4 Month Well Visit: Information for Parents & Caregivers

• Babies should be fed only breast milk (at the breast or in a bottle) or iron-fortified formula until they are 4-6 months old.

  • If formula feeding, be sure to prepare the formula using the directions on the container unless your child’s primary care provider has given you other directions.

  • Your baby does not need extra water.

• Hold your baby during feeding so you can look at each other. When using bottles, make sure you are always holding the bottle - not propping it up. Don’t give your baby a bottle while they are in their crib.

• Burp your baby during natural breaks in feeding.

• Pacifiers may help soothe your baby in-between feedings once breastfeeding is well established and your baby is gaining weight well.

• Signs your baby might be hungry: putting hand to mouth, sucking, rooting, or fussing.

• Signs your baby might be full: turning away from the breast or bottle, closing their mouth, or relaxing their arms and hands.

Feeding frequency and amount

• If taking a bottle, most babies take around 6 ounces of formula every 4 hours, around 30-32 ounces per day.

• Babies who only feed at the breast can be fed on demand - usually anywhere from every 1 to every 4 hours.

• If your baby is mostly receiving breastmilk, they need extra iron to help prevent anemia. You can:

  • Give an iron-containing vitamin supplement (such as Fer-in-Sol or Poly-Vi-Sol with iron).

  • Offer iron-rich foods when starting solids such as infant cereal or plant purees, like lentils, spinach, and beans.

• Your baby may start to go a little longer between overnight feeds.

Introducing Solids

• Some babies are ready to start pureed foods between 4 and 6 months of age.

• You can tell if your baby is ready for solids if:

  • They are able to sit with support.

  • They have good head and neck control.

  • They are interested in mealtimes or try to grab food off your plate.

• Do not be surprised if food ends up everywhere but your baby’s mouth at first.

  • Remember that starting solid foods is a slow process. At first your baby will still be getting most of their nutrition from breast milk or formula.

  • Start with just 1 or 2 teaspoons and increase slowly.

• Offer a variety of flavors and textures to encourage adventurous eating. You can buy or make your own baby food.

• Use a small bowl or dish - don’t feed directly from the jar. Throw away uneaten food from the bowl; refrigerate unused jar food for up to 2 days.

• Do NOT put cereal or purees in bottles - unless your baby’s pediatrician has advised you differently. This increases the risk of choking and does not help them feel full for longer.

• Do NOT give foods with honey or corn syrup until your baby is 1 year old due to the risk of an infection called botulism.

• Great first foods:

  • Avocado, banana, sweet potato, squash

  • Iron- and zinc-fortified infant cereals (mix with breast milk, formula, or water). Start with a thin consistency and slowly increase the consistency.

  • Cooked legumes like beans, peas, lentils

Food Allergies

• New research shows that early introduction (by 6 months) may help prevent food allergies.

• Common allergy-triggering foods: eggs, peanuts, tree nuts, milk, soy, wheat, sesame, fish, and shellfish.

• How to introduce allergenic foods:

  • Egg: fully cooked and include the egg white.

  • Peanut: peanut butter or peanut powder, mixed into a puree so it is not sticky.

  • Once tolerated, give egg and peanut butter/peanut powder 2-3 times per week to maintain tolerance.

• Wait 1-3 days between new foods to watch for reactions such as rash, vomiting or diarrhea.

• If your baby has severe eczema or a known food allergy, they may be at higher risk for food allergies. Talk to your child’s primary care provider about testing before introduction.

  See the Food Allergy Prevention article for more information.

• 400IU of vitamin D is recommended for babies up until 1 year of age.

• Breastmilk is not a good source of vitamin D. This means that all breast-fed infants should be given vitamin D supplements.

• All formula-fed infants who take less than 1000ml (approximately 33 ounces per day) should also be given vitamin D supplements.

• Vitamin D supplements are available over the counter and should be given once daily.

  • There are 2 main types of vitamin D drops available for babies. Check the packaging of the vitamin D supplement you have to make sure you are giving the correct amount.

    • Some have the recommended amount of vitamin D (400IU) in just one drop.

    • With others, you need to give the entire dropper. Use the dropper that came with the bottle of vitamin D.

Learn more about vitamin D for infants here.

Play and Learning

• Hold and talk to your baby often.

