptance of and coping with actual situation
      • Report of parents being threatened or abused as children
    • Baby
      • Good sucking instinct, eats and sleeps well, gains weight
      • Cries appropriately and quiets easily
      • Responds to parent’s voice, touch, and presence
  • Family status
    • Basic needs being met (referrals as needed with follow-up)
    • Family members
      • Adjusting to change in family routine
      • Appreciating emotional stress during this adjustment period
    • Support system
      • Father gives help and gets pleasure from new role
      • Mother has time to regain energy, catch up on sleep, and have free, peaceful periods with baby
    • Health status of all family members reviewed
  • Health habits
    • Nutrition
      • Mother
        • Happy with decision to breastfeed or bottle feed
        • Adequate diet, weight control (referrals as needed)
      • Newborn
        • Stomach holds about 4 oz and empties every 3 to 4 hours. Digestive system is still immature, so formula or breast milk is the only food appropriate at this time.
        • Requirement: 50 cal/lb/d or 110 kcal/kg/d, so a 10-lb baby needs 10 × 50, or 500 cal/d; a 4.54-kg baby needs 4.54 × 110, or 500 cal/d.
        • Standard formulas and breast milk have 20 cal/oz.
        • 500 cal divided by 20 cal/oz = 25 oz or 750 mL of formula per day
        • Number of feedings and amount per 24 hours
        • If reflux occurs, identify whether too many ounces are being given. Advise caregiver to prop baby up after feedings.
        • Projectile vomiting (refer to physician)
        • Burping gently accomplished
        • Satisfaction: Baby sleeps for up to 2 hours after feedings.
        • Formula with vitamins, iron, and fluoride per office protocol
    • Sleep
      • One or two sleep periods of up to 5 to 6 hours per 24 hours (individual pattern depends on temperament and energy level)
      • Awake for feedings every 3 hours (more or less)
      • Awake for only short periods and seldom awake without fussing
      • Sleeps through household noises; turns off stimuli, so quiet environment is unnecessary
    • Elimination
      • Stools
        • Breastfed baby: Stools with every feeding, not formed, yellow
        • Formula-fed baby: Stools less frequent, less loose, and stronger in odor than if on breast milk; light brown
      • Urine: Light in color, no odor; wet diaper at each feeding
  • Growth and development
    • Physical
      • Central nervous system: Most important and fastest-growing system, as brain cells are continuing to develop in both size and number. Effects of severe nutritional deprivation at this time cannot be reversed.
        • Holds head up when prone, to side when supine
        • Hands in fist; palmar grasp
        • Intense startle reaction
        • Vision: At age 2 weeks, baby is alert to moving objects and is attracted to light objects and bright color. Convergence and following are jerky and inexact.
        • Movements are uncoordinated but smooth.
        • Lusty cry
      • Cardiovascular system: The efficiency of this system is identified by the following:
        • Good color of body and warmth of extremities
        • Energy and vigor of activity
        • Increase of color during stress
      • Respiratory system: Breathing is still rapid and irregular.
      • Immune system
        • Antigen-antibody response is present by 2 weeks of age, so immunization program can be started then.
        • Maternal antibodies, which help protect baby from infection, are present.
    • Emotional development. Erikson: Trust vs. Mistrust. Quality of care provided can form the basis for baby’s feelings and attitudes toward self and the world.
      • Parents
        • Obtain gratification from child care
        • Feel adequate to care for baby
        • Have adequate support system; basic needs being met
      • Baby
        • Adequate physical development
        • Searching for mother’s face; making eye contact; smiling
        • Contented baby
    • Intellectual development. Piaget: Sensori-motor response. Stimuli to the five senses are the tools through which baby responds to environment.
      • Parents: Understand crying as instinctive response to other discomforts besides hunger
      • Baby: Individuality of response pattern becoming evident. Innate reflex responses guide spontaneous behavior.
  • Risk factors
    • Mother
      • Overload of responsibilities, inadequate support system
      • Low energy level and health problems
      • Distressed by child care
      • Postpartum depression
    • Newborn
      • Poor feeding habits, possible dehydration
      • Lags in physical development
      • Cannot be comforted
      • Low weight gain
  • Physical examination
    • Growth
      • Weight gain 1 oz/d or about 2 lb/month
      • Use CDC growth charts (2000), available at: http://www.cdc.gov/growthcharts
      • Calculate BMI at every well child visit during childhood (see Barlow, 2007; Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report).
      • Fontanelles: Measure and record on growth charts until age of 3 years
      • Developing consistent growth curve
    • Appearance and behavior
      • Movements uncoordinated but vigorous
      • Intensity of startle reaction with easy quieting
      • Alert when awake; falls asleep easily
      • Good color, rapid change in color with activity and crying
    • Specific factors to note during routine physical examination
      • Head: Configuration and smooth movement, bulging or depressed anterior fontanelle; seborrhea
      • Eyes: Red reflex, discharge, reaction to light
      • Mouth: Thrush (irremovable white spots on tongue). Tongue should be able to protrude beyond lips.
      • Chest: Abdominal respirations, irregular rate
      • Heart: Refer to physician if abnormal heart sounds are present that have not been previously diagnosed. Sinus arrhythmia continues to be present; normal rate 100 to 130 beats/min
      • Abdomen: Navel, liver, spleen, femoral pulses, hernias
      • Extremities: Range of motion; hips; check for leg folds and abduction
      • Skin: Rashes, hemangiomas (measure and record)
    • Parent-child interaction
      • Parent: Expression of fatigue and nervousness in handling baby, and in ability to quiet baby (referrals or home visit)
      • Baby: Positive response to attention
      • Referrals to help parents develop positive attitudes toward their new roles
  • Assessment
    • Physical
    • Developmental
    • Emotional
    • Environmental
  • Plan
    • Immunization per office protocol
    • Fluoride, vitamins, and iron per office protocol
    • Problem list (devised with parent): SOAP (Subjective Data, Objective Data, Assessment, and Plan) format for each
    • Appropriate timing for office, home, or telephone visits
ANTICIPATORY GUIDANCE FOR THE PERIOD OF 2 TO 8 WEEKS
This is a quiet period of settling into a scheduled daily routine. It is also a time for parents to become sensitive to the individuality of the baby’s reactive pattern and to the interactive relationship that is being established between the mother and baby and the baby’s special response to the father’s or partner’s attention.
  • Overview
    • Parents
      • Becoming aware of baby’s reactive pattern and interactive relationship with baby
      • Check Breastfeeding Guidelines, p. 24.
      • Continue to monitor for postpartum depression
    • Baby
      • Physical
        • Smoother muscular movement
        • Hands reaching out
        • Settling in to a feeding and sleeping schedule
      • Emotional
        • Responding appropriately to type of care being given
        • Fussy baby needs careful investigation
      • Intellectual
        • Curiosity shown by searching with eyes and reaching out with hands
        • Responding by smiles and eye contact
          • Stimulation (see protocol, p. 37)
    • Watch for:
      • Family realizes this is an adjustment period and copes with new problems.
      • Baby sleeps and feeds without difficulty.
      • Baby progresses from innate reflex movements of sucking and grasping to kicking and crying.
      • Baby repeats purposeful actions, such as grasping objects (but does not let go at will), reaches out with arms when being picked up, and cries more selectively.
      • Baby turns to localize sound and quiets to pleasant music (still startled reaction to loud, sudden noise).
      • Baby accepts new experiences.
        • Expect fussing, but will eventually accept a different crib
        • Supplemental bottle for breastfeeding baby
        • Change of caregiver
      • Baby’s observation of caregiver
        • Eye contact
        • Baby’s facial expression changes on attempts to vocalize.
  • Expectations of this period
    • Parents
      • Developing confidence in ability to interpret baby’s needs
      • Enjoying and satisfied with new role
      • Understanding and coping with own physical and emotional status
    • Baby
      • Still settling into pattern of sleeping, feeding, and wakefulness
      • Quieting easily when needs are met
  • Family status
    • Basic needs being met; referrals as needed with follow-up
    • Parents adjusting to their new roles
    • Appropriate support systems available. Father or partner takes on some of the childrearing role.
    • Identify sexual abuse of or by any family members.
  • Health patterns
    • Nutrition
      • Formula or breast milk the only food necessary due to immaturity of gastrointestinal tract and slow development of digestive enzymes
      • Supplements of vitamins, iron, and fluoride per office protocol
    • Elimination
      • Stools continue to be loose.
      • Urine light in color and odorless. If this changes, identify the cause because this change can be an early indication of dehydration. Call the office if it continues.
  • Interpreting baby’s signals
    • Crying after feeding and diapering
      • Physical discomfort
        • Bowel movement: It is helpful to have something for the infant’s feet to push against. Hold the baby over the shoulder with one hand and place the other hand on the soles of the feet.
        • An air bubble in the stomach takes up space, is uncomfortable, and prevents the baby from eating as much as desired. Lay the infant across the parent’s folded knees with head resting on the adult’s arms. Hold one hand on the baby’s abdomen and gently rub back in an upward motion.
        • Diaper rash
          • Leave diapers off for short periods of time, if possible.
          • Try another brand if using disposables.
          • If using cloth diapers, change soaps, rinse well, and use vinegar in the final rinse.
          • Call the office if there is no improvement and report any vaginal irritation.
      • Missing physical contact and sounds heard in utero
        • Warmth and snugness: Wrap blankets tightly around baby and provide body support.
        • Music: Lullabies are important; recordings make it easy to supply music.
        • Rocking: Cradles and rocking chairs have proved effective over the years.
      • Need for stimulation
        • Fussing can be a way for baby to say he or she is not ready to go back to sleep.
        • Use a baby chest carrier: Baby enjoys parent’s heart sounds and motion.
        • Take a bath with the baby.
        • Air baths allow freedom of movement: Change baby’s position from back to stomach. Encourage tummy time while awake.
        • Take baby outdoors for a change of colors, sounds, and temperature.
        • A car ride can be used to calm baby down.
        • Change of caregiver to hold and talk to baby is helpful.
    • Continued fussing
      • Clothes may be uncomfortable; baby may be too hot or too cold.
      • Colic
        • Breastfeeding baby
          • Smaller and more frequent feedings
          • Mother’s diet: Restrict to simplest foods; no colas, coffee, tea; no medications or vitamins; add one food back at a time, and see if there is any change in behavior.
        • Formula-fed baby
          • Smaller and more frequent feedings
          • Eliminate vitamins and fluoride for a few days.
        • Return for medical check-up if no improvement.
        • Obtain extra caregivers so mother can get adequate rest.
  • Stimulation
    • Stimulation depends on baby’s energy level and individuality.
    • Baby reacts to stimulation of all the senses: Taste, touch, smell, sight, and hearing.
