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4 months



  • Length/Height and Weight
  • Head Circumference
  • Blood Pressure (if risk factors)


  • Vision/Hearing (if risk factors)


Developmental Surveillance: DENVER


Discuss With Parents of All Infants

  • Responding to their infant’s feeding cues indicating hunger (moving the head forward to reach the bottle or spoon) or fullness (leaning back and turning away from food).
  • Forgoing foods other than breast milk or infant formula until the infant is developmentally ready (at about age 4–6 months, when the sucking reflex changes to allow coordinated swallowing and the infant is sitting with support and has good head and neck control).
  • Introducing one single-ingredient food at a time, and observing the infant for 3 to 5 days for possible allergic reactions
  • Introducing iron-fortified, single-grain infant rice cereal as the first supplemental food because it is least likely to cause an allergic reaction.
  • Introducing a variety of pureed or soft meats, fruits, and vegetables after cereals. (The gradual introduction of a variety of foods, flavors, and textures contributes to a balanced diet and helps promote healthy eating behaviors.)

Discuss With Parents of Breastfed Infants

  • A demand for more frequent breastfeeding is usually related to their infant’s growth spurt. If an increased demand continues for a few days; is not affected by increased breastfeeding; and is unrelated to illness, teething,or changes in routine, it may be a sign that the infant is ready for solid foods.
  • Providing a vitamin D supplement (400 IU/day).
  • Providing an iron supplement (1 mg/kg of body weight/day) if the infant does not consume sufficient iron-rich foods.

Discuss With Parents of Formula-Fed Infants

  • Feeding their infant on average 30 to 32 oz of formula, but the infant may consume up to 26 to 36 oz of formula in 24 hours.
  • Vitamin supplements are not needed if their infant is consuming an adequate amount of iron-fortified infant formula appropriate for growth.

Psychosocial/Behavioral Assessment: Parent Screening Questionnaire (SEEK) Maternal Depression Screening: Edingburgh

In the past 7 days:

  1. Have you been able to laugh and see the funny side of things?
  2. Have you looked forward with enjoyment to things?
  3. I have blamed myself unnecessarily when things went wrong?
  4. I have been anxious or worried for no good reason?
  5. I have felt scared or panicky for no good reason?
  6. Things have been getting on top of me?
  7. I have been so unhappy that I have had difficulty sleeping?
  8. I have felt sad or miserable?
  9. I have been so unhappy that I have been crying?
  10. The thought of harming myself has occurred to me?



Immunization (Dtap, Hep B,IPV, Hib, PCV13, Rota)

Hepatitis B: This infection can lead to vomiting, stomach pain, jaundice (yellow skin and eyes), permanent liver damage, liver cancer, cirrhosis and death. Approximately 25% of children who develop lifelong hepatitis B infection die of related liver disease as adults.

DTaP (Diphtheria, Tetanus, Pertussis): This vaccine works to prevent three infections.

  • Diphtheria may cause a sore throat, suffocation, paralysis, heart failure, coma and even death. Before the vaccine, diphtheria caused more than 15,000 deaths in children each year.
  • Tetanus causes severe muscle spasms (including the mouth and jaw), breathing problems, severe heart damage, lung infections, coma and death.
  • Pertussis causes “Whooping Cough.” It may lead to severe coughing, pneumonia, seizures, brain damage, and death. Pre-vaccine, over 200,000 cases and up to 9,000 deaths were reported each year.

Hib (Haemophilus Influenzae type b): This infection may lead to breathing problems, meningitis, blindness, brain damage, paralysis, hearing loss and death. Before the vaccine, Hib meningitis killed 600 children each year and left many other children with deafness, seizures and mental retardation.

IPV (Polio): This infection leads to paralysis, difficulty breathing and death. Before the vaccine, 20,000 cases of polio were reported each year in the United States. Many children were left on crutches, in wheelchairs and on iron lungs.

Prevnar (Pneumococcus): This infection leads to ear infections, sinus infections, pneumonia, meningitis, sepsis (infection of the blood) and brain damage.

RotaTeq (Rotavirus): This infection may include fever, vomiting, upset stomach, and watery diarrhea that can last from 3 to 9 days, and can quickly lead to dehydration (loss of body fluids).


  • The first priority is to attend to the concerns of the parents. In addition, the Bright Futures Infancy
  • Expert Panel has given priority to the following topics for discussion in this visit:

Social determinants of health

  • Risks (environmental risk: lead, work-related exposures), strengths and protective factors (family relationships and support, child care)
  • Reduce lead exposure at home.
  • Maintain social contacts; make time for self, partner; spend time with your other children.
  • Make quality child care arrangements.

Infant behavior and development Infant self-calming, parent-infant communication, consistent daily routines, media, playtime

  • Continue calming strategies when baby is fussy.
  • Spend time talking/playing with baby.
  • Create daily routine for feeding/naps/bedtime.
  • Avoid TV and other digital media with baby.
  • Use quiet (reading, singing) and active (“tummy time”) playtime; provide safe opportunities to explore.

Oral health

  • Maternal oral health, teething and drooling, good oral hygiene (no bottle in bed)
  • Don’t share spoons; don’t clean pacifier in your mouth; maintain good dental hygiene.
  • Use cold teething ring to relieve teething pain.
  • Don’t put baby in crib with a bottle; never prop bottle when feeding.
  • Clean teeth/gums 2 times per day; use soft cloth/ toothbrush with tap water and small smear of fluoridated toothpaste (no more than a grain of rice).


  • Car safety seats, safe sleep, safe home environment
  • Use rear-facing car safety seat in backseat; never put baby in front seat of vehicle with passenger air bag. Keep baby in car safety seat at all times during travel.
  • Use seat belt; don’t drive under the influence of alcohol or drugs.
  • Put baby to sleep on back; choose crib with slats less than 2⅜" apart; don’t use loose, soft bedding.
  • Avoid burn risk while holding baby (drinking hot liquids, cooking, ironing, smoking); set home water temperature less than 120°F.
  • Don’t leave baby alone in tub, high places (changing tables, beds, sofas); keep hand on baby (“touch supervision”).
  • Keep small objects, plastic bags away from baby. Avo id infant walkers.

Anticipatory Guidance

Phone Line Hours

Monday:         7:30am - 4:30pm
Tuesday:         7:30am - 4:30pm
Wednesday: 7:30am - 5:30pm
Thursday:      7:30am - 4:30pm
Friday:             7:30am - 11:30am
Saturday:      7:30am - 11:30am

Office Hours

Monday:         7:30am - 4:30pm
Tuesday:         7:30am - 4:30pm
Wednesday: 7:30am - 5:30pm
Thursday:      7:30am - 4:30pm
Friday:             7:30am - 11:00am
Saturday:      7:30am - 11:00am

Lunch Hours

Monday - Thursday
11:00am - 1:30pm

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