Infancy: 2 Month Visit

By 2 months after birth, parents and their baby are communicating with each other. The parent and baby can gain each other’s attention and respond to each other’s cues. The baby looks into his parents’ eyes, smiles, coos, and vocalizes reciprocally. He is attentive to his parents’ voices, and reacts with enjoyment when his senses are stimulated with pleasant sights, sounds, and touch. The infant’s responses to his parents when they cuddle him or talk and sing to him provide important feedback that helps the parents feel pleasure and competence. Likewise, the parents’ prompt responses to his cries and other subtler cues help teach him cause and effect and, most important, trust.

Typically, parents have settled into their new roles, learning how to divide the tasks of caring for their baby, themselves, and the needs of the family. They may still feel tired and express a desire for rest. Other relatives and members of the support network feel a connection to the baby, and the parents are comfortable with them holding or caring for the baby.

The baby can now hold his head upright for brief periods of time while he is being held. His weight, length, and head circumference should increase along his predicted growth curve. Parents appreciate the health care professional’s review of early milestone development because it helps them understand and anticipate the resolution of newborn reflexes. The Moro reflex, reflex grasp, and tonic neck reflexes disappear before purposeful motor skills emerge. Opportunities for motor activity when the baby is awake, such as “tummy time,” should be encouraged because they promote head control.

Frequent feedings are still normal for the breastfed baby. The formula-fed baby may need to be fed less frequently. As the baby is able to consolidate longer sleep cycles, night feedings may occur less frequently. However, many babies have not yet begun to consolidate sleep, and many of those who have begun are likely to regress at times. Parents need to be counseled on delaying the introduction of solid foods until the middle of the first year of the baby’s life and when the baby shows definite signs of readiness. These signs include increasing volume of human milk or formula consumed, and continuing physical development. Although it is a common belief, adding cereal to the diet will not increase the hours of sleep at night. Rather, the frequency and duration of feedings, regular naptimes, and active playtimes are more likely to encourage a consolidation of nighttime sleep cycles and longer sleep duration.

As the infant and family settle into a routine, parents begin to resume more of their previous activities, reengage with other family members and friends, and return to school or work. Siblings and other members of the family can be encouraged to participate in the baby’s care, fostering their involvement and connection to the baby. Ideally, parents make plans to spend adult time together. Single parents may choose to spend time on outside interests and relationships. It also is important that other children in the family have some time alone with their parents for activities they enjoy.

Parents can encourage responsible siblings to participate in the care of the baby to help them feel a valued connection with their little sibling. Arranging for quality, affordable child care is an important priority.

The mother’s health (both physical and emotional) will determine her emotional and physical availability to care for her infant. Thus, she should consider talking with her partner and health care professional about completing her postpartum checkup and making family-planning arrangements.

At this visit, it is important for the health care professional to review infant safety measures, including appropriate sleep position and sleep practices, because families and other caregivers may have modified the recommended safe-sleeping measures because of perceived infant or caregiver needs. For example, the parents or other caregivers may feel that the infant’s sleep is less comfortable or that spitting up poses a choking threat if the infant is on his back. It is important to ask the parents about their caregiving practices or preferences to determine whether they differ from recommended practices. In addition, consideration should be given to the family’s environment and living circumstances, as some aspects of the child’s caregiving may not be under the control of the parent or primary caregiver. Health care professionals should be sensitive to cultural practices, gender roles, parental age, functional abilities, and financial independence of the parents.

The Bright Futures Tool and Resource Kit contains Previsit Questionnaires to assist the health care professional in taking a history, conducting developmental surveillance, and performing medical screening.

The interval history may be obtained according to the concerns of the family and the health care professional’s preference or style of practice.

• How are you feeling?

• How are things going for your family?

• How are things going for your baby? Tell me about your baby’s day. What are some of the best times of day with your baby? Some of the most difficult?

• What are some of the things you are doing to keep your baby healthy and safe? Does your child live with or spend time with anyone who smokes or uses e-cigarettes? Other than your baby’s birth, have there been any major changes in your family?

• Has your baby received any specialty or emergency care since the last visit?

