Growth and Development

YOUR NINE MONTH OLD CHILD

• Name:_______________________  Date:_______________
• Length inches:_________
• Weight lbs:____  oz:____
• Head Circumference cm:______

NUTRITION

• Three meals a day with two healthy snacks.
• To prevent iron deficiency, breastfed infants should take 1mL daily of Tri-Vi-Sol WITH IRON (over the counter) unless they are taking at least 24oz of iron-fortified formula or 2 servings of ¼ cup iron-fortified rice cereal daily.  If they are taking rice cereal as recommended, breastfed infants still need 0.5mL daily of Tri-Vi-Sol with iron to prevent vitamin D deficiency unless they are taking at least 16oz daily of supplemental formula.
• If you are nursing, breast feed after rather than before meals.
• Introduce finger foods; encourage family meals by pulling the high chair right up to the table.
• Present small amounts of finger food at a time.
• Encourage cup use.  Remember: no bottles in bed.
• FINGER FOOD (small pieces of food easily mashed between your fingers) – steamed chopped vegetables, ripe thinly sliced fruits, grated or cottage cheese, chopped/shredded meat, rice, pasta, toast with cream cheese, melted cheese, iron-fortified cereals.
• AVOID FOODS THAT PRESENT CHOKING HAZARD UNTIL AT LEAST 3 YEARS OLD: e.g. raw apple, raw carrot, raw celery, nuts, hotdogs, grapes, popcorn, raisins, hard candy, gum and marshmallows.
• Wait until you child is a year old to introduce acidic and potentially irritating foods such as citrus.  If there is a strong family history of food allergies, be cautious when introducing foods containing peanuts, tree nuts and white fish like cod or shellfish.

NUTRITION – LOOKING AHEAD

12 MONTHS: solids at three meals a day and two snacks, roughly 16 oz of breast milk or formula.  At 12 months, you can substitute whole milk for formula.  Continue whole milk until two years old to ensure adequate fat intake for your child’s developing brain.  Introduce whole milk in a cup with meals.

DENTAL HEALTH:

After meals, brush your child’s teeth while she/he sits in the high chair.  When they are comfortable with the bristles let your child have a turn after you.

DEVELOPMENT 9-12 MONTHS

•  Sits well with good head control.
•  Pulls to stand and may walk holding on to furniture.
•  Feeds finger food to self.
•  Assumes hand/knee position and may be crawling.
•  Hunts for a hidden toy.
• Mimics sounds: mama, dada, uh-oh.
• Imitates your use of objects such as the telephone, hairbrush or sponge.
• Waves, plays peek-a-boo, finds or looks for hidden objects.
• Bangs two cubes together.
• Responds to “no” but may not actually know what it means.
• If you have concerns about vision or hearing, please let your physician know.

SLEEP/PARENTING

• Your child may begin to resist going to bed as separation anxiety intensifies.  This is very normal.  Continue your reassuring night routine.  If/when night waking recurs; respond much as you did when you were initially teaching your baby to sleep through the night.  Make a brief, reassuring visit but let him/her stay in the crib; if visiting makes matters worse, consider not visiting.  Teach him/her that this is the way all nights will be.
• Many children have chosen a transitional object (favorite blanket, stuffed animal etc.).
• During the next few months, your child will want to touch, taste and play with everything that is within reach.  Curiosity is vital to development.  Your job is to allow him/her to explore safely.  Distraction is usually a successful way to deal with undesirable behavior at this age.

SAFETY

• Now is the time for parents to discuss what is and is not important, what is and is not off limits.
• Consistent messages are very important.  The message must be simple, clear, and supported with action if needed.  For example, if an object is potentially a real danger, say “no,” take the off-limit object away and provide a safe substitute.  Show your child what to do rather than just focusing on what not to do.
• Your child has a short memory; do not expect learning to occur after one or two incidents.
• Increased mobility creates a bigger challenge for you to make the world a safe place for your child.  THOROUGHLY CHILD-PROOF YOUR HOME.  Protect from falls – secure gates, doors, windows and screens.  Keep sharp objects away – knives, razor blades, plastic wrap boxes etc.  Secure heavy objects — furniture, lamps, potted plants, TV’s, etc.
• Improved fine motor abilities give children access to previously unavailable dangers such as small disc batteries, magnets, plant parts and other items that represent a choking hazard.
• Always use a properly fitting car seat.  The rear center seat is the safest position for your child.  To see if your car seat is installed properly and/or to find a certified passenger safety technician in your area you may call 866-SEATCHECK (866-732-8243) OR visit www.seatcheck.org
• Once a child is over 12 months old and 20lbs, they can legally be turned to face forward; however we, and The American Academy of Pediatrics, recognize that your child will be 5 times safer in a rear facing position until as old as two years.
• Check your smoke detectors and fire extinguishers on a regular basis.  Have a family exit plan: ladders in upstairs bedroom, etc.  Carbon Monoxide detectors are highly recommended in the home.
• DO NOT USE WALKERS WITH WHEELS!  They are associated with serious injury.  Walkers are not helpful in learning to walk.  STATIONARY devices such as Exersaucers or Johnny Jump Up Baby exercisers are generally okay.
• Poisoning of infants and children is common.  In case of ingestion of poisons, call the Poison Control Center immediately.  Keep this number by ALL your phones: 800-222-1222.

