2 months old

Milestones

Vision: looks at faces in line of vision, attempts to look at parent; tracks to midline and maybe all around (120 degrees in the 8-10 week; 180 degrees by 3 months);. Focuses accurately by 2-3 mos of age. Depth perception to understand the 3-D world not yet developed (3rd to 5th month). If cannot fix and follow by age 2 mos, needs referral to ophtho!!! Vision Development
Language and Communication: coos, different crying for different needs; responds to sounds by becoming quiet/alert or cooing in response to voice. At 1.5 months, reciprocal social smile. (spontaneous social smile in response to familiar face @ 4 mos). Gets bored (cries, fussy) when no changes in activity occur!
Fine Motor: briefly holds a rattle, hands fisted half the time. Persistent fisting at 3 mos  is the earliest symptom of neuromotor dysfunction.
Gross Motor: when prone, hold head temporarily erect 45 degrees and moves it side to side. Consistent head control in supported sitting position. Red flag: rolling prior to 3 mos may indicated hypertonia.

Physical Exam

• Stills murmur 3-6 y/o, but occasionally in infancy. Pulmonary flow murmur of newborn (Peripheral pulmonary stenosis), usually disappears by 6 mos.
• Look for red reflex, palpate fontanelle
• Assess femoral pulses
• Umbilical cord is detached and umbilicus is healing
• Check Ortolani and Barlow
• Assess tone
• Stork bites disappear by 4-5 years of age. Mongolian spots fade by school age.
• Reflexes diappearing at this age (also see Newborn reflexes):
• Galant 2-3 mos (stroking along the paravertebral area causes lateral flexion of the trunk with the concavity toward the stimulated side)
• Placing/stepping: 2 mos/variable (when the dorsal surface of one foot touches the underside of a table, the infant places the foot on the table top)
• Palmar grasp disappears by 3-4 months, Moro by 4-6 months, ATNR by 4-6 months
• Tear formation begins 2-3 mos of age. Nasolacrimal duct not fully patent until 5-7 months. Purulent of mucoid eye drainage is common. Treat with lacrimal massage and gentle cleansing w water and cotton ball. Beware of redness or swelling. Refer to optho if infection suspected, or if eye drainage continues past 1 year of age.

Nutrition:

• feed q3-4h, and longer intervals at night. at 2 mos: 5-6 oz 5-6 times per day. Burping: try for 5 minutes and if seems comfortable, ok to give up.
• 4-6 wet diapers qd. Bottle-fed 1 BM qd. BF greater variability, can go 2-3 days without BM.
• Supplement with 400 IU Vit D if <1000 cc/day of formula or strictly breast fed (=32 oz or 1 quart). Vitamin D Supplementation, start between 2 weeks and 2 months of age.
• Feeding spurts occur at 3 months. 
• Juice and Water - never give before age 6 mos. 
• Fe if preemie or infant. If preterm <= 2mg/kg/d, max 15 mg/d. Give 1 month supply to prevent poisoning.
• No nutritional advantage to feeding solid foods before 4-6 m/o. (allergy, immature oropharyngeal/digestive processes)
• No honey or corn syrup in 1st yr of life (risk of botulism). Giving infants corn (Karo) syrup for constipation isn't recommended. As with other laxatives/stool softeners, it is effective in softening stool, but if excessive can cause diarrhea in infants, resulting in water and electrolyte losses. A 2006 AAP report notes: though corn syrup is manufactured under sanitary conditions, it cannot be guaranteed free of botulinum spores. However, there have never been any cases of infant botulism directly linked to corn syrup.
• No cow’s milk during first year of life. Poor source of iron. Can cause intestinal blood loss and exacerbate iron deficiency. Protein and sodium levels are too high. Low in vitamin C, E, and copper. Contains butterfat, difficult for babies to digest.
• Breast milk can be kept (a) at room temperature for 4 hours; (b) in the fridge for 3 days (ideal) to 8 days (acceptable); (c) in the freezer for 3 months (d) in deep freeze for 6 months (ideal) to 12 months (acceptable). If transporting breast milk in a ‘cooler’ with ice packs, use within 24 hours. Infant formula can be kept at room temperature for 2 hours. If formula is partly used, finish the rest within one hour from the start of the feeding. Formula should not be refrozen. Prepare only as much as you will need. Formula prepared from powder can be stored in the fridge for up to 24 hours. Liquid formula (ready-to-feed or prepared from concentrate) can be stored in the fridge for up to 48 hours. Finish powdered formula within one month after opening the can; store the can of powder in a cool dry place, not in the refrigerator or freezer.

Growth:

• Head circumference 0-3 mos: 2 cm/month.
• During first month, expect to gain 1 oz of weight per day (20-30 grams/day).
• By 3-4 month old, growth slows to 20 g/day.
• Anterior fontanelle closes 13 mos (7-19 mos).
• Posterior fontanelle is clinically inapparent at birth. Closes at 3 mos.

Anticipatory Guidance
Sleep:

• 16 h/day nl. Encourage parent to put pt in bed while awake. By 2 months of age: wakes 2-3 times per night, some sleeping 6 hours or more. 90% of babies sleep through night (6-8 hrs) by 3 mos. And obviously won't need to eat during this time, usually when they weigh 12-13 pounds, so larger babies may begin sleeping through the night even earlier than 3 mos. However, most children swing back and forth, sleeping fine for weeks or months, then returning abruptly to a late night wakeup schedule, usually related to growth spurts increasing the need for food (Feeding spurts), or teething or developmental changes.
• Back to sleep, through first year of life, especially in first 6 mos. Alter position of head to avoid making flat areas.
• Although this is a common belief, adding cereal to the diet will not increase the hours of sleep at night.

Colic

• 5 S: Suck, Swaddle, Shush, Swing, Side/Stomach position. When to stop swaddling? Baby will start to resist after a few weeks. But, this is when swaddling becomes most valuable. Try: after 2-3 mos, swaddle with one arm out. If fussier, continue wrapping (with both arms in) a few more weeks. If sleeps well with one arm out, probably doesn't need swaddling. Most are ready to be weaned off by 3-4 mos of age (some need it up to 9 months of age)

Safety

• Car safety <20 lbs, < 1yo  (9kg): rear facing, in back seat.
• Sleep on back; Don't leave alone on bed/table: roll over 3-4 mo
• Not excessive time in playpen or swing
• Supervise w pets
• Environmental smoke, bad for asthma, recurrent OM, BPD
• Guns
• Sunscreen (< 6 months. face/back of hands)
• CPR

Screening and Immunizations

• if preemie, low birth wt, sig hemolysis, blood loss, then H/H. Vision-Screening
• Preterm or low birthweight infants may become iron deficient at an early age and need iron supplements. Breastfed premature infants should begin an iron supplement  2 mg/kg/day by 2 months and consideration should be given to a phosphate supplement to avoid rickets.
• check if both newborn screens have been done
• Immunizations: Rota1, Prevnar1, Hib1, Pediarix1 (HepB2, DTaP1, IPV1)
• Common sequelae for DTaP: fever/irritability. Give one dose of tylenol at visit and another 4 h later. Warm compresses at injection sites. Can continue q4h.  Call MD if sig fever or irrit lasts longer than 24 h.

Final Advice
Expect:

• increased smiling, vocalization, head control reaching (see 4 mos).
• Concerning: apathy, poor response to stimuli. No TV under age
• Fever under 3 months old: Call MD