Pediatric Primary Care (21 page)

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.

CHAPTER 11

Nine-Month Visit

Patricia Clinton

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.