ACTIVITIES

• Talk and read and talk and read some more!  Identify body parts, label simple objects consistently.
• Now is a great time for hide and find games.  Try in-and-out-of-container games.

IMMUNIZATIONS

• No scheduled immunizations today.
• Catch-up on any missed immunizations.

NEXT VISIT

• Please schedule your child’s TWELVE MONTH WELL CHILD exam as you leave today.  Make sure this is scheduled ON or AFTER the first birthday for immunizations purposes.

YOUR EIGHTEEN MONTH OLD CHILD

• Name:_______________________  Date:_______________
• Length inches:_________
• Weight lbs:____  oz:____
• Head Circumference cm:______

NUTRITION

• Enjoy family meals.  Model good nutrition.  Minimize meal time battles.
• Expect swings in appetite.  The amount of food your child needs decreases as your child’s growth rate decreases.
• Use diet as a way to keep stools soft. Fluids and fiber are important.
• Your child should be taking drinks from a cup only.  Continue phasing out the bottle if your child hasn’t completely given it up yet.
• Offer a wide variety of foods from all the food groups daily.
• If there is a strong family history of food allergies, be cautious when introducing foods containing peanuts, tree nuts and white fish like cod or shellfish.
• Serve small portions and let your child request more if desired.
• Avoid juice; it often sabotages good nutrition and is not an essential part of a healthy diet.
• Offer whole milk with the three main meals.  Your child needs 16-24 oz a day.

DENTAL HYGIENE

• Continue brushing teeth daily with a pea sized amount of toothpaste with fluoride or without toothpaste.  Give the molar surfaces a good scrub with or without teeth.
• Fluoride supplements may be required if your baby does not receive water containing fluoride.

DEVELOPMENT 18-24 MONTHS

• Walks up steps holding on.
• Kicks and throws a ball.
• Enjoys large muscle activity.
• Sits in chair and feeds self with spoon.
• Draws “pictures.”
• 4-10 word vocabulary progressing to using two words together at two years.  Speech may not be clear.
• Uses “no” and “mine” to assert independence.
• Hits and bites; especially if excited, frustrated or having difficulty communicating.
• Enjoys books page-by-page and pointing to pictures.
• Recognizes names of people, objects and body parts.
• May sort shapes and colors
• Please let your physician know if you have any concerns about vision or hearing.

SLEEP

• Usually taking one nap.
• When your child climbs out of the crib, it is time to move to the mattress to the floor or a toddler bed.

PARENTING

• Exploring the boundaries established by your rules and your child’s physical and developmental limits will occupy much of his/her time over the next few years.  You are very important in showing him/her what is O.K. and what is not.  He/she will check in with you frequently for reassurance, guidance, and security.
• Your child is self-centered at this age.  It is developmentally difficult to share.  Minimize the frustration when your child is playing with friends by having reasonable expectations.  Offer toys that come as multiples (blocks, balls, etc.).
• Acknowledge new skills and independence.  Praise whenever possible.
• If your child does something that hurts another person, hurts property, or is harmful to themselves, a firm verbal reprimand, brief and clear, or “time out” is appropriate.  Having a lot of “time in” – gentle, nonverbal, physical contact is very reassuring to your child.
• Model a calm communication style.
• There are many approaches to discipline.  Now is a great time to talk to all your children’s caregivers and agree on consistent guidelines.
• Always use a properly fitting car seat.  The rear center seat is the safest position.  Once a child is over 12 months old and 20lbs, they can legally be turned to face forward; however we, and The American Academy of Pediatrics, recognize that your child will be 5 times safer in a rear facing position until as old as two years.
• Be very clear and consistent about street and parking lot safety—always hold hands or carry.
• Use sunscreen for all outdoor activities.
• Maintain regular checks on your smoke/carbon monoxide detectors and fire extinguishers.  Have a family emergency exit plan.

