4 months old

Sleeping less, crying less, smiling more. Smiles, squeal, laughs. Curious. Colic resolves by 3 mos. Persistent colic? eval child/family/environment.
Milestones:

• Vision: tracks horizontally across 180 degrees; Circular tracking of an object suspended through 360 degrees requires smooth pursuit movement and appears by 16 weeks; responds to sounds by becoming quiet/alert. Vision Development
  Language/Communication: squeals, says 'aah, ngah' @ age 3 mos; blows bubbles/raspberry, coos reciprocally; orients to voice; enjoys looking around; listens to music
  Smiling/Laughing: squeals/laughs; ready social smile (spont. social smile in response to familiar face)
  Fine Motor: hands open, reaches for objects, ulnar raking motion; hands to midline. Sees pellet, but makes no move toward it. Hand dominance prior to 18 mo may indicate weakness in contralateral hand. Persistent fisting is the earliest symptom of neuromotor dysfunction.
  Gross Motor: hold head erect and steady/no head lag; when prone, raises body using arms; back to front, front to back; When held erect, pushes with feet. Hands to midline, grasps objects (ulnar rake), brings them to mouth. Tripod sitting. Pulling directly to stand at 4 mos is a red flag for hypertonia.
  

PE:

• Look for congenital malformations. Red reflex. Hearing. Developmental dysplasia of the hip DDH (formerly Congenital hip dysplasia, CHD), asymmetric buttock creases. Torticollis, Metatarsus adductus.  Heart murmur. Stills murmur 3-6 y/o, but occasionally in infancy. Pulmonary flow murmur of newborn (Peripheral pulmonary stenosis), usually disappears by 6 mos.
• Eye alignment, hip dysplasia
• Reflexes: Reflexes diappearing at this age (Newborn reflexes):
• Rooting 3-4 mos (stroking the perioral skin at the corners of the mouth causes the mouth to open and turn to stimulated side)
• Palmar grasp 3-4 mos (pressing against palmar surface of the infant's hand results in flexion of all fingers, must extinguish in order to grab and let go of objects)
• Moro 4-6 mos: sudden movement of head, causes symmetric abduction and extension of the arms, followed by gradual adduction and flexion of the arms over the body)
• Assymetric tonic neck reflex: 4-6 mos (turning head to one side causes extension of extremities on that side, and flexion on the contralateral side, putting infant in 'fencing position; must extinguish in order to roll over)
• Tear formation begins 2-3 mos of age. Nasolacrimal duct no 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.
• Nutrition: Bottle fed? 26-36 oz qd (avg 30-32) . At 4 mos: 6-7 oz 4-5 times per day. High demand periods indicate growth spurt. Vit D if only breastfed or less than 500 cc formula/day. No honey or corn syrup in 1st yr of life.
  - Supplement with Vit D if <1000 cc/day of formula or strictly breast fed. Vitamin D Supplementation, start between 2 weeks and 2 months of age.
  - Juice and Water - never give before age 6 mos.
  - Introducing foods into an infant's diet. 4-6 mos, intro solid foods; one every 4 days, start with iron fortified rice cereal ( Iron supplementation, usually in the form of iron fortified cereals, should be started between 4-6 months.). Need good head control. No head lag.
  - if bottle fed: continue formula w/ iron
  - if br fed: supplemental Fe or iron containing foods by 6 mos of age.

- Avoid sharing spoons and cleaning a dropped pacifier with your mouth, to prevent transfer of dental caries-causing bacteria. Otherwise the risk of dental decay increases when his teeth come in.
Elim: patterns may change when start solids

Growth: Head circumference 4-6 mos: 1 cm/month. By 3-4 month old, weight gain slows to 20 g/day. Birth weight doubles within 5 months and triples within a year.
Sleep: up to 16 h qd. Sleeping becomes more regular, some sleep 5-6 hours at night and take 3 naps. Many 4-month olds continue to wake at night for feeding to receive adequate calories. Learn to fall asleep in crib, rather than being held. Back to sleep, through first year of life, especially in first 6 mos. No evidence that adding cereal to milk  helps babies sleep through the night.

Safety:
Infants reach and grab; don't hold infant while drinking hot liquid or smoking.
Don't leave alone on bed/table: roll over 3-4 mo
Car safety <20 lbs, < 1yo  (9kg): rear facing, in back seat.
Sleep on back
Supervise w pets
Environmental smoke, bad for asthma, recurrent OM, BPD
Guns
Not excessive time in playpen or swing
Sunscreen
CPR
Screening and Immunizations
Screening Labs: 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.

(abnormal eye alignment? Refer optho)

Immunizations: Rota2, Prevnar2, Hib2, Pediarix2 (Hep B (extradose), DTaP2, IPV2). Consider flu vaccine for caregivers of infants < 6 mos.
Next visit in 2 mos.
Expect:

• begin sitting unassisted around 6 mos