• Encourage active play. Offer colorful toys to hold or a floor gym to play with.

• Make time for quiet play too.

• Tummy Time: Put your baby on their tummy for playtime every day. This makes their neck and back muscles strong.

  • Always stay with your baby during tummy time.

  • Never let your baby sleep on their tummy.

• Read to your baby every day. Choose durable books made of cloth or thick board. Look for books with bright colors and large, simple pictures.

• ZERO Screen Time: Children under age two should have no screen time. This means no TV, tablets, or smartphones.

  • Do not prop your baby in front of a TV.

  • Do not have the TV on in the background.

  • Do not use digital media to calm your baby down.

• Create routines for feeding, nap time, and bedtime. This helps your baby know what to expect.

• Calm your baby with soothing and gentle touches when they are fussy.

• Massage the gums: Gently rub your baby's gums with a clean finger, clean washcloth, or a moist gauze pad. The light pressure can help relieve pain.

• Offer cool items to chew on: Give your baby a clean, firm rubber teething ring to chew on. You can chill the teething ring or a clean, wet washcloth in the refrigerator (not the freezer). Frozen items may be too hard and can hurt your baby's gums.

• Dry the drool: Wipe your baby's face often with a soft cloth to prevent a rash on their chin or cheeks.

• Pain relief medication: If your baby is very fussy and other methods aren't working, ask your pediatrician about using a weight-appropriate dose of acetaminophen.

• Do NOT use teething gels or creams that contain benzocaine (found in products like Baby Orajel, Anbesol, etc.). They are not safe for children under two.

• Do NOT use homeopathic teething tablets or gels. They may contain harmful ingredients like belladonna.

• Do NOT use amber teething necklaces or bracelets. They are a choking and strangulation risk.

• Keep your own teeth healthy. Go to your dentist twice a year. Healthy parent teeth mean you won't pass cavity-causing germs to your baby.

• Don’t share spoons with your baby or use your mouth to clean their pacifier.

• Clean your baby’s gums daily with a soft cloth. As soon as you see the first tooth, clean it two times a day with a soft cloth or a soft baby toothbrush.

• Use a small smear of fluoride toothpaste (no more than a grain of rice).

• Don’t put your baby in a crib with a bottle to help them fall asleep. This helps prevent tooth decay.

Every baby develops at their own pace. These are common milestones you may notice around this age.

Social and Emotional

• Smiles on their own to get your attention.

• Chuckles (not yet a full laugh) when you try to make them laugh.

• Looks at you, moves, or makes sounds to get or keep your attention.

• May squeal when happy or cry when hungry or wanting comfort.

• Enjoys toys that make noise when shaken.

Language and Communication

• Makes cooing sounds like “oooo” or “aahh”.

• Responds with sounds when you talk to them.

• Turns head toward your voice.

Cognitive (Learning, Thinking, Problem-Solving)

• Opens mouth when they see the breast or bottle if hungry.

• Looks at their hands with interest.

• May begin to roll from stomach to back.

Movement and Physical Development

• Holds head steady without support when being held.

• Holds a toy placed in their hand.

• Swings arms at toys.

• Brings hands to mouth.

• Pushes up onto elbows or forearms during tummy time.

• FREE behavioral and developmental assessments are available.

  • San Diego County residents through the First 5 Programs (888) 534-7785 or First5sandiego.org.

  • Southern Riverside residents through the Healthy Steps Programs (858) 966-8300 or Healthysteps.org.

  • Riverside and San Bernardino Counties are also served by Inland Regional Center (909) 890-4763.

Safe Sleep and Crib Safety

• Always place your baby on their back to sleep.

• Choosing a safe sleep space is important for your baby’s health and safety.

  • Use a firm sleep surface, like a crib, bassinet, or “Pack-and-play” with a tight-fitting sheet.

  • It should be in a safe location, away from heaters or direct heat sources.

  • Make sure the crib sides are fully up and secure.

  • Use a crib with slats no more than 2⅜ inches apart to prevent injury.

• Keep the sleep space bare - no pillows, blankets, stuffed animals, sleep positioners, or bumper pads. No toys in the crib.

• Room-sharing, NOT bed-sharing, is recommended for at least the first 6 months, ideally up to 1 year.

