Maternal and Child Health 4 Months

Maternal and Child Health 4 Months

Your Child's Health and Development
Immunisation: The next recommended immunisation is due at four months.

Safety: Increasing mobility can raise the risk of falls or accidents
Block off dangerous areas in the home, such a laundry or stairs
Keep hot things and dangerous areas out of baby's reach
Avoid using overhanging table cloths
Ensure your baby is not exposed to hazards such as leaded paint dust
Provide adequate protection from the sun
Ensure your baby is in a smoke free environment
Consider transferring babies to a forward facing car restraint once they weight between 8 and 9 kg.

Health Visits: General health and development check up including discussion concerns or questions with your Maternal and Child Health Nurse.

Nutrition and Growth: Breastmilk or formula is the main source of nutrition
Frequency of feeds continues to reduce - night feeds may reduce to one.
May introduce solid foods at around six months but this should be discussed with your Maternal and Child Health Nurse
Don't add sugar and salt to foods or drinks.
Don't give fruit juices, cordials or syrups.

Movement: Moves more deliberately as reflect movement decrease.
Lifts head and chest by supporting weight on arms when lying on stomach
Increase in neck and head control.
May roll from stomach onto back.
Clasps hands together and takes them to mouth.
Attempts to pick up objects using both hands.

Language: Laughs and babbles with increasing tone and intensity and enjoys being read to and looking at picture books.

Learning and understanding: Takes greater interest in surroundings, tries to prolong interesting happenings discovered accidently.

Emotional: Starting to develop wariness of strangers and parent separation anxiety.

Sleeping: Sleeps less during the day and may be ready to sleep in a cot.

Toileting: Type of bowel motions depend on diet.

Relationships: Recognises familiar faces and starts to interact more with others.

Behaviour: Vocalises to get attending and have needs met.

When Baby is Three or Four Months Old
Things to look at: Provide a wide variety of objects colours and textures for your baby to experience. Some suggestions are: Coloured cellophane panels on the windows, leaves moving in the wind, clothes flapping on the clothes line, rain on the windows; and sunlight on the flowers.

Learning about movement: Babies like to kick and turn their heads from side to side. They will roll to one-side and grasp things. Baby will hold a rattle for a few seconds. They can clasp hands, and suck their thumbs and fingers. They can reach out to touch things but they are not yet aware they can cause things to happen.
Clasp baby's hand and lift his or her arms slowly up and down. Bounce baby gently on your knee.
Give baby the opportunity to stretch and kick during bath time. Talk to them about parts of their bodies as they stretch and kick and give opportunities to play on the floor.
Babies learn their physical skills through practice. Place your baby on the floor on their back, tummy and sides, with plenty of space and opportunity to explore the surrounds. To assist movement take off the nappy and limit clothing when playing. Babies need to make their own decisions to move. They soon learn to stop for rest when required, and then play and move again. Given lots of opportunities the baby, with practice, gradually becomes stronger and enjoys spending longer times on the floor.
Give your baby lots of opportunities to explore your home, your garden or the local park. Walk using the pram, sling or carry baby facing away from you. Place a rug on the ground and enjoy watching them play.
There are times when you cannot be watching and so to ensure your baby is safe while not restricting activities, a square wooden playpen (with a base) is the best piece of equipment. In this your baby can roll, stretch, crawl, sit up, pull up to standing and walk around the edges.
Other equipment such as bouncinettes, baby swings, jolly jumpers, high chairs should be used sparingly, always under supervision and with caution. All these things restrict your baby's attempts at safe independent movement. If used, always place your baby back on the floor after ten minutes. None of these items really contributes to the development of your baby's motor skills.
Baby walkers are not recommended. They interfere with the normal development of balance and the ability of babies to get safely in and out of positions themselves. Babies need to test their own balance, pull to stand and walk sideways around furniture before they can begin to master walking by themselves. Baby walkers can be very dangerous near steps, objects or floor surface changes. If babies are moving in baby-walkers, they can easily bang their heads or tip over.
Babies learn to walk by themselves, in their own time.

Learning about touch: Babies at this age like to try and reach and grasp things. They bat at them, that is, they hit them with their hands accidently. To encourage them, place toys close to them. The toys should be semi-rigidly supported and not on a string as this could get caught around baby. Suspend large household items such as foil pie plates, bells and cotton reels. Make them large enough so that baby does not miss them when learning to bat.
Encourage you baby to be aware of their feet and the way they move by playing toe games. Play "this little pig went to market". Pat the bottom of baby's feet and recite rhymes such as "Pat-a-cake".
At this stage babies like to feel things. Use blankets with different edgings and of different textures to give baby the opportunity to finger different surfaces.