    • Caregiver interprets baby’s signals for rest and quiet, such as:
      • Overactive
      • Turning away
      • Fussing
    • Caregiver can provide proper stimulation by spending time feeding, holding, and rocking baby; changing baby’s position; establishing eye contact; and talking and singing to baby.
    • Suggested crib toys
      • Noisy clocks, music
      • Paint a happy face on a paper plate and hang it about 10 inches from the baby’s face, or attach it to side of crib.
  • Safety
    • Accidents happen most frequently:
      • When routine changes (holidays, vacations, illness in the family)
      • After stressful events for caregivers
      • When caregivers are tired or ill
      • Late in the afternoon
    • Accident prevention
      • Crib: Slats no more than 2 3/8 inches apart; firm mattress; no plastic used as mattress cover; crib bumpers
      • House: Fire alarm system; fire escape plan; no smoking in nursery or house. Baby should never be left alone in house for even 1 minute.
      • Carrying: Football carry, with baby on hip with hand holding and protecting head; other hand free to prevent caregiver from falling
      • Car: Follow federal car seat mandate (see http://www.aap.org/healthtopics/carseatsafety.cfm)
      • Baby seat: Sturdy, broad-based; placed in safe, protected spot
    • Not all injuries are accidents. Investigate possible child abuse and neglect.
    • Babysitters
    • Emergency telephone numbers posted
  • Asking for help
    • Appreciate importance of establishing a good working relationship with baby
    • Concerns and problems need to be evaluated.
    • Telephone contact available with pediatric nurse practitioner; home visits, office visits, referrals made as needed
    • Resources
      • Support group of relatives, friends, community group
      • Information on child care: Library can provide reading list.
  • Mother’s plans to return to work
2-MONTH WELL CHILD VISIT
The continued close symbiotic relationship of parents and infant is characterized by the stabilization of physical systems and feelings of contentment and pleasure for parents and baby.
  • Overview
    • Parents
      • Evaluation of new role
      • Identification of baby’s developing skills and reactive patterns
      • Identification of any abuse of family members
    • Infant
      • Physical
        • Growth pattern, eating, and sleeping schedule evaluated
        • Health problems identified
      • Emotional
        • Contented infant: Social smile
        • Reacting to caregiver with enthusiasm
      • Intellectual
        • Responding to caregiver with smiles and vocalizing
        • Watching more intently
        • Reaching out to feel and touch
    • Risk factors
      • Fussy or apathetic baby needs further investigation.
      • Mother’s fear of abuse of self and infant
    • See Injury Prevention Guidelines, p. 20.
  • Injury prevention guidelines
    • Review safety protocol.
    • Age-appropriate precautions
      • From cradle to crib as baby’s size indicates
      • Cradle in safe area; siblings supervised
      • Crib: Away from windows with cords from blinds and curtains or drapes that could fall into crib
      • Sleeping on back, not sleeping in bed with adult
      • Siblings and pets supervised when near baby
      • Baby not left alone on changing table, bed, couch, bean bag, or floor
      • Limited use of swings and car seats to avoid too much pressure on lower spine
      • Supervised exercise on floor or in tub
      • Water safety: Baby can drown in less than 1 inch of water.
      • Choking: Good habit to begin keeping small objects out of baby’s area; cords from toys and cradle gyms should be secured.
      • No smoking in house; check other caregivers.
      • Prevent caregiver from falling by keeping stairs and floors clear of clutter. Carry baby so caregiver has one hand free to catch self if he or she trips.
      • Use chest packs carefully; follow manufacturer’s instructions.
      • Appropriate car seats (see http://www.aap.org/healthtopics/carseatsafety.cfm)
    • See protocol for special at-risk caregivers.
    • See protocol for frequency of accidents. Not all injuries are accidents; check for abuse.
  • Child abuse
    • Age-specific concerns for safe environment
    • Physical identification
      • Failure to thrive: Burns, bruises, apathetic, difficult to comfort
      • Family presenting with unnecessary visits
      • Any injury with delayed office visit or unreliable history
    • At-risk baby
      • Difficult to care for
      • Continuing physical problems
    • Identify:
      • Caregivers, adults, and siblings with at-risk patterns of behavior.
      • Abuse of other family members
  • Developmental process
    • Parents
      • Deriving pleasure and satisfaction from care of baby
      • Developing confidence in ability to understand and fulfill baby’s needs
      • Establishing consistent schedule
    • Baby
      • Normal developmental pattern
      • Cries appropriately and quiets easily
  • Family status
    • Lifestyle: Adequate housing and finances to meet needs
    • Parental roles: Establishing responsibilities; feeling gratification and pride in new roles
    • Siblings: Parental understanding of siblings’ reactions to changes
    • Concerns and problems: Ability to identify problems and to cope; referrals as needed
    • Parents
      • Physical status: Energy level, postpartum examination, family planning
      • Emotional stability: Satisfactory support system; pride and pleasure in baby
      • Appropriate plans for returning to work: Continuing breastfeeding, supplemental feedings, breast pump available, reliable caregiver
      • Identifying if any member of family is being abused
  • Health habits
    • Nutrition
      • Mother
        • Breastfeeding: Understanding of dietary requirements
        • Weight control
        • Establishing a feeding schedule
      • Infant
        • Formula or breast milk continues to be adequate nutrition because immaturity of gastrointestinal tract and slow development of digestive enzymes can cause difficulties if other food is added.
        • Vitamin D supplementation 400 IU/day by 2 months of life for all breastfed infants unless they are weaned to at least 500 mL/d of vitamin D-fortified formula or milk. All non-breastfed infants who are ingesting less than 500 mL/d of vitamin D-fortified formula or milk (see Gardner & Greer, 2003).
        • Feedings: Showing satisfaction, sucking strength, beginning to establish a schedule
        • Requirement: 50 cal/lb/d or 110 kcal/kg/d, so a 10-lb baby needs 10 × 50, or 500 cal/d; a 4.54-kg baby needs 4.54 × 110, or 500 cal/d
        • Standard formulas and breast milk have 20 cal/oz.
        • 500 cal divided by 20 cal/oz = 25 oz or 750 mL of formula per day
    • Sleep
      • Mother needs at least one sleep period of 6 hours for sufficient deep sleep.
      • Infant
        • Has one sleep period of up to 6 to 7 hours and sleeps a total of 14 to 16 h/d
        • Filters out household noises
        • Awake for longer periods without fussing
    • Elimination
      • Bowel movements at each feeding; continue to be loose
      • Urine: Light in color, little odor; strong odor and dark color indicate need to investigate for dehydration.
  • Growth and development
    • Physical
      • Central nervous system
        • Head is not held at midline
        • Arms have random movements.
        • Hands are held in fists, thumbs inside.
        • Startle reflex is less intense.
      • Gastrointestinal system
        • Sucking reflex continues to be strong.
        • Satisfaction is important: If not met by frequent feedings, pacifier is helpful.
        • Swallowing from a spoon is difficult because tongue thrust still occurs.
        • Drooling and taste buds are not present until 3 months of age.
        • Stomach somewhat larger; now holds 4 to 6 oz and empties every 3 to 4 hours
        • Frequent watery stools continue because intestinal tract is immature and cannot absorb fluids well.
      • Excretory system
        • Immature kidney structure affects stability of fluid and solute balance.
        • Wet diaper at each feeding
        • Urine: Light in color
      • Immune system: Still somewhat protected by mother’s immunity
        • Antigen-antibody response present by 2 months of age: Immunizations per office protocol
        • Maternal antigens still present in bloodstream
    • Emotional development. Erikson: Basic trust. Close symbiotic relationship of parents and child continues to envelop baby in an environment without stress. Needs of food, warmth, and human contact must be met to continue the establishment of security and trust in baby’s new world.
      • Parents
        • Able to quiet baby
        • Make eye contact with baby
        • Respond to and appreciate baby’s developing activities
      • Infant
        • Consistent physical growth
        • Self-quieting
        • Cries appropriately
    • Intellectual development. Piaget: Baby is learning through sensorimotor response to bodily needs. Eye contact and a responsive smile or irritability are early indications that baby is taking in the world around him or her.
      • Parents
        • Understand that crying is an instinctive response to discomfort.
        • Take time and interest to understand baby’s signal of distress
        • Spoiling is not an issue at this age; a crying baby needs attention.
      • Infant
        • Low patience level; cannot postpone, need satisfaction; does not anticipate, so unable to wait
        • Language begins with random vocalizing other than crying.
        • Begins to make different sounds for different needs, such as whimpering for unhappiness and cooing for contentment
  • Risk factors
    • Parents
      • Lack of pride in baby
      • Unresponsive or over-responsive to baby
      • Low energy level
      • Inadequate support system
    • Infant
      • Poor feeding habits; weak sucking reflex
      • Lethargic
      • Cannot be comforted
      • Stops crying and fussing only with difficulty
      • Does not respond to soothing music. Stops at loud unpleasant noises (such as vacuum cleaner) to shut out the world around him or her.
    • Child abuse high-risk indicators
      • Parents
        • Cannot quiet baby
        • Overwhelmed by child care and dissatisfied with parental role
        • Mother fears for her own safety
        • Isolated from friends and relatives
        • History of child abuse in their own lives
        • Alcohol, drug and/or substance abuse
  • Physical examination
    • Growth
      • Length and weight: Coordinate within two standard deviations on growth charts. Use CDC growth charts (2000), available at: http://www.cdc.gov/growthcharts
        • Weight gain: 1 oz/d or 2 lb/month
        • Length increase: 1 in./month
        • Calculate BMI at every well child visit during childhood (see Barlow, 2007).
      • Fontanelles: Measure and record
    • Appearance and behavior
      • Alertness: Eye contact, responsive smile
      • Activity level: Smooth, uncoordinated movement with less vigorous movements in legs than in arms
      • Color: Pink; color changes quickly with activity level and temperature of environment.
    • Specific factors to note during routine physical examination
      • Head: Configuration and smooth movement; bulging or depressed anterior fontanelle; seborrhea
      • Eyes: Smooth tracking, reaction to light, dacryostenosis, discharge; tears present from 2 to 3 months of age
      • Mouth: Check for thrush (irremovable white spots on tongue). Tongue should be able to protrude beyond lips.
      • Chest: Abdominal respirations, irregular rate
      • Heart: Shunts closed. Refer to physician if abnormal sounds are present that have not been previously diagnosed.
      • Abdomen: Navel, femoral pulses, hernias, distention
      • Extremities: Range of motion, smooth movements. Hips, check leg folds and abduction.
      • Skin: Rashes, hemangiomas (measure and record), bruises, burns
      • Neurologic: All reflexes present but less intense
    • Parent-child interaction
      • Parent: Expression of fatigue and nervousness in handling baby; ability to quiet baby; referrals or home visit as indicated
      • Baby: Responsive to parent’s attention
  • Assessment
    • Physical
    • Developmental
    • Emotional
    • Environmental
  • Plan
    • Immunization series per office protocol: Discuss importance of completing and recording series.
