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

CHAPTER 8

Two-Month Visit

Candace F. Zickler

Breathing difficulties, 786.09

No urine output in 12 hours, 788.2

Colic, 789

Poor feeding, 783.3

Decreased bowel movements, 564

Seizures, 780.39

Fever, 780.6

Vomiting, 787.03

Irritability, 799.2

 

I. GENERAL IMPRESSION

A. Parents should be enjoying their infant and taking joy from infant's accomplishments.

B. Infant is more responsive with smiling and cooing.

C. Parents should have many questions and be able to share stories of babies' activities.

II. NUTRITION

A. Two-month old infant will take 6-8 oz/feeding, 4-6 feedings/24 hours (94–130 cal/kg/day). Feedings should be more predictable and infant should have periods when he/she sleeps for 3-4 hours at a time.

B. Baby should take in 90 of feeding in first 20 minutes.

C. Hold infant in semi-reclined position; burp every 1–2 oz.

D. Specialized formulas have similar preparation directions; read labels. Goat's milk, whole cow's milk, rice milk have inadequate amounts of vitamins and minerals.

E. Serve formula at room temperature. Do not microwave to heat. Do not let formula sit out to warm for more than 15–20 minutes.

F. Clean technique is sufficient for mixing formulas.

1. Clean off cans with soap and water before opening.

2. Use hot soapy water and bottlebrush to clean nipples and bottles or clean in dishwasher.

G. No bottle propping. Pacifiers are used for non-nutritive sucking. Breastfeeding should be well established before starting infant on a pacifier, but babies who suck pacifiers are at decreased incidence of sudden infant death.

H. No smoking or drinking hot beverages while holding baby.

III. ELIMINATION

A. Should have 1–5 yellow pasty, but formed stools/24 hours.

B. Breastfed babies may have more stools than bottle-fed babies.

C. Void every 1–3 hours or with each feeding and diaper change.

IV. SLEEP

A. Babies sleep 16–18 hours/24 hours. Infant is developing sleep pattern. May sleep through night. May have longer awake periods during day.

B. Sleep cycles have both active and quiet sleep periods in equal proportions. Each sleep cycle lasts 50–60 minutes. Infants are less efficient with sleep and easily interrupted with noise. Should be alert for feedings, nurse vigorously for 15–20 minutes, and fall back to sleep/stay awake for short periods.

C. Babies should sleep in own cribs, not with parents, to decrease smothering injury to infant.

1. Babies should sleep on back in cribs to decrease incidence of sudden infant death syndrome (SIDS).

2. No pillows/toys that baby could get face against and smother.

V. GROWTH AND DEVELOPMENT

A. Growth. Plot length, weight, head circumference, and weight-for-height on the National Center for Health Statistics (NCHS) growth grids. Compare to last visit growth plots.

1. Babies should gain 0.5–0.75 oz/day or approximately 2 lbs/month for the first 4–5 months.

2. Infant grows, on average, 1 in./month for first 6 months.

3. Head circumference increases 0.5 cm/month in first year.

B. Development.

1. Holds head upright for short periods. Follows people and looks for voice.

2. Responds to smiling with return smile.

3. Babbles and makes sounds with prompt of verbal cue.

4. Shows interest in what is happening in room.

5. Moves all 4 extremities, simultaneously.

6. May cry but parents are learning what each cry means. Crying ceases when needs are met.

VI. SOCIAL DEVELOPMENT

A. Baby learning to “trust” parent and caretakers to meet needs.

B. Family is settling into routines with infant.

C. Listen carefully for frustration, potential for abuse/neglect. Discuss child's unique temperament characteristics, relate to parents' feelings.

D. Parent should be assessed for sadness, depression, fatigue.

1. Encourage mother to rest when baby rests/sleeps.

2. Encourage mother to take breaks away from baby to do self-nurturing (needs designated sitter).

E. Take baby on selective, limited outings because infant is not fully immunized; will only receive first set today.

F. Ask about plans for returning to work. Discuss guidelines for selecting sitter/ daycare.

G. May have “fussy” time of 1–2 hours/day, often in evening. Use “fussy” time as interaction time, not extra feeding. Cry gradually decreases by 3 months of age. Baby may have symptoms of “colic” (starts 2–3 weeks of age, ceases by 12 weeks). Infant cries for prolonged periods, no specific cause or etiology identified. Infant continues to grow well. Infant is alert and playful at other times. Infant may require additional comfort measures to quiet and settle and should be accepted as expected for age.

H. Should have some supervised, “tummy” play time while awake.

I. Encourage parent to actively talk, play with infant. Select age-appropriate toys.

VII. IMMUNIZATIONS (SEE APPENDIX A)

A. Infant will receive first set of immunizations today. Combinations are available that decrease number of injections. Parents trust providers to guide them in their decision to immunize their children. Need to discuss risks and benefits of immunizations and have parent sign consent. The following immunizations are best practice for 2-month-old infants.