• Has your child or anyone in the family, such as parents, brothers, sisters, grandparents, aunts, uncles, or cousins, developed a new health condition or died? If the answer is Yes: Ascertain who in the family has or had the condition, and ask about the age of onset and diagnosis. If the person is no longer living, ask about the age at the time of death.

• See the Social Determinants of Health priority in Anticipatory Guidance for social history questions.

Do you or any of your baby’s caregivers have any specific concerns about your infant’s learning, development, or behavior?

Clinicians using the Bright Futures Tool and Resource Kit Previsit Questionnaires or another tool that includes a developmental milestones checklist, or those who use a structured developmental screening tool, need not ask about these developmental surveillance milestones. (For more information, see the Promoting Healthy Development theme.)

• Smile responsively?

• Make sounds that let you know he is happy or upset?

• Make short cooing sounds?

• Lift head and chest when on stomach?

• Keep head steady when held in a sitting position?

• Open and shut hands?

• Briefly bring hands together?

The Bright Futures Infancy Expert Panel recommends a complete review of systems as a part of every health supervision visit. This review can be done by asking the following questions:

Do you have concerns about your infant’s

• Head

  • – Shape

• Eyes

  • – Discharge

• Ears, nose, and throat

• Breathing

• Stomach or abdomen

  • – Vomiting or spitting

  • – Bowel movements

  • – Belly button

• Genitals or rectum

• Skin

• Development

  • – Muscle strength, movement of arms or legs, any developmental concerns

During the visit, the health care professional acknowledges and reinforces positive parent-infant interactions and discusses any concerns. Observation focuses on

• Are the parents responsive to the baby, to hunger or satiation cues, distress, or need for attention?

• How do the parents interact with their baby, such as through gazing, talking, smiling, holding, cuddling, comforting, and showing affection?

• What are the parents’ appearance and emotional state? Do they support each other, and demonstrate confidence with the baby’s care and contentment? Are they depressed, tearful, angry, anxious, fatigued, overwhelmed, or uncomfortable?

A complete physical examination is included as part of every health supervision visit.

When performing a physical examination, the health care professional’s attention is directed to the following components of the examination that are important for an infant this age:

• Measure and plot on appropriate WHO Growth Chart

  • – Recumbent length

  • – Weight

  • – Head circumference

  • – Weight-for-length

• Skin

  • – Inspect for skin lesions, birthmarks, and bruising.

• Head

  • – Palpate fontanelles occipital shape (flatness).

• Eyes

  • – Examine pupils for opacification and red reflexes.

  • – Assess visual acuity using fixate and follow response.

• Heart

  • – Auscult for murmurs.

  • – Palpate femoral pulses.

• Musculoskeletal

  • – Perform Ortolani and Barlow maneuvers.

  • – Inspect for torticollis.

• Neurologic

  • – Evaluate tone, strength, and symmetry of movements.

Newborns and infants younger than 6 months are at risk of complications from influenza, but are too young to be vaccinated for seasonal influenza. Encourage influenza vaccine for caregivers of infants younger than 6 months and recommend pertussis immunization (Tdap) for adults who will be caring for the infant.

Consult the CDC/ACIP or AAP Web sites for the current immunization schedule.

CDC National Immunization Program: www.cdc.gov/vaccines

AAP Red Book: http://redbook.solutions.aap.org

The following sample questions, which address the Bright Futures Infancy Expert Panel’s Anticipatory Guidance Priorities, are intended to be used selectively to invite discussion, gather information, address the needs and concerns of the family, and build partnerships. Use of the questions may vary from visit to visit and from family to family. Questions can be modified to match the health care professional’s communication style. The accompanying anticipatory guidance for the family should be geared to questions, issues, or concerns for that particular infant and family. Tools and handouts to support anticipatory guidance can be found in the Bright Futures Tool and Resource Kit.

Probe for stressors, such as return to work or school or the inability to return to work or school, competing family needs, or loss of social or financial support. Provide guidance, referrals, and help in connecting with community resources as needed.

Suggest community resources that help with finding quality child care, accessing transportation or getting an infant car safety seat and crib, or addressing issues such as financial concerns, inadequate means to cover health care expenses, inadequate or unsafe housing, limited food resources, parental inexperience, or lack of social support.