Using hands: Babies like to watch their hands. At this age they are really beginning to learn a lot through touch.
Leave their hands free so that they can explore your face, their fathers beard and so on, with their eyes and hands.

Help baby solve problems: Baby at this age is able to follow moving things across, up and down. A baby now recognises sign and sound go together and recognise parents across the room.
Start to teach baby the difference between things. Stroke baby's cheek with different textures such as velvet, silk toweling, felt and netting. As you do this say something like "it's soft" or "it's cold".
Encourage babies to follow with their eyes. Play tracking games in both natural and artificial light, so they see different things in various ways. Use something black and white which is easy to see.

Language and music: Babies at this stage make more sounds such as squeals and shrieks of delight. They love people to pay attention to them and they like to be sung and talked to. At this age babies respond to smiling and talking, by smiling back. They now turn their heads towards sound, including music. You will find talking and crying often follow each other for no apparent reason. They enjoy making their own sounds.

Learning about language: Smile and coo at baby - use babies noises and repeat these back to them.
Encourage baby to respond with voice and movement, cuddle and touch baby, stoke face and sing lullabies.
At bath time, talk about various parts of the body and sing.
Stroke and tickle babies toes.
Babies hear a variety of sounds in their surroundings; for example, footsteps, voices, running water, household appliances, and so on.
Use different tones of voice when talking to baby.
Bounce baby on your knee, sing bouncing nursery rhymes.
When changing baby, talk softly about what you are doing and respond to coos as you talk.

Things to listen to: Give baby a range of gentle, familiar and unfamiliar sounds and watch for their reaction to new sounds.
Let baby hear different voices, singing, humming, whistling.
Let baby hear all sorts of music, but don't have background noise on constantly as it will mask many sounds and baby will become unaccustomed to silence.

Some Rhythmic Rhymes
If you're happy and you know it, clap your hands (clap, clap)
If you're happy and you know it, clap your hands (clap, clap)
If you're happy and you know it, then you really ought to show it
If you're happy and you know it, clap your hands (clap, clap)

If you're angry and you know it, stamp your feet…
If you're sad and you know it, wipe your eye…If you're angry and you know it, stamp your feet…
If you're sleepy and you know it, nod you're head…

Hickory dickory doc
The mouse ran up the clock
The clock struck one
The mouse ran down
Hickory dickory doc

Twinkle, Twinkle little star
How I wonder what you are
Up above the world so high
Like a diamond in the sky
Twinkle, Twinkle little star
How I wonder what you are

Round and round the garden, like a teddy bear, one step, two step, tickle you under there.

Baby's diet - six months to two years
Introducing baby to solid foods: Introducing solid food is an important stage in a baby's life. It needs a lot of patience on your part, practice on baby's part and a lot of learning by everyone!

Principles: Babies usually start spoon foods at six months of age, but discuss when to start with your Maternal and Child Health Nurse. Signs of food readiness include: chewing movements, tongue moves back and forth, baby looks interest in foods you are eating.

Begin with smooth foods. Baby learns to chew between six months and eight months so slowly increase the texture from smooth to mashed to finger foods. Begin with small amounts from one to two teaspoons and gradually increase. Each food needs to be offered separately for three days before offering a new food.
The amount and variety are gradually increased, one food at a time. Use family foods (where possible freshly picked or purchased and freshly prepared). Additional quantities can be frozen in ice cube trays, pressed out and stored as cubes in freezer bags.
Commercial baby foods in jars and cans are generally not necessary as they tend to lack texture and often do not allow experience in food flavours. If used all the time baby may find the adjustment to family foods difficult but they can be useful in an emergency when travelling or visiting.
Do not add sugar, salt or spices
It is recommended that breast milk or formula is the most suitable milk under 12 months of age.

Examples of some suitable foods for babyAge: Six Months
Offer milk from approximately 30 minutes to 60 minutes prior to solids.

Cereal/Rice: Start with one teaspoon, increasing to between six and eight teaspoons. Mix with boiled water, expressed breast milk or formula to make a sloppy paste.
Fruit including pears, apples, ripe banana, avocado, melon: Start with one teaspoon, increasing to between six and eight teaspoons. Serve steamed, microwaved, pureed or finely mashed.
Vegetables including sweet potato, potato, pumpkin, zucchini: Start with one teaspoon, increasing to between six and eight teaspoons. Serve steamed, baked, microwavesd, pureed, sieved or finely mashed.

