Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1068E (07/08)

STATE OF WISCONSIN Reprinted and adapted with permission from Memee K. Chun, M.D.

GENERAL PEDIATRIC CLINIC ­ 9 MONTH VISIT
(See 2nd page for 9-Month Anticipatory Guidance) Completion of this form is voluntary. Patient Name Accompanied by Parental Concerns Alertness Date of Birth Age Height Weight Today's Date

Head Circumference

Activity Adaptability to examination Feeding: Milk, type _______ Amt / day __________oz. Bottle _____ Cup _____ Self Feeding _______ Solids: type & meals / day

(Cross off parts not examined or not applicable)
Part Skin: Color, texture, hair, scalp, bruises, scars Head & Face: Symmetry, AF open ( ) Eyes: Pupils, conjunctivae, EOM, peripheral vision Ears & Nose: Canals, tympanic membranes, turbinates, nodes Mouth & Throat: Tongue, pharynx, number of teeth ( ) Neck & Chest Heart & Lungs: Rhythm, S1, S2, Number ( ) Abdomen & Spine: Contour, palpation Extremities: Hips, tibiae, feet, standing position Genitourinary: Testes ( ), foreskin, retraction, vagina Neuromuscular: Tone, C2-12, reflexes, DTRs, babinski Nodes Describe abnormal findings. N Abn

Sleeping: Behavior at naps, bedtime

Family activity with baby

Parents' Description of Baby's Temperament: Reaction to new situations, adaptability, persistence / attention span, distractibility, threshold level

Problems Identified and Reviewed

Physical and Emotional Status

Diet: Use of spoon and cup, finger foods, add egg whites, normal drop in appetite. Anticipatory Guidance: Discipline, limit setting, clinging, fear of strangers, bedtime and nap routines Safety: Stairs, fans, heaters, drawers, pins, nuts, paint, plants. Syrup of Ipecac. Car seat. Home water temp.

Developmental Observations NO*. = Not Observed by parents or R. O. NO* examiners R. = Reported, O. = Observed G.M. Stands holding on Pulls to standing Walks holding on to furniture Gets to sitting Crawling on hands & knees P.M. Thumb-finger grasp Holds two cubes, bangs them together Lang. Babbles Mama, Dada, nonspecific P.S. Initially shy with strangers Plays repetitive game (e.g. Pat-a-cake, bye bye) Feeds self using fingers Parents' Interactions with child NO* = Not observed Here O. NO* O. = Observed M = Mother F = Father Touches baby Talks to baby Spontaneously identifies positive qualities of baby Responds verbally to baby's vocalization Limits activity by physical actions Limits activity by verbal command Allows baby to explore Calmly holes to quiet baby Consoles baby who shows reservations of strangers Other Observations

_____________________________ ______________
SIGNATURE ­ Provider
Return to clinic in _____ months.

Development & Parent-Child Interaction

Date Signed

General Pediatric Clinic / 9 Month Visit F-1068E (07/08)

