Health Supervision Visit, 4 Months

Assess

• Anthropometric measurements
• Physical examination
• Adequacy of human milk and formula intake
• Screen for food insecurity using the validated 2-question Hunger Vital Sign tool
  • 1 in 7 children live in a household experiencing food insecurity.
  • Rates of food insecurity are higher in households with children younger than 6 years, single parent households, and immigrant, Black or Latinx families.
  • Provide resources for families experiencing food insecurity. (Table 3)

Discuss

• Begin iron supplement (1 mg/kg/d) for exclusively breastfed infants (may not be necessary for infants being fed iron-rich foods such as red meat and green leafy vegetables).
• Introduce solid foods at about 6 months.
  • Up to 1/3 of infants in the United States receive complementary food or beverages before 4 months of age.
  • There is evidence that shows delaying the introduction of allergenic foods (including peanut, eggs, and fish) beyond 4 to 6 months can prevent atopic disease. However, introduction of solid foods should not be delayed beyond 6 months.
  • Introducing infant-safe peanuts early may prevent peanut allergy.
    • Introduce infant-safe forms of peanuts as early as 4 to 6 months of age for infants with severe eczema and/or egg allergy)
      • Consider introducing peanut-containing foods in the office versus the home.
      • Use appropriate testing (eg, IgE test, skin prick, oral food challenges).
• Juices should not be offered.
  • Increases risk for loose stool and diarrhea
  • Decreases appetite for nutrient-rich food
• Continue vitamin D at 400 IU/day.
• Advise that when bottle-feeding, hold baby (instead of propping up the bottle). Advise parents to never put the baby to bed with a bottle.

Calculations

Estimated energy requirements (kcal/d) for infants 3 to 5.99 months (weight in kg; height in cm)

• Males: −716.45 − (1.00 × age) + (17.82 × height) + (15.06 × weight) + 50
• Females:  −69.15 + (80.0 × age) + (2.65 × height) + (54.15 × weight) + 60