Tell me about your living situation. Do you live in an apartment or a house? Is permanent housing a worry for you?

Do you have the things you need to take care of the baby, such as a crib, a car safety seat, and diapers? Does your home have enough heat, hot water, electricity, and working appliances? Do you have health insurance for yourself? How about for the baby?

Within the past 12 months, were you ever worried whether your food would run out before you got money to buy more? Within the past 12 months, did the food you bought not last and you did not have money to get more?

Have you ever tried to get help for these issues? What happened? What barriers did you face?

How do you deal with family members who criticize you or offer suggestions that are not helpful?

• Programs and resources are available to help you and your baby. You may be eligible for the WIC food and nutrition program. Several food programs, such as the Commodity Supplemental Food Program and SNAP, the program formerly known as Food Stamps, also can help you. Would you like their numbers? Would you like someone from our office to help you get in touch with them?

• It’s good that these things are not a concern for you right now. If things change, please consider us a place where you can get ideas about whom to contact for help. We know how important these things are to helping you keep your baby and your family healthy and safe.

• One way to deal with unwanted advice from family and friends is to acknowledge their concerns and desire to help and then change the subject to something you do agree on. Trying to justify your desire to follow the recommendations of your health care professional may only lead to a long and futile conversation.

Parents reach out to families and friends for support and information for strategies in caring for their child. Making friends with adults who have a child the same age can help parents establish a support network that is useful in planning same-age playgroups and visiting neighborhood playgrounds. Families who are living with others (eg, their elders, those who are helping them from being homeless, or teen parents living with their parents) may have little control over their environment and caregiver roles and responsibilities. For some families, gender roles may preclude women from asking men for help. In a culturally sensitive way, health care professionals can develop strategies with parents and the family about how to support the mother’s needs.

What help do you have with the baby? Are you getting enough rest? Have you been out of the house without the baby? Who takes care of the baby when you go out? How does your baby handle this separation? Do you know parents of babies your baby’s age? Do you feel you can reach out to them for help and advice? What are your plans for returning to school or work? Would you like any help in locating affordable, safe, quality child care?

• It is important to take time for yourself as well as time with your partner. Your baby has a strong need to be with you. This need is stronger for some babies than for others. Let me know if you would like some suggestions for how to arrange time away from the baby or ideas for creative ways to spend time with your partner that do not compromise your baby’s needs, such as activities when she is sleeping.

• It is important for you to identify ways to keep in contact with your friends and family members so that you do not become socially isolated.

At this time, parents may need to return to work or school and should make plans for quality, affordable child care. Parents may benefit from guidance in finding child care and ensuring that caregivers are providing developmental stimulation as well as physical care. Reassure parents about how their baby can thrive in child care. It is important for them to find a person or place they can trust, that will keep their baby safe and consider her developmental needs, while engaging the parents in their infant’s progress through sharing of daily activities.

Parents may need reassurance during this time of transition to someone else sharing the care of their baby. Separation usually is hard, and the parent may feel guilty and will need to be able to trust or receive support from family members and the child care provider. Changes in routine and separation also may be hard on the infant, and parents may find it helpful to spend extra time comforting the infant during the transition.

What have you done about locating someone for child care when you return to work or school, need to run errands, or go out with family? Are you comfortable with these arrangements?

How do you feel now about leaving your baby with someone else? Have you talked with your child care provider about your baby’s routines and how to let you know how your baby did during the day?

• We can give you suggestions about how to find good child care, if you wish. Standards for child care exist. You should look for licensed child care centers and family child care centers that meet specific criteria. It is important to visit and spend time in any setting where you will be leaving your baby to make sure you know how it operates.

• You can expect a good child care provider to have good infection control practices in place and to give you a daily activity report about your baby’s feedings, sleep, play, and elimination.

• It is not uncommon for mothers to have strong feelings about leaving their baby. Knowing that your baby is with someone you trust and who will take good care of her is a very important first step.

• Regular and predictable routines build your child’s social and emotional competence.