Anticipatory Guidance Page 2

Diet Use of spoon ­ although the hand to mouth movement is well developed at this age, the use of the spoon as an extended hand is not working. The baby is more likely to hit the table or plate with the spoon or play the "I drop, you pick up" game throughout the meal. Nevertheless, a little help in guiding the filled spoon into the mouth from time to time will seed the idea and if allowed to experiment, the baby will start using the spoon as a feeding tool. The parents need to be told there will be a mess and if they greatly dislike the mess, it may be better to delay the actual spoon self-feeding or give suggestions like ­ newspaper around the high chair, feeding outside, (a dog!). Use of cup ­ similarly the hand to mouth coordination is not steady but this can be developed by putting very little fluid in the cup (prevents choking and over spilling) and a guiding hand. Finger foods ­ The diet still needs to be watched so that not too many new foods are added all at once. Small pieces of soft solid foods can be given, especially when the parents are eating. These should be easily picked up by either the whole hand or by thumbindex opposition if the baby has developed this grasp. Eggs are started by some people at this age. Citrus fruits such as orange juice are also sometimes started at this age although there are other juices more suitable, and in a family with allergies it may be better to delay both the egg and citrus fruits. Baby cereals should still be encouraged because of the iron content. Most solids and adult cereals have much less iron. Normal drop in appetite ­ the growth rate slows down and the baby's interest in the environment increases. These two factors plus self-feeding lead to a decrease in total food intake which leads to parental anxiety. The parents will often give milk by bottle which the baby can take faster than eating solids. This creates a problem, the "milk baby" syndrome. The baby then eats less solids because milk satisfies their caloric needs. Milk is a poor supplier of iron (unless formula is used). Anticipatory Guidance Discipline, setting limits. Around nine months, the baby is beginning to understand the word "no", especially if accompanied by a serious look on the parent's face and removal from whatever the baby was doing. This is a good age to explain that disciplining can be taught without the use of physical punishment in the form of slapping, spanking or hitting. The type of physical punishment which can be used is body restraint or removal of the object that is not to be touched. Verbal commands should be clearly differentiated into two levels. The everyday "no, don't touch, etc." and the emergency "NO" which should be followed by physical restraint. This latter is reserved for dangerous situations such as touching the stove, oven, fireplace, going out in the street, etc. The child should understand the difference in this command by the time they are running around. It should stop them right there. To be useful, it must be used consistently for a few situations only and never when the child is in a situation where they will not be hurt. Setting limits to a few situations is very important. It is equally important to allow the child a chance to explore and learn, as long as they are not at risk. Some parents feel that their home environment should be "child oriented" and the child has to learn the limits. Most "adult" homes have many objects which are valuable or a danger to the child. The whole day may be spent in limit setting and "no" may become the child's first word. Such a situation may prohibit exploration and even a normally active child may be described as "into everything" since everything is an untouchable. It is important to suggest that these parents leave a few "nontouchables" whereby the child can be taught discipline but also to allow the child more freedom in exploration and learning. Fear of strangers ­ sometime in the second half of the first year, most babies go through a stage of being acutely aware of his parents and daily caretakers and rejecting all others, including the grandparents and sometimes the working parent as well. This stage may last a few days to several months, depending on the baby's temperament and how frequently they are in contact with other adults. The parents can make this stage less traumatic if they allow the baby to do the approaching. If there are babysitting changes at this time, the parents can expect noisy objections from the child. A hospitalized child may need the parent around during the waking hours. Sleeping (See 12 months for one nap) Two naps are required by most babies. Because of their increasing interest and mobility, naptime can be delayed but invariably the baby's sleep needs will be met and if delayed too long, they may take their second nap in the early evening, thus delaying the time before they are ready for night sleep. Bedtime routine is important for the baby's sense of regularity and undisturbed sleep. Because of more intense attachment at this stage, the baby might cry at night and reassurance by voice or hand may be sufficient for the child to go back to sleeping. Picking up, feeding, changing, socializing, all lead to increased night awakening and calling for attention. Safety Stairs ­ the baby is mobile and is not aware of danger. A barrier at the top of the stairs is important. If the mother is close at hand, the baby may crawl up and be caught before trying to come down. Many babies can be taught to come downstairs sliding on their stomachs, legs first. Similarly, they can be taught to ease off a couch or table, feet first. Drawers ­ upper extremity development may be advanced enough for the baby to open drawers and low closet doors, and take everything out and climb in. The main advice is to be sure there is nothing sharp, heavy or too small such as pins which can be swallowed. All chemicals should be moved to locked closets. Plants can fall on the baby, or be eaten, and most of them are potentially poisonous. The paints in older houses, outdoors, indoor and furniture pieces all contained lead. Now only outside paints have lead. This was the most common cause of lead poisoning and the eating of nonfood substances is called PICA. Car Seat Encourage continued use. Home Water Temp The baby is becoming more adapt at hand manipulations so turning the hot water temperature down to below 120° is essential.

Syrup of Ipecac
See six-month.