ACTIVITIES

• Books, puzzles, building blocks, stacking toys, and stringing large beads.
• Somersaults, climbing, and dancing to music.
• Drawing/finger painting, Playdough® and clay, tracing your hand.
• Encourage children to put away toys as part of the playing. Start this habit early ☺
• Discuss limits on TV, video, and computer.
• Continue counting and alphabet introduction.

SAFETY

• Never leave your child unsupervised. Curiosity is increasing rapidly but judgment lags behind. Be especially careful with curling irons, hot ovens and stove tops, knives and other areas where unsupervised experimenting might be harmful.
• Teach animal safety.
• Use sunscreen for all outdoor activities and be aware of water safety.
• When in the car, your child should always remain in the car seat.
• This is a peak age for poisoning. Check your home carefully.  Keep the Poison Control Center’s phone number near ALL of your phones 800-222-1222.

IMMUNIZATIONS

• Hepatitis A – Most babies have no reaction or are somewhat sleepier following their immunization.  Your baby may develop a fever and/or be fussy for 24-48 hours.  A tender lump at the injection site may occur and persist for a week.  Acetaminophen may be given if any of these symptoms are present.

NEXT VISIT

• Please make an appointment for when your child is TWO YEARS old.
• Please bring your yellow immunization card for updating.
• Please write down all your questions and concerns to address with the doctor at your next visit

YOUR TWO YEAR OLD CHILD

• Name:_______________________  Date:_______________
• Length inches:_________
• Weight lbs:____  oz:____
• Head Circumference cm:______

NUTRITION

• Continue to offer non-fat milk with every meal.
• If your child does not drink fluorinated water, ask about fluoride supplements.
• Avoid juice except for dessert.
• Vitamins are not necessary if your child has a balanced diet.
• Appetite improves over this next year.  Continue to be aware of choking foods.
• Avoid control struggles over food.
• Eat together as a family
• Model good nutrition
• Use diet as a way to keep stools soft.  If constipation becomes a problem, offer water or diluted apricot, pear or prune juice.

HYGIENE

• Continue brushing teeth daily with a pea sized amount of toothpaste with fluoride
• Avoid giving milk for at least 30 minutes before bedtime.  The sugars in milk can cause horrible tooth decay.  Now is the time to discontinue the bottle entirely if you haven’t already done so.

DEVELOPMENT TWO-THREE YEARS

• Climbs well, walks up and down stairs alternating feet, kicks ball and runs easily.
• Draws vertical, horizontal and circular strokes with a pencil.
• Has a vocabulary of 50 words, using 2-3 word sentences, pronouns (I, me, you, we).  Stuttering is common.  Understands on, in, and under.  Refers to self by name.
• Imitation and active imagination.
• Curiosity about body parts.
• Learning to dress self.
• Washes and dries hands; loves water play.

• Please let your physician know if you have any concerns about hearing and vision.

PARENTING

• Try to set up a routine pattern for the day.  Your child is more likely to be hungry at mealtimes, tired at nap time, happier and under better control though the day.  It will provide a sense of control by “knowing” what comes next.
• Give your child undivided attention at times.  Get down on the floor and have “child directed play time.”  Take time to do some things slowly, at a child’s pace.
• Do not phrase things in a question when they are not questions.  “Do you want to go to bed now?”, “Can I check your ears now?”  This gives the impression there is a choice involved when there is not.
• Give advance notice when you need your child to change his/her activity.
• Imaginary playmates may join your household.  Dreams may intensify as imagination develops.
• Frustration, anger and temper tantrums are inevitable.  Allow your toddler to express emotions but help her/him channel them away from overly aggressive behavior.  Limit setting and consistency are important.
• Continue clear, consistent messages regarding appropriate and inappropriate behaviors.
• Follow your established bedtime ritual.  Move to a regular bed by 3-4 years.  Use a mattress on the floor or “toddler bed” when your child is able to climb out of the crib before 3-4 years.
• Show affection and celebrate accomplishments.
• Facilitate independence, when appropriate encourage the “me do it,” and teach how to put on clothes step-by-step.  Put “difficult” clothes out of reach.  Place step stools at the sinks and in the kitchen. Put hooks for coats at the two year height and place non-breakable dishes and cups in accessible drawer.
• Be deliberate about TV, video and computer time.  Discuss it and limit it.
• Begin teaching your child your family’s emergency exit plan.