Age: Six to Eight Months
Cereal Wheat based (eg. mixed Farex, high protein) oats (porridge): ½ small cup to 1 small cup. Mixed with formula or water.
Fruit including peaches, kiwifruit and mango: ½ small cup to 1 small cup. Mashed and can be mixed with cereal.
Vegetables including carrots, green vegetables, peas and beans: ½ small cup to 1 small cup. Steamed, baked or microwaved, mashed.
Diary products: mild natural yoghurt can be mixed with fruit.
Chicken, red meat, pasta, rice: breast of chicken may be cooked until tender and flaked finely with vegetables. Lamb/beef/minced meat.
Drinks: As solid foods increase, they tend to replace milk intake. At this stage, babies usually learn more easily to drink from a cup. Offer water (water must be boiled until six months) and avoid fruit juices, soft drinks and cordials as sugar may damage infant teeth.
Finger foods (commence around seven months): Babies must always be seated and closely supervised when eating finger foods (foods held by baby) as pieces can break off and cause choking. Rusks (from the supermarket). Bread (low salt, wholemeal) cut into finger shapes and dried in a cold oven for one hour to two hours. Pieces of fruit (eg. kiwi, grated apple, banana, orange segments, peaches and avocado). Bones (eg. smooth chop bones). Pieces of cooked vegetables (eg. broccoli, cauliflower, asparagus).
Supermarket Foods: When buying supermarket foods, use low salt products and familiarise yourself with additive codes, avoiding food additives where possible. If there is a strong family history of food sensitivities such as cow's milk, wheat, eggs or peanuts - read labels carefully, it may be necessary to avoid these foods until baby is over one year old. Discuss this with your Maternal and child Health Nurse or doctor.

Age: 8 Months to 12 Months
Food may be offered prior to milk at this age.
Baby will now be able to eat foods prepared for the rest of the family, fruits, and vegetables being chopped, not mashed including:
Toast and sandwiches fillings could include cottage cheese, smooth peanut butter, margarine and a thins crape of vegemite, avocado, banana and scrambled eggs.
Legumes (beans, peas) and lentils cooked thoroughly
Cups with straws (most babies can learn to use a straw at this age, useful when traveling)
Bottles can now be scaled clean but teats should still be sterlised.
Dairy Products: Whole cow's milk can be introduced in small amounts into spoon food, however cows milk is not recommended as a drink until after 12 months. Low salt cheese can be grated and mixed with vegetables.
Eggs: As some babies are sensitive to egg, give ½ teaspoon softly cooked egg yolk on its own , and observe for any reaction such as vomiting, reddening of the skin around the baby's mouth during the next hour or a fine body rash within 24 hours. If no reaction, increase the quantity until the whole yolk is taken. Once baby is used to egg yolk, cooked egg white is small amounts may be offered and increased gradually. If there is a family history of allergy to eggs do not offer egg until baby is over one-year-old. Egg can be given scrambled, in custard or a variety of other ways.
Fish: Boneless white fish may be steamed or baked and flaked finely with vegetables.

Age: One Year to Two Years
Milk: Calcium and protein are now also obtained from spoon foods. The daily requirements of calcium at this age is 700mg. This can be obtained from 600mls of milk. Other dairy products can be substituted (eg yoghurt has similar calcium content per volume and cheese 30gsm = 200mls of milk).
If you need more information on foods containing calcium, ask your Maternal and Child Health Nurse.
Soy formulas may be used to one-year-old. These formulas may be continued until the second year or calcium fortified soy milk may be given after one year.
Bottles are no longer necessary. Try to discontinue before the age of two years.

Guidelines for giving water to babies and young children
Age: Birth to six months
Under normal environmental conditions no liquid other than breast milk or formula is required.
In extreme and prolonged heat although the supply of breast or bottle feeds can be increased, boiled water can also be offered.
If using tap water, bring to the boil, then cool before using it.
When making up formula boiled water should be used.

Age: After six months
Apart from milk, water is the best drink to offer.
It is good to offer water from a cup.
Australian city tap water generally does not need to be boiled.
When making up formula, Australian tap water can be used without boiling if made up just before use.
If formula for several feeds is to be made ahead of time (which is not ideal), boiled water should be used.

Age: Up to one year
If bottled spring water or purified water is use, it should be refridgerated if kept after opening. Use as soon as possible after opening.

General Diet: Consider your child's diet in the context of the whole family's nutrition. It is easier if you do not have soft drinks, lollies and foods high in sugar or food colourings in the home.
Most children lose their appetite when teething or if unwell. Do not worry for a few days, but encourage plenty of fluids.
Many children have a reduced food intake between one year and two years. Never force-feed your child. If anxious about your child's food intake, discuss this with your Maternal and Child Health Nurse.
Remember meal times should be happy times for everyone to enjoy.

Family Food for Children in the First Year of Life

Birth: First choice is breast milk. If this is not possible, formulas made for babies under 12 months old as recommended by the Maternal and Child Health Nurse.

