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
     A dental sealant or a topical fluoride is crucial in preventing tooth decay

Vaccinations
It 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 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, etc.

What to expect during a 4-Month-Old Physical

Developmental Surveillance

  • Social Language and Self-Help
    • Laughs aloud
    • Looks for Parent when upset
  • Verbal Language
    • Turns to voices
    • Makes extended cooing sounds
  • Gross Motor
    • Supports self on elbows and wrist on stomach
    • Rolls over from Stomach to back 
  • Fine Motor
    • Keeps hands unfisted
    • Plays with fingers in the midline
    • Grasps Objects

BEHAVIORAL HEALTH

  • 3Psychosocial/Behavioral Assessment
  • 4Maternal Depression Screening

5PHYSICAL EXAMINATION

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

6Immunization

  • Recommended age for catch-up immunization
    • Hepatitis B (HepB)
  • Recommended age for certain high-risk groups
    • Meningococcal (MenACWY-D ≥9 mos; MenACWY-CRM ≥2 mos)
  • 2nd Dose Rotavirus (RV) RV1 (2-dose series)
  • 2nd Dose Rotavirus (RV) RV5 (3-dose series)
  • 2nd Dose Diphtheria, tetanus, & acellular pertussis (DTaP:<7 yrs)
  • 2nd Dose Haemophilus influenza type b (Hib)
  • 2nd Dose PedvaxHIB
  • 2nd Dose Pneumococcal conjugate (PCV13)
  • 2nd Dose Inactivated poliovirus (IPV: <18 yrs)
  •  7Anemia*
  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. This assessment should be family-centered and may include an assessment of the child’s social-emotional health, caregiver depression, and social determinants of health. //pediatrics.aappublications.org/content/135/2/384
  4. Screening should occur per //pediatrics.aappublications.org/content/126/5/1032
  5. At each visit, age-appropriate physical examination is essential, with infants 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).
  6. Every visit should be an opportunity to update and complete a child’s immunizations. //redbook.solutions.aap.org/SS/Immunization_Schedules.aspx. 
  7. Perform risk assessment or screening, as appropriate, per recommendations in the current edition of the AAP Pediatric Nutrition.

* risk assessment to be performed with appropriate action to follow, if positive

4-Month-Old Anticipatory Guidance

Social Determinants of Health

◊ Risks (environmental risk: lead, work-related exposures) ◊ Strengths and Protective Factors (family relationships and support, child care)

  • Reduce lead exposure at home
  • Maintain social contacts
    • Make time for self, partner
    • Spend time with your other children.
  • Make quality childcare arrangements.

Infant behavior and development

◊ Infant Self-Calming ◊ Parent-Infant Communication ◊ Consistent Daily Routines ◊ Media ◊ Playtime

  • What do you do to calm your baby? What do you do if that does not work? Do you ever feel that you and/or other caregivers may hurt the baby?
    • Continue calming strategies when the baby is fussy. 
  • Spend time talking/playing with the baby.
  • Create a daily routine for feeding /naps/bedtime.
  •  Avoid TV and other digital media with the baby.
  •  Use quiet (reading, singing) and active (“tummy time”) playtime
  • provide safe opportunities to explore.

Oral Health

◊ Maternal Oral Health ◊ Teething and Drooling ◊ Good Oral Hygiene (no bottle in bed)

  • Don’t share spoons; don’t clean pacifiers in your mouth; maintain good dental hygiene.
  • Use a cold teething ring to relieve teething pain.
  • Don’t put the baby in a crib with a bottle; never prop a bottle when feeding.
  • Clean teeth /gums 2 times per day; use a soft cloth/toothbrush with tap water and a small smear of fluoridated toothpaste (no more than a grain of rice).

Nutrition and feeding

◊ General Guidance on Feeding ◊ Feeding Choices (avoid grazing) ◊ Delaying Solid Foods ◊ Breastfeeding Guidance ◊ Supplements and Over-The-Counter Medications ◊ Formula­Feeding Guidance

  • Exclusive breastfeeding for about the first 6 months is ideal
  • The iron-fortified formula is recommended substitute.
  • Delay solid foods until baby is 6 months old.
  • If breastfeeding: 
    • Recognize growth spurts
    • Give baby vitamin D (400 IU per day)
    • Begin infant iron supplementation
    • Discuss safe pumping/ storing breast milk
    • Report any medications/ supplements /herbs /vitamins.
  • If formula feeding:
    • Prepare /store formula safely
    • 8 to 12 times in 24 hours; 30 to 32 oz total
    • hold baby semi-up right
    • consider contacting WIC.

Safety

◊ Car Safety Seats ◊ Safe Asleep ◊ Safe Home Environment 

  • Car Seats
    • Use a rear-facing car safety seat in the backseat
    • Never put the baby in the front seat of a vehicle with a passenger airbag
    • Keep the baby in a car safety seat at all times during travel.
  • Use a seat belt; don’t drive after using alcohol or drugs.
  • Put baby to sleep on back; choose the crib with slats less than 2¾” apart; don’t use loose, soft bedding; 
  • Avoid burn risk while holding a baby (drinking hot liquids, cooking, ironing, smoking)
  • Set the home water temperature to less than 120°F.
  • Don’t leave baby alone in:
  • Tub
    • High places (changing tables, beds, sofas)
    • Keep a hand on the baby (“touch supervision”).
    • Keep small objects, and plastic bags away from the baby. Avoid infant walkers.

Goals For 4-Month Checkup:

◌ 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.

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