4 wks

History

• Feeding? Breast vs bottle. Stooling/urination patterns. Vegan mom?
• Routine and schedule?
• Best and difficult times?
• Tired or blue? If so, ask about drugs/alcohol use.
• Who helps with baby?
• Lead or Tb exposure

Milestones

Vision: watches person, stares at face, follows moving object. Fixes and follows to midline (horizontal tracking progresses from 30 degrees at birth to 120 degrees at 4 weeks of age). Can focus, but not very well. Poor depth perception of the 3D world (3rd to 5th month).  Can see distinguish high-contrast colors between 2-4 wks of age. Born with ability to see facial features at arms length, but attracted to high contrast borders, like hairline or edge of face. Will look at i.e. nose and mouth around 2 mos of age.  See Vision Development
Language/Communication: responds to sound by quieting or turning toward source; startles to loud noise
Smiling/Laughing: beginning to smile
Fine Motor: Hands tightly fisted.
Gross Motor: while prone holds chin up and turns head, head lag, when supine lies in tonic neck posture.

Physical Exam

• Assess for jaundice; Stork bites disappear by 4-5 years of age. Mongolian spots fade by school age
• Look for red reflex, palpate fontanelle
• Stills murmur 3-6 y/o, but occasionally in infancy. Pulmonary flow murmur of newborn (Peripheral pulmonary stenosis), usually disappears by 6 mos.
• Assess femoral pulses
• Umbilical cord is detached and umbilicus is healing
• Check Ortolani and Barlow
• Assess tone
• Reflexes diappearing at this age (also see Newborn reflexes):

• Galant gone by 2-3 mos (stroking along the paravertebral area causes lateral flexion of the trunk with the concavity toward the stimulated side)
• Placing/stepping: gone by 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

Nutrition and Growth

• Encourage breast feeding for the first 4-6 months of life. Trivia: formula spit up often stains more than breast milk spit up.
• At 1 month: 4-5 oz 5-6 times per day. Feeding spurts occur at 3-4 weeks, 3 months. Average girl will take 24 oz/day. Average boy: 27 oz. Average range 20-32 oz qd.
• Feed baby until baby is satisfied, does not need to finish bottle. Do not heat bottles in microwaves. Burping: if no burp by 5 minutes and seems comfortable, ok to give up.
• No bottle propping.
• “Don’ts”: Juice and Water - never give before age 6 mos.  Do not start solids until age 4-6 mos. No honey, corn syrup or karo syrup (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.Supplement with Vit D 400 IU if <1000 cc/day of formula or strictly breast fed. Vitamin D Supplementation, start between 2 weeks and 2 months of age.  Vegetarian/vegan moms: Take multivitamin containing iron, zinc and vitamin B12. Vit B12 especially important with vegan moms consuming no animal products.
• In preterm infants, total body iron is less at birth than in term infants, and neonatal iron stores are depleted more rapidly. Iron deficiency can, therefore, develop by 2 to 3 months of age in preterm infants who are either breastfed or bottle-fed with a formula that is not iron-supplemented. It is generally recommended that preterm infants begin iron supplementation (2 mg/kg/day) at 1 month of age, either as iron-fortified formula or as iron supplementation in breastfed infants.
• 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).

Anticipatory Guidance

Crying: increases in first 6-8 weeks. during first 3 months, 2-3 hours per day of crying is normal. If crying, check diaper, consider if baby is hungry.  Colic.
Elim: urine stream in males should be straight and forceful. 6-8 WD/day. 3-4 BM/day. By 6 weeks, breast fed babies may stool as infrequently as q3days.
Sleep: erratic pattern. Alter position of head to avoid making flat areas. Back to sleep, through first year of life, especially in first 6 mos. Parents: sleep when babies sleep during day. Arrange for primary caregiver for a few hours of personal time each week.
Other: Tear formation begins 2-3 mos of age. Nasolacrimal duct not fully patent until 5-7 months.

Safety

• Car safety <20 lbs, < 1yo  (9kg): rear facing, in back seat.
• Sleep on back
• Supervise w pets
• Household safety: Don't leave alone on bed/table: roll over 3-4 mo. Smoke detectors, water temp.
• Environmental smoke, bad for asthma, recurrent OM, BPD
• Guns
• Not excessive time in playpen or swing
• Sunscreen
• CPR / First Aid Kit
• When to call 911
• Rectal temp 100.4 or 38 C is fever. Take rectal temps until 3-4 mos old.
• Wash hands frequently with soap and water.
• Crib slats less than 6 cm apart (2 3/8 inches)

Screening and Immunizations

• Review nbn metabolic screen. Order 2nd screen if hasn’t been done yet.
• Was hospital hearing screen normal? Assess hearing grossly.
• Vision-Screening
• Immunizations: Hep B#1 or 2 at one month

Next visit at age 2 mos.
Expect: Expect increased smiling, vocalization, head control reaching (see 4 mos). Concerning: apathy, poor response to stimuli.

Final Advice

• Be aware of baby blues
• Make or obtain a mobile, since babies begin fixing their vision on moving and bright colored objects, and a rattle because babies start to grasp and hold onto objects.
• Encourage tummy time.
• Talk to babies to stimulate language
Fever under 3 months, call MD