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

CHAPTER 11

Nine-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

Separation anxiety, 309.21

I. GENERAL IMPRESSION

A. On the move! Need to explore critical for cognitive development.

B. Rapidly gaining new motor/cognitive skills; 9-month olds present new challenges to parents.

C. Separating from parents is difficult.

II. NUTRITION

A. Caloric needs: 98–100 kcal/kg/day.

B. Breastfeeding/formula feeding.

1. Infant receiving most nutrients from solid foods.

2. Continue to encourage breastfeeding through fi rst year.

3. If using formula, continue with iron-fortifi ed product.

4. Avoid cow's milk until after first year.

C. Assess for risk factors, screen for iron-defi ciency anemia if necessary.

1. Watch for use of cow's milk, low-iron formulas, low intake of iron-rich foods.

2. Supplement as necessary (see Chapter 32 for more on iron-defi ciencyanemia).

D. Solids.

1. Infant should be eating table food with family.

2. Finely chopped meats may be introduced.

3. Finger foods appropriate at this time as fi ne pincer grasp has developed.

4. May take up to 10 offerings before infant accepts new food.

E. Eating habits/safety.

1. Offer liquids from cup.

2. Limit juice to 4–6 oz/day.

3. No honey or corn syrup (Karo) until after fi rst year.

4. Offer solids 3–4 times/day.

5. Atmosphere should be relaxed, pleasant. Expect a mess!

6. Avoid foods that may cause choking: grapes, raisins, peanuts/peanut butter, popcorn, hard candy, carrots, celery, other hard vegetables/ fruits.

8. Encourage infant to self-feed; provide infant with spoon.

9. Watch for infant cues to signal satiation.

III. ELIMINATION

A. Voiding pattern.

1. Stays dry for longer periods.

2. Usually voids after naps.

B. Stooling pattern.

1. Stools usually firm, dark.

2. Individual pattern established between 9 and 12 months.

3. Generally 1-2 stools/day (but may vary considerably between infants).

IV. SLEEP

A. Requirements.

1. Total sleep in 24 hours between 11 and 13 hours.

2. Night awakenings common but should be able to put self back to sleep.

3. Continues to nap in morning and afternoon.

B. Environment.

1. Bedtime rituals well established.

2. Room should remain dim and not overly warm.

C. Safety.

1. Avoid bottles in bed.

2. Lower crib mattress.

3. Remind parents about removing blind or drapery cords, hanging objects (especially mobiles), small objects in cribs.

V. GROWTH AND DEVELOPMENT

A. Physical.

1. Growth is slower in second half of first year.

2. Weight gains average 1 lb/month and length 1 in./month.

3. Growth should be steady but pattern may vary from early infancy; growth spurts more common.

B. Motor.

1. Fine.

a. Pincer grasp developed. Able to pick up small objects.

b. Begins to poke with index finger.

c. Can drop, bang, throw objects.

d. Can self-feed.

2. Gross.

a. Sits well.

b. Creeping/crawling.

c. May begin to pull up on furniture.

d. Weight bearing when pulled to stand.

3. Infant reflexes.

a. Primitive reflexes should be absent.

b. Parachute reflex emerges.

C. Cognitive.

1. Object permanence more prominently developed.

2. May look for objects and go after them.

D. Language.

1. Combines syllables.

2. Imitates speech sounds. Uses intonations.

3. “Dada” and “mama” are nonspecific.

4. Responds to name.

VI. SOCIAL DEVELOPMENT

A. Relationships.

1. Beginning to indicate wants.

2. May begin to wave “bye-bye.”

B. Environment: conditions that foster trust and development of positive psychosocial feelings. Separation anxiety emerges. Stranger anxiety apparent.

VII. IMMUNIZATIONS (SEE APPENDIX A)

A. Make up for missed immunizations.

B. Influenza annually.

VIII. SAFETY

A. Infant care activities.

1. Always check bathwater temperature.

2. Never leave infant alone in tub, changing table, highchair.

3. Use sunscreen; avoid prolonged sun exposure.

B. Environment.

1. Use car seat consistently.

2. Never leave infant alone in car.

3. Avoid use of walkers.

4. Reinforce “baby proofing”: outlet covers, door drawer latches, safety gates. Remove cords, wires, string, small objects, plastic bags from baby's environment.

5. Keep sharp objects out of reach.

6. Maintain smoke-free environment; use smoke alarms.

7. Do not leave alone in room with pets or young children. Keep litter boxes away from infant's environment. Feed pets in area away from infant; do not allow infant near pet when eating.

8. Avoid tablecloths or remove heavy/hot objects from tables with tablecloths.

9. Keep toilet lid down, remove buckets with water.

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

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

12. Keep houseplants out of reach; remove any poisonous plants.

IX. ANTICIPATORY GUIDANCE

A. Parent-infant interaction.

1. Continue to encourage floor time for infant to provide opportunities to explore.

2. Talk with infant while engaging in other activities (e.g., grocery shopping).

3. Continue singing and movement activities with infant. Play games such as “peek-a-boo.”

4. Encourage reading activities with picture books, infant board books.

5. Foster infant's ability to self-soothe with transitional objects such as blanket, stuffed toy.

B. Discipline.

1. Discuss appropriate discipline measures aimed primarily at protecting infant from injury such as physical removal from danger.

2. Distraction most effective to redirect behavior.

3. Limited use of word “no.”

4. Begin to think about rules: keep them few and simple.

5. Consistency is key to discipline.

C. Oral hygiene.

1. No bottles in bed.

2. Use soft toothbrush without toothpaste to clean teeth. Assess fluoride source and supplement as necessary (see Appendix B).

D. Illness prevention.

1. Review illness symptoms/interventions.

2. Reinforce importance of handwashing.

3. Use cool mist vaporizer for upper respiratory illness.

E. When to call healthcare provider:

1. Breathing difficulties.

2. Seizures.

3. Irritability.

4. No urine output in 12 hours.

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.

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

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

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

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



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