TOILET TRAINING

• Watch for signs of readiness which would include: waking up dry in the morning or from naps, awareness prior to urinating and stooling, interest in toilet activity.
• Get a potty chair (floor level) and a foot stool for comfortable seating on the toilet.
• Talk about toilet activity.
• When your child looks interested, or is squirming, or wakes up dry, enthusiastically say “Let us see if pee or poo comes out,” and proceed to the toilet.  If there is resistance, slow down.  If there is any success or interest, commend and praise our child.

ACTIVITIES

• Play outside, gardening with supervision.
• Read picture books, play with puppets or dress up clothes and props.
• Coloring/finger painting, Playdough®/clay, musical instruments and listening to music.
• Bake cookies, rip salad greens to make dinner.

SAFETY

• Teach respect for animals, especially if the animal is eating or playing with their own toys.
• Hold hands while crossing the street and in parking lots.
• Teach caution and respect for water and cars.
• When tricycle riding (or any other sport activity) begins, always use a helmet and other appropriate safety equipment.
• Always apply sunscreen before all outdoor activities.
• Continue using a car seat with harness until 4 years or 40 lbs, then switch to a booster seat.
• Your child should never be alone in the car or in the house.
• Regularly check your smoke/carbon monoxide detectors and fire extinguishers.  Frequently review your emergency family exit plan.
• Poisoning remains high at this age.  Keep the Poison Control Center’s phone number near ALL of your phones.  800-222-1222

IMMUNIZATIONS

Hepatitis A #2 and catch-up immunizations.  Most children have no reaction or are somewhat sleepier following their immunization.  Your child may develop a fever and/or be fussy for 24-48 hours.  A tender lump at the injection site may occur and persist for a weeks.  Acetaminophen may be given if any of these symptoms are present.

YOUR FOUR YEAR OLD CHILD

• Name:_______________________  Date:_______________
• Length inches:_________
• Weight lbs:____  oz:____

• BP________/________

NUTRITION

• Educate regarding eating a balanced diet and reasons for it.
• Eat together as a family.  Model good nutrition and exercise habits.

DEVELOPMENT

• Knows colors, dresses self, climbs well, draws and knows some letters.
• Is familiar with using scissors.
• Able to clearly communicate with adults other than parents.

DENTAL CARE

• Continue taking your child to the dentist every six months.  We can recommend a dentist if you don’t already have one.
• Ask about fluoride supplements if your child drinks non-fluorinated water.

SLEEP

• Bedtime rituals.
• Read, read, read and read some more!

PARENTING/SAFETY

• Safety – teach water safety; consider swimming lessons.  Use bike helmets and other safety equipment appropriate for the activity.
• Parenting – model behavior and control temper; be consistent.  Use logical consequences for behaviors. Discuss what they should be with your child and why.  Have conversations involving why, when and how.
• Give your child simple jobs around the house (which you do not have to redo).
• Talk to your child about gun safety.  If there are guns in the house, lock them and store ammunition separately under a separate lock.
• Continue stranger training.  Teach your child not to accept food, rides, or help from people you do not know. Teach your address and phone numbers.  Identify the “helping strangers” when you are out in the community. Let your child know that only people who are helping to keep them clean and healthy should be touching their bottom.
• Be deliberate about TV, video and computer use.  Discuss and limit it.
• Activities/Development – Card games, cut, paste, and paint.  Get outside!  Join play/activity groups.
• When your child is over 4 years OR 40 lbs., you may switch from a car seat with harness to a belt-positioning booster seat.
• Regularly check your smoke/carbon monoxide detectors and fire extinguishers.
• Frequently review your family emergency plan.
• Always call the Poison Control Center immediately for ingestion of poisons.  Keep this number near ALL your phones: 800-222-1222

IMMUNIZATIONS

• Catch-up immunizations if required.

NEXT VISIT

• Your next appointment will be at FIVE YEARS of age
• Please bring your yellow immunization card for updating.
• Please write down all your questions and concerns to address with the doctor at your next visit

YOUR SIX-NINE YEAR OLD CHILD

• Name:_______________________  Date:_______________
• Length inches:_________
• Weight lbs:____  oz:____

• BP________/________

NUTRITION

• Balance diet.  Limit junk food.  Avoid eating in front of the TV/computer.
• Eat together as a family whenever possible.  Continue to model good nutrition and exercise habits.

DENTAL CARE

Continue taking your child to the dentist every six months.  Ask me about fluoride supplements if your child drinks non-fluorinated water.

SCHOOL

• Keep in touch with your child’s teacher.
• Help your child organize.  Set up a clear spot for your child’s school things.

