2 Month Well Child Care
AAP Board Content Specifications:
 Evaluate the motor developmental progress/status of an infant at 2 months of age,
including recognition of abnormalities
 Evaluate the cognitive and behavioral developmental progress/status of an infant
2 months of age, including recognition of abnormalities
 Immunizations:
o Recognize adverse reactions to various vaccine constituents and manage
appropriately
o Know the indications, safety, and schedule for the pneumococcal vaccine,
hepatitis B, pertussis, polio, rotavirus, hib
AAP priorities to assess for this visit:
 Parental well-being, parental roles, family support, sibling relationships
 Infant behavior, developmental changes, physical activity
 Infant-Family synchrony (parent-infant separation, child care)
 Nutritional adequacy
 Safety
Questions:
1) What are some questions to ask the parents at this visit? What interactions should
you observe?
2) What are some developmental milestones a two-month old should have achieved?
3) What is an appropriate diet? What further recommendations should you give at
this appointment?
4) What parts of the physical exam are important?
5) What vaccinations do you give at this age?
6) What safety topics should be addressed at this visit?
7) What anticipatory guidance is important at this age?
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1) Parent-Child Interaction:
Parental Questions?
o How are things going?
o Maternal post-partum checkup? Depression?
o What kind of support system do they have?
Parent-Child Interaction
o How responsive are the parents and the infant to each other
o Do parents appear comfortable with infant and responsive to infant’s
distress, comforting, and feeding cues?
o Parental roles- Do parents support each other or show signs of
disagreement?
o Do parents seem anxious, depressed, fatigued, or overwhelmed?
2) Developmental milestones: What to expect for this visit & in the upcoming months
Age
Gross Motor
2 m/o
*Push to prone, holds
up chest while prone
*Able to hold up head
3 m/o
*Partial head lag
when pulled from
sitting
Fine Motor
*Hands unfisted 1/2
time
*Tracks past midline
*Diminishing newborn
reflexes
*Bats at objects
*Sustained palmar
grasp
Communicative
*Indicates boredom
(cries/fusses)
*Coos
*Clearer behaviors
to indicate needs
*Regards small
objects
Social
*Social smile
*Attempts to look
at parents
*Consoles/comforts
self
*Echoes speaker
*Babbles
3) Diet:
 At 2 months breastfed infants need about 8-12 feeding in 24 hours.
 Bottle fed infants take about 21-32 oz in 24 hrs (usually 4-6 oz every 3-5 hrs).
 Babies only need breast milk or iron-fortified formula in the first 4-6 months of
life. Parents should not start solid foods until 4-6 months, when infant is
developmentally ready.
 The only supplement is Vitamin D for exclusively BF babies (Dvisol/Trivisol/Polyvisol) or babies taking under 1L of formula.
 Avoid honey & cow’s milk
o Botulinum spores in honey put an infant under 1 year old at risk for
infantile botulism.
o Cow’s milk has been shown to increase intestinal blood loss by 30% in
infants <1 yr old. Also, higher concentrations of calcium & phosphorous
concentrations in cow’s milk, combined with low ascorbic acid leads to
low bioavailability of iron. Furthermore, there is a higher solute load puts
more strain on the infant’s kidneys.
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4) Physical Exam:
 Plot Wt, Ht. and HC; Infants in the first 3 months of life should gain 30gm/day
 Head: palpate fontanelles, sutures
 Eyes: red reflex, tracking, watch for fixed eso/exotropia, opacification
 Mouth: look for thrush
 CV: listen for murmur, check pulses (including femoral)
 Abdomen: feel for masses, HSM
 Musculoskeletal: Perform Barlow and Ortolani maneuvers; look for torticollis
 Neuro: check tone, strength, symmetry of movements
 Skin: check for bruises and rashes
Growth & Caloric Requirements
Age
Daily weight
gain
g/day
Monthly
weight
gain
lb/month
Monthly
Lt
cm/month
Monthly
HC
(cm/mo)
Recommended
Kcal/kg/day
Kcal/kg/day
0-3 months
25-35
2 lb
2.6-3.5
2
115
3-6 months
6-12
months
15-21
1.25 lb
1.6-2.5
1
110
10-13
1 lb
1.2-1.7
100
1-3 yrs
4-10
13 oz
0.7-1.1
0.5
0.270.15
4-6 yrs
5-8
8 oz
0.5-0.8
7-10 yrs
5-12
6 oz
5-6 cm/yr
11-18 yrs
Varies
Catch Up
(FTT)
Infant: 6090
Child: 30
100
M: 1.5-6cm/6 mo
F: 1.5-5cm/6 mo
5) Vaccinations:
 Pediarix (Dtap, Inactivated Polio, Hepatitis B), Hib, PCV 13, Rotateq
 Influenza for family members when children <6 months
6) Safety Topics:
 Remember, BACK TO SLEEP! Discuss other ways to reduce SIDS.
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Crib slats < 2 3/8 in. (60mm); playpen mesh weave <1/4 in. (6 mm)- never leave
baby in a mesh playpen with the drop-side down or in crib with rails down
No extra water is required or recommended.
Remember, NO BOTTLE PROPPING!
Rear- facing car safety seat in back seat for all transportation until 2 y/o
Set water heater to 120°; test water before placing infant in bath; never drink hot
liquids while holding baby
Always monitor baby on changing table, bed, counters, couches-They always
learn to roll for the first time when you’re not looking!
7) Anticipatory Guidance:
 Encourage parents to have alone time together and individually to promote
physical and emotional health needed to care for baby. Also do not become
socially isolated from friends and family.
 Have 1:1 time with siblings. Involve siblings in care of baby as age appropriate.
 Young infants cannot be “spoiled” by holding, cuddling, talking or singing to
them. In fact, engaging in these activities during alert states helps strengthen the
trust and bond between parents and baby as well as language development.
 Encourage regular sleep/wake pattern by having baby placed in crib while still in
drowsy state to calm self to sleep. Feed more frequently during the day to
encourage longer stretch of sleep at night.
 Infants should not sleep in the parents bed, but a nearby sleep environment is
recommended
 Do not smoke inside home, car, or around infant.
 Start “Tummy Time” when infants are awake
 Respond to your baby’s sounds by making sounds, showing your face to
encourage “talk back”
 Vitamin D Supplementation:
o Supplement breastfeed & partially breastfeed infants with 400 IU of
Vitamin D beginning in the first few days of life. Supplementation should
continue until the infant is weaned to 1 L/day or 1 quart/day of Vitamin D
fortified formula or whole milk (AAP 2008 Policy Prevention of Ricketsattached).
o All non-breastfeed infants who ingest < 1000 ml/day of Vitamin D
fortified formula should receive vitamin supplement of 400 IU/day (AAP
2008 Policy of Rickets).
o Preterm infants, when able to tolerate full enteral feeds, should be taking
400 IU of Vitamin D with max of 1000 IU/day (AAP 2013 Clinical Report
on Calcium & Vitamin D Requirements on Enterally Fed Preterm Infants)
References:
1. American Academy of Pediatrics, Bright Futures 3rd edition. 2008: 319-333.
2. Behrman, RE et al. Nelson Textbook of Pediatrics 16th edition. Philadelphia: WB
Saunders Company, 2000.
3. Kleigman, RM et al. Nelson Textbook of Pediatrics 18th edition. Philadelphia: WB
Saunders Company, 2007.
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