Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 10

Six-Month Visit

Patricia Clinton

Breathing difficulties, 786.09

Rash, 782.1

Irritability, 799.2

Seizures, 780.39

No urine output in 12 hours, 788.2

 

I. GENERAL IMPRESSION

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

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

II. NUTRITION

A. Caloric and nutrient needs.

1. 95-105 kcal/kg/ day.

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

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

B. Breastfeeding.

1. Continue to encourage breastfeeding through first year.

C. Formula feeding.

1. Continue with iron-fortified formula.

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

D. Solid foods.

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

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

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

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

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

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

7. Meat not added until later in first year.

8. Avoid feeding as a comfort measure.

E. Eating habits/safety.

1. No bottles in bed.

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

3. No honey until after first year.

4. Vary textures from pureed to fine grind.

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

III. ELIMINATION

A. Continues to have 6 wet diapers/day.

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

IV. SLEEP

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

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

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

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

E. Transitional objects continue to be important.

F. Night feedings not needed.

V. GROWTH AND DEVELOPMENT

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

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

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

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

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

F. Rolls over both directions.

G. Bears weight on legs.

H. Moro and tonic neck reflexes have disappeared.

I. Responds to name.

J. Babbles (“ba,” “ga,” “da”), laughs, squeals.

VI. SOCIAL DEVELOPMEN

A. Enjoys interacting with parents.

B. Expects that needs will be met and expresses frustration when they are not.

C. Separation anxiety emerges.

D. Begins to differentiate angry or friendly tone of others and respond accordingly.

E. Uses gestures to gain attention (pointing, reaching).

VII. IMMUNIZATIONS (SEE APPENDIX A)

A. DTaP #3.

B. Hib (depending on which vaccine used).

C. IPV #3 (3rd dose anytime between 6 and 18 months).

D. PCV #3.

E. RV (not necessary if Rotarix administered at 2 and 4 months).

F. Influenza ann

VIII. SAFETY/ANTICIPATORY GUIDANCE

A. Always check bathwater temperature. Never leave infant alone in tub or on changing table.

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

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

D. Avoid use of walkers.

E. Baby proof environment with outlet covers, door and drawer latches, safety gates. Remove cords, wires, string, or plastic bags from baby's environment. Avoid tablecloths; remove heavy/hot objects from tables that have tablecloths.

F. Maintain smoke-free environment, ensure smoke alarms in baby's home.

G. Do not leave alone in room with pets or siblings.

H. Monitor for small objects or toys especially if other young children present.

I. Keep bathroom door closed, toilet lid down, remove buckets with water.

J. Use protective enclosures around swimming pools, hot tubs, other water sites (ponds, fountains).

K. Provide poison control number to be placed by telephone; syrup of ipecac no longer recommended.

L. Play games such as “peek-a-boo.” Encourage reading activities with picture books, infant board books.

M. Treat teething discomfort with oral massage, frozen wet washcloths, other cold hard objects for chewing, acetaminophen or ibuprofen. Discourage use of numbing gels because of likelihood of numbing entire oral cavity, suppressing gag reflex.

N. Assess fluoride source, supplement as necessary (see Appendix B).

O. Illness prevention.

1. Review illness symptoms and interventions.

2. Reinforce handwashing.

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

P. When to call health care provider:

1.Breathing difficulties.

2.Irritability.

3.No urine output in 12 hours.

4.Seizures.

5.Rash.

6.Concerns.

BIBLIOGRAPHY

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

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

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

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

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

Recommendations for using fluoride to prevent and control dental caries in the United States. Morb Mortal Weekly Rep. 2001;50:RR-14.



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