    • Problem list (devised with parent); SOAP for each
    • Indicate to parents the appropriate timing for future office visits
ANTICIPATORY GUIDANCE FOR THE PERIOD OF 2 TO 4 MONTHS
A responsive smile is one of the first important signs that the baby is beginning to take the outside world into account. As babies’ physical systems stabilize and mature, their energies are freed, enabling them to become aware of what is going on around them. Although they continue to respond instinctively, they are developing a reactive pattern to the world. They react joyfully and energetically to care that is consistent and loving, but they react with crying and irritability when their basic needs are not met. By 4 months of age, their reactions are less instinctive and they begin to respond in a manner that will best serve their own purpose.
  • Overview
    • Parents
      • Understanding and keeping records of development, description of baby’s moods, and reactions to care
    • Infant
      • Physical
        • Increase in activity level and strength; muscular movements becoming more refined
        • Reaches out and holds on but does not let go at will
        • Eating and sleeping schedule being established
      • Emotional
        • Becomes upset when mother goes out of sight (see this guideline for details)
        • Importance of a primary caregiver
      • Intellectual: By age 4 months, the baby’s crying when the mother goes out of sight is the beginning of memory development and the baby’s striving to control his or her world. Parents must understand that this is a necessary step toward reaching out of self but must not hinder this development with overindulgence.
    • Risk factor: No consistent caregiver with whom baby can develop a relationship
    • See Injury Prevention Guidelines, p. 20.
    • Watch for:
      • Moving from innate reflexive movement to purposeful activity
      • Repeating activities to create results, such as hitting mobile to cause it to move
      • Body movements more vigorous but still uncoordinated
      • Head held at midline so baby can follow moving objects
      • Finds hands and watches them intently
      • Arms held out to be picked up
      • Watches mother intently, follows her, responds to her with vigorous arm and leg movements, attempts to vocalize to her, and turns to her voice
      • By 4 months, reacts to mother’s going out of view
      • Parents becoming aware of and appreciating the baby’s developmental strides
  • Expectations of this period
    • Parents
      • Responsive to baby’s rhythms and signals
      • Can define and appreciate baby’s individuality
      • Safety for self and family; fear of abuse
    • Infant
      • Responds to primary caregiver with responsive smile, extends eye contact, turns to voice
      • Comforted and quieted easily
        • Increased awareness of separation from mother causes distressful crying because object permanence is not yet present.
        • Parents must understand and appreciate this first clash of wills.
        • Playing music and keeping baby around family activities may help dispel this feeling of desertion.
        • Too-frequent changes of caregivers may inhibit the development of this first important step toward attachment.
  • Family status
    • Basic needs being met
      • If referrals are made, follow-up to be sure appropriate help is received.
      • Adequate support system available
    • Parents
      • Adjustment to and enjoyment of new roles
      • Understanding of symbiotic role of mother and baby and that both will have a broadened emotional base by age 4 months
      • Knowledge and appreciation of childhood developmental tasks
    • Child abuse high-risk indicators
      • Maladjustment to new roles and responsibilities by parents
        • Fatigue and poor health in parents
        • Crankiness in baby
      • Unrelieved social and emotional pressures
      • Aggressive pattern of behavior by those in contact with baby
      • Caregivers abused in their own childhood
  • Health patterns
    • Nutrition
      • Formula or breast milk continues to be adequate nutrition.
      • Do not substitute with cow’s milk.
      • Offer water between feedings, particularly in warm weather, because baby loses fluids quickly; color and odor of urine indicate state of hydration.
      • Baby begins to develop pattern of eating five or six times a day. Night feedings continue until larger amount is taken during the day. Stomach has 4- to 6-oz capacity.
      • Hold baby when bottle-feeding to continue development of close relationship. Never give baby a bottle in bed: Baby will fall asleep with bottle in mouth, which can lead to tooth decay due to prolonged exposure to lactose, the sugar in milk.
      • If baby continues fussing after and between feedings, investigate other areas of need satisfaction. Schedule office visit if problem continues.
    • Sleep
      • Sleeps for longer periods (up to 8 hours); total of 14 to 16 h/d
      • Night feedings discontinued when able to take larger feedings during day
      • Sleeps through family noises; being kept within family activity area or having music played during naps continues ability to sleep through normal sound levels.
      • By 4 months of age, baby is aware of separation from mother and may have difficulty falling asleep. Soft music may help.
    • Elimination
      • Stools: Maturation of gastrointestinal tract allows better fluid absorption, so stools are firmer and less frequent.
      • Urine: Kidneys do not function at mature level until 4 months of age, so dehydration is still a concern.
  • Growth and development
    • Physical
      • Central nervous system
        • Myelination continues in a cephalocaudal direction.
        • Fastest growing system; adequate nutrition essential for maximum development
        • Head: From resting on crib to holding up at midline
        • Arms: From random to purposeful movements
        • Hands: Opens and closes hands; thumbs held in grasping position
        • Extremities: Legs more vigorously active
        • Vision: Bifocal vision develops when head held at midline; mother observes finding hands, scrutiny of faces, attraction to colors
        • Hearing: Sound discrimination (recognizing voices); mother observes baby turning toward sound of her voice.
    • Emotional development
      • Basic trust continues to be established.
      • Primary caregiver provides consistent loving care. Too many different caregivers can interfere with the establishment of basic trust.
      • Baby responds to caregiver by vocalizing, making eye contact, and smiling.
    • Intellectual development
      • Reactive patterns becoming more stable and consistent: Quiet or noisy, energetic or passive, joyful or somber
      • Awareness of and attachment to primary caregiver established, but object permanence (memory) is not yet present, so there are distress signals if baby observes mother or primary care-giver leaving.
      • Language: Experiments with making sounds; pays close attention to mother’s mouth as she talks
  • Risk factors
    • No loving primary caregiver
    • Cranky, inconsolable baby
  • Childrearing practices
    • Consistent schedule; few changes for visits or visitors
    • Touching, rubbing, rocking needed in addition to food and sleep
    • Early intervention for concerns and problems
  • Stimulation
    • Communication and sounds
      • Sing to child.
      • Encourage smiling and laughing.
      • Use music and rhythms only as a quiet background.
      • Introduce sounds: Running water, rattles, household noises.
    • Touch and smell
      • Cuddling, holding, kissing, stroking
      • Feed and change from both sides.
    • Sight
      • Place a single bright object, such as a mobile, 12 inches from eyes; change it frequently.
      • Move objects in arcs and circles for eyes to follow.
    • Gross motor
      • Exercise arms and legs while bathing.
      • Place baby on stomach on a firm surface (preferably on the floor, if safe from siblings and animals).
      • Help baby roll over, first from stomach to back.
      • Use bounce chair to increase leg strength and enjoyment of body movement.
    • Fine motor
      • Give baby objects of various textures to handle.
      • Bring hands together around bottle or toy.
      • Provide bright objects for eyes to follow.
    • Feeding: Make feeding relaxed and pleasant, staying generally within feeding time of every 3 or 4 hours.
    • Schedule: A consistent daily routine helps establish body rhythms and anticipatory responses.
    • Watch for baby’s cues of overstimulation.
  • Safety
    • Accidents happen most frequently:
      • When usual routine changes (holidays, vacations, illness in the family)
      • After stressful events for caregivers
      • When caregivers are tired or ill
      • Late in the afternoon
    • Accident prevention
      • Crib away from window and curtain cords
      • Fire: Never leave baby in house alone; install smoke alarms, window guards, carbon dioxide detectors.
      • Never hold baby in lap. Follow federal car seat mandate (see http://www.aap.org/healthtopics/carseatsafety.cfm). Seats must face rear of vehicle.
      • Baby seat: Baby strapped in; seat in safe, protected area
      • Keep all objects smaller than 2 inches in diameter out of baby’s reach.
      • Do not leave baby alone on bed or couch. Developing strength makes it possible for the baby to roll over or migrate to edge and roll off.
    • Not all injuries are accidents. Investigate possible child abuse and neglect.
    • Instructions to babysitters
    • Emergency telephone numbers posted
4-MONTH WELL CHILD VISIT
The close symbiotic relationship between mother and child is changing in the direction of individualization for both of them.
  • Overview
    • Parents
      • Can describe effects of new baby on all family members
      • Show appreciation for baby’s increasing physical skills, individual temperament, and way of reaching out and getting attention
      • Identify any abuse of family members
    • Infant
      • Physical
        • Increase in weight and height continues on previous pattern on growth chart.
        • Holding head in midline; purposeful reaching out
      • Emotional
        • Turning to mother when distressed
        • Fussing when mother goes out of sight
      • Intellectual
        • Purposeful repetition of activities
        • Stimulated by activities of caregiver, bright objects, and sounds in environment
    • Risk factors
      • Dissatisfaction by parent with new role
        • Lack of confidence in ability to provide adequate care
        • Cannot spend extra time with baby
        • Fearful of safety for self and baby
      • Baby difficult to comfort
    • See guidelines for specific factors to be noted in physical examination.
  • Injury prevention
    • Review safety protocol.
      • Age-appropriate precautions need special attention as baby increases in strength and activity.
        • Can push off bed, changing table, or couch; can move to head or foot of crib; can get tangled in blankets
        • Beginning to get hand-to-mouth, so all small objects within reach are dangerous.
        • Crib gyms and toys must be removed if baby can reach them.
        • Can reach out and hit caregiver’s hot drink
        • Should ride facing backwards in rear seat if possible; never place child in front car seat if there is an air bag in passenger side of front seat. (See AAP guidelines for car seat, available at: http://www.aap.org/healthtopics/carseatsafety.cfm.)
      • Put baby in safe place, such as crib or playpen, when left alone, even for a few minutes.
      • No baby walkers or jumpers
    • See protocol for special at-risk caregivers.
    • See protocol for frequency of accidents.
  • Child abuse
    • Age-specific concerns: Falls: Broken bones rare at this age from fall of moderate height
    • Physical identification
      • Shaken baby syndrome indicated if other family members abused: May have abnormal respiratory pattern and bulging fontanelles
      • All bruises and burns need investigation.
