The Sixth-Month Exam
Ellen Link, MD, Assistant Professor
Division of General Pediatrics, Department of Pediatric
University of Iowa Hospitals and Clinics
Winter 1999

A recently published survey suggests that 79% of parents of very young children want more information about child-rearing from their child's health care provider. This same survey shows that only 39% of parents read or look at a book with their child on a daily basis. In addition, it finds that breast-feeding and daily reading are much more likely if encouraged by the health care provider.

Routine health care visits are an ideal opportunity to discuss not just "medical" issues, but parenting issues as well, and to offer guidance on a variety of topics. Bright Futures Guidelines for Health Supervision (see Resources) suggest several general interview questions that can be used at any visit. These questions are open-ended, to encourage discussion.

The visit can be started with "How are you? How are things going?" Inquire about any major changes or stresses in the family. Discuss what the parents enjoy most, and least, about their baby. Ask them how their other children are dealing with the new baby, and explore family activities.

Obtain details about the baby's feeding patterns, sleep routines, and how the family approaches discipline. Inquire about whether the parents have time to themselves, and make sure no one has ever hurt the child or parent. Determine whether there are guns in the house, and how they are stored. Explore neighborhood safety.

If both parents work, ask about how this is going, and about the type of childcare being used.

It is important during early health care visits to determine if anyone is smoking in the home. Inquiries should also be made about indications of parental depression. Ask if the parent has felt sad or depressed in the last week, or for more than two weeks during the past year. Parental depression can significantly affect a child's development. If you suspect depression, the parent needs to be diagnosed and referred for treatment as soon as possible.

6-month milestones. It is crucial to do developmental surveillance at all health care visits. Observe how the baby communicates her needs and responds to others. Specific milestones to be met at six months include:

• Shows differential recognition of parents
• Babbles reciprocally
• Says Da Da or Ba Ba
• Smiles and laughs
• Squeals
• Imitates razzing noise
• Turns to face sounds
• Grasps and mouths objects
• Holds head steady when pulled into a sitting position
• Rakes in small objects with arms
• Rolls
• Self-comforts
• Sits up with support
• Stands briefly with support
• Transfers a cube from hand to hand
• May have first tooth

Observe the interactions between parent and child. Do they talk, look, and play with each other? Is the parent following safe practices in the exam room?

The physical exam

A complete physical exam should be performed. Specific attention should be paid to:

• Head circumference
• Length
• Weight
• Weight for length
• Red reflex
• Strabismus
• Tooth eruption
• hip dysplasia
• Muscle tone
• Use of extremities
• Foot deformities
• Any signs of abuse

Screens should include hematocrit; appropriate immunizations should be given.

Anticipatory guidance

• Encourage parents to start solid foods if this has not already been done. They should also introduce the use of a sippy cup.
   
• Encourage parents to brush their child's teeth, and explore the child's daily fluoride level exposure.
   
• The family should develop a bedtime routine, and the child should have his own bed. Small stuffed animals or soft blankets can help with this transition if needed.
   
• Tell parents to read to their child daily if that hasn't already been happening. Suggest that it can be nice to incorporate reading into the bedtime routine; this can be another way to be sure reading happens every day. Talking, singing songs, and playing music for infants is also very important.
   
• Discussions about safety are also timely during the six-month visit. Encourage parents to childproof their home, using gates on stairways and window guards. Poisons, medications, and small or dangerous objects should be stored out of reach of the baby.
   
• Discuss signs of illness, and talk with parents about when it is important to call the doctor. Learn how they would handle a health emergency with their baby. Emergency phone numbers should be kept by the phone.
   
• Remind parents to keep their baby's car seat facing the rear of the car for the child's first year. Warn them against the use of walkers, which can cause injury.
• Warn the parents that the child may soon develop anxiety around strangers, and may have difficulty separating from them.
   
• Explore the family's need for financial assistance, and direct them to services as appropriate.

Each health maintenance visit is an ideal opportunity to explore the health, and the well-being, of both the child and the family, and to offer guidance that can promote the child's optimal development.

Resources

American Academy of Pediatricians [AAP] Guidelines for Health Supervision III. AAP Publications, PO Box 747, Elk Grove Village, IL 60009-0747.

Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. National MCH Clearinghouse, 8201 Greensboro Drive, Suite 600, McLean, VA 22102.

Age-specific Bright Futures Encounter Forms help providers make health care visits as effective as possible; forms also provide questions relevant to anticipatory guidance. Forms for families help them set visit goals. Both can be found online at http://ww.brightfutures.org/.

McLearn, KT et al. Listening to Parents: A National Survey of Parents with Young Children. Archives of Pediatrics and Adolescent Medicine, March 1998.

Encouraging dialog during the six-month exam