Signs of Food Readiness: Chewing movements begin
Tongue moves back and forth
Able to hold head up and take solids
Begin introducing solids from a spoon after milk feeding.

6 Months: Rice cereal 'best' first food (eg. Heinz or Farex).
Cereals are diluted with breast milk, formula or water
Fruit: pears, apples, ripe bananas, avocado, lemon.
Vegetables: sweet potato, potato, pumpkin, zucchini - mash finely, then gradually increase the texture.

6-8 Months: Cereal, wheat based (eg. Mixed Farex - high protein), oats - instant (porridge).
Fruit: could include peaches, mango, kiwifruit
Vegetables: offer more variety
Dairy products: yoghurt fromage frais, custard (no eggs)
Chicken, red meat, pasta and rice
Introduce a cup with water or formula.

Finger Food: Finger foods commence around 7 months old.
Babies may always be seated and closely supervised when eating finger foods (foods held by baby) as a piece can break off and cause choking - pieces of cooked vegetable, eg. broccoli, cauliflower.
Soft fruit wedges or slices
Rusks, bread, toast slices.

8-12 Months: Infant muesli
Fruit (all fruits except passionfruit and berry fruits)
Other vegetables including legumes (beans, peas) and lentils cooked thoroughly
Dairy products: whole cow's milk. Small amounts may be introduced into spoon foods.
Cheese: low salt, grate and mix with vegetables
Eggs (up to two per week) Yolk: start with a small amount a few drops ¼ teaspoon of cooked (soft boiled) yolk. Slowly increase until the whole yolk is taken. Then the white - in small amounts gradually increasing. Eggs can be boiled, poached, scrambled or omelette. Also in desserts eg. custards.
Fish (beware of bones)
Tofu (bean curd).

12 Months: Weetbix, vitabrits and smooth peanut butter.

1-2 Years: Family meals and other beans eg. kidney, cannellini, soy.

Do not give baby nuts, seeds, raw carrot or other small hard foods which may cause choking.
If there is any reaction to eggs eg. rash or vomiting, STOP immediately and discuss with maternal and child health nurse.

Foods not suitable for infants or those which should be used with care:
Honey: Honey can contain the spores of Clostridium botulinum, and it is recommended that it not be given to children aged less than two years old. Previously, honey was prohibited in foods for infants in Australia, but it is now permitted providing it has been treated to inactive C botulinum. This is indicated on the label by the term 'sterilised honey'. After the age of 12 months, children are less susceptible to this bacterium.

Tea: Tea contains tannins and other compounds that blind iron and other minerals, thereby reducing their bioavailability. Furthermore, sugar is often added to tea, increasing the risk of dental cavities.

Nuts: Nuts are a problem with small children because of the risk of inhalation. For this reason they should not be given to children aged less than five years old. In addition, all nuts pose a risk of allergy.Fruit Juice: Juices made from compressed fruit contain all the nutrients in fruits but not the dietary fibre. They have historically been given to children to prevent Vitamin C deficiency and scurvy.
Fruit juice offers no nutritional benefits to infants under six months of age; for infants over six months of age, drinking water or milk and consuming whole fruit are preferable. Excess consumption of fruit juice by young children have been associated with gastroenteritis symptoms, failure to thrive, decreased appetite, loose stools and failure to gain weight. Milk drinks (for children aged more than 12 months old) or water are good substitutes - milk is particularly beneficial because of its calcium content.

Cow's Milk: It is recommended that children under the age of 12 months should not be given cow's milk. The composition of cow's milk is not ideal for infants. Compared with breast milk and infants formula, cow's milk contains much higher level of protein, sodium, potassium, phosphorus and calcium and lower levels of iron, vitamin C and linoleic acid, adding to the difficulty of providing a balanced diet for older infants. The higher levels of protein, sodium and potassium in cow's milk have been associated with an increased renal solute load.

Reduced Fat Milks: In Australia, reduced fat milks are recommended for older children and for all adults as part of a healthy diet. They are not recommended for children aged less than two years old.

This information was compiled by Bayside City Council Maternal and Child Health Nurses using, but not limited to the following resources: Australian Breastfeeding Association, Centre for the Study of Mothers and Children's Health (La Trobe University), Child Accident Prevention Foundation Australia, Continence Foundation of Australia, Department of Human Services, From Birth to Five Years, National Health and Medical Research Council, Physiotherapy Association of Australia, Play in Early Childhood from Birth to Five Years, Post and Ante Natal Depression Association Incorporated and SIDS Australia.
For more information phone 03 9599 4444 or visit the website www.bayside.vic.gov.au




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