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Q&A with Dr. Sara Connolly: What to expect from the 4-month checkup

Bundoo Expert

Dr. Sara Connolly
Bundoo Pediatrician

Sara Connolly, MD, FAAP, is a Board Certified Pediatrician who practices in Palm Beach County, Florida.

When your baby is 16 weeks old, he or she will get all of the necessary immunizations and checkups, but what are these, exactly? Dr. Sara Connolly, Bundoo Pediatrician, goes over concerns of sleep, food, developmental setbacks, and what parents should be looking out for around this time.

Bundoo: What do you look for at this age in terms of developmental milestones, both physically and intellectually?

Dr. Sara Connolly: Four-month-olds are so much fun! Unlike the sleepy newborn, or the fussy 2-month-old, a 4-month-old baby can really begin to interact, smile, and giggle. They reach out and grab my stethoscope, they may want to roll over as I examine them, and they will grab a hold of a tongue depressor and put it into their mouths to explore, if given the chance. They begin to seek out their caregivers’ faces when faced with the uncertainty of the exam, looking for reassurance. Finally they give me a good idea of how easily they are soothed as they recover from the vaccine experience. As I interact with the infant during the exam, I am watching that all of these milestones are occurring.

It seems like many babies make some big leaps forward in development right around this age, with rolling over, sleeping through the night, and interacting with people. Are there are “red flag” milestones that you look for at the 4-month checkup?

We look for difficulty feeding as evidenced by failure to gain weight. We also look for the muscle tone of a baby. Babies can be too floppy, unable to hold their head and bring their hands to their mouths. They can also be too tight, unable to stretch out their arms and legs or unable to roll because their limbs get in the way. A baby who is not yet sleeping through the night is not a ‘red flag,’ but it is an opportunity for pediatricians to discuss sleep training and inquire about how the entire family is doing with lack of sleep. Babies who are not making eye contact, not cooing or showing a social smile, or not turning to sound are all worrisome and need further evaluation.

What are the most common questions you hear from parents at this checkup? What seems to be the top concern?

Sleep and feeding! At this point, families are tired. Many babies are sleeping for eight-hour stretches at this point, but some are not. These families are not only sleep-deprived but often feel like they are doing something “wrong” because their infant does not sleep. We spend a great deal of time talking about patterns of sleep and how to help infants learn to sleep longer.

Food is also an issue. Parents want to know when to begin solids and what to say to well-meaning relatives who are pushing them to start. We look closely at growth to show parents how their feeding pattern is working well and offer reassurance and encouragement.

Transitioning to solid food becomes an issue around now. The American Academy of Pediatrics recommends 6 months of exclusive breastfeeding if possible, but surveys show that many parents start their babies on solids as early as 4 months. Are there circumstances in which it’s OK to start solids this early, or do you uniformly tell parents to hold off as long as possible?

This question is difficult because there are many different variables when it comes to solids. For babies who are gaining weight well, I offer reassurance that solids are not necessary. We discuss developmental cues that indicate that your child is getting more ready to eat solids, and I remind parents that solids are given only by spoon and not in a bottle. Babies need good control of their heads, necks and mouths to be able to coordinate feeding from a spoon. Four months is usually too early for those skills.

What kind of safety considerations do you recommend parents make around the house? Should a house be fully baby-proofed already?

I remind parents not to allow their infants to rest unattended on a couch, bed, or other raised surface in order to avoid rollover falls. I also remind them that infants should sleep on a firm mattress without blankets or pillows in a cool room, away from any smoke. Now that babies can bring their hands to their mouths, I remind them to have a play space clear of all small objects that could choke the baby.

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