1. Hepatitis B 2: After the birth dose, the hepatitis B series can be completed with either monovalent HepB or a combination vaccine containing HepB. Administer 4 doses of HepB to infants if combination vaccines with HepB are given after the birth dose.

2. DTaP #1 (diphtheria-tetanus-acellular pertussis). Minimum age of 6 weeks.

3. IPV #1 (inactivated poliovirus). Minimum age of 6 weeks.

4. Hib #1 (Haemophilus influenzae type b). Minimum age of 6 weeks.

5. PCV #1 (pneumococcal conjugate). Minimum age of 6 weeks.

6. RV (rotavirus vaccine). Minimum age of 6 weeks. Maximum age of 14 weeks and 6 days to start series.

B. Giving acetaminophen prophylactically after immunizations may decrease the response to the vaccine. Few infants run fevers after immunizations.

VIII. SAFETY/ANTICIPATORY GUIDANCE

A. Needs safe sleep position “back to sleep.”

1. Not safe for baby to sleep in adult bed.

2. Discuss temperature of room, temperature of water, bathing safety guidelines.

3. Discuss appropriate amount of clothing to keep baby comfortable in varied environments.

B. Never leave baby unattended near pet or sibling.

C. Keep hand on baby when on changing tables, sofas, avoid risk of falling.

D. Review need for car seat that is Federal Motor Vehicle Safety tested and approved, installed properly in backseat, facing backward in automobile. Contact local hospital, fire department, or March of Dimes chapter for car seat rental program.

E. No smoking around infant.

F. To treat constipation, advise giving extra water (no more than 1 oz/day).

G. No solids should be offered. Offer pacifier if acting “hungry” or going to nap.

H. Make sure smoke detectors are installed and functioning in home. Home should have working fire detectors, a fire evacuation plan, and periodic drills to ensure preparedness.

I. Limit sun exposure, use sunscreen with SPF rating of at least 15 if out for even 15 minutes of direct sun exposure. Protect babies by using hats and long sleeve shirts and pants.

J. Baby will be seen for regular appointment again at 4 months. Discuss skills infant will acquire and how to work with baby to learn them: babbling, cooing, trying to roll over, and more. Discuss second set of immunizations, similar to what baby had at this visit.

K. Remind parents of when and how to call the healthcare provider.

1. Breathing difficulties.

2. Seizures.

3. Irritability.

4. Poor feeding, vomiting.

5. No urine output in 12 hours, black/decreased bowel movements.

6. Any fever.

7. Praise the parents for all that they are doing for the infant.

BIBLIOGRAPHY

Back to Sleep, Tummy to Play. Healthy Child Care America; 2009: http://www.healthychildcare.org/pdf/SIDStummytime.pdf. Accessed June 2, 2011.

Car Safety Seats: A Guide For Families 2011. American Academy of Pediatrics Healthy Children website:http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx. Accessed July 20, 2011.

Centers for Disease Control and Prevention. Growth Charts for Birth through 36 Months. CDC website:http://www.cdc.gov/growthcharts/clinical_charts.htm. Accessed June 2, 2011.

Dowshen S. Choosing Child Care. KidsHealth from Nemours; 2007: http://kidshealth.org/parent/positive/amily/child_care.html. Accessed June 2, 2011.

Hagan JF, Shaw JS, Duncan P, eds. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. American Academy of Pediatrics;2008: http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html. Accessed June 2, 2011.

Oral Health Initiative: Protecting All Children's Teeth: Nonnutritive Sucking, Pacifiers. American Academy of Pediatrics; 2010: http://www.aap.org/oralhealth/PACT/ch8_sect1b.cfm. Accessed June 2, 2011.

Port Washington Fire Department. E.D.I.T.H. Exit Drills in the Home.http://www.pwfd.com/content/850_fs3.html. Accessed August 9, 2011.

Recommended Immunization Schedule for Persons Aged 0 through 6 Years–United States 2010. Centers for Disease Control and Prevention website: http://www.cdc.gov/vaccines/recs/acip. Accessed June 2, 2011.

Soloway KB. Prophylactic Acetominophen could lower response to childhood immunizations. Medscape Today; 2009: http://www.medscape.com/viewarticle/712540. Accessed June 2, 2011.

Task Force on Sudden Infant Death Syndrome. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk. American Academy of Pediatrics website: http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;116/5/1245. Accessed June 2, 2011.

Tips and Tools: Safety for Your child; Birth to 6 Months. Retrieved from http://www.healthychildren.org/english/tips-tools/Pages/default.aspx. Accessed June 2, 2011.

White J. Overview of Infacnt Colic.http://baby.about.com/od/healthandsafety/p/infant_colic.htm. Accessed June 2, 2011.



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!