    • At-risk baby
      • Difficult baby to care for; continuing physical problems; physical abnormalities
      • Failure to thrive
    • Identify:
      • At-risk caregivers
      • Abuse of other family members
  • Developmental process
    • Mother
      • Returning to pre-pregnant health pattern (weight and energy level)
      • Coping with family responsibilities
      • Relating to other family members
      • Developing or returning to outside interests
      • Appreciating importance to baby of one primary caregiver
      • Returning to work, finding a satisfactory caregiver
      • Able to continue breastfeeding (see Breastfeeding Guidelines, p. 24)
    • Infant
      • Schedules for feeding and sleeping being established
      • Investigating environment: Reaching out with arms, grasping with hands, searching with eyes
      • Social awareness: Smiling and vocalizing for reaction from parent, crying at separation from family
  • Family status
    • Concerns and problems: Ability to identify problems and to cope; understanding of problem-solving techniques; referrals as needed
    • Siblings
      • Parents’ understanding of siblings’ adjustment to family changes
      • Time allotted for continuing involvement with them
    • Adequate support system for all members
    • Abuse of any family members identified
  • Health habits
    • Nutrition
      • Mother
        • Breastfeeding: Understanding of dietary requirements
        • Weight control: Adequate diet
        • Use of drugs, cigarettes, alcohol
      • Infant
        • Breast milk or formula with iron per office protocol: Approximately five feedings daily; amount depends on weight and correlation of weight with length (as shown on growth chart); no other foods needed
        • Water offered between feedings if strong odor and color of urine indicate need for more fluids
    • Sleep
      • One long sleep period of up to 6 to 8 hours; total of 15 h/d
      • Awake for roughly 2-hour periods with less fussing
      • Crying when put to bed; baby is aware of separation from parent
    • Elimination
      • Bowel movements: Not formed but less frequent
      • Urine: Important to note color, odor, amount
  • Growth and development
    • Physical
      • Central nervous system: Increased myelination
        • Holds head at midline while prone; lifts head and chest while supine
        • Body: Rolls from front to back
        • Extremities: Arms beginning purposeful reaching; hands open, beginning to grasp; legs held off crib, vigorous kicking
      • Vision: Bifocal, staring, searching
      • Speech: Experimenting with sounds; attempting to imitate
      • Hearing: Localizing sound; quieted by pleasant sounds (voice and music)
    • Emotional development. Erikson: Basic trust. Adaptation through experience. An environment providing adequate physical care and consistent, loving attention fosters the feeling that the world is a safe and dependable place.
      • Appropriate physical growth
      • Baby relaxed, easily quieted
      • Baby turns to caregiver when distressed
    • Intellectual development. Piaget: From 4 to 6 months of age, automatic and random reactions are progressing to purposeful repetition of activities to form patterns of intentional action. Baby begins to adapt behavior through the following experiences:
      • Anticipating and waiting (for feeding, to be picked up)
      • Greeting caregivers with sparkling eyes, vigorous body activity, gurgles, and smiles as repetitive response to loving care, or fussing, crying, poor sleeping if this is the only way to have needs met
      • Repeating activities but cannot instigate them at will
  • Risk factors
    • Parents
      • Dissatisfaction with role; unsure of ability to provide adequate child care
      • Unresponsive or over-responsive to baby
      • Cannot tune in to baby’s signals
      • Fear of abuse to self or baby
    • Infant
      • Feeding problems; failure to thrive
      • Excessive activity and crying
      • Difficult to comfort; unresponsive
    • Child abuse high-risk indicators: Parents
      • Inability to quiet baby; feeding problems
      • Fatigue; overload of responsibilities
      • Inadequate support system
      • Aggression as a reactive pattern
  • Physical examination
    • Growth
      • Length commensurate with established pattern
      • Weight varying with caloric intake, energy level, and illnesses: Weight within two standard deviations of length. Use CDC growth charts (2000), available at: http://www.cdc.gov/growthcharts
      • Calculate BMI at every well child visit during childhood (see Barlow, 2007).
      • Genetic factors should be considered.
    • Appearance
      • Color still easily affected by environment and activity
      • Movements becoming smooth and coordinated
      • Legs: Alternate flexing
    • Specific factors to note during routine physical examination
      • Anterior fontanelle measurements: Bulging, depressed
      • Skin: Seborrhea, rashes, bruises, burns
      • Heart sounds: Refer to physician if murmur present.
      • Hips: Equal leg folds, full abductions
      • Extremities: Forefoot adduction
      • Reflexes: Still present but of diminished intensity; check for head lag and poor muscle tone.
    • Caregiver-child interaction
      • Caregiver: Holds baby close to body; makes eye contact when baby responds; able to quiet baby
      • Baby: Responsive to caregiver’s attention
  • Assessment
    • Physical
    • Developmental
    • Emotional
    • Environmental
  • Plan
    • Immunizations
    • Screening: Laboratory tests and developmental screening as indicated; be sure to have results of newborn screening testing.
    • Problem list (devised with parent); SOAP for each
    • Indicate appropriate timing for office visits
ANTICIPATORY GUIDANCE FOR THE PERIOD OF 4 TO 6 MONTHS
This is a delightful period in which the now physically well-organized baby turns outward to caregivers and environment and finds that his or her activities can influence the outside world.
  • Overview
    • Parents
      • Responsive to baby’s needs
      • Understanding and appreciating baby’s developmental strides
      • Asking for help if concerned
    • Baby
      • Physical
        • Increased vigorous body movements
        • Appropriate weight and height gain
        • Eating and sleeping with schedule established
      • Emotional
        • See guidelines for discussion of separation anxiety.
        • Responding to attention with smiles, gurgles, reaching out
      • Intellectual
        • Beginning of object permanence (memory): Will begin to understand that caregiver’s absence is not permanent
        • Beginning to initiate purposeful activities
    • Risk factors
      • Low growth rate
      • Apathetic; difficult to comfort
      • No loving primary caregiver
      • Not turning outward to investigate environment
    • See guidelines for specifics of childrearing practices and accident prevention.
    • Watch for:
      • Contented, energetic, healthy baby
      • Increase in body activity; attempting to roll over
      • Random activity to purposeful behavior; repeating activity to get desired results
      • Fussing to get mother back in view
      • Developing self-quieting routine
      • Follows moving object but still does not follow if object goes out of line of vision
      • Coordination of hand-eye movement improving
      • Positive response of caregiver helps develop baby’s confidence in ability to control world and begins building self-esteem.
  • Expectations of this period
    • Parents
      • Respond to baby’s overtures for approval and attention
      • Concerned by negative behavior; investigate and ask for professional help if unsuccessful in understanding and coping
      • Provide loving, approving primary caregiver
    • Infant
      • Gurgles, smiles, vigorous body movements, and sustained eye contact get responses of approval and attention.
      • Increased fussing, wakefulness, and poor feeding also get attention and will become a pattern of response if that is the only way attention is obtained.
    • Separation anxiety: Baby has increased awareness of primary caregiver, and object permanence (memory) is not sufficiently developed for baby to realize that disappearance of caregiver is not permanent.
      • Parents: Understand problem of separation anxiety; keep baby in family area; family noises not diminished for baby. Voice contact and music may help this transitory problem.
      • Infant: Fusses when left at bedtime; even mother’s walking out of room causes tears of anguish.
  • Family status
    • Parents provide adequate environment for each family member.
    • Parents understand developmental needs of each child.
    • Sufficient support system exists for parents’ needs; not using children as only means of gratification.
    • Identify sexual abuse to or by any family member
  • Health patterns
    • Nutrition
      • Baby continues to require about 50 cal/lb or 90-120 kcal/kg daily.
      • Breast milk or formula is the only food needed until roughly 6 months of age.
      • Vitamins and fluoride are continued per office protocol.
      • A consistent growth pattern is one of the indicators of the state of nutrition.
      • Continued fussing or crying after feeding: Investigate reasons other than hunger (discomfort, unsatisfied sucking instinct, need for comfort or cuddling). Schedule office visit if problem continues.
    • Feeding
      • Stabilizing schedule: Sleeping through the night (8 hours); as size of stomach increases, larger feedings possible during the day
      • Tongue thrust diminishing
      • Taste buds mature; taste discrimination present
      • Solid foods not needed for proper nutrition. Add rice cereal with iron only per office protocol.
      • Be alert to overfeeding. A healthy baby is best able to regulate when and how much to eat. Parents should pay attention to signals and not force extra formula or cereal.
    • Drooling
      • Increased activity of salivary glands; not always an indication of teething
      • Up to 2 years before automatic swallowing is present
    • Sleep: Fussy at bedtime
      • Try leaving on dim light or music.
      • Keep baby in crib, but do not eliminate all family sounds; baby is self-quieting with the security of being near others.
    • Elimination
      • Bowel movements are better formed as gastrointestinal tract matures.
      • Distention caused by undigested foods or illness: Limit diet by eliminating all foods but formula. If it continues, dilute formula with water; call office if no improvement.
      • Urine: Watch color and amount; increase fluids if necessary; call office if no improvement.
  • Growth and development
    • Physical
      • Central nervous system still the fastest growing system; adequate nutrition mandatory for its development
      • Gross motor skills: Able to sit with support; rolling over; putting weight on feet; enjoying bounce chair
      • Fine motor skills: Reaching out and grasping; bringing hand to mouth at will
    • Speech
      • Experimenting with making sounds; trying to repeat them
      • Paying attention to mouth action of caregiver; attempting to imitate
      • Listening to own sounds; attempting to repeat
    • Emotional development. Erikson: This period is the beginning of the baby’s establishment of trust in self. By their beguiling ways, babies enchant their caregivers into providing attention, and they learn to repeat the activities that bring them this attention.
      • Smiling, vocalizing, making good eye contact
      • Has a loving, approving primary caregiver with whom a positive response pattern can be developed
    • Intellectual development. Piaget: Developing object permanence (memory) by finding consistent results from own activities and from those of others
      • Beginning to realize that if mother leaves, she will return
      • Anticipating events of daily routine
      • Spends much time repeating simple activities
        • Reaching out and touching: Has awareness of sizes, shapes, textures
        • Listening: Shows recognition of familiar voices and sounds; responds to rhythms
        • Looking: Is fascinated by faces (even own reflection), varied colors and shapes
        • Large muscle development: Enjoys free activity, bounce chair, and swing; hitches body to reach out and grasp toys
        • Body confidence: Enjoys being tossed, swung high (Caution: Swinging or lifting by arms can dislocate elbows.)
      • Language: Parents respond to baby’s vocalizing; baby attempts to imitate and repeat sounds.
  • Risk factors
    • Parents
      • Inability to cope with problems
      • Lack of pleasure and satisfaction in child care
      • Not understanding importance of child development principles
    • Infant
      • Physical developmental lag
      • Nutritional deprivation and inadequate growth pattern
      • Emotional immaturity: Unresponsive; no eye contact; dominant mood of fussiness
      • Inadequate child care; no one significant person as caregiver
  • Childrearing practices
    • Regular schedule with as few interruptions as possible; baby’s learning to anticipate events is helped by consistency of schedule.