PARENTING

• Encourage physical exercise and outdoor activities.  Model the behaviors for your child.  Self esteem is largely a reflection of parental love and acceptance at this age.
• Discuss current events, advertising, books, and share your family values with your child.  Ask what she/he thinks and feels about things.  Openly discuss the hazards of smoking, drug use, and alcohol.
• Lock all guns and reinforce gun safety.  Keep all ammunition locked away separately from guns.
• Continue to teach and reinforce personal safety and stranger training.
• Be very deliberate about TV, video and computers.  Discuss it and limit it.
• Teach your child about water and bicycle safety.  Now is a great time for swimming lessons.  Continue to be consistent with helmet use.  Continue to model and reinforce seatbelt use.
• Continue using booster seat until your child fits properly in regular seat belts.  Generally they are not ready to come out of the booster seat until 8 years old or 80 lbs.  To see if your child is ready, try these tests:
• Does the child sit all the way back against the auto seat?
• Do the child’s knees bend comfortably at the edge of the auto seat?
• Does the lap belt fit snugly across the top of the thighs?
• Does the shoulder belt come across the center of the shoulder and chest?
• Can the child sit like this the whole trip?

If you answer “no” to any of these questions, your child needs to ride in a booster seat.  For further information call 1(800) BUCK-L-UP.

SAFETY

Keep Poison Center phone number available – (800) 222-1222.

YOUR TEEN

• Name:_______________________  Date:_______________
• Length inches:_________
• Weight lbs:____  oz:____

• BP________/________

• Hearing: _______Vision: R: ___/___   L: ___/___

PHYSICIAN RELATIONSHIP

• The physicians in this office are here to help you be as healthy as you can be.  We encourage your parents to express concerns they have about your health, yet as you grow up our primary relationship is with you.  We encourage confidential interviews.
• Your health is our primary concern.  We encourage you to talk to your parents about your health.  However, if you are capable of making sound decisions about your health, Colorado State Law allows you to seek medical care for the following conditions, even without the consent of your parents: Birth control and pregnancy related care, mental health conditions (such as depression) and alcohol, and drug problems if over age 14, and sexually transmitted diseases including HIV/AIDS testing, if over age 14
• The records and information about these conditions in general are private and require your consent before they can be released to anyone else.  This means that no one except your doctors and nurses (not even your parents) can access the parts of your records about the above conditions without your permission.  There are exceptions when yours or someone else’s health and well-being are in immediate danger.  Please feel free to discuss with your doctor any questions you have regarding privacy of the information you provide during the appointment.

NUTRITION

Are you comfortable with your nutrition and your weight?  Your body and nutritional needs are changing; to stay healthy, eat a balanced diet with an emphasis on grains, fruits and vegetables.  Limit fat and cholesterol.  Include foods rich in calcium and iron.  Drink plenty of water.  Maintain caloric balance with exercise and activity.  Please ask questions about your nutrition or weight.

SUPPLEMENTS

We advise a multivitamin if you are choosing a vegetarian diet.

HYGIENE

You are responsible for your own hygiene.  Daily dental flossing and brushing with toothpaste is advised with dental visits every six months. If acne is a problem for you, please discuss it with us, there are many good treatments for acne. Use sunscreen.

SPORTS

Regular physical activity is a key component of good health.  A good goal is 30-60 minutes per day. Find an activity you enjoy alone, or with friends, or with a team.  Limit TV to <2 hrs/day.  Drink caffeine free fluid to maintain hydration with athletics. Please discuss sports supplements and medications with us before using them.

RELATIONSHIP WITH PARENTS

Your parents’ role in your life is changing.  Now your parents are helping you make wise decisions, not making the decisions for you. Discuss current events, drugs, alcohol and sex with your parents.  Encourage your parents to share their views about sex, the emotional and physical consequences with you.  Who are your social supports?  Who do you talk with when something is bothering you?  Who do you feel accepts you as you are?

SCHOOL

You are responsible for your schoolwork now.  Set goals for yourself.  Ask for help: that is why you have teachers.  Get to know one teacher reasonably well and help that teacher to know you well.  School success and school enjoyment go hand in hand.  Find something you enjoy learning about.

SAFETY

Risk taking is a normal adolescent behavior.  Risks come in all shapes and sizes.  When you consider taking a risk pause to consider the possible consequences of your choice and your behavior; Are you willing to take responsibility and accept the consequences?  Discuss safety issues as a family. Helmets and seatbelts can prevent many injuries and deaths.  Encourage your friends to use them too.

IMMUNIZATIONS

We will check to be sure you are up to date on Td (tetanus, diphtheria), MMR, Meningococcus (if you are in a dorm at college), Hep B, Hep A and Varicella.

NEXT VISIT

Ask us anything about your health at your next annual visit.