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Your Baby at Four Months

By Dr. Boettcher

The first four months have provided many wonderful memories.  More moments will follow in the next few months.  Continue to nurture and love your infant and involve the whole family in her care.

DEVELOPMENT:            

You may have noticed that many of your baby’s initial reflexes, such as the startle and rooting reflex, have disappeared.  When he is pulled to a sitting position, he has very little head lag and is able to balance his head well in the sitting position.  If propped up he will be able to sit and when held in a standing position he can bear weight on his legs.  Many babies of this age have started to roll from their bellies to their backs, but going the other direction usually takes a little more time.  From his belly, he should be raising his head and chest off the floor at 90 degrees.

By this age, your baby's vision has improved, and she is starting to have eye-hand coordination.  You may have noticed that your baby inspects and plays with her hands and may pull clothing or a blanket over her face to play.  She may try to reach for objects, but often overshoots.  She grasps objects with both hands and will play with a rattle placed in her hands, but cannot pick it up if it is dropped.  Almost everything that finds its way into her hands will soon be in her mouth

Your baby has started to laugh out loud and make more sounds.  He becomes bored if left alone and demands attention by fussing.  Ways to stimulate your baby's senses at this age include placing him so he can look in a mirror.  Brightly colored toys that are small enough to grasp but not small enough to fit in the mouth are appropriate.  He still enjoys being talked to and having the sounds he makes repeated.  Laugh when he laughs, call him by name, crinkle different papers by his ear, and place rattles or bells in his hand and show him how to shake them to stimulate his sense of hearing.

Giving her soft toys of different textures and placing her naked or only in a diaper on a soft furry rug can stimulate her sense of touch.  Her sense of motion can be stimulated by the use of a swing or stroller, bouncing her in your lap while holding her in a standing position, helping her roll over, and supporting her in a sitting position.

Over the next couple of months, you will notice even more changes.  By six months, he will be able to sit in a high chair with a straight back and roll from his back to his belly.  He will recognize his parents, and therefore begin to fear strangers.  Variations in the rate of development are normal.  Discuss specific concerns with your health care provider.

Teething is another thing that may occur in then next few months.  Usually, babies get their first teeth between 4 and 12 months of age.  You may notice your baby drooling more than usual and chewing on everything.  She may be more irritable than usual, and some babies have looser bowel movements with teething.  Fever (temperature > 101) is not a result of teething.  For the discomfort we suggest Acetaminophen (Tylenol in a dose appropriate for his weight), cold teething rings, or other firm objects to chew.  Use topical preparations such as Anbesol, Oragel, or Numsit sparingly, if at all, since large amounts can be harmful to your baby.

FEEDING:

We encourage exclusive breast-feeding or formula feeding until 4- 6 months.  Your provider will advise you about when to start introducing solid foods to your babyInitially, cereals and baby foods are started simply to give your baby practice with new tastes, new textures, and a new way of eating.  Your baby will continue to get nearly all her nutritional needs from the breast or formula.  Her first food should be iron fortified rice cereal.  Start with a tablespoonful and mix it with formula or breastmilk.  Do not expect your baby to swallow much cereal.  She will take bites, but her tongue movements will push the food out of her mouth.  This is normal and it will take a while for her to learn to keep the food in her mouth.

There are many different approaches to starting solids.  Ask your provider about how to start your baby on new foods.  One method is the old-fashioned approach of slowly adding a food:  After he has gotten used to taking the cereal and demonstrated the ability to swallow the new texture, introduce a new food, one at a time.  Feed each new food a few times over 3 or 4 days before starting another new food.  Another philosophy is to ensure that the baby can take from the spoon and then just provide any combination of pureed baby foods.  Continuing to provide new experiences each feeding.   Meats can usually be started around  6-7 months of age. You can prepare baby foods at home if you puree or finely grind them and avoid excessive spices or salt.  Do not give honey before one year of age due to the risk of infantile botulism.

It is important to follow your baby’s cues during feedings.  Watch for signals that she is full such as fussing, clamping her mouth shut, or turning her head away.  Your baby knows how much food she needs, so listen and watch for these cues.  She needs time to adjust to the new tastes, textures, and ways of eating solid foods.  Do not rush through mealtimes.  If you rush, meals will not be pleasant for you or the baby.  Meals should be a pleasant time to nurture and interact with her. Mealtime will also be a messy time.  Do not expect your baby or the feeding area to be clean afterward.  If mealtimes and feeding are a problem with your infant, please call our nurses for some guidance.

SLEEPING:      

About l0-15 percent of children between 4 and 24 months of age have problems sleeping at night.  This is evident as it always seems your baby is the only one of your group of friends to have sleep problems.  However, as you can see by the amount of books regarding sleep problems, you are not alone.  Babies wake up and cry one or more times during the night in order to be fed or to receive attention from their parents.  These incidents usually occur every night.  In most instances, he has had the behavior since birth.  If your child fits this description, please ask your physician for the appropriate information and necessary steps to assist you and your family in solving his sleeping problems.  Also, the nurses are able to provide additional counseling.  There are several ways to address the problem, we will try to match the appropriate technique with you and your child’s temperaments and tolerances to increase your success and decrease your stress.

