2 Month Physical – Powers Development Guide

Why are Physicals Important!?

Development Surveillance
Detect and prevent developmental delays and possible diseases so they can be treated early

Measurements 
Both growing too slowly or too fast may indicate a nutritional or other health problem.

Screenings

   – Lead 
     Toxic Lead Levels cause behavioral and learning difficulties, anemia, seizures and other medical problems. 

   – Vision 
     Performing well at school can be very difficult if a child has vision problems.

   – Blood Pressure / Hypertension  
     Reducing blood pressure during childhood and adolescence will result in a reduced risk of heart disease and death in adulthood.

   – Oral Health
     Dental sealant or a topical fluoride is crucial in preventing tooth decay

Vaccinations
Keeps you from getting and spreading the diseases such as, Measles or polio, which cause life-altering changes or death. 

Behavioral Assessment
Mental health problems affect about 1 in 10 children and young people; they include depression, anxiety and conduct disorder. 

Anticipatory Guidance 
A crucial part of pediatric care and has been shown to reduce caregiver anxiety and ER/Urgent Care Visits.

Get access to community resources
Having access to resources such as food banks, shelters, mental or behavioral health experts ect.

What to except during a 2 Month Old Physical?

Developmental Surveillance

• Social Language and Self-Help
  • Smiles Responsively
  • Sounds that show happiness/upset
• Verbal Language
  • Makes short cooing sounds
• Gross Motor
  • Lifts head and chest on stomach
  • Keeps head steady in sitting position
• Fine Motor
  • Opens and shuts hands
  • Briefly brings hands together

Behavioral Health

• ⁴Psychosocial/Behavioral Assessment
• ⁵Maternal Depression Screening

⁶PHYSICAL EXAMINATION

• HISTORY
  • Initial/Interval
• MEASUREMENTS
  • Length/Height and Weight
  • Head Circumference
  • Weight for Length
  • ¹Blood Pressure*
• SENSORY SCREENING
  • ²Vision*
  • ³Hearing
  • 3-5 days àß 1 Month – 2 Month
• PROCEDURES
  • These may be modified, depending on entry point into schedule and individual need.
  • Newborn Blood
  • 3-5 days àß 1 Month – 2 Month

⁷Immunization

• Recommended age for certain high-risk groups
  • Meningococcal (MenACWY-D ≥9 mos; MenACWY-CRM ≥2 mos)
• 2^nd Dose Hepatitis B (HepB)
  • àß 1 Month – 2 Month
• 1^st Dose Rotavirus (RV) RV1 (2-dose series)
• 1^st Dose Rotavirus (RV) RV5 (3-dose series)
• 1^st Dose Diphtheria, tetanus, & acellular pertussis (DTaP: <7 yrs)
• 1^st Dose Haemophilus influenzae type b (Hib)
• 1^st Dose PedvaxHIB
• 1^st Dose Pneumococcal conjugate (PCV13)
• 1^st Dose Inactivated poliovirus (IPV: <18 yrs)

1. Blood pressure measurement in infants and children with specific risk conditions should be performed at visits before age 3 years. 7 //pediatrics.aappublications.org/content/140/3/e20171904). 
2. Instrument-based  screening may be used to assess risk at ages 12 and 24 months //pediatrics.aappublications.org/content/137/1/e20153597
3. Verify results as soon as possible, and follow up, as appropriate.
4. This assessment should be family-centered and may include an assessment of child social-emotional health, caregiver depression, and social determinants of health. //pediatrics.aappublications.org/content/135/2/384
5. Screening should occur per //pediatrics.aappublications.org/content/126/5/1032
6. At each visit, age-appropriate physical examination is essential, with infant totally unclothed and older children undressed and suitably draped. The extent of the physical examination is determined by both the reason for the visit and diagnostic considerations raised during the taking of the history. //pediatrics.aappublications.org/content/127/5/991.full).
7. Every visit should be an opportunity to update and complete a child’s immunizations. //redbook.solutions.aap.org/SS/Immunization_Schedules.aspx.