Discuss the mother’s perspective of her own health and steps she is taking to care for herself. Mothers at this stage may feel sad, exhausted, frustrated, discouraged, or disappointed in their ability to care for their infant. Health care professionals should take into account economic pressures on the family, the need for the mother to return to work quickly, the need to care for other children, and neighborhood issues, such as safety and lack of sidewalks and recreational space. Provide phone numbers and contact information if the mother expresses any concerns about taking care of herself, and provide follow-up to ensure that she is able to access these resources.

To both parents: How are you feeling?

To the mother: Have you had a postpartum checkup? Did you discuss family-planning arrangements at this checkup? With your partner? What have you heard from your obstetrician about resuming your normal daily activities after delivery? What do you do to take care of yourself?

• Because your role as parents requires both physical and emotional energy, you must take care of yourselves so you can care for your baby.

An estimated 10% to 20% of women struggle with major depression before, during, and after delivery of a baby. Perinatal depression has substantial personal consequences and interferes with quality of child-rearing, adversely affecting parent-infant interactions, maternal responsiveness to infant vocalizations and gestures, and other stimulation essential for optimal child development.

Because pregnancy and childbirth are supposed to be a joyous occasion, women may feel that they are going to be bad mothers if they are depressed. It is important for apprehensive patients to understand what postpartum depression is, know that many women experience similar feelings, and realize that untreated postpartum depression may have adverse effects on women’s health and their baby’s health and development.

What are some of your best, and most difficult, times of day with your baby? How are you feeling emotionally? Have you been feeling sad, blue, or hopeless since the delivery? Are you still interested in activities you used to enjoy? Do you find that you are drinking, using herbs, or taking drugs to help make you feel less depressed, less anxious, less frustrated, and calmer? Who has been available to assist you at home? Who has been the most help to you?

• Many mothers feel tired or overwhelmed in the first weeks at home. These feelings should not continue, however. If you find that you are still feeling very tired or overwhelmed, or you are using over-the-counter or prescription medication, drugs, or alcohol to feel better, let your partner, your own health care professional, or me know so that you can get the help you need.

Sibling adjustment is a process over time and not yet complete at only 2 months of age. Behavior regression and jealousy sometimes occur and are normal.

Parents can help older siblings by including them in the care of the new baby in developmentally appropriate ways. Reading, talking, and singing together assures older siblings of their importance to parents and their value in the family.

How are your other children? Are you able to spend time with each of them individually?

• One of the ways that you can meet the needs of your other children is by appropriately engaging them in the care of the baby. Having them bring supplies and hold the baby’s hand are 2 ways they can help. Giving them a “baby doll” of their own to hold, feed, and diaper is important; so is setting aside regular one-on-one time with your other children to read, talk, and do things together.

The parents are beginning to experience some of the joys of their baby’s behavior, such as an emerging smile, longer periods of alertness, and responsiveness. Parent uncertainty or nervousness, an uninvolved partner, or a statement that caring for the baby is “work,” without relaxed or pleasant moments, requires further exploration and counseling. Additionally, a lack of parental involvement, as shown by a lack of questions about the baby and her development, or a demeanor of sadness, withdrawal, or anger, should trigger further exploration and counseling.

What do you and your partner enjoy most about your baby? What are some of your best times of day with her? What are you enjoying about caring for your baby? What is challenging about caring for your baby?

Has your child care provider expressed any concerns about your baby’s development?

• At 2 months of age, your baby is beginning be alert and awake for longer stretches of time. She also will begin to respond more actively to you now by smiling and babbling. Make the most of this new development by cuddling, talking, and playing with your baby.

• It is important to know that a young infant cannot be “spoiled” by holding, cuddling, and rocking her, or by talking and singing to her. Spending time playing and talking during quiet, alert states helps strengthen your relationship with your baby by building trust between both of you.

Assist the parents in becoming attuned to their infant’s ability to handle stimulation and movement, and how best to incorporate activity into their infant’s daily routine. Resources for parents to learn infant massage can be provided if parents are interested.

What sounds does your baby make? Does the baby startle or respond to sounds and voices? Does she look at you and watch you as you move your face when you talk? What do you think your baby is feeling and trying to tell you? How does it make you feel? How do you know what your baby wants? Have you noticed any differences in her cries?