All children, especially during the first year of life, may awaken several times each night, but if they have developed good bedtime routine, most can put themselves back to sleep.  The ones who have not learned how to do this cry for a parent.  If you provide too much attention (constant rocking or feeding to sleep, for example), the infant becomes dependent on you for return to sleep.  These infants are known as trained night criers.  The infants who demand to be fed as well as held are called trained night feeders.  We have various handouts and references that will assist you in correcting the problem.

By 4 months of age, about 90 percent of infants are able to sleep more than eight consecutive hours without feeding. It is important to start correcting problems as early as possible.  The older the child is, the harder he is to treat.  Put your baby to bed when he is awake but very drowsy.  Many trained night feeders and criers are rarely, if ever, placed in their cribs awake.  If he goes to sleep in your arms occasionally, that is fine.  However, try to place him in the crib awake but drowsy for bedtime and all naps.  His last memory should be of the crib, not of you or the bottle.

If the crib is in your bedroom, move it to a separate room so your baby’s normal tossing and turning do not awaken you.  If this is impossible, cover one of the side rails with a blanket so she cannot see you when she awakens.  Do not change the diapers during the night.  Most babies can survive until morning with a soiled diaper. If you must change your child, use minimal lighting, do it quietly, and without entertainment.   It may be need to be changed if you are treating a bad diaper rash.  Eliminate long naps.  If your baby has napped for more than three hours, wake her.  If she takes three naps per day, decrease it to two.

Call the office and one of our nurses will assist you.   If you feel the crying has a physical cause, if someone in your family cannot tolerate the crying, or if the above steps or nurse advice do not produce improvement in sleep habits within two weeks, please make an appointment with your regular pediatrician.  Please, feel free to contact us during office hours if you need additional information on sleep problems.

SAFETY:             

Between 4 and 7 months, most babies have developed the ability to roll over, sit momentarily, grasp and manipulate small objects, and put everything in their mouths.  Because of these increased developmental accomplishments, his potential for injury has also increased.  There is no substitute for common sense when it comes to your baby's safety.  You can help keep your child safe by following these safety tips:

Auto Safety

  • Until 2 years of age, it is recommended that your baby ride in a carseat facing backwards every time the car is moving. 
  • The center of the back seat is the safest location of the infant seat, so use it if you can. 
  • Use an infant seat appropriate for his weight and height.  It may be time to change from the infant carrier.
  • Never leave the baby in a parked car. 
  • Always check the carseat’s temperature before using it. 
  • For information on all types of car seats, you can call the Auto Safety Hotline at 1-800-424-9393.

Crib Safety

  • Place crib in a safe area, away from windows and mini-blinds.
  • Do not use soft mattresses, pillows, or quilts in the crib.
  • Do not tie toys across crib rails.
  • Place the baby on his back or side to sleep, never put the child to sleep on his stomach at this age.

Falls

  • Use restraints in high chairs and infant seats, and keep crib rails raised to full height.
  • Use safety gates to prevent access to stairs.
  • Do not use walkers, if you have a walker, remove the wheels or lock the wheels.
  • Falls greater than 3 feet in height need to be evaluated immediately, please call us. 
  • Any fall associated with vomiting, loss of consciousness, or decreased awareness needs immediate evaluation.

Choking and Suffocation

  • Check all toys for removable parts and keep small objects (coins, buttons, etc.) out of her reach and off the floor.
  • Use pacifiers with one piece construction and do not tie pacifiers or place jewelry around her neck
  • Do not feed her hard candy, nuts, popcorn, food with pits or seeds, grapes, or whole hot dogs.
  • Avoid balloons as playthings, and keep baby powder out of her reach.
  • Store batteries in a safe area, and discard all batteries appropriately.
  • Never leave your child alone in the bath - even for a moment.

Poisoning

  • Post the Poison Control Center number next to the phone: 1-800-222-1222.
  • Place all medications, cleaning supplies, and toxic substances on a high shelf or in a locked cabinet.
  • Keep plants on a high surface or hang them out of your child's reach.
  • Be sure lead based paint has not been used on any toys, furniture, or in your home.

Bodily Injury, Bums, and Fire Prevention

  • Turn the water heater temperature to 120ºF and keep fire and matches out of reach of all children.
  • Keep pot handles turned toward back of the stove and keep him out of the kitchen while cooking.
  • Do not smoke or drink hot liquids while holding the baby.  Place hot objects on a high surface.
  • Avoid toys that are long and pointed or excessively loud and check toys for sharp or jagged edges.
  • Keep all sharp objects out of the baby's reach and do not let electrical or drapery cords dangle.

Smoking:

  • Do not smoke.  While in the process of quitting, go outdoors and never smoke in the car.  Smoking is associated with increased ear infections, pneumonia, colds, and increased risk of crib death.  For assistance contact the Smoking Cessation Hotline at 1-866-QUIT-YES or DMG’s smoking cessation programs at 630-871-6699.