    • Demanding of attention: Respond within reason; provide other stimulations, such as variety in toys, sounds, things to look at
    • Weaning: Separation awareness at 4 to 5 months is a difficult period for baby, so weaning is more easily accomplished at 3 months or at 6 months.
    • Day-care centers: Ratio of caregivers to infants, 1:3; visual and auditory stimulation provided; opportunity to exercise (not kept in crib all the time); time for caregiver to hold and cuddle
    • Babysitter: Careful selection; know personally or get references; set up job description, pay schedule, telephone contacts; caregiver spends time with family before left alone with baby
  • Stimulation
    • Communication and sounds
      • Call baby by name.
      • Describe what you are doing; name objects.
      • Point out various sounds: Whispering, the wind, cars, animals.
      • Provide a background of soft music: Music that is too loud prevents learning from usual sounds of environment.
    • Touch and smell
      • Rub baby with different textures: Silk, feather, wood, yarn.
      • Play touching games, such as “this little piggy.”
      • Point out various odors: Flowers, clothes, foods.
    • Sight
      • Move crib around room; move infant to different rooms and near windows.
      • Use bright sheets, blankets, clothing.
      • Hold baby up to a mirror to see reflection.
    • Gross motor
      • Sitting position for short periods
      • Sits up on a mat on the floor
      • Time spent on protected area on floor for large muscle activity
    • Fine motor
      • Colorful plastic keys on a ring
      • Cradle gym
  • Safety
    • Accidents happen most frequently:
      • When usual routine changes (holidays, vacations, illness in family)
      • After stressful events for caregivers
      • When caregivers are tired or ill
      • Late in the afternoon
    • Accident prevention
      • Crib should be away from open window and curtain cords.
      • Fire: Never leave baby in house alone. Install smoke alarms.
      • Automobiles: Never hold infant in lap. Follow federal car seat mandate. Infant seat must face rear of vehicle.
      • Baby seat: Baby strapped in; seat in safe, protected area
      • Keep objects smaller than 2 inches in diameter out of baby’s reach (see current AAP guidelines for infant seats, available at: http://www.aap.org/family/carseatguide.htm).
      • Be alert to baby’s developing ability to become self-propelled.
    • Not all injuries are accidents. Investigate possible child abuse and neglect.
    • Instructions to babysitters
    • Emergency telephone numbers posted
6-MONTH WELL CHILD VISIT
Children of this age are concentrating on what is going on around them. Repetitive activities replace random movements.
  • Overview
    • Parents
      • Appreciating baby’s developing personality and skills
      • Providing safe environment for increased mobility of baby
      • Identifying any abuse of family members
    • Infant
      • Physical
        • Sits without support
        • Transfers objects from one hand to the other
        • Teething
          • Makes for a cranky baby
          • Increased incidence of upper respiratory infection
      • Emotional
        • Keen observer of what is going on around him or her
        • Responds to music and motion
        • Turns to caregiver for support and comfort
        • Turns to name when called
      • Intellectual
        • Random activities replaced by purposeful actions. One of first such actions as teeth erupt is learning not to bite nipple when breastfeeding.
    • Risk factors
      • Poor weight gain
      • Frequent illnesses
      • Check safety guidelines
    • See guidelines for specific factors to be noted in physical examination.
  • Injury prevention
    • Review safety protocol.
    • Age-appropriate precautions
      • Increased activity of creeping, rolling over, sitting up, reaching out, and ability to get hands to mouth make constant supervision necessary.
      • Time to baby-proof house; see protocol.
      • Crib
        • When baby can pull self to sitting, kneeling, standing position, have mattress low enough so he or she cannot fall out.
        • Remove bumpers that baby could climb on.
        • Remove toys with strings or cords to avoid choking.
        • Keep sides of crib up and securely locked.
        • Have crib in safe area, away from drapes and cords from blinds.
      • Have safe place to put baby when he or she must be left alone, even for a few minutes.
      • Baby needs freedom to investigate the world; gates and doors keep baby in safe area.
      • Cover electrical outlets with protectors; pad sharp edges of furniture; keep cords, such as lamps and telephones, out of reach.
      • Developmentally, baby cannot remember “no” or “don’t touch” to prevent repeating activity.
        • Begin using a particular tone of voice that means “No!” or “Stop!”
        • Behavior control not yet established
      • Use appropriate car seat (see http://www.aap.org/healthtopics/carseatsafety.cfm).
    • See protocol for special at-risk caregivers.
    • See protocol for frequency of accidents. Not all injuries are accidents; check for abuse.
  • Child abuse
    • Age-specific concerns
    • Physical identification
      • Injuries with delayed treatment and confused history of accident
      • All bruises and burns investigated
      • Fearful child, uncontrolled crying during examination
      • Sudden infant death syndrome: Investigate, as family members may be abused.
    • At-risk infant
      • Difficult to care for; physical disabilities
      • Overactivity; difficult to feed and to get to sleep
      • Poor sleeping pattern
      • Frequent illnesses
    • Identify:
      • At-risk caregivers
      • Abuse of other family members
  • Developmental process
    • Parents
      • Understand developmental principles and appreciate baby’s accomplishments
      • Developing a philosophy of childrearing practices
      • Provide adequate stimulation and safe environment
    • Infant
      • Sits propped up or in baby seat
      • Scrutinizes all that can be touched and seen (particularly primary caregiver)
  • Family status
    • Basic needs being met
    • Marital stability
    • Single parent
      • Needs being identified and goals established
      • Referrals: Provide with follow-up
      • Visits scheduled to provide support and help in establishing healthy childrearing practices
      • Reporting fear of abuse
    • Parents
      • Concerns and problems: Ability to identify problems and to cope
      • Realistic assessment and appropriate expectations of baby’s development
      • Deriving satisfaction and pleasure from parental role
      • Mother’s interests defined as student; working, special interests
      • Child care arrangements: Day care center, babysitters
      • Fear of abuse identified
  • Health habits
    • Nutrition: Diet history
      • Breastfeeding: Supplementary formula, weaning
      • Formula: Number of feedings and amount
      • Vitamins and fluoride per office protocol
      • Other foods: Rice cereal with iron as the first food
    • Sleep
      • Sleeps for up to 8-hour period at night
      • Awake for 4-hour periods
      • Less fussing when put to bed; self-quieting routine being established
    • Elimination
      • Bowel movements less frequent, better formed; distention and flatulence with diet change
      • Urine better concentrated: Color and odor used as indicators of hydration
  • Growth and development
    • Physical
      • Central nervous system
        • Vertical position possible, with ability to sit and hold head erect
        • Puts weight on legs; stands with support
        • Grasps with both hands; transfers from one hand to another
      • Teething
        • Usually the first teeth cause physical discomfort, and succeeding eruptions are less difficult; chilled pacifier is helpful.
        • Importance of night bottle syndrome understood
      • Period of low immunity, causing susceptibility to infections; beginning to develop their own immune responses as mother’s response wanes.
      • Vision: Improved distance vision and depth perception; staring at objects or movement at distance
      • Speech
        • One-syllable babbling; attempts to imitate sounds
        • Watches intently the mouth of someone speaking to him or her
    • Emotional development. Erikson: Establishment of basic trust is evident by baby’s turning out to explore environment. Baby is eager to touch, feel, and taste all within reach. Baby watches caregivers in particular. Establishing a close attachment to one person who can give support to explorations is a preliminary step toward the next developmental task of beginning the path toward independence.
      • Eager to touch, feel, and mouth all things within reach
      • Watches results of activity with surprise and pleasure
      • Responds to mood of caregiver
      • Keen observer of activities of caregiver
    • Intellectual development. Piaget: Development of object permanence (memory). Repetition of activities and finding consistency of results replace random movements with purposeful activity. Baby attempts to repeat the kind of activity that affects the care and attention he or she receives.
      • Daily schedule important
      • Responds to familiar voices and sounds
      • Cries and fusses more selectively
      • Delights at return of primary caregiver
      • Language: May be less vocal, as main concern is observing environment and caregivers
  • Risk factors
    • Parents
      • Unresponsive to baby’s cues
      • Restless at confinement of parental role
      • Overprotective: Giving too little stimulation or opportunity for physical activity or new adventure
      • Not providing one consistent caregiver
    • Infant
      • Not attempting to reach out
      • Lack of body confidence; rigid body movement
      • Unsatisfied needs; whiny
      • Restless sleep
      • No loving, approving primary caregiver
    • Child abuse high-risk indicators: Parents
      • Low self-esteem; lack of confidence and competence in managing their world
      • Rigid response pattern
      • Marital conflict
      • Fatigue; overload of responsibilities
      • Inadequate support system
      • Child abuse in parent’s childhood
  • Physical examination
    • Growth: Continues on established pattern. Check for excessive or inadequate weight gain.
      • Use CDC growth charts (2000), available at: http://www.cdc.gov/growthcharts
      • Calculate BMI at every well child visit during childhood (see Barlow, 2007).
    • Appearance and behavior
      • Sits with support
      • Good head control
      • Happy, bright-eyed; delightful member of the family; not generally fussy or fearful
    • Specific factors to note during routine physical examination
      • Anterior fontanelles: Bulging, depressed
      • Skin: Seborrhea, rashes, bruises, burns
      • Eyes: Equal tracking
      • Teeth: May be erupting; gums swollen
      • Heart sounds: Refer to physician if murmur present.
      • Hips: Equal leg folds, full abductions
      • Extremities: Forefoot adduction
      • Reflexes: Disappearance of tonic neck reflex, Moro reflex; sucking and rooting (when awake), palmar grasp still present
    • Parent-child interaction
      • Mother holds baby less closely; is willing to have others care for baby.
      • Baby responds to others but still turns to mother for comfort.
  • Assessment
    • Physical
    • Developmental
    • Emotional
    • Environmental
  • Plan
    • Immunizations and laboratory tests as needed; AAP recommends hematocrit or hemoglobin at 9-12 months of age.
    • Problem list (devised with parent); SOAP for each
    • Appropriate timing for office visits.
ANTICIPATORY GUIDANCE FOR THE PERIOD OF 6 TO 9 MONTHS
  • Overview
    • Parents
      • Understand physical changes
      • Ask for help as needed
      • Show pride in and affection for baby
    • See guidelines for specifics of stranger anxiety.
    • Infant
      • Physical
        • Increased activity, losing chubbiness
        • Rolls over and reaches out to obtain what he or she wants
        • Teething and illnesses less a problem by 8 months. See guidelines for introduction of new foods and homemade baby food.
      • Emotional
        • Illnesses, new activities, and adventures broadening emotional responses
        • Needs primary caregiver for comfort and support
      • Intellectual
        • Watch persistence in trial and error to accomplish new skills.
        • Frequent failures can cause frustration and fussiness.
    • Risk factors
      • Safety
      • Frequent illnesses
    • See guidelines for specifics of childrearing practices and safety protocols.