How would you describe your baby’s personality? How does she respond to you? Is it easy or hard to know what she wants? What does your baby do with her hands?

• Responding to your baby’s sounds by making sounds, too, and by showing your face as you talk, encourages her to “talk back,” especially during dressing, bathing, feeding, playing, and walking. This kind of “turn taking” is a foundation of language and conversation. Singing and talking during these typical daily routines also encourages language, as does reading aloud, looking at books, and talking about the pictures. Gradually, your baby will increase the variety and frequency of the sounds she makes as well as how she responds to sounds, especially her parents’ voices.

• It is important to understand and recognize your infant’s early temperament and personality so that you know how to adjust to meet her needs. As you learn about her temperament and the way she processes sensory stimulation, such as whether she is active, quiet, sensitive, demanding, or easily distracted, you will be better able to understand how it affects the way your baby relates to the world.

• Getting in tune with your baby’s likes and dislikes also can help you feel comfortable and confident in your abilities as a parent. Infant massage is a helpful way for you to understand what your baby likes or dislikes. It can help you calm and relax her, and it enhances your baby’s ability to go to sleep easily. Infant massage also offers important health and developmental benefits for premature infants and babies with special health care needs. It helps them sleep, regulate, and organize their waking and sleeping patterns, and promotes muscle tone and infant movement.

Parents with atypical and inconsistent sleeping patterns of their own, and parents of infants with difficulty developing consistent sleep patterns, irritability, difficulty consoling, or difficulty with feeding, may also need additional counseling because all these problems may be related to poor sleep patterns.

How is your baby sleeping? What are some of your favorite routines with your baby?

• Your baby is still developing regular sleep patterns. Help her by paying attention to her cues for sleep and by sticking to a regular schedule for naps and nighttime sleep. Infant irritability usually is caused by lack of sleep.

• By this point, you may be waiting for your baby to sleep through the night. It’s normal for babies this age to continue to wake frequently at night. Placing your baby in her crib in a drowsy state encourages her to learn to sleep on her own.

As more families and children have access to and exposure to digital media, it is important to assess for the use of such devices and offer guidance regarding media in the home.

Is there a TV or other digital media device on in the background while your baby is in the room?

• Babies this young should not watch TV or other digital media. Some parents try to calm their fussy babies by sitting them in front of a TV show or video, but this may make them fussier in the long run, and doesn’t help them learn ways to soothe themselves. Try other ways to soothe your baby when she is fussy, such as taking a walk, holding her in a carrier, decreasing the amount of stimulation and noise in the home, or using infant massage; or, ask someone else to hold the baby and take a break.

• Having a TV on in the background can distract you from reading your baby’s cues. Reading infant cues is important to learning about your baby’s patterns of behavior and developing sensitive interactions with the baby. These interactions between you and your baby are crucial for language, cognitive, and emotional development.

While observing the infant in prone position, discuss the importance of tummy time in the baby’s daily activities. During the physical examination, demonstrate how the infant will try to grasp objects held close to her hand and learn to put her hands in her mouth, which aids in self-consoling.

Physical activity is important for all of us, even young children. How is your baby moving about now?

• When babies are awake, they enjoy looking around their environment and moving their bodies. One of the first skills babies must learn is holding their head up. One of the ways babies learn to do this is through tummy time. Although babies need to sleep on their backs, we want to encourage them to play on their tummies. Tummy time also can help prevent the development of a flat area on the back of the head.

Counsel parents that the infant’s crying may increase at this age, but the crying spells will decrease over time. Parents may need strategies that will help them find ways to console their baby, and they need to be counseled about the fragility of an infant’s head. Help parents understand that they are teaching the infant to trust that she will be cared for when they quickly respond to their infant’s crying. This responsiveness will not spoil the infant, as many parents believe.

The safest cover for the infant is a sleepsack or footed sleeper, which can keep the baby warm without the concern of suffocation from a blanket. Swaddling is discouraged after 2 months of age.