2 Month Old Anticipatory Guidance

Social Determinants of Health

◊ Risks (living situation and food security) ◊ Strengths and Protective Factors (family support, Child Care)

• Tell me about your living situation. What are your resources for caring for the baby?
  • Community agencies can help you with concerns about your living situation.
• Within the past 12 months, were you ever worried whether your food would run out before you got money to buy more?  Within the past 12 months, did the food you bought not last and you did not have money to get more?
  • Programs like WIC and SNAP are available to help you if you have concerns about your food situation. 
• Handle unwanted advice by acknowledging, then changing, subject.
• Take time for self, partner. Maintain social contacts.
• How do you feel about leaving your baby with someone else?
  • Choose quality child care; recognize that separation is hard.

Parent and family health and well-being

◊ Post­Partum Checkup ◊ Depression ◊ Sibling Relationships

• Have postpartum checkup; talk with partner about family planning.
• Over the past 2 weeks, have you ever felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things?
  • Anxiety and Depression is common after birth
  • Getting enough sleep/physical activity and eating healthy helps
  • Talk with me if feelings last more than 2 days.
• Spend time with your other children; engage them in care of baby if appropriate.

Infant behavior and development

◊ Parent-Infant Relationship ◊ Parent-Infant Communication ◊ Sleeping ◊ Media ◊ Playtime ◊ Fussiness

• What do you and your partner enjoy most about your baby? What is challenging?
  • Hold, cuddle, talk, sing to baby.
• What do you think your baby is feeling and trying to tell you?
  • Learn baby’s temperament, personality. 
• Pay attention to baby’s cues for sleep; develop schedule for naps and nighttime sleep
• Put baby to bed awake but drowsy.
• Avoid TV and other digital media with baby.
• Use “tummy time” when awake.
• Calm baby by stroking head, gentle rocking, walking with baby in stroller.
• Never hit or shake baby.

Nutrition and feeding

◊ General Guidance on Feeding and Delaying Solid Foods ◊ Hunger and Satiety Cues ◊ Breastfeeding Guidance ◊ Formula-Feeding Guidance

• Exclusive breastfeeding for about the first 6 months of life provides ideal nutrition
  • supports best growth and development
  • iron-fortified formula is recommended substitute
  • recognize signs of hunger, fullness
  • expect 6 to 8 wet cloth diapers per day or 5 to 6 wet disposable diapers
  • 3 to 4 stools per day; no extra fluids
  • burp baby at natural breaks in feeding.
• If breastfeeding: How is breastfeeding going? Is baby breastfeeding exclusively? If not, what else is baby getting?
  • Provide 8 to 12 feedings in 24 hours    
  • Give baby vitamin D (400 IU per day)
  • Mothers should continue prenatal vitamin with iron
  • healthy diet (fish, protein).
• If formula feeding: How is formula feeding going for you and your baby? Have you offered your baby anything other than formula?
  • Prepare/store formula safely
  • Feed 6 to 8 times in 24 hours
  • 26 to 28 oz formula total
  • Hold baby semi-upright; don’t prop bottle. 

Safety 

◊ Car Safety Seats ◊ Safe Asleep ◊ Safe Home Environment ◊ Burns ◊ Drowning and Falls

• Car Seats
  • Use rear-facing car safety seat in backseat
  • Never put baby in front seat of vehicle with passenger air bag
  • Keep baby in car safety seat at all times during travel.
• Use seat belt; don’t drive after using alcohol or drugs.
• Put baby to sleep on back; choose crib with slats less than 2¾” apart; don’t use loose, soft bedding; have baby sleep in your room in own crib.
• Don’t drink hot liquids while holding baby; set home water temperature less than 120°F.
• Don’t leave baby alone in:
  • Tub 
  • High places (changing tables, beds, sofas)
  • Keep hand on baby (“touch supervision”).

Goals For 2 Month Check up:

◌ Be gentle and patient ◌ Get more sleep ◌ Make a budget ◌ Leave your work at the office ◌ Focus on self-care ◌ Meditate as a family ◌ Find an outlet ◌ “cell-free” zone ◌ Spend more time with your partner ◌ Take more baths ◌ Have a girls’/boys’ night ◌ Be more flexible ◌ See your child for who they are ◌ Teach your child to speak up ◌ Help those less fortunate ◌ Drink more water ◌ Find 30 minutes a day of “me” time ◌ Challenge yourself ◌ Focus on experiences, not things ◌ Make health a priority ◌ Start—or finish—a degree ◌ Inform yourself ◌ Maintain balance ◌Laugh often ◌ Cook dinner more frequently ◌ Ask for help ◌ Have designated “cheat” days ◌ Stop having FOMO ◌ Say “I love you” more often