• Your baby should not sleep on or in:

  • Soft surfaces like your bed or couch

  • Loungers or pillows like “Dock-a-tot”

  • Bouncers or swings

  • Car seats. If your baby falls asleep while you are driving, that is fine - but once you get to your destination, take them out of their car seat and move them to a safe sleep space.

• Swaddling should not be used after 2 months of age.

• Do not put your baby to bed with a bottle.

Sleep Patterns and Tips

• Most 4-month old’s sleep about 14 to 17 hours in a 24-hour period.

• Your baby may sleep for longer stretches at night and take 2 to 3 naps during the day.

  • It is normal for babies at this age to wake up during the night. Some may need to feed; others may just need comfort.

  • Feeding right before bed does not guarantee longer periods of sleep.

  • If your baby wakes up often, try offering a pacifier.

• Try to follow a consistent sleep routine - this helps your baby learn when it is time to sleep.

• Put your baby in their sleep space when they are drowsy but still awake to help them learn to fall asleep on their own.

• Keep your baby’s sleep space quiet, dark, and calm to help your baby settle.

• Always wear your seat belt. Your baby's safety depends on you staying safe too.

• Never drive after drinking alcohol or using drugs. Never text or use a cell phone while driving.

• Never leave a child alone in a car.

• Use a rear-facing car seat in the back seat of your car. Keep your child in a rear-facing seat as long as possible, up to the seat's weight and height limits (this could even be up to age 4).

• Never place a car seat in the front seat of a vehicle, especially one with a passenger airbag.

• Check the harness: The straps should be over their shoulders. Adjust the harness so you can only slip one finger underneath the straps at your child's chest. Place the chest clip at armpit level.

• Use your car seat correctly: Read the directions, or call your local police department or fire station for help installing it.

• Keep cords, ropes, or strings away from your baby, especially near the crib. These can wrap around a baby's neck and choke or strangle them.

• Don’t let your baby wear necklaces or bracelets.

• Remove hanging mobiles or toys before your baby can reach them.

• Keep small objects, small toys, plastic bags, balloons and baby powder away from your baby.

• Don't offer toys with sharp edges or small parts that might come loose.

• Check your smoke detector to make sure it is working. Keep a fire extinguisher in or near the kitchen.

• Prevent scalds or burns: Set your water heater to 120°F (49°C) or below. Check formula temperature carefully - it should be warm or cool to the touch.

• Never eat, drink, or carry anything hot near your baby or while you are holding them.

• Never leave the baby alone except in a crib with the sides up.

• Do not leave your baby on high surfaces, like changing tables, beds, or sofas. A fall from just 2 feet can cause serious injuries. Always keep a hand on them.

• Don’t use a baby walker. Not only do they not help your baby learn to walk, they are also a safety hazard. They can tip over easily, allow babies to fall down stairs, and help them reach dangerous places that would otherwise be out of reach.

• Never leave an infant or toddler in a bathtub alone - even if they are in a “bath seat” or ring.

• Keep the Poison Control Center number saved in your phone: 1-800-222-1222 or 911 in an emergency.

• Avoid smoking, vaping, alcohol, and drug use around your baby.

• Create a tobacco-free home and car to keep children healthy.

• Babies exposed to smoke have more frequent and more severe respiratory infections.

• Resources if you are thinking about quitting:

  Call 1-800-NO-BUTTS

  https://www.nobutts.org

  https://kickitca.org/

• Immunizations protect your child against serious, life-threatening diseases.

• The routinely recommended vaccines at this well visit are:

  • DTaP (Diphtheria, Tetanus, acellular Pertussis)  

  • Hib (Haemophilus influenza type B)  

  • Polio  

  • Hepatitis B

  • Pneumococcal (PCV20)  

  • Oral Rotavirus  

  • RSV - This depends on the time of year and whether the birth parent received the RSV immunization during pregnancy.

• It is safe for your child to be given all recommended vaccines according to the schedule published by the American Academy of Pediatrics.

• Vaccines are safe, effective, and proven to save lives.

• At CPCMG, we offer combination vaccines whenever possible to decrease the number of injections. At this visit, your child’s primary care provider may recommend a combination vaccine that includes DTaP, Hib, Polio, and Hepatitis B.  

• If you have concerns about vaccines, please talk to your child’s primary healthcare provider for accurate information.

• Learn more about recommended immunizations from the American Academy of Pediatrics.