Putting their hands to their mouth and sucking is an important self-comforting strategy used by infants, and it is an important step in self-regulation. Explain that this strategy helps infants with the earliest feelings of competence and mastery.

If the infant is very irritable, parents need to find a way to avoid frustration. They need to be cautioned to never shake their infant or leave her with someone who may harm her, because it causes severe, permanent brain damage. Provide telephone numbers for local community resources that can help parents.

How much is your baby crying? How often? What are some of the ways you have found to calm your baby when she is crying? What do you do if that does not work? Do you still swaddle your baby?

Do you ever feel that you or other caregivers may hurt the baby? What makes you feel that way? How do you handle the feeling?

• Spending time playing and talking to your baby during the quiet, alert times during the day supports her continuing brain development. Many babies have fussy periods in the late afternoon or evening. These are normal. There are many possible strategies for calming your baby, including just being there with her, talking, patting or stroking, bundling or containing, holding, wearing in a sling or carrier, and rocking. Other calming strategies include caressing or dancing with your infant, walking with her in a carriage or stroller, and going on car rides. Remember that your baby is not trying to make you angry—she is just having a rough time and still needs someone to be there. Ask a family member, neighbor, or trusted friend to stay with your crying baby for a few minutes to allow you to take a break. If you are alone, you can try putting the baby in her crib, closing the door, and checking on her every few minutes.

• It is no longer safe to swaddle your baby unless you are holding her in your arms. If your baby rolls to her tummy while swaddled tightly, she may not be able to move her head and keep her airway open. This can increase her risk of suffocation.

• At this age, your baby is developing the ability to put her hands to her mouth, suck on her fingers or her thumb, or use a pacifier. This is one of the ways your baby will learn to calm herself, and it is normal, age-appropriate behavior. She will use these methods until she is able to use other self-calming strategies.

• Never, ever, shake your baby or otherwise harm your baby, because it could cause permanent injury, including brain damage. If you ever feel that you need help because your baby is crying so much, contact me or other community resources that can help you.

By the second month of life, infant growth and the parent’s comfort in feeding their infant should be well established. Infants who are struggling with maintaining a good growth pattern or parents who are struggling with feeding routines, extremely long feedings, or infrequent feedings should have additional support, guidance, and counseling to determine potential underlying infant developmental concerns or parenting knowledge issues.

How is your baby’s feeding going? Tell me about all the foods and fluids you are offering your baby. What questions or concerns do you have about feeding?

• Exclusive breastfeeding for about the first 6 months of life provides ideal nutrition and supports the best possible growth and development. If you are still breastfeeding, congratulations!

• If your baby is not breastfed, iron-fortified formula is the recommended substitute during the first year of life.

• Do not give your baby food other than breast milk or formula until he is developmentally ready, which is at about 6 months of age.

• Usually, healthy babies do not require extra water. On very hot days with no air conditioning, babies will benefit from some extra water. Breast milk and formula, when properly prepared, are adequate to meet the baby’s fluid needs. Juice is not recommended.

Parents begin to learn their infant’s cues for hunger and satiety.

How do you know if your baby is hungry? How do you know if he has had enough to eat? How easily does your baby burp during or after a feeding?

• Breastfed and formula-fed infants have different needs for the frequency of feeding, although both breast milk and formula provide all the nutrition that infants need until about 6 months of age.

• To prevent overfeeding, which often leads to more frequent spit-ups, recognize your baby’s individual signs of hunger and fullness. An infant’s stomach is still small. Therefore, your baby still needs to eat every 2 to 4 hours, even during the night. Hopefully, your baby will have one longer stretch at night of 4 to 5 hours without feeding.

• Burp your baby at natural breaks, such as midway through or after a feeding, by gently rubbing or patting his back while holding him against your shoulder and chest or supporting him in a sitting position on your lap.

Explain that as infants grow, they are more easily distracted during feeding and may need gentle repetitive stimulation, such as rocking, patting, or stroking. The infant may need a quiet environment, perhaps with low lighting and without other people present. Feeding times offer a wonderful opportunity for social interaction between the infant and the mother.

Counsel mothers on safe storage of human milk.