    • Importance of understanding tone of voice
      • Baby responds to caregiver’s tone of voice.
      • Baby’s behavior control not yet established
    • Watch for:
      • Cranky, fussy periods caused by:
        • Teething (should refer to primary provider if fever is also present)
        • Illnesses: Ear infections, upper respiratory infections
        • Introduction of solid foods (stomachache, distention)
        • Increased mobility (cuts, bruises)
        • Less able to be distracted from desired quest
      • Turns to caregiver for comfort
  • Expectations of this period
    • Parents
      • Positive reinforcement of baby’s accomplishments
      • Provide stimulating but safe environment
    • Infant
      • Increased awareness; insatiable desire to investigate; reaching out to touch, taste, scrutinize
      • Baby is increasingly fussy. He or she wants to reach out and experiment and is frustrated when unable to do so.
    • Stranger anxiety
      • By 8 months of age, object permanence (memory) is present. Baby can identify from whom he or she most often receives attention and comfort and appears to concentrate attention on this one person. Other adults seem to interfere with his or her efforts to form a close attachment to this primary caregiver and so are rejected.
      • This attachment is the beginning of the baby’s forming the emotional capability for future relationships of trust and love.
      • Lack of stranger anxiety can indicate that the baby has not one significant caregiver.
      • Critical caregiver misunderstanding of this crying can hinder baby’s trust in environment.
  • Family status
    • Basic needs being met; assess coping ability; referrals as needed
    • Problem-solving techniques used
    • Parents
      • Appreciate and evaluate child’s developmental progress
      • Understand individuality of each child
    • Identify sexual abuse to or by any family member
  • Health patterns
    • Nutrition
      • Breastfeeding: Solids should be introduced by 6 months; breast milk is low in iron.
      • Weaning: There is no right time for weaning; it depends on the mother’s schedule and feelings and the baby’s cues. Delay if the baby is fussy from teething or is ill. Do it slowly, over a week or more. Follow office protocol for change from breast milk to formula.
      • Vitamins, including A and D, and fluoride continued per office protocol
    • Introduction of new foods
      • Add one new food at a time (per week) so any allergic reaction can be identified.
      • Cereal is the first new food; start with iron-fortified rice cereal, which is the least allergenic cereal. Use dry cereal mixed with apple juice, formula, or breast milk. Begin with 1 to 2 tbsp once a day, increasing gradually to a third or a half cup total, fed twice a day. If this is tolerated, barley or oatmeal can be tried.
      • Vegetables or fruits are the second food; 1 tsp at a time, working up to 3 to 4 tbsp of fruits and vegetables by 1 year of age.
        • Vegetables should be introduced first, because they are harder to learn to like than fruits, which are sweeter. Begin with green ones, then yellow.
        • Fruits: Bananas and applesauce are constipating; pears, peaches, and prunes are bowel softeners.
      • Egg yolk can be given at 6 months of age; hard-boil and strain over foods. Delay introduction of egg whites until all other foods have been introduced.
      • Meats: Introduce last. Try all kinds. Buy jars of meat; mixed dinners have only small amounts of meat.
      • Do not feed from the jar unless the whole jar is to be used, because saliva from the spoon stays in the jar and can cause spoilage. Refrigerate any food not used.
      • Most commercially prepared baby foods contain no preservatives and are acceptable. Do not season with salt or sugar: These are unnecessary and can lead to poor eating habits.
    • Homemade baby foods
      • Equipment needed
        • Electric blender, food processor, or food mill
        • Clean pans for cooking
        • Utensils: Vegetable brush, spatula, peeler, knife
        • Ice cube trays, preferably with separate pop-out cubes
      • Freezing and serving
        • After food is prepared and pureed, pour into ice cube trays.
        • Freeze quickly.
        • Pop out frozen cubes and put into plastic freezer bags; label and date.
        • Each cube contains about 3 tbsp.
        • Before a meal, take out food cubes and thaw in the refrigerator or warm in a warming dish or in an egg poacher over hot water.
        • Cubes travel well for short trips; they defrost quickly.
      • Food preparation
        • Fruits
          • Fresh fruits retain the best nutritional value, but juice-packed canned or frozen fruits may also be used.
          • Cooked, fresh or canned fruits blend very well into a fine puree.
          • Do not add sugar; babies prefer the natural sweetness in fruits.
          • Pureed fruits can be added to cottage cheese or plain yogurt (a good source of protein, calcium, and riboflavin).
          • Avoid pure honey due to risk of botulism
        • Vegetables
          • Fresh vegetables have the best nutritional quality; frozen vegetables are more convenient; canned vegetables are already cooked and need only be pureed.
          • Use canned vegetables that have no salt.
        • Meats, poultry
          • Meats tend to shred in the blender rather than puree; if ground first, they are easier to puree; add 1 cup of liquid per pound of ground meat.
          • Chicken livers puree very well.
          • Meats should be cooked by braising or roasting, not frying; no seasoning is necessary.
        • Fish
          • Should be poached or baked; preferably cod, haddock, or flounder
          • Do not give shellfish to infants (can cause allergies).
          • One pound of fish yields about eight food cubes.
        • All foods can be combined to make stew-like dinners. Meat, potato, and vegetable, for example, can be pureed together; seasoning is unnecessary.
      • Freezer life of home-prepared baby foods
        • Temperature must be 0°C (32°F) or below; use a true freezer or a separate-door freezer-refrigerator combination; freezer compartment inside refrigerator does not stay cold enough.
        • Timetable for keeping foods
          • Fruits: 6 months
          • Vegetables: 4 months
          • Meats: 3 months
          • Liver: 1 month
          • Fish: 1 week
          • Poultry: 3 months
          • Dried beans, peas, and so forth: 3 months
          • Combination dinners: 2 months
    • Establishing good eating habits
      • Baby will take sufficient food for needs. When satiated, he or she does not take food from spoon and pulls back. Do not force food.
      • Babies are messy and will spit out food, throw food, upset dish, not sit still.
      • Always use a quiet, matter-of-fact manner.
      • Nutritional patterns established during infancy can have lifelong effects.
        • Feeding is a learned experience; each child develops at his or her own rate.
        • Food preferences are acquired.
        • Ethnic patterns influence food preferences.
    • Sleep
      • Less fussing at bedtime; may need favorite toy or blanket
      • Sleeps through the night; awakes early; does not cry; can amuse self for a short period
      • Still needs two naps
    • Elimination
      • New foods are usually no problem if added slowly; if a problem does occur, eliminate the new food and try again later in small amounts.
      • Urine: Continue to check amount, color, and odor for indication of hydration.
  • Growth and development
    • Physical
      • Teething: Baby’s first experience with pain; usually the first tooth is the most bothersome. Reduce gum swelling and pain by providing a cold, wet cloth to chew on or a chilled pacifier.
      • Low immunity: Susceptible to infections; immune system still immature and protection from maternal antigens diminished
      • Gross motor skills: Progressing from immobile to self-propelled; sitting to creeping to crawling to standing is a long period of trial and error.
      • Fine motor skills: Use of hands to reach out, grasp, and let go at will; touching as means of investigating; reaching out as a perceptual motor skill
      • Speech
        • Attempts to duplicate sounds; repeats syllables such as dada, mama
        • Babbles contentedly to self on waking
    • Emotional development. Erikson: Establishment of basic trust gives baby assurance to investigate environment. This is done tentatively, with looking back at or returning to caregiver for reassurance. A significant caregiver is needed to provide encouragement for these new adventures.
      • Increased awareness of movement, color, sounds
        • Keen observer of movement, color, sounds
        • Reaching out to touch and hold
        • Fascinated by looking at and picking up small objects
      • A dangerous period because baby can physically get to more places and cannot yet be trusted not to repeat undesirable behaviors.
    • Intellectual development. Piaget: Object permanence (memory) is becoming better developed, and baby uses repetitive actions to establish purposeful activity.
      • Repetitive actions are building up memory of cause and effect.
      • Develops control by persistent trial and error; gets to sitting position unaided; manages to crawl in the right direction and around obstacles. Frequent failures cause increase in frustration and fussiness.
      • Increase in watching and studying caregiver
      • Sitting up improves depth perception, so studies things in motion carefully
      • Language
        • Enjoys being talked and sung to; responds to rhythms
        • Attention to goings on in environment supersedes concentration on vocal development.
        • Responds to caregiver’s tone of voice
  • Risk factors
    • Parents
      • Cannot cope with baby’s periods of frustration
      • Fail to provide stimulating environment; baby given no opportunity to move about freely
      • Child abuse high-risk indicators present
    • Infant
      • Physical developmental lag
      • Passive: Does not attempt to reach out and investigate
      • Lack of loving, approving, consistent caregiver
  • Childrearing practices
    • Increased fussy periods can be due to frustration at not being able to get at or have what he or she wants.
    • The baby’s being persistent and difficult to distract makes life more complicated for caregivers and baby.
    • Use tone of voice to show approval or disapproval of baby’s activities.
    • Environment important
      • Area large enough to satisfy new skill of crawling
      • Safety the main factor
        • Baby cannot be trusted to control behavior.
        • Eliminate all small objects, because everything possible is put in mouth.
        • Almost constant surveillance is necessary; siblings and babysitters need careful instructions.
  • Stimulation
    • Communication and sounds
      • Praise language attempts, but do not overemphasize.
      • Provide toys that make noise or music.
      • Sing and talk to baby; demonstrate rhythms.
    • Touch and smell
      • Demonstrate various motions, such as swinging, water play, dancing.
      • Tickling and touching games
      • Textured and patterned objects to handle
      • Identify different odors.
    • Sight
      • Alternate toy selection: Divide into groups and change groups frequently.
      • Mirror play
      • Indicate outdoor objects in motion: Trucks, cars, birds, airplanes.
    • Gross motor
      • Rock back and forth on beach ball on stomach.
      • Needs support while sitting; sitting alone
      • Water play
      • Jumper swing; feet supported
      • Open, safe area for crawling
    • Fine motor
      • Blocks, lids, pans to bang
      • Various-sized containers to fill and empty
      • Small objects of various shapes to handle (too large to be swallowed)
    • Feeding
      • Offer cup.
      • Finger foods: Offer crackers or hard toast (zwieback), especially when teething.
      • Baby dips fingers into foods and brings them to mouth.
  • Safety
    • Accidents happen most frequently:
      • When usual routine changes (holidays, vacations, illness in family)
      • After stressful events for caregivers
      • When caregivers are tired or ill
      • Late in the afternoon
    • Accident prevention
      • Baby-proof house
      • Mobility: Be prepared for unexpected mobility of baby; new skills make constant surveillance necessary.
      • Be aware that all objects picked up go into the mouth.
      • Choking: First-aid instruction per office protocol
      • Water safety: Never leave baby alone in tub or wading pool.