Common side effects from vaccines

• Fever - can be treated with acetaminophen.

• Soreness - can be treated with a cool compress.

• Swelling at the injection site - can be treated with a cool compress.

For more details, visit the immunizations section on our Health Hub.

Call your child's primary care provider if:

• Your child has a rash or any reaction other than fever and mild irritability.

• Your child has a fever that lasts more than 36 hours.

• More than half of new parents experience “postpartum blues”.

  • This usually starts 3 or 4 days after delivery and usually gets better within 1 to 3 weeks.

  • Symptoms can include tearfulness, feeling tired or sad, and trouble thinking clearly.

  • These feelings are linked to a sudden drop in hormones after birth.

• Many parents feel guilty or confused about these emotions, especially when they expected to feel only joy.

• There are healthy ways to manage postpartum blues.

  • Acknowledge your feelings. Talk with a partner, trusted friend, your healthcare provider, or your baby’s primary care provider.

  • Get enough rest. If possible, sleep when your baby is asleep.

  • Ask for help. Let others help with meals, baby care, or tasks around the home.

  • Stay connected. Try not to isolate - spend time with people who support you.

• If you are still feeling down by the time your baby is 1 month old, please talk to your healthcare provider. You might benefit from counseling or other support.

• If your feelings are making it hard for you to care for yourself and your baby, get help as soon as possible.

  Helpful access and crisis lines:

  San Diego County 888-724-7240

  Riverside County 951-686-HELP (4357)

  Crisis Text Line: 741741 - text any word (like HELP or TALK) to start a discussion

  You can call the National Suicide Prevention Lifeline (text 988) at any time to speak with someone immediately.

  For more information on 10 signs of postpartum depression, click here.

  For more information and resources for therapists and counselors in San Diego County and Riverside County, click here.

• Your family is probably getting used to new routines. Keep in mind that as your baby gets older and changes, the routines will change too.

• If you have older children, the excitement of having a new baby in the home might be fading. You might be noticing more unwanted behaviors from your older children. This is normal and happens often.

  • Find small but safe ways for your other children to help with the baby, such as bringing you things you need or holding the baby’s hand.

  • Spend special time with each child reading, talking, and doing things together.

• You may be looking into options for childcare for your baby. It’s normal to feel sad or worried about leaving your baby with someone else. Look for mature, trained, and responsible caregivers.

• Take time for yourself and your partner. Spend time with family and friends.

• Let your child’s primary care provider know if:

  • You feel unsafe or have been hurt by someone close to you. We can connect you with confidential support and hotlines.

  • You are worried about your living situation or having enough food.

• Programs like SNAP and WIC may help with:

  • Buying formula for infants.

  • Getting food for breastfeeding parents and children up to age 5.

  • For more information on the WIC program please ask your doctor or contact WIC directly.

    • WIC San Diego 1-800-500-6411, http://sandiegowic.org/

    • WIC Riverside: 1-800-472-2321, http://cms.sbcounty.gov/wic/Home.aspx

Your baby's next well visit should be at the age of 6 months.

• We will talk about:

  • Taking care of your baby, your family, and yourself.

  • Feeding, sleep, and developmental milestones.

  • Teaching and playing with your baby.

  • Brushing your baby’s teeth and dental care.

  • Keeping your baby safe at home, outside, and in the car

• Bring your child’s immunization card to all visits.

• We are here for you between Well Visits!

  • We understand that it is not possible to address all concerns at the Well Visit.

  • For medical conditions, illnesses, mental health and behavioral health, and other concerns between Well Visits, please schedule an appointment with your child’s primary care provider.

Immunizations

Immunizations protect your child against serious, life-threatening diseases.

The routinely recommended vaccines at the next well visit (the 6 month visit) are:

• DTaP (Diphtheria, Tetanus, acellular Pertussis)

• Hib (Haemophilus influenza type B)

• Polio

• Pneumococcal (PCV20)

• Oral Rotavirus

• Depending on the season, flu and COVID-19 vaccines may be recommended.

At CPCMG, we offer combination vaccines whenever possible to decrease the number of injections. Your child’s primary care provider may recommend a combination vaccine that includes DTaP, Hib, Polio, and Hepatitis B.

Learn more about recommended immunizations from the American Academy of Pediatrics