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Since the infant is 9 months of age, the WHO growth chart should be used to assess the female child. The CDC recommends use of the WHO charts for infants under 2 years of age as they are recognized as a better indicator of growth in early development, showing infant to toddler growth in optimal conditions and assuming breastfeeding for at least 4 months without introduction of other food sources and still breastfeeding with other nutrition sources at 12 months of age. I compared the CDC percentiles posed in the DQ question to the WHO charts and the results were comparable.

I would note the stature and build of the parents of the child as well, as this is important to consider when assessing an infant (and child) for growth.

The first thing to assess upon entering the infant’s space is how she reacts to you, the nurse who is most likely a stranger. Does the child hide her face and cling to the parent? Is the child consolable and does she rely on a comfort item from home? Does the child calm once she sees the parent comfortably interact with the nurse as the nurse interviews the parent and notes any concerns they have at this interaction. Also make note of how the parent reacts to healthcare providers; notice any signs of neglect, abuse, signs on the child that do not have explanation or do not seem right.

During my physical assessment of the child, I would make note of her developmental milestones listed by the CDC for 9 month old infants. I could show the child my stethoscope and see if she points at it with a finger and does she reach for it and grab with a thumb and finger? I could hand the baby a tongue depressor and watch to see how she learns about it. Does she put it in her mouth? I could drop a small toy on the exam table to watch the child look for it as it falls and then cover it with a drape to see if she looks for it. Does she delight in finding it in a makeshift game of peek-a-boo?

I would talk to the parent about the infant’s feedings. Have solid foods other than breastmilk or formula been introduced? If dry cereal or other finger food has been introduced, can the child use the pincher grasp to pick up a piece, transfer one hand to the other, and put a piece in her mouth (however successful attempts may be!)?

Finally I would assess muscle development and gross motor skills, including the parent’s replies in the assessment as well, as it not always possible to ask a 9 month old girl to pull up to standing on demand. Does the child sit up unassisted, can she stand supporting her own weight, does she crawl?

Does the child understand and react to “no” and does she babble at any point during the interaction?

I would talk to the parent about what to watch for next at the 12 month stage and could point them to a paper copy, online reference or phone app to read about 12 month milestones.

Lastly, I would check what vaccines are recommended, and let parents know a flu shot can be given over 6 months of age. I would ask about eruption of teeth, discuss comfort measures and dental checkups. I would inquire about the child’s sleep environment and habits, and remind parent that the crib mattress should be at the lowest position to prevent falls. I would inquire about car seat and remind parent that AAP advises rear-facing until age 2. I would ask about safety in the home and ask if the parents have inspected for electrical risks, cord dangers, security of windows and doors with a crawling climbing infant in the home. I would ask about the possibility of lead paint in the home especially with a teething infant who is becoming increasingly mobile.

Recommendations are based on evidence-based practice because this will help ensure the child develops, meeting milestones and not falling behind. Evidence shows infant safety and security can be protected by following safe sleep practices and AAP guidelines. Milestones from the CDC help assess every child using a uniform set of criteria that most children of certain ages will have met. Identifying possible delays helps enhance developmental support and further investigate and address any other risk factors early.

References

Centers for Disease Control and Prevention. (2019, January 11). Growth charts – WHO child growth standards. Retrieved from https://www.cdc.gov/growthcharts/who_charts.htm

Centers for Disease Control and Prevention. (2019, October 24). Important milestones: Your baby by nine months. Retrieved from https://www.cdc.gov/ncbddd/actearly/milestones/milestones-9mo.html