Vitamin D supplementation (400 IU per day) is recommended for all full-term breastfed infants beginning at hospital discharge. Breastfed preterm or low birth weight infants will need multivitamin drops and iron supplementation at 2 mg/kg/day by 2 to 6 weeks of age until solid food introduction.

How is breastfeeding going for you and your baby? Is your baby breastfeeding exclusively? If not, what else is the baby getting? Do you need any help with breastfeeding? Does it seem like your baby is breastfeeding more often or for longer periods of time? In what ways is breastfeeding different now from when you were last here? How can you tell if your baby is satisfied at the breast? Is your child care provider supporting your breastfeeding efforts?

Are you planning to return to work or school? If so, will you express your breast milk? Does your school or workplace have a place where you can pump your milk in privacy? How will you store your milk? How long will you keep it?

Do you eat fish at least 1 to 2 times per week? Do you have protein-containing foods every day, such as eggs, chicken, beef or pork, or dairy? Are you able to be physically active most days?

• Breastfed infants continue to need about 8 to 12 feedings in 24 hours. They may feed more frequently when they go through growth spurts. By 3 months of age, breastfed infants generally will be feeding every 2 to 3 hours. If your baby is receiving frequent feedings during the day and continuing to receive between 8 and 12 feedings in 24 hours, he may have one longer stretch of 4 to 5 hours at night between feedings.

• Consider how to plan your activities and schedules to make things easier when you are home or out with your baby. Storing breast milk properly is very important. If you are interested, I can give you written guidelines to help you make sure your stored breast milk remains safe for your baby.

• I can help you with strategies to support breast milk production if you will be away from the baby for extended periods.

• If you are breastfeeding your baby, be sure that you are giving him vitamin D drops.

• You may continue to take your prenatal vitamin with iron every day to ensure adequate intake of vitamins or minerals. Discuss with your obstetric team how long you should continue to take it. If you do not consume any animal products in your diet and follow a vegan diet, your supplement should include vitamins D and B₁₂ as well as iron and zinc.

• Eating a small serving of fish 2 times a week provides important nutrients for your baby. Canned light tuna, salmon, trout, and herring are the best choices to give your baby the neurobehavioral benefits of an adequate intake of an important fat called DHA.

• It is best to avoid 4 kinds of fish that are high in mercury. These fish are tilefish, shark, swordfish, and king mackerel.

• Consuming small amounts of protein-containing foods, like lean meat, poultry, dairy products, beans and peas, eggs, processed soy products, and nuts and seeds, every day is recommended.

If parents feel that they do not have time to hold the bottle, review the importance of the feeding relationship and the benefits of holding the infant during feeding, as well as the risks of propping the bottle. Parents also may need to be reminded not to put the baby to bed with a bottle.

The usual amount of formula for a 2-month-old in 24 hours is about 26 to 28 oz, with a range of 21 to 32 oz.

How is formula feeding going for you and your baby?

What formula do you use? Is the formula fortified with iron? How often does your baby feed? How much does he drink at a feeding? Have you offered your baby anything other than formula? What questions or concerns do you have about the formula, such as cost, preparation, and nutrient content?

How do you hold your baby when you feed him? Do you ever prop the bottle to feed or put your baby to bed with the bottle?

• Babies who receive formula usually will feed every 3 to 4 hours, with one longer stretch at night of up to 5 or 6 hours at night between feedings. Overall, a 2-month-old still needs about 6 to 8 feedings in 24 hours.

• When feeding your baby, always hold him in your arms in a partly upright position. This will prevent him from choking and will allow you to look into his eyes during feedings. Feeding is a wonderful opportunity for warm and loving interaction with your baby.

• Do not prop a bottle in your baby’s mouth or put him to bed with a bottle containing juice, milk, or other sugary liquid. Propping and putting him to bed with a bottle increases the risk of choking and of developing early tooth decay.

• Never heat a bottle in a microwave. If you wish to warm a bottle, a hot water bath is recommended.

Review car safety seat guidelines with the parents.

Counsel parents that their own safe driving behaviors, including using seat belts at all times and not driving under the influence of alcohol or drugs, are important to the health of their infant.

Do you have any questions about using your car safety seat?