      • Provide safe spot for baby when caregiver is out of sight (playpen, crib).
      • Use proper car seat at all times.
    • Investigate possibility of child abuse and neglect if many bruises or burns are present, if child is extremely resistant to strangers, or if child has rigid body and movements.
    • Instructions to babysitters
    • Emergency telephone numbers posted
9-MONTH WELL CHILD VISIT
This is a watershed period in which the physical and emotional patterns developed during the past 9 months provide new skills. With increased physical abilities and the establishment of basic trust, infants begin, in their own way, to test out and develop their capabilities. Erikson defines this process as moving from the stage of basic trust to the new stage of autonomy.
  • Overview
    • Parents
      • Understand baby’s new needs of a safe environment to explore and investigate. Understand the baby’s frustrations and anxiety from these new adventures.
      • Baby rejects all other adults and turns only to primary caregiver for comfort.
      • Primary caregiver needed to provide safety and encouragement
      • Identify any abuse of family members.
    • Infant
      • Physical
        • Increased mobility: Persistent in exploring
        • Increased interest in food
        • Difficulty falling asleep
      • Emotional
        • Developing confidence in own capabilities
        • Finding ways to gain control of world, such as refusing food, crying at parents’ leaving, staying awake at night
      • Intellectual: Increase in memory; helping him or her to rely on world and repeat activities, either positive or negative, that get attention
    • Risk factors
      • Parents’ unrealistic expectations of baby
      • Lack of consistent caregiver
    • See guidelines for specific factors to be noted in physical examination
  • Injury prevention
    • Review safety protocol.
      • Age-appropriate precautions
        • Toddlers cannot be trusted.
        • Consistent behavior control is not yet established.
        • Natural curiosity and energy lead to unexpected activities.
      • Caregivers: Be sure that they understand safety precautions
        • Constant supervision necessary
        • Reaction to injury is imitated by child.
          • Calmly and reassuringly take care of situation; promote confidence in child’s world
          • Avoid over-response to accidents
        • Begin to establish off-limit areas.
        • Provide a safe place where child can be placed in an emergency or when left alone.
      • Most common accidents
        • Poisons; medications
          • Put all poisons, pills, cough syrups, high up, locked and out of reach
          • Pocketbooks can contain dangerous pills.
        • Falls
          • Toddlers tumble and fall easily, but call doctor if child has fallen on head or does not respond to voice.
          • Gates, doors, window screen guards necessary
        • Burns
          • Avoid carrying hot liquid or food near child.
          • Protect stoves, wall heaters, floor heaters, cooking utensils, wood stoves.
        • Fires
          • Test batteries in smoke alarms monthly.
          • No smoking in house
          • Establish fire drills.
      • Safety checks
        • Lead paint, if in older house or apartment
        • Gates on stairs: Give infant time to climb stairs under surveillance.
        • Electrical outlets capped
        • Cleaning fluids, soaps, medicines high up and locked
        • Appropriate car seat used at all times (see http://www.aap.org/healthtopics/carseatsafety.cfm)
        • Safe place to put baby while not in caregiver’s sight, such as playpen or crib
  • Child abuse
    • Physical identification
      • Broken bones not usual in toddler’s frequent falls and tumbles
      • Bruises and burns may be caused by careless caregiver, but investigation is important.
    • At-risk infant
      • Difficult child to care for
      • Unsafe environment
      • Inadequate medical care
    • Identify:
      • At-risk caregiver
      • Abuse of other family members
  • Developmental process
    • Parents
      • Understand baby’s new needs
        • Provide adequate, safe environment for exploring.
        • Accept baby’s periods of frustrations and anxiety caused by new adventures.
      • Develop a philosophy of childrearing to promote positive behavior patterns.
      • Report abuse to self or family.
    • Infant
      • Eager to move about; frustrated at confinement
      • Persistent, less distractible
  • Family status
    • Parental concerns and problems: Ability to identify problems and to cope
    • Parental and sibling roles redefined to accommodate the increased activity and safety needs of baby
    • Child care arrangements adequate to provide safety and promote development
  • Health habits
    • Nutrition
      • Diet history; tolerance and acceptance of new foods. Minced foods (including meat), enriched breads, potatoes, rice, and macaroni can be introduced, as well as cottage cheese, soft cheese, and egg yolks. Be aware of overfeeding child with high-calorie foods or too much milk.
      • Eating habits can be a battleground between parents and baby; parents should accept and outwit an uncooperative, independent baby.
      • Nutritional needs: Decrease amount of breast milk or formula to 12 to 16 oz/d; introduce cup.
    • Sleep
      • Difficulty falling asleep, turning off stimulation
      • Awake for periods during the night
      • Fretful sleep; carryover from daytime activities
    • Elimination
    • Dental care
      • Importance of night bottle syndrome understood
      • Teething: Number of teeth; problems during eruptions
  • Growth and development
    • Physical development
      • Central nervous system: Myelination to extremities (giving strength and control)
      • Immune system: Maternal antigens decreased; baby developing own immunity; particularly susceptible to upper respiratory infections
      • Hematopoietic system: Maternal red blood cells decreased; baby now developing sufficient red blood cells for own needs; iron-fortified foods per office protocol
      • Vision: Eye-hand coordination and depth perception improving
      • Hearing: Reacts to whisper test; localizes sounds
    • Emotional development. Erikson: With the security of basic trust, baby is free to:
      • Become aware of the differences in people and sense their importance to him or her. For babies with strong support from a specific adult, other adults do not provide the same feeling of security, which may cause “stranger anxiety.”
      • Move physically out into the environment; eager to use new physical skills to explore
      • Develop a sense of own capabilities
      • Expand emotional responses to new experiences
        • Frustration in the long process of learning new skills
        • Anxiety at leaving the safety of physical and emotional supports: Walking without mother’s hand; watching mother put on her coat to leave baby with someone else
        • Affection: Returning to parent for encouragement and support
    • Intellectual development. Piaget: Progressing from equilibrium to disequilibrium as new physical and emotional development produces new challenges
      • Intentional behavior replaces random responses with increasing ability to form patterns of behavior.
      • Persistent repetition while practicing new skills
      • Language
        • Repeats definite sounds; begins to understand the meanings of a few words (although unable to use them), such as no, good, bye-bye
        • Regularly stops activity when name is called
  • Risk factors
    • Parents
      • Unrealistic expectations of baby’s control of behavior: Overprotective or underprotective; coerces baby to perform desired behavior
      • Dissatisfied with role of parenting in this new phase (end of baby’s complete dependency)
      • History of child abuse in own family
    • Infant
      • Not exhibiting drive to investigate surroundings
      • A “too-good baby”: Shallow emotional responses
      • Dull personality; irritable; unloving
      • No primary caregiver with whom to form loving relationship
  • Physical examination
    • Growth: Continuing on established pattern; length, weight, and head circumference within two standard deviations.
      • Use CDC growth charts (2000), available at: http://www.cdc.gov/growthcharts
      • Calculate BMI at every well child visit during childhood (see Barlow, 2007).
    • Appearance and behavior
      • Beginning to lengthen out
      • Activity level: Difficult to keep baby lying down on examination table, quieter on mother’s lap
      • Serious scrutiny of strangers; difficult to establish eye contact
    • Specific factors to note during routine physical examination
      • Skin: Excessive bruising or burns, carotenemia
      • Eyes: Equal tracking without strabismus
      • Teeth: Central incisors present
      • Ears: Mobility of tympanic membrane, ability to locate sound
      • Musculoskeletal: Bearing weight on legs; hips (Ortolani’s click); equal gluteal folds; tibial torsion; genu varum; externally rotated hips; stance; gait
      • Genitalia: Female: Irritation-discharge; male: Phimosis, descended testes
      • Reflexes: Presence of parachute reflex; sucking and rooting no longer present
    • Parent-child interaction
      • Baby turns to parent for support when frightened.
      • Cheerful, pleasant rapport between parent and child
  • Assessment
    • Physical
    • Developmental
    • Emotional
    • Environmental
  • Plan
    • Screening: Hematocrit or hemoglobin, lead screening recommended at 9-12 months by AAP, developmental assessment
      • Assess for high lead levels (see AAP guidelines for screening for elevated blood lead levels, available at: http://pediatrics. aappublications.org/cgi/content/abstract/101/6/1072).
    • Problem list (devised with parent); SOAP for each
    • Appropriate timing for office visits
      • Continued close contact during this critical period
      • Visits planned according to needs of family and developmental and physical needs of baby
      • Home visits to assess environment as indicated
ANTICIPATORY GUIDANCE FOR THE PERIOD OF 9 TO 14 MONTHS
These 6 months are a critical period for both parents and child, because during this time, a cooperative working relationship between parent and child needs to be established. During this period, children, with their new skills in moving about, are eager to investigate their surroundings in their own way, at their own pleasure, without any interference. Parents must provide protection during these adventures and must help the child learn that only acceptable behavior will receive rewards and praise. In turn, the child is learning that his or her need for approval and affection may be worth the effort of accepting these constraints. It is through this willingness to compromise that the child experiences the wonderful feelings of self-worth and self-confidence.
  • Overview
    • Parents
      • Parents must learn the importance of this period so they can continue their appreciation and understanding of their baby’s free-wheeling activities.
      • During this period, a quiet, consistent schedule is important.
    • Child
      • Physical: Needs safe environment but with opportunity to investigate, examine, and use stored-up energy
      • Emotional: Slowly beginning to accept behavior control with kind support and gentle reinforcement of appropriate behavior
      • Intellectual
        • Recall of previous results of a particular activity
        • Responds to caregiver’s voice; upset by disapproval
    • Risk factors
      • Parents lack understanding and have unrealistic expectations.
      • Child lacks energy and curiosity in his or her environment.
    • See guidelines for specific factors on caregiving arrangements.
    • Watch for:
      • Child is less cranky; usually no problem with teething; developing immune system helps prevent illnesses.
      • Development of speech slows as child concentrates on new physical activities.
      • Broader emotional reactions, such as affection, stubbornness, fear, anger
      • Reaction to positive or negative reinforcement
      • Improved memory: Will look for object when taken away and hidden
      • Strong attachment to mother; other adults, even usual caregiver or grandmother, may cause outburst of crying.
  • Expectations of this period
    • Parental tasks
      • Provide a safe environment that gives child the opportunity to use new motor skills of crawling, climbing, and walking and that also satisfies child’s need to investigate by touching, tasting, and manipulating.
      • Provide a reliable and consistent caregiver who will be aware of the child’s activities at all times and who will provide positive reinforcement for appropriate behavior.
      • Provide a routine schedule that the child can anticipate; this will help child accept daily events and develop a sense of consistency in the world.
