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


Four-Month Visit

Patricia Clinton

Dehydration, 276.5

Fever, 780.6

Diarrhea, 787.91

Vomiting, 787.03


A. Four-month-old infant is generally well integrated into family unit, interacts with family members, is beginning to actively explore environment by making more purposeful movements.

B. Patterns of sleeping, eating, elimination are fairly well established.


A. Caloric needs: 98-108 kcal/kg/day.

B. Breastfeeding.

1. Recommended as sole source of nutrition.

2. Infant easily distractible.

3. Support mother in continuing to nurse throughout first year.

4. Vitamin D supplementation recommended at 400 IU/day.

C. Formula feeding.

1. Iron-fortified only.

2. No cow's milk of any kind.

D. Introduction of solids.

1. May begin after 4-month visit.

2. Preference is to postpone until 6 months to minimize allergies.

3. Introduce solids when tongue thrust diminishes, infant has good head control (see Chapter 10).


A. Voiding pattern.

1. Average 6-8 wet diapers/day.

2. Illness (fever, vomiting, diarrhea) associated with decreased voiding and concerns of dehydration.

B. Stooling pattern.

1. Breastfed infants generally have 1 stool/day to 1 stool every 7-10 days.

2. Consistency more important than frequency.

3. Stools should be soft, semiformed, odor not offensive.

4. Formula-fed infants generally have 1 or more stools/day, color varies by formula, may be more odiferous.


A. Requirements.

1. Nighttime 9-12 hours; may still waken for nighttime feedings.

2. Naps 2-4 times/day; 30 minutes to 2 hours.

B. Environment.

1. Begin to establish consistent bedtime routine.

2. Put to bed drowsy but awake.

3. Room temperature should be temperate and not excessively warm.

4. Transitional object such as blanket may be comforting.

5. Room dim, may use night-light.

6. Cosleeping is family/culturally determined; encourage discussion, avoid being judgmental; safety should be focus.

7. Avoid bottles in bed.

C. Safety.

1. Put to bed on back. Once he/she rolls over, infant determines position during sleep.

2. Sleeping surface should be firm; avoid pillows, comforters. Slats 2 3/8 in. apart; corner posts 1/16 in. high.

3. Smoke-free environment.

4. Remove mobiles, Venetian blind cords, other hanging toys before infant learns to pull up in crib.


A. Growth.

1. Infants should gain 0.5-1 oz/day or about 2 lbs/month; doubles birth weight between 4 and 6 months.

2. Infants grow, on average, 1 in./month.

3. Head circumference increases 0.5 cm/month.

B. Development.

1. Grasps objects, begins with raking motion.

2. Brings hands together.

3. Follows objects with eyes to 180°.

4. Good head control. Lifts head and chest when prone.

5. Bears weight on legs.

6. Rolls from front to back.

7. Rooting and palmar grasp disappear.

8. Moro, Babinski, and tonic neck no longer as prominent, may disappear by 4 months.

9. Begins to link event with action such as quieting when put in nursing position.

10. Ability to wait begins to develop as infant learns to anticipate response from caregiver.

11. Cooing, laughing, squealing. Vocalizes in variety of ways to initiate and sustain interaction.

12. Beginning to listen when others speak.


A. Relationships.

1. Recognizes primary caregiver.

2. Variety of facial expressions such as smiling, surprise, fear.

3. Enjoys being cuddled.

B. Environment: conditions that foster trust, positive psychosocial feelings, development.

1. Learning to trust caretakers.

2. Responsiveness to infant's needs and cues reinforces trust and does not result in spoiling.

3. Smiles are purposeful.


A. Review immunization schedule: DTaP #2, Hib #2, IPV #2, PCV #2, RV #2, hepatitis B if not previously started.

B. Review immunization reactions.


A. Always check bathwater temperature.

B. Never leave infant alone in tub or on changing table.

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

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

E. Avoid use of walkers.

F. Begin “baby proofing”: outlet covers, door and drawer latches, safety gates. Remove cords, wires, string, plastic bags from baby's environment.

G. Maintain smoke-free environment.

H. If mother is returning to work, plan strategies for breastfeeding.

I. No honey or corn syrup (Karo).

J. Do not prop bottles. Do not put cereal in bottles.

K. Allow infant to self-regulate amount eaten: Watch for cues, e.g., turning head away.

L. Secure infant in highchair. Never leave infant alone in highchair. M. Encourage floor “tummy” time so infant can begin to explore surroundings.

N. Talk, read, sing to infant.

O. Use variety of toys/other household objects to stimulate infant. Introduce infant to different textures in toys, objects.

P. Discuss infant's temperament and how it relates to sleep/wake activities.

Q. Begin exploring parental ideas about discipline.

R. Cleanse gums with soft cloth after feeding.

S. Increased drooling indicates functional salivary glands, not teething.

T. Stress handwashing by all caregivers.

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

V. Review guidelines for calling healthcare provider, illness signs (i.e., fever, vomiting, diarrhea).


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Centers for Disease Control and Prevention. 2011 Recommendations and Guidelines: Childhood & Adolescent Immunization Schedules. Accessed June 2, 2011.

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Ontario Society of Nutrition Professionals in Public Health. Pediatric Nutrition Guidelines for Primary Care Providers. Ontario, CA; 2008: Accessed June 2, 2011.

Porter RS, Kaplan JL. The Merck Manual Online: Accessed June 2, 2011.

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

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