• A rear-facing car safety seat that is properly secured in the back seat should always be used to transport your baby in all vehicles, including taxis and cars owned by friends or other family members.

• Never place your baby’s car safety seat in the front seat of a vehicle with a passenger air bag because air bags deploy with great force. When it hits a car safety seat, it causes serious injury or death.

• Car safety seats should be used only for travel, not for positioning outside the vehicle. Keep the harnesses snug whenever your baby is in the car safety seat. This will help prevent falls out of the seat and strangulation on the harnesses.

• Your own safe driving behaviors are important to the health of your children. Use a seat belt at all times, do not drive after using alcohol or drugs, and do not text or use mobile devices while driving.

For information about car safety seats and actions to keep your baby safe in and around cars, visit www.safercar.gov/parents.

Find a Child Passenger Safety Technician: http://cert.safekids.org. Click on “Find a Tech.”

Toll-free Auto Safety Hotline: 888-327-4236

It is recommended that the infant sleep in a separate, but proximate, sleep environment. The infant should sleep in a crib, bassinet, or cradle in the same room as the parents. Infants should not share a bed with parents or any other caregivers or children. A pacifier should be offered when the baby is falling asleep. At the same time, health care professionals should be aware of parents’ cultural traditions and beliefs about infant sleep and sleep location.

Where does your baby sleep? What position does your baby sleep in? Is your baby having any difficulty sleeping on her back? Do you provide your child with a pacifier when she falls asleep? Where does your baby sleep when in child care?

• Don’t forget to reduce the risk of sudden infant death, by following “back to sleep” and “tummy to play.” Make sure that any others who put your baby down to sleep also follow back to sleep.

• Your baby should sleep in your room in her own crib, but not in your bed.

• Offer your baby a pacifier when she is falling asleep.

• The room temperature should be kept comfortable. Make sure your baby doesn’t get too warm or cold while sleeping.

• If possible, use a crib purchased after June 28, 2011, as cribs sold in the United States after that date are required to meet a new, stronger safety standard. If you use an older crib, choose one with slats that are no more than 2⅜ inches (60 mm) apart and with a mattress that fits snugly, with no gaps between the mattress and the crib slats. Drop-side cribs should never be used.

• If you choose a mesh play yard or portable crib, consider choosing one that was manufactured after a new, stronger safety standard was implemented on February 28, 2013. If you use an older product, the weave should have openings less than ¼ inch (6 mm) and the sides should always stay fully raised.

• If your baby is cared for by others, such as in a child care setting or with a relative, be sure to emphasize the importance of safe sleep practices with that caregiver.

As the baby develops more fine and gross motor skills, it is important to review with the parents how to keep the home environment safe. Discuss the importance of not leaving the baby alone in a tub of water—even for a second—even when using a bath seat. Also, the baby should never be left unattended in high places, such as changing tables, beds, sofas, or chairs.

Safety issues apply to all homes where the baby spends time, including child care and at grandparents’ and friends’ homes.

Have you made any changes in your home to keep your baby safe?

• Do not drink hot liquids while holding the baby.

• To protect your child from tap water scalds, the hottest temperature at the faucet should be no higher than 120°F. In many cases, you can adjust your water heater. Before bathing the baby, always test the water temperature with your wrist to make sure it is not too hot.

• Never leave your baby alone in a tub of water, even for a moment. A bath seat or bath ring is not a safety device and is not a substitute for adult supervision. Your baby can drown in even a few inches of water, including in the bathtub, play pools, buckets, or toilets. A supervising adult should be within an arm’s reach, providing “touch supervision,” whenever babies are in or around water.

• Leaving the baby on a changing table, couch, infant seat, or bed is never safe because of your baby’s ability to roll or push off. At this age, your baby’s legs are getting stronger now and her newborn reflexes that prevent rolling over are gradually fading away. Because your baby is now bigger and stronger, it is important to always keep one hand on the baby when changing diapers or clothing on a changing table, couch, or bed, especially as she begins to roll over.

• Do not put your baby in a bouncy seat, recliner, or positioning seat on an elevated surface like a countertop or coffee table. Keep these devices on the floor when they are in use.