ibabydoc.com - 4 Month Well Checkup

FOUR-MONTH CHECKUP

Physical Examination

Height, weight and head circumference should be plotted on the growth chart and development should be checked.
Typically a baby will have lost 10% of their birth weight between four to five days of age, regained birth weight by two weeks of age and then gained a pound every two weeks after that.
Typically a baby will be double the birth weight at 4 months of age and triple by one year of age.
If the baby is not gaining properly this is called failure to thrive. The reasons for this can be discussed. These reasons include not eating enough food, not mixing the formula properly if the baby is formula-fed, or difficulty with breast-feeding, including improper technique or poor supply of breast milk.
If the baby is gaining too much weight then feeding history can be reviewed to determine if feeding is being done every time the baby simply needs to have their suck reflex satisfied with either a thumb or pacifier.
The head circumference is reviewed to be sure that it is not too large (macrocephaly) or too small (microcephaly). Cephalohematoma (swelling over one bone of the skull) from birth should be resolved by now. A hydrocephalus (water in the brain) can cause an enlarged head at this age. Microcephaly can happen from a congenital infection, a small baby, or can be a sign that the skull is not growing properly due to craniosynostosis (fused cranial bones).
The temperature is checked to be sure that it is not too high, which can be a sign of infection or over bundling of the baby or too low which can be a sign of poor temperature instability from either low body fat or infection.

The examination will include a head-to-toe evaluation.

The skin is checked for rashes, moles, lesions, and birthmarks.
The head is checked to be sure that there are not any abnormal lumps or bumps and that the head is growing properly and of proper size.
The ears are checked to make sure that there is normal positioning on the head, that the ear canals are open and lead to the eardrum and that the eardrum or tympanic membrane is of normal shape, color and movement.
The eyes are checked for a red reflex. The red reflex happens when light shines into the retina and reflects back to the observer. Sometimes this is seen in pictures known as "red eye". If there is no red reflex this can be a sign of something blocking vision such as a cataract. The eyes are also checked for strabismus (the eyes pointing in different directions).
A clear discharge or crusting can be a sign of a blocked tear duct. Message techniques can be reviewed.
The nose is checked to be sure that the nasal canals are open. Many babies at this age are breathing through their nostrils and any difficult breathing patterns can be a sign of a closed nares or choanal atresia.
The throat is checked to look for cleft lip and palate, tooth development, and tongue-tie.
The neck is checked for enlargement of the thyroid, any masses, cysts or torticollis.
The clavicles are checked to be sure that any fractures from birth are healed.
The heart is checked for rate, rhythm, and for murmurs.
The chest is checked for symmetry of the ribs, and any abnormal rib structures such as pectus excavatum (funnel chest).
The lungs are checked for normal breath sounds and respiratory rate.
The abdomen is checked for bowel sounds and is palpated deeply to check for enlarged organs such as kidney, liver or spleen or any masses that can signify a tumor. The abdomen is also checked for an umbilical hernia or inguinal hernia.
The hips are checked for instability or dislocatability. If there is a hip instability either an x-ray or ultrasound can be performed to look for developmental hip dysplasia.
The genitals are checked to look for any abnormalities. In a male both testes will be palpated to be sure that they are in the scrotum and the penis will be checked for normal size. The urethra should come out of the tip of the penis. If it doesn't this is called a hypospadius, which will need surgical repair. The scrotum is checked for hydrocele (fluid in the scrotum). In a female, the vagina is checked for any labial adhesions or imperforate hymen. A milky white or blood-tinged discharge is normal.
All extremities are checked for symmetry and movement. Any difficulty such as Erb's Palsy or Klempke's Palsy (floppiness of one arm from birth trauma) should be resolved at this point. If not a visit to the physical therapist may be indicated.
The pulses are checked to look for normal blood flow.
The fingers and toes are checked for proper blood flow, shape and size. The feet are checked for clubbing or abnormal shaping.
The infant's reflexes, strength, head control and tone of the body are checked to look at the overall neurological status.
The back is checked to look for neural tube defects, which are openings along the spine.
The anal canal is checked for patency and size.

After the physical examination is performed the pediatrician should do a review with the parents.

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