Shaking Prevention:

  • Never shake or hit your baby.  If you are angry or feel out of control, place your baby down safely and take the time to regain control.  Contact the FUSSY BABY NETWORK at 1-888-431-BABY if you feel your baby’s crying or needs are overwhelming you.  This is a free service.

VITAMINS:  

If you are breast-feeding your infant, continue with her vitamin D or multivitamin drops and your prenatal vitamins with iron.  Also, breastfeeding moms may want to take the DHA supplements.

ILLNESS:     

Many common childhood illnesses can be effectively managed at home.  Please use the provided booklet:  The Baby Book:  Infant and Pediatric Care  for information on most common pediatric problems and illnesses.  For illnesses or concerns that are not responding to your care, please call your provider’s office to talk to the nurses for advice on managing these situations.  Our nurses have an abundant amount of information regarding common childhood illnesses, diseases, behaviors, and home management tips for these.  If your child needs to be seen, they will make the appropriate appointment.  We are available 24 hours a day, including weekends and holidays.  If you have an urgent need after hours, please feel free to contact us, and the physician on-call will gladly assist you.

 DuPage Medical Group Pediatrics has many office hours available after work and school.  We have our Immediate Care Center, which is available seven days a week.  On the weekend afternoons and holidays, when most pediatric offices have closed, we have the Pediatric After Hours Care Clinic.  If your provider’s office is closed or does not have availability for you, please contact 1-888-MY-DMG-DR (693-6437).  As there are many available options to be seen conveniently at times outside of normal business hours, we hope to be able to decrease your use of the emergency rooms for non-emergent illnesses. This will provide a huge savings for your family, and help with the continuity of care as the visit is within DuPage Medical Group.   Please use the emergency room for truly urgent or emergent illnesses.  Some insurance companies require physician approval prior to going to the emergency room, so if it is not a life-threatening problem, but you think your child needs to be seen urgently, please contact your provider who can assist you in that decision and provide the proper referral is it is needed.  For life-threatening problems, please call 911 for immediate assistance.

IMMUNIZATIONS:         

At 4 months, your baby needs the following vaccines:  IPV #2 (polio), DTaP #2 (diphtheria, tetanus, and whooping cough), Hib #2 (Hib meningitis), Prevnar #2 (pneumococcal meningitis), and Rotateq #2 (rotavirus).   Most of these vaccines are combined, which decreases the total number of actual shots.  Following the immunizations, especially the DTaP and the Prevnar, he may experience side effects that are usually mild and temporary.  These include soreness, swelling, and redness in the legs where the shot was given, a mild fever, and fussiness which may last up to two days after the shots are given.  We suggest you give acetaminophen (Tylenol) at the recommended dose for his weight.  The dosing charts can be found in “The Baby Book:  Infant and Pediatric Care.”  The expected side effects are listed in the vaccine information sheets provided.  If you elect not to follow our recommendations of immunizations, we need to counsel you regarding the possible deleterious effect this may have on him and the community.  We will then request that you sign a Vaccine Refusal form indicating that we counseled you about these dangers.  If your child has had a severe or unusual reaction to shots in the past, please let us know before the immunizations are given.

Notify us if any problems occur, such as:

  • An unusual, high-pitched cry or crying without stopping for 3 hours or more.
  • Very high fever (over 105°F) or convulsions.
  • Other symptoms you think are serious.

From September to June, we recommend flu shots for infants 6 months and older, along with all family members.  Children less than 9 years will need two shots separated by at least one month the first time they receive the flu shot.  In most cases, your provider is able to offer the entire family (parents, grandparents, and nannies too) the flu vaccine.  This program has made it more convenient for families and has really helped us see less influenza the last couple of years.

If mom, dad, or grandparents have not gotten the whooping cough vaccine (TdaP), which is recommended for all adult caregivers of infants, please let us know, as in most cases we are able to provide this service for them.

MYCHART:

DuPage Medical Group has become a leader in the area regarding electronic medical records.  With the expansion of the electronic medical record, we can now provide our families with access to much of the same medical information that we have through MyChart.  Immunization records, medication lists, allergies, lab and X-ray results, growth charts, and appointment reminders are all available through this wonderful program.  Also, the ability to communicate with your provider for non-urgent medical questions can be done via email with MyChart.  We encourage all our families to sign up for this secure and useful online medical record portal.  The opportunity to sign up will be given to you at check in.  If you have any questions regarding this program, please call or discuss with your provider.

NEXT APPOINTMENT:

Please schedule your baby's next appointment for 6 months of age at checkout.   Please try to arrive 5 -10 minutes before your appointment so the necessary paperwork can be done.  Unfortunately, sometimes unexpected or complicated problems will cause us to be slightly delayed and you may need to wait awhile.  Bring toys and be prepared to feed your infant if necessary.  We would appreciate your understanding. 

 


Topics and Subtopics: Children's Health & Infant Care

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