      • Provide freedom of activity within this environment and schedule so that there is as little opportunity for rebellion and frustration as possible.
      • Understand the developmental stages so that unattainable tasks are not expected (such as toilet training, table manners, sharing, reliable behavior control).
      • Understand that attention given to a particular activity will cause this activity to be repeated. Rewards and praise for a behavior will help establish this behavior as a pattern. Unacceptable behavior will also be repeated if that is the only way that attention is gained.
      • Provide a primary caregiver who will give encouragement and comfort and who will accept the child’s attempts to express affection.
    • Baby’s developmental tasks
      • Master the physical skills of walking and using the hands to carry and manipulate objects
      • Use new physical skills and self-confidence to investigate surroundings
      • Learn by repetition of an activity to anticipate its result
      • Develop a close relationship with and affection for someone outside self through consistent interaction with that person
    • The nurse practitioner can now plan extended office visits, or if possible do a home visit, to be a resource for and support to the parents in understanding and coping during this critical period of growth.
  • Family status
    • Basic needs being met
      • Referrals: If made, follow-up to ensure appropriate help is received.
      • Adequate support system available
    • Family unit
      • Mother
        • Satisfied with lifestyle; confident, cheerful, energetic
        • Support system intact; outside interests present
        • Maturation level: Own needs being met; can view child objectively and not as the only means of satisfying her needs
        • Coping with confusion of women’s role in today’s society: Women’s rights, career planning, divorce, separation, men’s changing role
      • Working mother
        • Satisfied with child care arrangements
        • Adjusting to physical stress of two jobs
        • Able to express and work through emotional reactions, such as guilt at leaving home, distress if going to work is a necessity, and satisfactions from new role
      • Single parent
        • Needs identified and goals established
        • Referrals: Provide follow-up.
        • Visits scheduled to provide support and help in establishing healthy childrearing practices
        • Fear of violence and abuse identified
      • Mother and father
        • Developing a unified philosophy of childrearing
          • Evaluating their own upbringing as to disciplinary practices and cultural influences
          • Identifying how these influence their childrearing practices
          • Gaining knowledge of developmental principles
        • Interactive patterns and communication skills
          • Reactive pattern when under stress
          • Knowledge and application of problem-solving techniques
      • Siblings: Goal is to develop positive feelings toward each other.
        • Each child should have the opportunity to develop at his or her own pace without interference.
        • Separate planning for each child (bedtimes, activities, play, schools)
        • Playing together and sharing takes about six years to develop. Children need to learn to respond to disagreements with positive behavior patterns.
        • Parents reinforce positive behavior and demonstrate gentleness.
        • Parents appreciate children’s attempts to show concern for one another.
    • Identify sexual abuse to or by any family member
  • Health patterns
    • Nutrition
      • Child showing less interest in food; too busy investigating world
      • Growth rate slowed, so smaller intake normal
      • Anemia: Be sure hematocrit is done.
        • Diet high in iron, vitamin C and calcium. 500 mg calcium/d for 1-3 years old
        • After 12 months when formula is changed to whole milk, cut back milk intake to 12 to 16 oz/d.
      • Balanced diet to include:
        • Finger foods: Fruit, vegetables, meat
        • Protein: Eggs, fish, whole-grain cereals, meat
        • Milk: 12 to 16 oz per office protocol
        • Water: Offer frequently. Avoid soda. Give diluted fruit juices, not “fruit drinks.” Be aware of overfeeding with high caloric foods or drinks.
    • Sleep
      • Child often needs help slowing down. Establish bedtime routine, with quiet time for reading or music; not a time for roughhousing.
      • Waking during the night; needs reassurance often; when further along in establishing autonomy, will sleep soundly all night
        • Develop routine for these periods, such as diapering, playing soft music, singing; use night-light.
        • Part of developmental pattern; needs careful consideration and consistent response
      • Watch carefully for attempts to climb out of crib; safety is the prime consideration.
        • If child is climbing out, leave sides down so he or she can get out without a serious fall.
        • Put a mattress on the floor or get a regular bed.
        • Child-proof room, particularly ensuring that window screens are secured and bureau drawer hooked closed.
        • Put gate on child’s room door so he or she cannot roam the house while parents sleep.
    • Elimination
      • Muscle control of sphincters not sufficiently developed to begin toilet training
      • Bowel movements and urinary output can help in evaluation of dietary and liquid intake.
      • Constipation (cow’s milk can cause problems); to prevent, include in diet large amounts of water, whole-grain cereals, dried fruits; ask for professional help if problem continues.
  • Growth and development
    • Physical
      • Motor development
        • Gross motor: Joys and perils of learning to creep, crawl, walk, and finally climb; getting direction straightened; moving forward or backward at will; negotiating obstacles; pulling up to standing position and learning to get back down; using hands and arms as balancing pole; needing to carry something in hands
        • Fine motor: Manipulating objects; turning knobs; pulling, opening, poking; using pincer grasp
      • Reaction to pain
        • Inability to locate
        • Reduces activity level
        • Irritability the usual indicator
      • Reaction to illness
        • Skill development halted
        • Return to earlier developmental stage
        • Separation from primary caregiver overwhelming
    • Emotional development. Erikson: Progression from basic trust to stage of autonomy. This is a transitional period that, if successful, shows the amazing progress from a stationary, happy infant to a mobile, impatient, energetic investigator. Children begin to realize, through the encouragement of caregivers, that they have the ability to be all right, most of the time, on their own.
      • Affection: Returns hugs and kisses
      • Joy: Excitement at parent’s return, at accomplishing a task, at rhythm of body movement
      • Ambivalence of feeling: Returning to earlier behavior patterns when tired, distraught, or ill
      • Obstinate: Persistent in solving problems by trial and error
      • Anger: At body constraint, at interruptions during play
      • Fear and anxiety: Natural response to new adventures, so reassurance from primary caregiver important
      • Distress: Irritable, apathetic, unlovable (risk factor if this is dominant mood)
    • Intellectual development. Piaget: Development of causality. Child is progressing from random activities to intentional activities by observing and recalling previous results of a particular activity.
      • Steps in learning self-control
        • Watches response of caregiver to efforts to conform
        • Delayed gratification: Waiting for meals to be served; waiting to be picked up when first awake
        • Amuses self for longer periods
        • Comforts self
      • Memory
        • Recognizes self in mirror (reaches up to touch something on self seen in mirror)
        • Anticipates sequence of daily routine
        • Object permanence: Will search for an object after it is out of sight
        • Recognizes sounds: Car or footsteps; individual voices
        • Repeats actions: Plays “pat-a-cake,” waves “bye-bye”
        • Recognizes foods and demonstrates likes and dislikes
      • Language
        • Word development: Repeats definite sounds (dada, mama)
        • Understands words before being able to use them (commands, names, body parts)
        • Listens to own voice
        • Attends as caregiver names objects
        • May subordinate language development while attending to new motor skills
  • Risk factors
    • Parents
      • Dissatisfaction with role
      • Own experiences of abuse
      • Emotional poverty (low self-esteem, rigid response patterns, marital conflict)
      • Fear of violence and abuse
    • Child
      • Developmental and physical lags
      • Irritable, apathetic, overly cautious
  • Childrearing practices
    • Parents have confidence in coping with spontaneous feelings of frustration, boredom, anger; appreciate the need for ingenuity, patience, and positive ways of expressing these emotions.
    • Honest responses: Child soon learns which behaviors bring hugs and which bring disapproval.
    • Reinforce positive behavior; set up environment so few opportunities for negative behavior.
    • Identify individuality of child’s capabilities and reactive patterns.
    • Provide cheerful, fun-loving environment.
    • Let baby try to solve own problems; help only when necessary.
    • Caregiver arrangements
      • Babysitter/day care
        • Able to be regular caregiver
        • Cheerful and energetic but gentle
        • Responsible: Follows daily schedule; takes safety precautions; responds appropriately to baby’s cues; enjoys child care
      • Day care center
        • Parents should investigate and observe several centers before choosing one.
        • State-approved, with professional, educated personnel
        • Environment: Attractive, quiet; sufficient space for activities; sufficient equipment for stimulation; safety precautions observed
        • Caregiver: Consistency in child’s caregiver; responds to individual needs; has time to give individual attention
        • Health services
          • Safe, sanitary conditions
          • Nutritious food
          • Identification of sick child: Appropriate plans for care
          • Health education services to parents: Group meetings, regular health bulletins to families
        • Evaluation of facility
          • Observe children enrolled (relaxed, happy children).
          • Watch responses of caregivers to children’s requests.
          • Get assessment from other parents.
  • Stimulation
    • Communication and sounds
      • Provide toy phone; let child listen to real phone.
      • Use single names for toys, foods, names, animals.
      • Name and point to body parts.
      • Play blowing games: Bubbles, horns.
      • Provide noisy push-and-pull toys.
      • Read books with simple, repetitive themes and rhymes.
    • Touch
      • Encourage baby to return affection by hugs and kisses.
      • Bathtub toys: Boats, various-sized containers, colored sponges
    • Sight
      • Texture pictures: Encourage touching; change often.
      • Change of environment: Trips to the store, out in the car; point out distant objects, such as birds, planes, clouds.
    • Gross motor
      • Removing clothes
      • Fetching and carrying
      • Opportunity to climb up and down stairs, with supervision
      • Walking backward
      • Walking on variety of surfaces: Grass, mattress, sidewalk
      • Using wading pool with supervision
    • Fine motor
      • Puts things in boxes and takes them out
      • Plays in sandbox with spoons, cups, cars, strainer
      • Transports objects
      • Builds tower with blocks
      • Opens, shuts cupboard doors
    • Feeding
      • Feels food: Raw, cooked, dough, vegetables, liquid
      • Splashes, stirs, pours
      • Feeds self; uses cup
      • Can use mealtime to demonstrate he or she can get own way
  • Safety
    • Accidents happen most frequently:
      • When usual routine changes (holidays, vacations, illness in family)
      • After stressful events for caregivers
      • When caregivers are tired or ill
      • Late in the afternoon
    • Accident prevention
      • Increased mobility: Child needs freedom to investigate but must also have constant surveillance.
      • Safe place to put baby while caregiver is out of sight
      • Falls and burns: First-aid instructions per office protocol
    • Investigate frequent injuries for possible child abuse and neglect.
    • Instructions to babysitters
    • Emergency telephone numbers posted
12- TO 15-MONTH WELL CHILD VISIT
This is a period of consolidation. Newfound physical skills are being refined, and the progression from dependence toward independence is becoming a smoother path, although frequent backsliding is still seen. The excitement of mastering physical skills and the courage to do it by themselves make for happier and more relaxed toddlers.
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Jun 7, 2016 | Posted by in PEDIATRICS | Comments Off on Well Child Visit Guidelines and Anticipatory Guidance

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