By now you and your infant should be getting to know one another quite well.  You have a better understanding of what the baby wants, and she knows how to get it!  The 2 month old will easily watch the caregiver's face and respond to a smile.  Your infant responds with signs of happiness (smiling, cooing, movement of the arms and legs) and signs of fussiness (crying, frowning, agitated movements, back arching).  Your baby can hold up her head for several seconds or longer.  The newborn reflexes begin to disappear.  If you are lucky, your baby will sleep for 4-5 hours between feedings.

Development History

Social - Infants at this age begin to interact with the environment.  Infants will smile responsively to caregivers and begin to make "cooing" noises when happy.

Communication - The two-month-old infant may begin showing different types of cries for different reasons:  hunger, discomfort, and fatigue.  Cooing sounds indicate happiness.

Cognitive - The infant may become irritable when bored.  She begins to show interest in toys and faces in the line of sight (but won't necessarily reach for them yet).

Motor skills - The infant now has good control of her head.  The head doesn't flop over when the infant is lifted.  When she is placed on her belly, she can lift her head and push up with her hands to look forward.  The infant brings her hands to her face and may begin sucking on fingers.

Physical exam

Measurements - Height, weight, and head circumference should be measured and compared to normal values on a growth chart.  Many major medical problems present with growth delay.

Skin - Are there rashes? Infants develop rashes frequently and there are many types.  Most rashes are harmless but check with your doctor.  Seborrhea (cradle cap), diaper rashes, newborn acne, and even eczema may be seen at this age.  Jaundice (yellow skin color) at this age is unusual and should be evaluated by a doctor.

Head - Is the fontanel soft and flat?  Some flattening fo the head may begin to appear if your baby prefers to lay in one position.  Can your baby lift her head when on her belly?  She should.  Does the head fall backwards when she is on her back and you pull her up gently by her arms?  She should be able to keep her head from falling back fairly well.

Eyes - Do the eyes move in all directions?  They should.  Do the pupils shrink in response to light?  They should.  Do the eyes move together? They should.  Do the pupils both shrink and dilate at the same time?  They should.  Does she follow objects with her eyes?  She should follow objects with her eyes at least to the midline.  Vision is still pretty lousy but improving.

Heart - Are there any heart murmurs?  Are the pulses strong?  A typical heart rate at this age is between 120 and 140 beats per minute.

Abdomen - Is the belly soft?  It should be.  Are the liver and spleen the normal size?  The edges of the liver and spleen can normally be felt as far as about 2 cm below the rib cage edge.

Muscles and bones - Can she move all her arms and legs?  Is there normal strength and tone?  Arm and leg movements are fairly vigorous at this age.

Neurologic - Is the infant active when awake?  Are there any abnormal movements?

Metabolic screen

These results should be available and should be reviewed.  This test may need to be repeated if a value is borderline.

Parent sanity check

• Many mothers have returned to work.  What are the child care arrangements?  Are there problems with breast feeding (breast feeding pain, poor breast milk production)?
• How is the mother feeling?  Post-partum depression is still a possibility at this point.  Concerned mothers should seek medical help or counseling.
• What are the mother's plans for birth control or family planning?
• How is the mother coping with the lack of sleep from nighttime feedings and from the infant's increased crying frequency and duration?
• Does the mother have help?  Is the father involved?  Is the extended family helpful?
• Is the mother using alcohol or drugs to help "ease the stress of parenting"?

Family's with post-partum stress should seek help from community resources including social clubs, faith-based organizations, friends, mother's clubs, etc.  Ask your pediatrician for ideas.

Safe sleeping

According to the American Academy of Pediatrics...

"Place babies to sleep on their backs to reduce the risk of SIDS. Side sleeping is not as safe as back sleeping and is not advised."

See article on safe sleeping for infants...

Daily routines

Infants thrive on routines and familiar faces.  Establishing feeding times (about every 3-4 hours) instead of simply offering the breast or bottle constantly will help your baby maintain a normal wake-feed-play-sleep cycle.

Feeding

Infants at this age should feed every 2-4 hours.  The average infant at this age will take between 20 - 30 ounces of milk per day.  It is difficult to know how much milk a breastfed baby is taking.  Clues that the baby is getting enough milk include:

• Wet diapers occur at least every 4 hours
• Good weight gain
• The baby is alert and active when she is awake
• The fontanel is soft and flat
• The skin is soft, smooth and pink
• The infant seems satisfied after feeding
• Breast milk leaks from the opposite breast during feeds
• Breast milk is visible around the baby's lips
• Swallowing sounds can be heard during feeding
• Milk can be heard in the baby's belly after a feed (don't shake your baby to find out!)
• Mild occasional spit ups reveal milk in the spit up material
• A pediatrician can use a scale to weigh the infant before and after feedings (a very accurate scale is required)
• Limited or no jaundice

Spitting up or vomiting

Spitting up is common at this age.  Spit up material should look like milk or be clear. Spit up or vomited material should never contain blood and should never have a yellow or green appearance.  Spit ups are typically harmless if they are a small amount.  Forceful vomiting or spitting up significant amounts after every bottle feed is not normal.

Call your doctor for spitting up associated with...

• Weight loss
• Excessive fussiness or apparent discomfort
• Breathing problems or choking
• Forceful vomiting
• Blood in the spit up material
• Spit up material that is green or yellow (after drinking only milk)
• Poor feeding
• Any other concerns

Wet diapers

Your infant should have a wet diaper at least every 4-6 hours.  More frequently is okay!  Urine should have limited or no smell, a light yellow or clear color, and no blood.

Stools

• There is a wide variation in what is considered normal frequency of dirty diapers.  Some infants have a stool only once every 3 days.  Others may have 10 small stools a day.
• At 1 month of age an infant's stools should be yellow, loose and seedy.  The "seeds" are clumps of white or yellow stool debris.
• There should be no blood in the stools and stools should not be pale (gray or white).

Vaccines

It is time for the first major set of vaccines!  Your baby should have received the first hepatitis B vaccine in the first week of life.  It is often given in the newborn nursery.  It is now time for multiple vaccines which may include: hepatitis B (HepB), rotavirus, diphtheria - tetanus - pertussis (DTaP), Haemophilus influenzae type b (Hib), pneumococcus (PCV), and Poliovirus (IPV).

The CDC vaccine schedule can be viewed here.  CDC Vaccine Schedule.

Safety and preventative care

Your doctor should answer any questions you have regarding car safety seats, cribs, tobacco smoke, bathing, toy safety, etc.

References

Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics, 16th Edition. Philadelphia: W. B. Saunders. 2000.

Hagan JF, Shaw JS, Duncan PM, eds. 2008 Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics.

Healthy child care by the Center for Disease Control, http://www.healthychildcare.org/pdf/SIDSparentsafesleep.pdf, accessed Sept. 24, 2010.

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