The Canandaigua Medical Group
Well Child Care - Your 4 Month Old Child

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YOUR FABULOUS FOUR MONTH OLD (14-18 WEEKS)

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Good going!! You’ve made it through some treacherous waters, and are now realizing that babies aren’t quite as fragile as you thought. Neither are you! Just as you were adapting to certain behaviors and patterns, it’s time for some more adventures. A few ideas and thoughts below may help as you observe your changing infant to prepare you for the storms ahead.

Baby’s vision continues to sharpen. He/she has definite preference for shiny objects, the color red, complex patterns, and your face. By now, vision and hearing coordinate so that he/she knows what sound or voice goes with what object or person. Language develops in subtle but important ways – give and take cooing games become more imaginative with baby adding “raspberries”, laughing and squealing. Gurgling, chuckling and variable voices for different caretakers begin to emerge. Touch still remains in important communication method – enjoy it often.

Motor skills begin to separate more clearly into fine and large (or gross), coordination. Large motor skill gains will include rolling (usually back to front first), pushing chest off surface when on stomach and extending head to 90 degrees. There will be much better head support when pulled to sit, though back is still hunched when sitting. This all stems from increasing leg and back strength, and gradual disappearance of primitive, protective reflexes. Higher brain functions are taking over! Sudden motor gains need to prompt even more attention to safety measures. Fine skills gained may include vigorous reaching with both hands, midline play, body exploration, finger watching and hand grabbing. He/she can hold and activate a rattle.

By now baby has usually progressed far into control of physiologic processes, (the work of living). Around the fourth month of life, all of these changes can result in a pleasant period known as the “honeymoon period”. Voiding and stooling are in a consistent pattern (unless there is illness), sleep is at least five hours at night, and often quite a bit more. Colic has subsided, crying behavior decreases now as the infant responds to consistency of care in his/her world. Babies can actually work to engage you in their emotions by now – how you attend to them at these moments is important! Despite this tremendous emotional demand, continue to take special time with each sibling and with spouse or significant other to gain perspective.

Play creatively and unhurriedly with your baby. NO TV, or VIDEOS are recommended—too risky! Perhaps now is the time to lower housekeeping or employee standards as the new priority of a child emerges. Playpens with bright, safe, soft, large toys are a learning paradise. Toys that can be used in a variety of ways are most pleasing and challenging. You begin to teach your child about the world by how you play. If this is difficult for you, you may want to discuss it with your pediatrician.

Your baby feels important, secure and loved with your undivided play attention. Don’t miss out on this vital interaction! Questions about feeding techniques and what to feed often emerge, especially if your baby is in the normal bottom half of the growth curve, (remember, half of all babies are!). Breastfeeding (exclusive or supplemented), remains ideal. Do not introduce cow’s milk! Vitamin D supplements may need to continue. Certain babies may need their hemoglobin or blood count checked. Solids are introduced differently from doctor to doctor and family to family. There is evidence that premature introduction of multiple proteins may increase the incidence of allergy development later in life. Generally, if your baby is thriving, happy, sleeps, voids and stools well, it is advisable to continue delay of solid food introduction for another month or so. If given approval, rice cereal is sometimes started as a first solid at about five months of age. Please discuss this with your regular doctor.

Teething may start during this time. Cool or slushy teething rings, numbing rub-ons, or a proper dose of acetaminophen at the bad times are acceptable; so are thumb and finger sucking or pacifiers. Drooling may or may not be associated – at the same time they teethe, infants salivary glands become more active but reflex swallowing lags behind. Teething may cause irritability, crankiness, sleeplessness and fever up to 100.5 degrees F but not cold symptoms or ear infections. The infant may also be teething at the time he/she has another cause for fever. Fever in an ill-looking child still needs evaluation – any fever over 104 degrees F needs a visit with the doctor! Lower fevers can be discussed as to need for appointment.

Skin problems continue to abound, especially diaper area ones. Gentle warm water or Domeboro’s solution cleaning followed by emollients (Desitin, Aquaphor, A&D, Zinc Oxide, Butt Paste, Triple Paste or Eucerin), are helpful. Get persistent or angry rashes checked. Remember that sunscreen (SPF 30 or greater)! Insect repellents should be used only after discussion with your pediatrician.

Familial adjustments may still need attention, particularly as most mothers working outside the home will have returned either full or part-time. Cognitive and intelligence skills are not adversely affected by alternate caretakers – but there is evidence that infants under 12 months whose mothers work full-time are more likely to develop less secure patterns of attachment. A good quantity of time with both mom and dad are critical to provide no matter what the work schedules! Financial goals may need readjustment as compromise toward optimal family health is sought. Contagious illnesses are more prevalent in day-care children. Babies in day care develop social skills sooner and are more aggressive.

Safety and accident prevention retain high importance! Continue car seat use, rear facing. Keep up to date on current safest models. Small objects should be far removed. Due to the advanced reaching skills, keep hot objects and liquids away, as well as medicines and chemicals. Continue to double-check the baby-proofing of the home. Do not use a walker or stander. Babies in swings or bath need supervision at all times. Avoid baby powder (it can be inhaled). Watch out for plastic bags and latex balloons (mylar ones are safer). Update emergency numbers, if necessary. Keep cigarettes unlit and away from baby. Cool vaporizers are best if needed: watch extension cords, plugs, tablecloths. Put the coffee table away. Pacifiers may help prevent SIDS, so they are o.k. Avoiding smoke and keeping baby sleeping on his/her back definitely reduce SIDs incidence. Tummy time while supervised is still important several times a day.

Another series of immunizations will need to be given. The risks of not having immunizations remain orders of magnitude higher than any perceived risk of the vaccines themselves. There is no significant mercury or preservative exposure in the vaccines your child will receive. Acetaminophen to reduce fever and/or leg pain is acceptable in appropriate dosages. Cool massages/wash cloths can help as well.

Baby’s increasing self-awareness may serve to make you more self-aware. It may be a time to rethink and readjust financial, familial, social, societal, intellectual, recreative, and spiritual priorities. True character will surface during the stressful child rearing times. If help in defining questions or priorities is needed, continue to seek professional clerical, psychological, or medical advice. You’re doing well, see you in two months.

Remember, “A baby dances with its feet in the air.” -- Ruth Krauss.

Prepared by David L. Ragonesi, M.D., F.A.A.P.

Revised 3/07

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